The nurse performs digital removal of a fecal impaction for the client with atrial fibrillation and heart failure. Which is the most serious unexpected client assessment the nurse assesses during the procedure?

Question

1. Rectal bleeding
2. Perianal redness
3. Liquid stool leakage
4. Abdominal cramping

Answer 1

1
1. Clients with atrial fibrillation and heart failure are usually on an anticoagulant to prevent formation of mural thrombi; the most serious unexpected finding during im-paction removal is client rectal bleeding. Rectal bleeding from the client on anticoa-gulation is very difficult to control because of the anatomical location and the in-creased bleeding time of the client's blood. The nurse should stop the procedure, keep the client's head low, as long as the client tolerates the position, and notify the provider.
2. Perianal redness can indicate regional irritation or future skin breakdown and the nurse should plan care to restore the perianal tissue integrity; however, this is not more important than bleeding.
3. Liquid stool leakage during impaction removal can indicate ineffective impaction removal and the client potentially needs assistance with bowel evacuation and in-creased fiber, fluids, and physical activity.
4. Abdominal cramping cues the nurse to stop the impaction removal and allow the cramping to subside before continuing with the procedure.