The purpose of this activity is to enable the CNA to identify and aid in the management of constipation in patients.
At the end of the activity, the learner will be able to:
Constipation is the most frequently reported gastrointestinal problem and can affect a person’s mental and physical health. Health care workers need to be alert to any conditions which may cause constipation. Management and prevention are the best interventions to improve the quality of life of patients with symptoms of constipation.
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 (Bardsley, 2015). It consists of the cecum, colon, rectum, and anal canal. The large bowel has several functions which include storage; absorption of water, electrolytes, and vitamin; and elimination of waste (Bardsley, 2015). 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 G.I. tract propels food and digestive material forward. Since stool is composed of 75% water and only 25% waste, it is normally propelled 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 (Grossman & Porth, 2015). In the colon, two types of movements of motility occur. Compartments called haustra that churn the material into a small ball like manner due to circular contractions of the muscle layers (Grossman & Porth, 2014). Next are propulsive peristaltic movements contract and move the fecal matter forward. The mass movements last approximately 30 seconds followed by 2 to 3 minute of relaxation. This series of movements may last only for 10 to 30 minutes but can occur several times a day (Grossman & Porth, 2014). This movement is what initiates defecation. It takes 24-48 hours to move stool through the colon.
Defecation is further controlled by two sphincters. 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 gives the signal for the need to defecate.
Constipation is the infrequent or incomplete passage of stool. The stool is usually hard and can be difficult to pass. Common causes of constipation include not recognizing 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 (Sorrentino & Remmert, 2016). Peristalsis is slower which may cause incomplete emptying. There is also a higher risk for intestinal tumors and other intestinal disorders (Sorrentino & Remmert, 2016) 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 is said to occur 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 evacuation, or overflow (Bardsley, 2015).
Constipation is a problem for over 16% of the general population (Tian et al., 2016). In nursing home residents over the age of 60, symptoms of chronic constipation occur in 50% of the population (Mounsey, Taleigh, & Wilson, 2015). The result is a devastating impact on the health care system. It is estimated that approximately 2.5 million physician visits and 92,000 hospitalizations are due to constipation symptoms (Mounsey, Raleigh, & Wilson, 2015). Further, symptoms of constipation tend to be seen more in women than men. However, women are more likely than men to seek health care treatment (Bharucha, Pemberton & Locke, 2013). Additional risk factors include lower socioeconomic status, lower parental education, less activity, medication, depression, physical and stressful life events (Bharucha, Pemberton, & Locke, 2013).
Constipation can occur as either a primary symptom or as a secondary symptom (Schmidt & de Gouveia Santos, 2014). Note that constipation is not a disease but rather a sign or symptom of something else (Woodward, 2012). There can be several reasons a patient has constipation. These can be divided into three categories: normal-transit constipation, slow transit constipation, and disorders of rectal evaluation.
Normal transient constipation or functional constipation difficulties in defecation usually responds to increased fluid and fiber intake. Slow transient constipation is more infrequent bowel movements often caused by alterations in colon function (Grossman and Porth, 2014). Hirschsprung Disease is an extreme form of slow transient constipation. The disease is actually in defects in the intestinal wall that occur during embryonic development. Although most patients with this disease present problems in infancy or early childhood, some do not have symptoms until later in life. Rectal evaluation disorders most commonly occur due to deficient muscle coordination or strength of the pelvic floor or in anal sphincter (Grossman & Porth, 2014). Other diseases associated with chronic constipation include neurological disorders such as spinal cord injury, Parkinson’s disease, multiple sclerosis, endocrine disorders such as hypothyroidism and obstructive lesions in the gastrointestinal tract (Grossman & Porth, 2014).
Constipation is the most common side effect of opioid use among the elderly (Gonzales et. al., 2015). This not only has serious potential consequences but can also have a significant impact on the person’s quality of life. In fact, over 80% of older adults on opioids for pain report constipation as a side effect (Rogers, Shengelia, & Reid, 2013). Opioids have an adverse effect on the gastrointestinal system including delayed gastric emptying and decreased water in the bowels that can lead to slowing or peristalsis and a decrease urge to defecate (McMillan, Tofthagen, Small, Karver, & Craig, 2013).
