# Situation: An 80-year-old woman in a long-term care facility takes oral morphine daily for osteoarthritis pain and has chronic kidney disease with an estimated glomerular filtration rate (eGFR) of 25 mL/min/1.73 m². She has not had a formed bowel movement in 6 days and has had no antibiotics in the past 3 months. Today she has passed small amounts of liquid brown stool into her brief four times, has lower abdominal discomfort, and is newly confused. Her temperature is 36.8 °C. What is the MOST likely explanation?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630480  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: An 80-year-old woman in a long-term care facility takes oral morphine daily for osteoarthritis pain and has chronic kidney disease with an estimated glomerular filtration rate (eGFR) of 25 mL/min/1.73 m². She has not had a formed bowel movement in 6 days and has had no antibiotics in the past 3 months.

Today she has passed small amounts of liquid brown stool into her brief four times, has lower abdominal discomfort, and is newly confused. Her temperature is 36.8 °C. What is the MOST likely explanation?

## 보기

1. Infectious diarrhea needing a stool test for toxins
2. Liquid stool seeping around hard stool in the rectum **✔ 정답**
3. Loose stools from opioid withdrawal after missed doses
4. Fecal incontinence from a weak anal sphincter

**정답: 2**

## 해설

Liquid stool can ooze around a hard fecal mass and be mistaken for diarrhea. After 6 days without a formed stool while on an opioid, with abdominal discomfort and new confusion, fecal impaction is most likely and is confirmed by digital rectal examination.

## 심화 해설

Overflow around an impaction
After 6 days without a formed bowel movement while taking daily morphine, the most likely problem is fecal impaction: a mass of hard, dry stool that she cannot pass. Bacteria and secretions liquefy stool above the mass, and that liquid seeps around the hard stool and leaks out in small amounts. This paradoxical diarrhea (overflow) is easily mistaken for true diarrhea. Small, frequent leaks of liquid stool after days without a formed stool point to impaction, not infection. The diagnosis is confirmed by digital rectal examination.

Why she is confused
In older adults, fecal impaction often presents atypically. Abdominal discomfort, restlessness, urinary retention, and new confusion (delirium) may be the main signs. Her age, opioid use, and reduced mobility in long-term care all raise the risk. The confusion should prompt the nurse to look for a reversible cause, and constipation with impaction is a common one.

Why the other explanations do not fit
Infectious diarrhea, such as Clostridioides difficile infection, is unlikely because she is afebrile at 36.8 °C, has had no antibiotics in the past 3 months, and has not had a formed stool for days, which is the opposite of an infectious pattern. Opioid withdrawal can cause loose stools, but she takes morphine daily and nothing suggests missed doses. Fecal incontinence from a weak anal sphincter would not explain the 6-day absence of formed stool or the abdominal discomfort. Watch out! Giving an antidiarrheal to a client with overflow would worsen the impaction.

| Feature | Fecal impaction with overflow | Infectious diarrhea |
| --- | --- | --- |
| Preceding pattern | Days without formed stool | Usually normal stools before |
| Stool | Small, frequent liquid leaks | Large-volume watery stools |
| Fever | Usually absent | Often present |
| Risk factors | Opioids, immobility, older age | Antibiotics, exposure to infection |
| Confirming step | Digital rectal examination | Stool testing |

Exam takeaway
When liquid stool appears after several days without a formed stool, especially in an older adult on opioids, think impaction first and confirm by rectal examination before any antidiarrheal is considered. Key point! New confusion in an older adult can be the presenting sign of fecal impaction.

## 임상 시나리오

Fecal Impaction with OverflowRecognizing paradoxical diarrhea
After 6 days without a formed stool on daily morphine, small liquid leaks suggest fecal impaction: liquid stool seeps around a hard mass in the rectum.

Older adults may present with abdominal discomfort and new confusion. She is afebrile at 36.8 °C and has had no recent antibiotics, so infection is unlikely.

The nurse reports the findings and the diagnosis is confirmed by digital rectal examination.

CautionDo not give an antidiarrheal for overflow stool; it worsens the impaction.

## 핵심 개념

- **Fecal impaction** — A hard, immovable mass of stool in the rectum or colon that the client cannot pass.
- **Paradoxical diarrhea** — Liquid stool leaking around an impacted fecal mass, mimicking diarrhea.
- **Digital rectal examination** — Examination of the rectum with a gloved, lubricated finger to detect stool, masses, or tenderness.
- **Delirium** — An acute, fluctuating disturbance of attention and cognition, often triggered by a physical cause in older adults.

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