Fundamentals - Practice & Skills, part 25: Laxatives, Enemas, and Fecal Occult Blood Testing
This article covers laxatives, enemas, and fecal occult blood testing. You can follow along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
When you see this Cool Chicken, that indicates one of Cathy's silly mnemonics to help you remember. The Cool Chicken hints in these articles are just a taste of what's available across our Level Up RN Flashcards for nursing students!
Laxatives are medications that promote emptying of the intestinal tract. They are often prescribed to treat constipation.
The different kinds of laxatives include osmotic, bulk forming, and stimulant laxatives.
Osmotic laxatives are a type of medication used to treat constipation, as well as to prep the bowel prior to a surgery or procedure.
Bulk forming laxatives
Stimulant laxatives are medications used for constipation, as well as for bowel prep prior to a surgery or procedure.
For a deeper dive into laxative pharmacology, please check out our pharmacology flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Enemas are solutions that are instilled into the intestinal tract via the rectum to help remove feces or to give medications to the patient.
As with laxatives, there are different types of enemas, including cleansing enemas and oil retention enemas.
Cleansing enemas stimulate the colon to contract and eliminate stool. This type of enema may include large-volume cleansing enemas or prepackaged disposable enemas.
Oil retention enemas
Oil retention enemas lubricate the feces in the rectum and colon, making it easier to pass.
How to administer an enema (best practices)
- Have a bedside commode, bedpan, or bathroom ready for use
- Warm the enema solution to room temperature
- Elevate the solution less than or equal to 18 inches above the level of patient’s anus
- Position the patient in modified left lateral recumbent position (Sims'), on their left side with their right leg flexed
- Lubricate the enema tip if it is not pre-lubricated
- Insert the tip of the enema into the anus three to four inches (7.5 cm – 10 cm), angling the tip toward the umbilicus (belly button)
- Administer the enema slowly over 5 – 10 minutes
- If the patient reports abdominal cramping, lower the solution container
- Once administration is complete, encourage the patient to remain on their side and to retain contents, which means resisting toileting for about 10 minutes or as prescribed per order
- When it is time for the patient to toilet, assist them to the bathroom or bedside commode
Key nursing points when administering enemas
Why elevate the enema solution less than or equal to 18 inches above the patient?
The higher the bag, the more forcefully and faster the fluid is going to flow because of gravity. If the patient complains of cramping because of the rate at which the fluid is being instilled, try lowering the bag. When the bag is lowered, the rate at which the enema is delivered slows, and that may help with cramping.
Why instruct patients to resist the urge to toilet following an enema?
Patients should be instructed to resist the urge to toilet for approximately 10 minutes (or as prescribed per order) especially when being administered medicinal enemas. This is to ensure that the patient is retaining the medication for the prescribed amount of time. If the enema/medication comes out immediately, it won’t be effective.
Why lubricate the tip of an enema?
Lubricating the tip of an enema will ease its use and allow it to remain in the rectum longer. The longer the enema remains in the rectum, the more it’s going to help promote the expulsion of those fece (or administer the medicine).
When administering a rectal suppository, position the patient in Sims’ position so that they are on their left side with the right leg flexed over. Then, insert the suppository about one inch into rectum.
It is important that the suppository gets past the internal sphincter so that it will stay inside the rectum, but it is not necessary to push the suppository too far. Also make sure to push the suppository along the wall of the colon so that it is not being pushed directly into stool, because then the suppository is not going to be effective.
Patient education for administering rectal suppositories
It is important to ensure the patient understands the process for inserting rectal suppositories in the event these are prescribed for home use and the patient is not being supervised by a nurse.
Digital removal is the manual removal of hardened stool in the rectum with a gloved, lubricated finger.
Fecal occult blood test
A fecal occult blood test is used to identify blood in stool, especially when blood may not be visible to the eye (occult means hidden; the test screens for blood that cannot be seen by the naked eye, e.g., microscopic blood).
Alternative names for this process include FOBT, occult blood testing, fecal blood test, or stool guaiac test.
Indications for administering a fecal occult blood test
Instructions for administering a fecal occult blood test
When administering a fecal occult blood test, use an applicator to apply a small amount of stool onto the testing card slots A and B. The stool should be taken from two separate areas of the specimen in order to test for multiple areas in the stool to see if there’s bleeding anywhere along that line.
Apply reagent to the card; the card will turn blue if there is blood. If there is no blood, there will be no color change.
If Blood is present, the card turns Blue.
If the test shows the presence of blood, the patient will require prompt evaluation (e.g., a colonoscopy).
Best practices for administering a fecal occult blood test
The following practices should be followed when administering a fecal occult blood test:
- Collect three samples from (three) separate bowel movements
- Collect stool in a clean container free from urine
Hi. I'm Meris, and in this video, I'm going to be talking to you about laxatives, enemas, and fecal occult blood testing. I'm going to be following along using our Fundamentals of Nursing Flashcards. These are available on our website, leveluprn.com. If you already have a set and you're following along with me, I'm starting on card number 127. Let's get started. So first of all, I want to tell you that if you stay until the end, I'm going to share with you a very real thing that happened to me with a patient. So you're really not going to want to miss this, I promise you. So let's talk about laxatives versus enemas and rectal suppositories. So laxatives are actually going to be medications that promote emptying of the intestinal tract. There's lots of different kinds. And if you are studying for pharmacology, I would definitely recommend checking those out in our pharmacology flashcards to get more information.