Along with opioids, other medications can also induce constipation. In the elderly, in particular, medications include anticholinergic agents, calcium supplements, calcium channel blocker, and non-steroidal anti-inflammatory drugs (Gallegos-Orozco, Foxx-Orenstein, Sterler, & Stoa, 2012). These medications can reduce the 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 (Grossman & Porth, 2014). This can cause large amounts of feces to accumulate in the rectum.Without treatment, a fecal impaction can occur which is a serious complication. A fecal complication is 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, 2016). Distention may also occur along with a fever. Compression 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 (Grossman & Porth,2014). Feculent actions may also result from disease, tumors, neurogenic disorders, chronic use of antacids or bulk laxatives, a low residue diet, medications or prolonged bed rest (Grossman & Porth, 2014). In cases where fecal impaction is suspected, digital examination of the rectum is done to assess for fecal mass. This is typically done by the nurse or physician.
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 to develop regular patterns of elimination.
Lifestyle modifications include increasing fiber content, particularly in the elderly 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 prune juice to the diet. However, this must be done slowly as sudden increases of fiber can cause gas and bloating (Gallegos-Orozco, Foxx, -Orenstein, Sterler, & Stoa, 2012).
Other nonpharmacological interventions include a toileting schedule and biofeedback. Schedule toileting after meals. The patient should sit on the toilet with their feet elevated on a small step to allow for an easier bowel movement. This position will have the patient’s knees higher than the hips, leaning forward with elbows on knees for support (Bardsley, 2015). Allowing adequate time and privacy for bowel evacuation. Biofeedback training is especially helpful for patients who have impaired pelvic floor muscles. The goal is to retrain patients to relax the pelvic floor muscles while at the same time producing a contraction of the abdominal muscles. This should only be done by a trained professional.
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. There are several types of laxatives that can be given and it will depend on the patient’s symptoms, comorbidities, side effects, speed of action, and patient compliance (Bardsley, 2015).
Educating patients on the importance of diet, exercise, and toilet training can vastly improve symptoms and is often a first-time treatment (Gallegos-Orozco, Foxx-Orenstein, Sterler, & Stoa, 2012). 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. Be sure to ask the patient about prescription and nonprescription medications to identify those that cause constipation. Suggest exercise if possible. Range of motion can also be done if the patient is bed-ridden (Grossman & Porth, 2014).
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 in promoting normal 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 and increase the frequency of bowel movements. Adults should get at least 18-30 grams of fiber per day (Bardsley, 2015). 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 take effect. The patient may need laxatives until results of increase fiber are seen (Bardsley, 2015). Furthermore, adequate fluid intake in also important. On average, fluid intake should be about 1.5 to 2 liters a day (Bardsley, 2015). Older adults may not be able to drink this much fluid in a day. Substitute fruit juices if needed and recommended by the nurse or dietician.
Note that if laxatives, stool softeners or enemas are needed, check with the state board to see if a Certified Nursing Assistant can perform the procedure.
Be sure to follow standard precautions and avoid contaminating any services. Always wear personal protective equipment if needed or as stated by the care plan. Observe if the patient is having problems chewing or swallowing as they may need a special puréed diet or a soft diet (Acello & Hegner,2016). Alert the nurse to any changes in eating habits. Be sure to assist with toileting on regular intervals, usually after meals (Acello & Hegner, 2016). 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 is 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 (Acello & Hegner, 2016).
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 in a professional manner. Do not laugh or make fun of the patient. Provide the patient with dignity, comfort and self-esteem at all times.
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 the reason for his distress, he answers that he feels nauseous and that 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 that he normally has a bowel movement twice a day. 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 is able to remove. This gives Mr. Samuels some relief as he is able to pass additional stool on his own within an hour. He was also ordered a laxative for today to help his bowels move. You and the nurse develop a plan of care. What might this plan consist of?
Mr. Samuels will need to be monitored closely throughout the day to make sure the impaction does not reoccur.
Mrs. Jones is a 62-year-old female with a history of Parkinson’s disease. She is currently bedridden but is able to 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 in several days. Upon further questioning, you find that Mrs. Jones is not able to drink large amounts of fluid, and her diet consists mostly of soft foods. You also note that Mrs. Jones is on several medications. When you talk to Mrs. Jones, she is able to tell 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 evacuating all of her bowel movement. She does not complain of pain, bloating or gas. However, she does admit that she is also having trouble urinating. You report these findings to the nurse. You and the nurse, as well as the dietitian, develop a plan of care that involves a diet change. What might you expect will change in Mrs. Jones’ diet plan?
Additional fiber should be added to Mrs. Jones 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 discomfort with gas and bloating. A laxative is also added until the fiber can be increased enough to be effective. Mrs. Jones also 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.
You explain this to Mrs. Jones and to her daughter telling them that the additional fiber and fluid will help Mrs. Jones to evacuate her bowels and make her more comfortable.
You will also need to teach Mrs. Jones daughter how to document her intake of food and fluid as well as her bowel movements. This will help to determine if the plan of care is working.
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