The nurse assesses the client during digital removal of a fecal impaction. Which client assessment data does the nurse determine is an unexpected finding?

Question

1. Complaints of abdominal cramping
2. Large amount of brown liquid stool
3. Blood pressure 130/86 mm Hg, stable
4. Heart monitor shows sinus bradycardia.

Answer 1

4
4. Sinus bradycardia is a heart rate less than 60 beats/min and is consistent with clin-ical indicators for vasovagal stimulation from digital removal of fecal impaction. This heart rate is usually too slow to maintain an adequate cardiac output, so the client becomes hypotensive, lightheaded, and may lose consciousness. As a result, the nurse stops the procedure, assesses client vital signs and neurological status, and calls for help to anticipate a potential need for emergency interventions. Usually, bradycardia from vasovagal stimulation resolves spontaneously; however, the nurse also notifies the provider to deliver safe and effective nursing care.
1. The nurse expects abdominal cramping; the nurse instructs the client to focus on slow, even breathing and proceeds with removal slowly and gently to minimize cramping.
2. The client can pass a large amount of stool after some or the entire impacted stool is removed because fecal matter frequently accumulates behind the impaction in the colon.
3. Stable blood pressure is a highly desirable finding.