Care of the Patient with Constipation

Constipation is the most frequently reported gastrointestinal problem and can affect a person’s mental and physical health. Healthcare workers need to be alert to any conditions that may cause constipation. Management and prevention are the best interventions to improve the quality of life of patients with constipation symptoms.

The lower gastrointestinal tract, or large bowel, is about 4 1/2 to 5 feet long and approximately 2.4 to 2.7 inches in diameter. It consists of the cecum, colon, rectum, and anal canal. The large bowel has several functions, including storage, absorption of water, electrolytes, and vitamins, and getting rid of waste. The longer the stool stays in the bowel, the more water is reabsorbed back into the body, leaving a hard mass that becomes difficult to pass.

Motility or movement throughout the gastrointestinal (G.I.) tract moves food and digestive material forward. Since stool is composed of 75% water and only 25% waste, it is usually moved through the intestinal tract by muscle contractions. Constant waves through the intestinal tract are called peristaltic movements or waves and move food through the GI system. The peristaltic movement is called peristalsis and is what initiates defecation. It takes 24-48 hours to move stool through the colon.

Two sphincters further control defecation (having a bowel movement). One is the internal involuntary anal sphincter the other is the external voluntary anal sphincter. Impulses through nerve endings give the signal to increase peristaltic movements to relax the internal sphincter and cause the external sphincter to constrict. This signals the need to defecate.

Constipation is when stool does not pass often enough or does not pass completely.

The stool becomes hard and can be difficult and painful to pass. Common causes of constipation include not feeling the urge to defecate, inadequate fiber intake, inadequate fluid intake, weakness of abdominal muscles, inactivity and bed rest, pregnancy, and hemorrhoids. Aging causes changes in the gastrointestinal tract. Peristalsis is slower, which may cause incomplete emptying. There is also a higher risk for intestinal tumors and other intestinal disorders (Sorrentino & Remmert, 2021).

The definition of constipation can be tricky because bowel function can differ in every patient. The average bowel movements can occur once daily to three times per week, depending on the individual. Constipation occurs when there are less than three bowel movements a week or if the bowel movement changes and is a consistent problem for the patient. Assessment of the patient’s patterns should be discussed and documented. Chronic constipation occurs when there are less than two movements a week, along with other symptoms such as bloating, pain, difficulty or incomplete defecation, or overflow. (Sorrentino & Remmert, 2021).

Rectal defecation disorders most commonly occur due to poor muscle coordination or strength of the pelvic floor or in the anal sphincter. Other diseases associated with chronic constipation include spinal cord injury, Parkinson’s disease, multiple sclerosis, endocrine disorders such as hypothyroidism, and growth in the gastrointestinal tract.

Constipation is the most common side effect of opioid use among the elderly. This has potentially severe consequences and can significantly impact the person’s quality of life. Opioids hurt the gastrointestinal system, including delayed gastric emptying and decreased water in the bowels that can lead to slowing or peristalsis and a reduced urge to defecate.

Other medications, along with opioids, can also cause constipation. In the elderly, in particular, medications include anticholinergic agents, calcium supplements, calcium channel blockers, and non-steroidal anti-inflammatory drugs. These medications can reduce intestinal smooth muscle contractility and motility, which decreases peristalsis and fecal movement, leading to constipation.

Older adults with chronic constipation may develop dilation of the rectum, colon, or both. This can cause large amounts of feces (bowel movement) to accumulate in the rectum. A fecal impaction can occur without treatment, which is a severe complication. A fecal complication is the retention and buildup of feces in the rectum, which can be hard or putty-like. Liquid stool will often pass around the impaction and leak out of the anus. The patient may complain of abdominal pain, nausea, cramping, and rectal pain (Sorrentino & Remmert, 2021). Distention of the abdomen may also occur along with a fever. The pressure on the urethra may also cause urinary incontinence. An impaction can occur in any age group but is more common in older adults who are less active. Impaction may result from disease, tumors, neurogenic disorders, chronic use of antacids or bulk laxatives, a low-residue diet, medications, or prolonged bed rest. In cases where fecal impaction is suspected, a nurse or a doctor does a digital rectum examination to assess for fecal mass. A nursing aide is not trained to do a digital rectum examination. There are many nerves, and the tissue can become very thin and easy to poke through. It is easy to injure a patient during a digital rectal exam.

