Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?
A.
Abdominal girth.
B.
Breath sounds.
C.
Bowel sounds.
D.
Vital signs.
The Correct Answer and Explanation is:
Correct Answer: C. Bowel sounds
Explanation:
Before performing a digital removal of a fecal impaction, assessing bowel sounds is the most important step for the nurse to take. This assessment is crucial because bowel sounds provide valuable information about the state of the gastrointestinal (GI) tract, specifically whether there is normal peristalsis or any obstruction.
Bowel Sounds and Peristalsis: Bowel sounds are produced by the movement of the intestines as they push contents through the GI tract. These sounds are an indirect indication of peristalsis, the rhythmic contraction of the muscles in the intestinal walls. Normal bowel sounds suggest that peristalsis is occurring as expected, which is important before attempting to remove a fecal impaction. In contrast, hypoactive or absent bowel sounds could indicate an underlying obstruction, ileus, or reduced peristaltic activity, which might complicate the removal procedure and increase the risk of complications, such as perforation.
Importance of Bowel Sounds: If bowel sounds are absent or significantly diminished, it may suggest a partial or complete bowel obstruction. In such cases, the digital removal of fecal impaction could exacerbate the problem, potentially leading to perforation or worsening of the obstruction. On the other hand, if bowel sounds are present and active, this suggests that the GI tract is functioning adequately, and it may be safer to proceed with the intervention.
Other Assessments: While the other options, such as assessing abdominal girth, breath sounds, and vital signs, are important in the overall evaluation of the patient’s condition, they do not provide specific information about the state of the GI tract related to fecal impaction. For example:
- Abdominal girth is useful in assessing distension, which may occur with impaction, but does not directly indicate peristaltic activity.
- Breath sounds are important for respiratory assessment but are not directly relevant to fecal impaction.
- Vital signs provide general information about the patient’s condition, but again, do not offer specific insights into bowel function.
Conclusion: Assessing bowel sounds is critical because it directly evaluates the function of the GI system, which is essential before attempting digital removal of a fecal impaction. This assessment helps ensure the procedure is performed safely, reducing the risk of complications such as bowel perforation.