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Friday, November 26, 2010

Constipation

Constipation

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


Discussion of the Problem
Constipation is the most common bowel-management problem in the elder population.  It is one of the four most common problems related to fecal elimination namely; constipation, diarrhea, bowel incontinence, and flatulence. It is usually episodic; however, it can become a lifelong, chronic problem. Constipation can be caused by the following factors: too little fluid, too little fiber, inactivity or immobility, disruption in daily routines, lack of privacy, irritable bowel syndrome (IBS), neurological conditions, stroke, paralysis, pelvic floor dysfunction or muscle damage, pregnancy, use of medications (analgesics, overuse of laxatives, iron supplements, antihistamines, antacids, and antidepressants), overuse of enemas, ignoring the need to defecate, stress and depression. If the constipation becomes chronic, it could lead to development of hemorrhoids, diverticulosis and rarely, perforation of the colon. Sudden death could also occur during straining of a stool. The Valsalva maneuver can present serious problems to people with heart disease, brain injuries, or respiratory disease. Obstipation, the complete lack of passage of stool, could occur when tumors are present in the colon and rectum. Other medical conditions that could cause constipation as follows: disc surgery, fecal diversions, anemias and renal dialysis. Although dietary management, increasing fluid and fiber, still remains the most effective treatment for constipation, exercise and daily routine are important as well.

Nursing Interventions Classification (NIC)
  • Bowel Training
  • Constipation/Impaction Management
  • Teaching: Prescribed Medication

Nursing Outcomes Classification (NOC)
  • Bowel Elimination
  • Medication Response
  • Self-Care Toileting

Goal and Objectives
  • Patient or caregiver will articulate procedures that will avoid recurrence of constipation.
  • Patient will demonstrate changes in behaviors or lifestyle, as necessitated by causative, contributing factors.
  • Patient will exhibit active bowel sounds or peristaltic activity.
  • Patient will pass soft, formed stool at a regularity perceived as "normal" by the patient.
  • Patient will pass stool of soft or semiformed consistency without straining.

Subjective and Objective Data
  • Abdominal distention
·         Abdominal pain/rectal fullness, nausea
  • Anorexia
·         Change in frequency, consistency, and amount of stool
·         Decreased bowel sounds
  • Dull headache, restlessness, and depression
  • Frequent but nonproductive desire to defecate
·         Increased abdominal girth
  • Nausea and vomiting
  • Passage of hard, dry stool
  • Passage of liquid fecal seepage
  • Straining at stools
  • Verbalized pain or fear of pain

Related Factors:
·         Altered nerve stimulation, ileus
·         Changes/restriction of dietary intake
·         Drug therapy side effects
·         Emotional stress, lack of privacy
  • Fear of pain
·         Hormone-secreting tumor, carcinoma of colon
·         Immobilization, decreased physical activity, lack of exercise, use of opiates/narcotics
  • Inactivity, immobility
  • Inadequate fluid intake
·         Irritation of the GI mucosa from either chemotherapy or radiation therapy; malabsorption of fat
  • Lack of privacy
  • Laxative abuse
  • Low-fiber diet/fluid intake; changes in digestive processes
  • Medication use
  • Neurologic disorders
  • Pain/discomfort in abdomen or perineal area and swelling in surgical area
·         Physical factors: abdominal surgery, with manipulation of bowel, weakening of abdominal musculature
·         Placement of ostomy in descending or sigmoid colon
  • Pregnancy
·         Reduced intestinal motility, compression of bowel (peritoneal dialysate); electrolyte imbalances; decreased mobility
  • Tumor or other obstructing mass

Assessment (Dx)
  • Assess and document usual pattern of elimination then compare it with present pattern. Take in to consideration the following characteristics: size, frequency, color, odor and quality. The "Normal" frequency of passing stool varies from twice daily to once every third or fourth day. Establishing what is "normal" for each individual is important.

GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL
ELIMINATION PATTERN ASSESSMENT
SUBJECTIVE
1. What is your usual frequency of bowel movements? _________________
            a.         Have to strain to have a bowel movement? No__ Yes__
            b.         Same time each day? No__ Yes__
2. Has the number of bowel movements changed in the past week?
            No__ Yes__ Increased?__ Decreased?__
3. Character of stool
            a.         Consistency: Hard__ Soft__ Liquid__
            b.         Color: Brown__ Black__ Yellow__ Clay-colored__
            c.         Bleeding with bowel movements: No__ Yes__
4. History of constipation: No__ Yes__  How often? ____________________      
5. History of diarrhea: No__ Yes__ When?___________________________
6. History of incontinence: No__ Yes__ Related to increased abdominal pressure             (coughing,        aughing, sneezing)? No__ Yes__
7. History of travel? No__ Yes__ Where?____________________________
8. Usual voiding pattern:
            a.         Frequency (times per day) ____ Decreased?__ Increased?__
            b.         Change in awareness of need to void: No__ Yes__ Increased?__ Decreased?__
            c.         Change in urge to void: No__ Yes__ Increased?__ Decreased?__
            d.         Any change in amount? No__ Yes__ Increased?__ Decreased?__
            e.         Color: Yellow__ Smokey__ Dark__
            f.          Incontinence: No__ Yes__ When? _____________________________

Difficulty holding voiding when urge to void develops? No__ Yes__
Have time to get to bathroom: Yes__ No__ How often does problem reaching bathroom occur?
            g.         Retention: No__ Yes__ Describe: _____________________________
            h.         Pain/burning: No__ Yes__ Describe: ___________________________
            i.          Sensation of bladder spasms: No__ Yes__ When? ________________

OBJECTIVE
1. Auscultate abdomen:
            a.         Bowel sounds: Normal__ Increased__ Decreased__ Absent__
2. Palpate abdomen:
            a.         Tender: No__ Yes__ Where?_________________________________
            b.         Soft: No__ Yes__; Firm: No__ Yes__
            c.         Masses: No__ Yes__ Describe: _______________________________
            d.         Distention (include distended bladder): No__ Yes__ Describe: _______
            e.         Overflow urine when bladder palpated? Yes__ No__
3. Rectal Exam:
            a.         Sphincter tone: Describe: ____________________________________
            b.         Hemorrhoids: No__ Yes__ Describe: ___________________________
            c.         Stool in rectum: No__ Yes__ Describe: _________________________
            d.         Impaction: No_- Yes__ Describe:______________________________
            e.         Occult blood: No__ Yes__ Location: ___________________________
4. Ostomy present: No__ Yes__ Location: ___________________________


  • Assess and document for history of neurologic diseases, for example multiple sclerosis and Parkinson’s disease. Alteration of the colon’s ability to perform peristalsis may be affected by neurologic disorders.

  • Assess current use of medication that may contribute or cause constipation. Narcotics, antacids with calcium or aluminum base, antidepressants, anticholinergics, antihypertensives, and iron and calcium supplements are some examples of drugs that can cause constipation.

  • Assess dependency on enemas for elimination. Because the colon becomes distended and does not respond normally to the presence of stool, abuse or overuse of cathartics and enemas can result in dependence on them for evacuation,  

  • Assess for anxiety/fear with regards to pain. Anorectal disorders like hemorrhoids and anal fissures are painful and can cause ignoring urge to defecate, which over time results in a dilated rectum that no longer responds to the presence of stool.

  • Assess for laxative use, type, and frequency. The function of the nerves and muscles of the colon function inadequately in producing urge to defecate due to chronic laxative use. Over some time, the colon becomes atonic and distended.

  • Assess usual dietary habits, eating habits, eating schedule, and liquid intake prior to hospitalization. An alteration in mealtime, type of food, interruption of usual schedule, and anxiety can lead to constipation.

  • Evaluate activity level. Prolonged bed rest, lack/decrease in exercise, and inactivity contribute to constipation.

  • Evaluate the degree of patient’s tendency to delay the defecation that may contribute to constipation. Ignoring the urge to defecate eventually leads to chronic constipation. It is because the rectum no longer senses, or responds to, the presence of stool. The longer the stool remains in the rectum, the drier and harder (and more difficult to pass) it becomes.

  • Explore the possible causes of delayed onset/absence of effluent. Auscultate for bowel sounds. In constipation bowel sounds are commonly decreased.

  • Inspect perianal skin condition frequently, noting changes or beginning of skin breakdown. Assist patient with perineal care after each bowel movement (BM). Proper perineal care prevents skin excoriation and breakdown.

  • Monitor and document intake and output (I&O) with specific attention to food/fluid intake. Excessive loss of fluids or liquids aids in identifying dietary deficiencies.

  • Monitor and document laboratory studies as indicated, e.g., electrolytes. Altered GI function may be caused by electrolyte imbalances that need to be corrected.

