Constipation

Constipation is a Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.

Almost everyone has it at some point in life, and it’s usually not serious. Constipation is common especially among older patients. The obvious culprits include a low fiber diet, repeatedly ignoring the urge to go, not drinking enough water, or a lack of exercise. Also, the use of medications, especially opioid analgesics, and overuse of enemas and laxatives, can cause constipation. Certain psychological disorders like stress and depression can also cause such condition. And because constipation is a case-to-case basis, some people believe they are constipated if a day passes without a bowel movement; for others, every third or fourth day is normal. Though common, constipation may also be a complex problem. Chronic constipation can result in the development of hemorrhoids; diverticulosis; straining at stool, and perforation of the colon. It is very important to be aware of the different possibilities because constipation can become a lifelong, chronic problem. Tumors of the colon and rectum can result in obstipation (complete lack of passage of stool). Thus, effective treatment for constipation includes fluids, activity, and fiber.

 

————-How to Assess as a Nurse ——————–

Assessment of the patient with Constipation includes a careful history and physical examination, followed by appropriate laboratory and radiological investigations. The tests conducted are directed by the clinical findings and should be used to strengthen the diagnosis as well assess the depth of the problem.

Assessment Rationales
Check on the usual pattern of elimination, including frequency and consistency of stool. It is very crucial to carefully know what is “normal” for each patient. The normal frequency of stool passage ranges from twice daily to once every third or fourth day. Dry and hard feces are common characteristics of constipation.
Take account of a possible laxative and enema use, type, and frequency. There is a big factor when patient becomes dependent on laxatives and enemas. Abuse of laxatives and enemas causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. In the long run, the colon becomes atonic, distended, and does not respond normally to the presence of stool.
Check out usual dietary habits, eating habits, eating schedule, and liquid intake. Irregular mealtime, type of food, and interruption of usual schedule can lead to constipation.
Assess the patient’s activity level. Sedentary lifestyle such as sitting all day, lack of exercise, prolonged bed rest and inactivity contribute to constipation.
Classify current medications usage that may lead to constipation. A lot of drugs can slow down peristalsis. Opioids, antacids with calcium or aluminum base, antidepressants, anticholinergics, antihypertensives, general anesthetics, hypnotics, and iron and calcium supplements can cause constipation.
Feel the need for privacy for elimination. Defecating is a private thing. Most patients may have a hard time having a bowel movement away from the sense of privacy in their home.
Evaluate for fear of pain with defecation. Conditions such as hemorrhoids, anal fissures, or other anorectal disorders that are painful can cause the patient to ignore the urge to defecate, which over time results in a dilated rectum that no longer responds to the presence of stool.
Consider the degree to which the patient responds to the urge to defecate. Ignoring the urge to defecate eventually leads to chronic constipation because the rectum no longer senses or responds to the presence of stool. The longer the stool stays in the rectum, the drier and harder it becomes. This will make the stool difficult to pass.
Know if there is a history of neurogenic diseases, such as multiple sclerosis or Parkinson’s disease. Neurogenic disorders may decrease peristaltic activity.

———-How to Intervene as a Nurse————

The following are the therapeutic nursing interventions for Constipation:

Interventions Rationales
Encourage the patient to take in fluid 2000 to 3000 mL/day, if not contraindicated medically. Sufficient fluid is needed to keep the fecal mass soft. But take note of some patients or older patients having cardiovascular limitations requiring less fluid intake.
Assist patient to take at least 20 g of dietary fiber (e.g., raw fruits, fresh vegetable, whole grains) per day. Fiber adds bulk to the stool and makes defecation easier because it passes through the intestine essentially unchanged.
Urge patient for some physical activity and exercise. Consider isometric abdominal and gluteal exercises. Movement promotes peristalsis. Abdominal exercises strengthen abdominal muscles that facilitate defecation.
Encourage a regular period for elimination. Most people defecate following the first daily meal or coffee, as a result of the gastrocolic reflex.
Digitally eliminate the fecal impaction. Stool that remains in the rectum for long periods becomes dry and hard; debilitated patients, especially older patients, may not be able to pass these stools without manual assistance.
Consider the following examples to minimize rectal discomfort:
  • Warm sitz bath
The warmth of the water relaxes muscles before defecation attempts.
  • Hemorrhoidal preparations
These over-the-counter preparations shrink swollen hemorrhoidal tissue.
For hospitalized patients, the following should be employed:
  • Unless contraindicated, encourage the patient to use the bathroom. For bedridden patients; assist the patient in assuming a high-Fowler’s position with knees flexed.
 A sitting position with knees flexed straightens the rectum, enhances the use of abdominal muscles, and facilitates defecation.
  • Close the bathroom door or pull curtains around the bed.
This position best uses gravity and allows for effective Valsalva maneuver.
Privacy is very important because it helps the patient feel comfortable for defecation.
For patients with neurological problems:
Abdominal massageUsing the heel of the hand or a tennis ball, apply and release pressure firmly but gently around the abdomen in a clockwise direction. Abdominal massage has been known to be helpful in neurogenic bowel disorder but not for constipation in older adults.
Digital anorectal stimulationA gloved lubricated finger is lightly inserted into the rectum and moderately rotated in a circular motion. This is performed for about 15 to 20 seconds until flatus/stool is passed. Digital stimulation increases muscular activity in rectum by raising rectal pressure to aid in expelling fecal matter.
Discuss with a dietitian about dietary sources of fiber. A person with enough knowledge about the matter will recommend sources of fiber consistent with the patient’s usual eating habits. A patient unaccustomed to a high-fiber diet may experience abdominal discomfort and flatulence; a progressive increase in fiber intake is recommended.
Explain to the patient and caregiver the importance of the following: These steps lead to establishing regular bowel habits.
  • A balanced diet that comprises adequate fiber, fresh fruits, vegetables, and grains
Twenty grams of fiber per day is suggested.
  • Sufficient fluid intake (eight glasses per day or 2000 to 3000 mL/day)
Increased hydration promotes a softer fecal mass.
  • A regular period for elimination and an adequate time for defection
 Successful bowel training relies on routine. Facilitating regular time prevents the bowel from emptying sporadically.
  • Regular exercise and activity
Exercise strengthen abdominal muscles and stimulate peristalsis.
  • Privacy for defecation
 Privacy allows the patient to relax, which can help promote defecation.
Explain the use of pharmacological agent as ordered. The use of laxatives or enemas is indicated for short-term management of constipation.
  • Bulk fiber (Metamucil and similar fiber products)
These laxatives increase fluid, gaseous, and solid bulk of intestinal contents.
  • Stool softeners (e.g., Colace)
These laxatives soften stool and lubricate intestinal mucosa.
  • Chemical irritants (e.g., castor oil, cascara, Milk of Magnesia)
These laxatives irritate the bowel mucosa and cause rapid propulsion of contents of small intestine.
  • Suppositories
These laxatives aid in softening stools and stimulate rectal mucosa; best results occur when given 30 minutes before usual defecation time or after breakfast.
  • Oil retention enema
This intervention softens stool.