# Situation: A 26-year-old man with an incomplete spinal cord injury at the fourth thoracic (T4) level from a fall 4 months ago is on a rehabilitation unit. He has an indwelling urinary catheter until his bladder program starts. He has not taken sildenafil or any other phosphodiesterase-5 inhibitor. His bowel program is being set up before discharge. Which plan is appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630530  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 26-year-old man with an incomplete spinal cord injury at the fourth thoracic (T4) level from a fall 4 months ago is on a rehabilitation unit. He has an indwelling urinary catheter until his bladder program starts. He has not taken sildenafil or any other phosphodiesterase-5 inhibitor.

His bowel program is being set up before discharge. Which plan is appropriate?

## 보기

1. Set a daily time; use lidocaine gel for digital stimulation **✔ 정답**
2. Limit fluids to 1 liter a day to keep the stool formed
3. Give a phosphate enema each morning to fully empty the bowel
4. Wait for the urge to pass stool before starting the routine

**정답: 1**

## 해설

A reflex bowel program uses a set time each day, stool softeners, a suppository, and digital stimulation. At T6 and above, lidocaine gel is used for rectal stimulation because rectal stimulation can trigger a dangerous rise in blood pressure. Adequate fluids and fiber keep the stool soft.

## 심화 해설

What a reflex bowel program is
An injury at T4 is above the sacral segments that control defecation, so the client has an upper motor neuron (reflex) bowel. The reflex arc between the rectum and the sacral cord is intact, but the brain can no longer sense rectal fullness or voluntarily control emptying. A reflex bowel program uses that intact arc on a predictable schedule: a set time each day, often after a meal to take advantage of the gastrocolic reflex, a stool softener, a rectal suppository, and digital rectal stimulation to trigger the reflex. Over weeks, the bowel learns to empty at the chosen time, which prevents accidents and impaction.

Why lidocaine gel matters at T4
Clients with an injury at T6 or above are at risk of autonomic dysreflexia, and rectal stimulation is a well-known trigger. Stretching the anal sphincter during digital stimulation or suppository insertion can set off a sudden dangerous rise in blood pressure. Using lidocaine gel as the lubricant numbs the rectal mucosa and reduces this risk. The nurse also teaches the client and caregivers to stop and sit him upright if he develops a pounding headache, flushing, or sweating during the program, and to check his blood pressure.

| Element of the program | Purpose |
| --- | --- |
| Same time every day | Trains a predictable reflex response |
| After a meal, sitting upright if possible | Uses the gastrocolic reflex and gravity |
| Stool softener, adequate fluids and fiber | Keeps stool soft and formed |
| Suppository and digital stimulation | Triggers the reflex arc |
| Lidocaine gel at T6 and above | Lowers the risk of autonomic dysreflexia |

Why the other plans are wrong
Limiting fluids to 1 liter a day would harden the stool and cause constipation and impaction, which is itself a dysreflexia trigger; adequate fluid and fiber are needed. A daily phosphate enema causes dependence, can disturb electrolytes, and is not part of a routine reflex program. Waiting for the urge does not work because rectal sensation is lost or unreliable after a cord injury at this level; the program follows a schedule, not a sensation.

Teaching for discharge
The nurse teaches the client and family the steps, the timing, the signs of dysreflexia, and how to manage them. Record keeping of results helps adjust the plan. Regular activity, consistent meals, and fluid intake support the routine.

Exam takeaway
Key point A reflex bowel program is scheduled, uses softeners, a suppository, and digital stimulation, and at T6 or above uses lidocaine gel to avoid autonomic dysreflexia.

## 임상 시나리오

Reflex Bowel Program After T4 InjuryScheduled emptying with dysreflexia safety
An injury at T4 leaves a reflex bowel: the sacral reflex arc works, but the client cannot sense fullness. Emptying follows a set daily time, not the urge.

The program uses a stool softener, adequate fluids and fiber, a suppository, and digital stimulation, ideally after a meal.

At T6 and above, use lidocaine gel for rectal stimulation because it can trigger autonomic dysreflexia.

CautionStop and sit the client upright if he develops a pounding headache or flushing during the program, and check his blood pressure.

## 핵심 개념

- **Reflex bowel** — Bowel function after an injury above the sacral cord: the emptying reflex is intact but sensation and voluntary control are lost.
- **Digital rectal stimulation** — Gentle circular stimulation inside the anal sphincter with a gloved, lubricated finger to trigger bowel emptying.
- **Gastrocolic reflex** — Increased colon movement after eating, used to time bowel programs.
- **Autonomic dysreflexia** — Sudden severe hypertension in injury at T6 or above, triggered by stimuli such as rectal stretching.

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