The goal of treatment is to relieve the cause of constipation and to promote regular and predictable bowel movements. This is usually achieved through lifestyle changes in diet. However, some people do require medications. Bowel retraining is also used to help the patient gain control and develop regular elimination patterns.

Lifestyle modifications include increasing fiber content, particularly in older people who commonly have poor diets. Fiber-rich foods include fruits, vegetables, bran, nuts, or fiber supplements. Another way to incorporate fiber is to add prunes or juice to the diet. However, this must be done slowly, as sudden fiber increases can cause gas and bloating.

Other nonpharmacological interventions include a toileting schedule. Schedule toileting after meals. The patient should sit on the toilet with their feet on a small step to allow for easier bowel movements. In this position, the patient’s knees will be higher than the hips, and they will lean forward with elbows on the knees for support. They need to allow adequate time and privacy for bowel evacuation.

Biofeedback training is helpful for patients who have impaired pelvic floor muscles. The goal is to retrain patients to relax the pelvic floor muscles while simultaneously producing a contraction of the abdominal muscles. A trained professional should only do this.

Enemas and suppositories may be ordered for the patient. However, because these are medications, the nursing assistant should check with their state to see if they are allowed to insert the suppository or give an enema.

Laxatives are an option for patients who are changing their diet and waiting for effects or if other means of treatments are ineffective. Depending on the patient’s symptoms, comorbidities, side effects, speed of action, and patient compliance, several types of laxatives can be given.

Educating patients on the importance of diet, exercise, and toilet training can vastly improve symptoms and is often the first treatment. However, it is important to identify learning barriers, such as hearing or visual impairments or cognitive decline, as these may impact how the interventions are carried out. Keeping a detailed bowel diary can also help to identify problems and help in bowel retraining. Suggest exercise if possible. Range of motion can also be done if the patient is bedridden.

Diet is also an important part of preventing constipation. Review the patient’s care plan for any diet considerations. A well-balanced diet of fruit, grains, and vegetables can help promote regular bowel passage. Soluble fiber such as oats, bran, and beans, as well as insoluble fiber found in wheat and whole grains, help to add water and bulk to the stool. This extra water and bulk will increase the frequency of bowel movements. Adults should get at least 18-30 grams of fiber daily. However, any increases should be done slowly to avoid bloating and gas. When increasing fiber in the diet, note that it may take several weeks to become effective. The patient may need laxatives until results of increased fiber are seen. Enough fluid intake is also important. On average, fluid intake should be about 1.5 to 2 liters daily. Older adults may be unable to drink this much fluid daily. Substitute fruit juices if needed and recommended by the nurse or dietician.

Observe if the patient has problems chewing or swallowing, as they may need a special puréed or soft diet. Alert the nurse of any changes in eating habits. Be sure to assist with toileting regularly, usually after meals. Provide privacy and warmth using a blanket if needed. Position the person in a sitting position if they are able. Also, make sure that the call light and toilet paper are within their reach. Perform perineal care as needed and watch for skin breakdown. Help the patient wash their hands and monitor for any change in their bowel habits.

Observe for abnormal stools, pain upon defecating, or excessive gas and bloating. Monitor the color, size, consistency, and character of the stool. Also, watch for blood, pus, or mucus within the stool. Any leaking that appears to be diarrhea should be reported in case of possible impaction. Observe for any abdominal distention uploading, frequent urination, inability to empty bladder, mental confusion, fever, or vomiting fecal matter. Report any unusual observations to the nurse immediately. Also, odor and noise are common. Always act professionally. Do not laugh or make fun of the patient. Provide the patient with dignity, comfort, and self-esteem at all times.

