Conquering Constipation By Rachel Hill RN MSN LPN

Conquering Constipation By Rachel Hill, RN, MSN LPN 2007, July/August 2007 2. 0 ANCC/AACN contact hours Online: www. nursingcenter. com © 2007 by Lippincott Williams & Wilkins. All world rights reserved.

Constipation Statistics n estimated prevalence from 2% to 28% n incidence increases with age n as high as 20% in older adults

Constipation Defined n infrequent or irregular defecation (less than three times/week) n hardened stool that’s difficult to pass n decreased stool volume or stool retention n feeling of incomplete bowel evacuation

Constipation Defined n colon absorbs too much water n colon’s muscle contractions become sluggish n causes stool pass too slowly

“Primary” Constipation Caused by problems that affect the bowels n immobility ■ overuse of laxatives n low-fiber diet ■ ignoring urge to defecate n inadequate fluid intake ■ changes in routine n lack of regular exercise ■ stress n pregnancy

“Primary” Constipation May be caused by medications n opioids ■ antidepressants n tranquilizers ■ antihypertensives n anticholinergics ■ antacids with aluminum

“Secondary” Constipation Caused by rectal or anal disorders n hemorrhoids or fissures n bowel obstruction n metabolic, neurologic, or neuromuscular diseases (diabetes, Parkinson's, MS)

“Secondary” Constipation n endocrine disorders (hypothyroidism) n connective tissue disorders (lupus) n colon disease (irritable bowel sydrome, diverticulitis)

Constipation in Older Adults age 65 and older present more frequently because: n Loose-fitting dentures or loss of teeth makes chewing difficult, leading the patient to choose soft, processed foods that are low in fiber. n Convenience foods, also low in fiber, are used by those who’ve lost interest in or have difficulty with eating.

Constipation in Older Adults n Some older patients reduce fluid intake if not eating regular meals, don’t have the ability to get their own drinks, or fear frequent bathroom trips. n Lack of exercise and prolonged bed rest decrease abdominal muscle tone, anal sphincter tone, intestinal motility. n Nerve impulses decrease with age, decreasing sensation of urge to defecate.

Chronic Constipation n Regularly ignoring the urge to go. n Rectal mucous membranes and muscles become insensitive to presence of fecal mass. n Stool is retained, colon becomes irritated, can cause abdominal pain.

Signs & Symptoms of Constipation Two or more of the following over more than three months = constipation n abdominal distention, bloating, or pain n gurgling, rumbling bowel sounds n indigestion n nausea and vomiting

Signs & Symptoms of Constipation n decreased appetite n headache n fatigue n sensation of incomplete evacuation at least 25% of the time

Signs & Symptoms of Constipation n sensation of fullness at least 25% of the time n need to strain during a bowel movement at least 25% of the time n elimination of small, hard, dry stool at least 20% of the time

Complications of Constipation n hemorrhoids n fecal impaction n bowel obstruction n bowel perforation n electrolyte imbalances

Complications of Constipation n chronic constipation linked with increased incidence of colon and rectal cancer n straining results in Valsalva maneuver, increases systemic blood pressure

Assessing Constipation n Obtain detailed health history. n Ask about exercise and activity level, normal fluid intake, diet. n Ask about normal bowel routine.

Diagnostic Tests n digital rectal exam n abdominal X-ray n stool for occult blood n sigmoidoscopy n bowel transit study n barium enema

Treatment n increasing fiber and fluid intake n bowel habit training n possible short-term laxative use

Laxatives to Manage Constipation Psyllium (Metamucil) n Classification: Bulk-forming. n Action: Polysaccharides and cellulose derivatives mix with intestinal fluids, swell, and stimulate peristalsis. n Patient Education: Take with 8 oz. water; follow with 8 oz. water. Don’t take dry. Report abdominal distension or unusual amount of gas.

Laxatives to Manage Constipation Magnesium hydroxide (milk of magnesia) n Classification: Saline agent n Action: Nonabsorbable magnesium ions alter stool consistency by drawing water into intestines by osmosis; peristalsis is stimulated. Action occurs within 2 hours. n Patient Education: Liquid more effective than tablet. Only short-term use recommended due to toxicity. Should not be taken by patients with renal insufficiency.

Laxatives to Manage Constipation Mineral oil n Classification: Lubricant n Action: Nonabsorbable hydrocarbons soften fecal matter by lubricating intestinal mucosa. Action occurs within 6 to 8 hours. n Patient Education: Don’t take with meals; can impair absorption of fat-soluble vitamins, delay gastric emptying. Swallow carefully.

Laxatives to Manage Constipation Bisacodyl (Dulcolax) n Classification: Stimulant n Action: Irritates colon epithelium by stimulating sensory nerve endings, increasing mucosal secretions. Action occurs within 6 to 8 hours. n Patient Education: Catharsis may cause fluid and electrolyte imbalance, especially in elderly. Swallow tablets; do not crush or chew. Avoid milk or antacids within 1 hour; enteric coating may dissolve prematurely.

Laxatives to Manage Constipation Docusate sodium (Colace) n Classification: Fecal softener n Action: Hydrates stool by surfactant action on colonic epithelium; aqueous and fatty substances are mixed. Doesn’t exert laxative action. n Patient Education: Can be used safely by patients who should avoid straining.

Laxatives to Manage Constipation Polyethylene glycol and electrolytes (Colyte) n Classification: Osmotic n Action: Rapidly cleanses colon; induces diarrhea. n Patient Education: Large volume product, takes time to consume safely. Can cause considerable nausea, bloating.

Adverse Effects of Laxatives n nausea and vomiting n electrolyte imbalances n abdominal cramps n dizziness n weakness n confusion n diarrhea n sweating

Risks of Chronic Laxative Use in Older Adults n increased constipation n lower albumin levels n diarrhea n n elevated magnesium poor response to bowel preparation for barium enema n elevated phosphate n increased risk of fecal impaction