A nurse is ordered to perform digital removal of stool on a client with stool impaction. Which of the following is an appropriate step in this procedure?
A) Position the client in supine position as dictated by client comfort and condition.
B) Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus.
C) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.
D) Instruct the client not to bear down while extracting feces to prevent vagal response.
Ans: C
For digital removal of stool: Position the client on the left side (Sims' position), as dictated by client comfort and condition. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, pointing toward the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client to bear down, if possible, while extracting feces, which will ease in removal.
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