Scenario/situation/patient description:

• You have been assigned to care for Mr. Samuels. He is a 68-year-old Caucasian male with a diagnosis of lung cancer. He is currently getting chemo treatments and is taking a mild opioid. When you enter the room, you notice that Mr. Samuels is very restless in his bed. As you step closer to him, you also notice that his abdomen is distended, and he looks distressed. You also note that he has not eaten his breakfast. When you ask Mr. Samuels why he is distressed, he answers that he feels nauseous and his stomach hurts badly. When you ask about his bowel movements, he tells you that he has not passed any stool in two days but has had some involuntary anal leaking of watery stool. He also tells you he normally has bowel movements twice daily.

Intervention/strategies:

• You immediately report your findings to the nurse. The nurse performs a digital exam and finds that Mr. Samuel has an impaction, which the nurse can remove. This gives Mr. Samuels some relief as he can pass additional stool on his own within an hour. He was also ordered a laxative for today to help his bowels move.

His new care plan:

• Observe his stool for color, consistency, smell, character, amount, and frequency. Also, note if there is any blood, pus, or mucus in the stool.
• Document the findings as well as the frequency of bowel movements.
• Provide privacy and warmth if needed.
• Help the patient to a position on the toilet for comfortable bowel movements.
• Observe for skin breakdown and apply a barrier if needed.
• Encourage activity if possible.
• Encourage fluids.
• Encourage foods that are high in fiber.
• Observe for pain, bloating, or gas.
• Make sure the call light and toilet paper are close to the patient.
• Provide perineal care if necessary.
• Use standard precautions and avoid contaminating surfaces.
• Report any unusual findings to the nurse.

Discussion of outcomes:

• Mr. Samuels's impaction was quickly relieved due to the CNA's observations and quick response. He will need to be monitored closely throughout the day to make sure the impaction does not reoccur.

Strength and weaknesses

• The response was timely and effective. However, because he was on opioids and was not as mobile, the care plan could have been improved when his condition changed to prevent the impaction.

Scenario/situation/patient description:

• Mrs. Jones is a 62-year-old female with a history of Parkinson’s disease. She is currently bedridden but can get to a bedside commode with help. Mrs. Jones lives with her daughter, who is her caregiver. Mrs. Jones’ daughter is concerned because her mother has not had a normal bowel movement for several days. Upon further questioning, you find that Mrs. Jones cannot drink large amounts of fluid, and her diet consists mostly of soft foods. When you talk to Mrs. Jones, she tells you that she is straining to have a bowel movement and often stops because she gets too tired. She does not feel like she is emptying all her bowel movements. She does not complain of pain, bloating, or gas. However, she does admit that she is also having trouble urinating.

Intervention/strategies:

• You report these findings to the nurse. The nurse and the dietitian develop a care plan and diet change. Additional fiber is added to Mrs. Jones's diet. Because she has mild difficulty swallowing and is already on a soft diet, the dietician recommends pureed foods or very soft, smaller foods that she can eat. Soluble and insoluble fiber foods can be pureed for her. Examples of these foods include bran, whole wheat, and vegetables. She can also take a fiber supplement that can easily be added to the pureed foods. However, this must be done gradually so as not to add to Mrs. Jones's discomfort with gas and bloating. A laxative is also added until the fiber can be increased enough to be effective. Mrs. Jones should increase her fluid intake. However, since she has not been able to drink an appropriate amount of water, prune juice can be added to her fluid regimen. Mrs. Jones and her daughter are educated that the additional fiber and fluid will help Mrs. Jones empty her bowels and make her more comfortable. Mrs. Jones's daughter is taught how to document her food and fluid intake and her bowel movements.

Discussion of outcomes:

• The CNA's observations and reporting allowed intervention quickly, preventing impaction and relieving constipation.

Strength and weakness:

• The intervention was appropriate, but the initial care plan could have been better to prevent problems.

There are many causes of constipation and impaction, but aging and immobility are major ones. CNAs are involved in preventing, identifying, and treating constipation and impaction. Observing and reporting are primary functions to prevent constipation and impaction. The CNA is the front-line observer. In addition, carefully following the care plan helps prevent constipation and impaction.

• Sorrentino, S., & Remmert, L. (2021). Mosby’s Textbook for Nursing Assistants (10th ed.). Elsevier.