Now, enemas are going to be solutions that are instilled into the intestinal tract by the rectum. So this is going to help to remove feces, or it can also be medicated enemas. There's lots of different types. And we do list out the different types - cleansing enemas, oil retention enemas, and all of those sorts of different kinds of enemas - because there are a lot. And then rectal suppositories, so important stuff to know here is that you're going to position your patient in Sims position, or exaggerated runner's position, so that they're on their left side with the right leg flexed over and then insert the suppository about one inch into the rectum. You do need to get past the internal sphincter so that it will stay inside the rectum, but you don't need to worry about pushing it too far past. And make sure you're pushing it along the wall of the colon so that you're not pushing it directly into stool because then it's not going to work.
All right. So moving on, we have a really important card. There's a lot of information on here because it all matters a ton. These are best practices for enema administration - this is card 128 - so I would definitely know this. I'm not going to go through every single one, but a few key points that I want to pull out is that you want to have the enema solution less than or equal to 18 inches above the patient. The higher the bag, the more forcefully and faster the fluid is going to flow because of gravity. So if your patient complains of cramping because of the rate at which the fluid is being instilled, try lowering the bag first. If we lower the bag, we lower the rate at which it's delivered, and that may help with cramping. The other thing is that we want our patients to try and resist the urge to toilet for approximately 10 minutes or as prescribed per order. But there's no point to the enema if it comes out immediately. Now, obviously, that can happen sometimes as well, but especially for medicated enemas, we want to make sure that the patient is retaining it for the prescribed amount of time. And also, for lubricating enemas, it's going to have the same requirement. The longer it stays in, the more it's going to help promote the expulsion of those feces.
Moving on to fecal occult blood testing. So sometimes you'll hear this called FOBT or occult blood testing or fecal blood test. There's lots of different cards. Oh, you'll also hear it called guaiac, stool, guaiac. Lots of different ways to say this. But basically, the point here is fecal, having to do with feces; occult, meaning hidden or hard to see; blood, blood; testing, testing. So we are testing for the presence of blood in the feces that we cannot see. I don't need a fecal occult blood test if I can see the blood, frankly, with my eyes. If there is gross blood, not meaning disgusting but meaning obvious to the naked eye, I don't need this. This is screening for invisible blood or microscopic blood. Big things to know here are going to be that you're going to use an applicator to apply stool to two areas on this card. The stool should be taken from two separate areas of the stool specimen so that we can test for multiple areas in the stool to see if there's bleeding anywhere along that line. And we do have a cool chicken hint here, which is that if blood is present, the card turns blue, B for blood, B for blue. Once you put the stool on the card, you'll flip it over and add a developer to it. And that developer is what will turn the card blue if there is blood. If there's no blood, nothing will happen. There will be no color change. Big key point, too, if there's blood, we don't just say, "All right, we have to evaluate it further." So this patient needs to be seen by GI or referred for colonoscopy. Super important.
All right. So that's it for laxatives, enemas, and fecal occult blood testing. I hope that review was helpful. If you enjoyed it, please like this video so that I know. And if you have a great story or a good way to remember something, comment it below because I want to hear it. And I know everybody else does too. Be sure that you are subscribed to our channel because, oh my gosh, we have a lot coming out for you, and you don't want to miss it. The next video in this series is going to be talking about hypoxia, hypoxemia, and techniques to improve oxygenation, which I'm going to say is going to be, probably, one of the most important videos we're going to have in this whole series. Thanks so much, and happy studying.
When I worked in EMS, I got a call one night and went to the house where we were called. And it was an unknown medical complaint. And so I go in, and I say, "How can I help you today?" And this woman says, "I'm bleeding really bad." And I said, "Okay. Where are you bleeding from?" And she told me she was bleeding from her rectum. And I asked her, "Was this new? What's going on? Tell me about the history of it." And she told me that it happened immediately after using a suppository that her doctor had prescribed to her. And I said, "Okay." I'm trying to think of like-- maybe she perfed her bowel or something like that. Well, no, what happened is-- and this is actually a really important story to underscore the importance of patient education and the importance of taking into consideration a patient's health literacy. What happened was she was given these suppositories by the pharmacy. They're all individually wrapped, and they are wrapped in foil. No one taught her to take it out of the foil. That's a thing that might be obvious to you or to me, but that's not obvious to everyone. So this patient inserted this suppository in its foil wrapping, without any lubrication or anything like that, and had seriously, seriously cut herself externally and internally and was bleeding pretty severely from her rectum. So just important to think about those little things that we take for granted as healthcare professionals that our patients may not know. So take the time to do that little extra bit of patient education.
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