  • Provide privacy for elimination (e.g., access to bathroom facilities with privacy during work hours or use of bedpan). Being away from home limits their ability to have a bowel movement as reported by many individuals.

Therapeutic Interventions
  • Assist in removal of fecal impaction digitally. Elderly patients (especially debilitated patients) whose stool remains in the rectum for long periods becomes dry and hard, may not be able to pass these stools without manual assistance.

  • Encourage daily fluid intake of 2000 to 3000 ml/day (2 to 3 liters/day), if medically not contraindicated. Patients with cardiovascular limitations, like most elderly patients, may require lesser fluid to be taken.

  • Encourage to establish a regular time for elimination. Depending on the person’s usual schedule, any time, as long as it is regular, is fine.

  • Instruct patient to increased fiber in diet (e.g., raw fruits, fresh vegetables, prunes, prune juice, cold cereal, and bean products); a minimum of 20 g of dietary fiber per day is essential to promote good bowel. Through the intestine, fiber essentially passes unchanged. When it reaches the colon, it absorbs water and forms a gel, which adds bulk to the stool and makes defecation easier.

  • Support physical activity and regular exercise (e.g., isometric abdominal and gluteal exercises). Defecation is facilitated through ambulation and/or abdominal exercises that strengthen abdominal muscles. Unless it is medically contraindicated.

  • To minimize discomfort, suggest the following measures:
    1. Warm sitz bath
    2. Hemorrhoidal preparations. These aids in shrinking swollen hemorrhoidal tissue.

STEP IN MAKING SITZ BATH
Step 1.  You need to get a bathtub, shallow bucket or a sitz bath.
Step 2.  Fill up your bathtub, bucket or sitz bath with warm water. The water should be warm enough to the point that it is almost uncomfortable, but not to the point that it is warm enough to burn. The water should be just deep enough to envelop your entire buttocks and hips.
Step 3. (Optional)  You can fill up another bathtub, bucket or sitz bath with cold water. You could move back and forth between the cold and warm water every few minutes.
Step 4.  The majority practitioners advise sitting in the water for about 20-30 minutes a number of times a week to promote healing.
Step 5.  When you’re done.  Get out of your sitz bath; make sure that you dry the region with a clean, cotton towel. Note that you should pat, not rub dry. Some practitioners recommend letting the area air dry however.
Note:  You can also add salts to sitz baths if your doctor advises it. The quantity of salt depends on the size of your sitz bath.

  • The following should be employed for hospitalized patients,:
    1. Allow patient adequate time to relax.
    2. Familiarize and reorient patient to location of bathroom and encourage use, unless medically contraindicated. To facilitate defecation, a sitting position with knees flexed that straightens the rectum may be used. This is to enhance the use of abdominal muscles which eventually facilitates easier defecation.
    3. Provide a warmed bedpan to bedridden patients and assist patient to assume a high-Fowler’s position with knees flexed. This position best utilizes gravity and allows for effective Valsalva maneuver.
    4. Provide curtain off the area. This promotes privacy.
  • Consult dietitian if necessary. A gradual increase in fiber intake is recommended by a professional.

Educative (Edx)
  • clarify or reinforce to patient and significant others the importance of the following:
    1. A balanced diet that contains adequate fiber, fresh fruits, vegetables, and grains is essential. Twenty grams per day is recommended.
    2. Adequate fluid intake. Drink 8 glasses/day or 2000 to 3000 ml/day. This facilitates defecation.
    3. Avoid gas-forming foods. Decreases gastric distress and abdominal distention.
    4. Privacy for defecation
    5. Regular exercise/activity. Regular activities promote better peristalsis.
    6. Regular meals. Successful bowel training relies on routine.
    7. Regular time for evacuation and adequate time for defecation. Regular time should be established to monitor patient’s elimination progress.

  • Discuss the use of pharmacological agents as ordered, as in the following:
    1. Bulk fiber (Metamucil and similar fiber products). These increase fluid, gaseous, and solid bulk of intestinal contents.
    2. Chemical irritants (e.g., castor oil, cascara, Milk of Magnesia). These drugs cause irritation of the bowel mucosa that result to rapid propulsion of contents of small intestines.
    3. Oil retention enema. This causes the stool to soften.
    4. Stool softeners (e.g., Colace). This lubricates intestinal mucosa and soften stool for easier evacuation.
    5. Suppositories. These help in softening stools and stimulate rectal mucosa; best results occur when given 30 minutes before usual defecation time or after breakfast.



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