Emi ly Booth RN BScN MN PHC-NPNURSE LED OUTREACH TEAM

Assessment and Management of

Constipation

Agenda

DefinitionTypes/ClassificationCausesAnatomy and PhysiologyBowel AssessmentTreatmentSummary/Conclusion

What is Constipation?

One or more of…

Excessive straining with bowel movementSense of incomplete emptying with BMFailed or lengthy attempts to defecateHard stoolsDecreased stool frequency

Prevalence

Most common digestive complaint4.53 million people per year2.5 million physician visits per yearTwice as common in women than men2 fold increase in LTC residents

Types of Constipation

Types of Constipation

Primary Causes:Disorder of neuromuscular function and

brain- gut functionSlow transit time (decreased propulsion of

stool)Evacuation disorders (incoordination of

contractions or inadequate relaxation of pelvic floor muscles during defecation)

IBS (genetic, environmental, social, biological, psych factors)

Types of Constipation

Secondary Causes: other conditionsDietary – inadequate fluid intake and

dietary fibreBehavioural – decrease physical activity,

failure to respond to initial urge to defecate, chronic use of stimulant laxatives

Metabolic – hypercalcemia, hypothyroidNeurologic – parkinsons, spinal cord

lesions, DMDisease of the colon – strictures, fissures, ca

Anatomy and Physiology

Anatomy and Physiology

Colon – divided into ascending colon ( from cecum to edge of liver border), goes across the abdomen under the stomach called the transverse colon and then descends down the left side of the abdomen (descending colon)and leads into the sigmoid colon and rectum

Ascending and transverse colon absorb H2O and electrolytes

Descending and sigmoid colon stores fecal matter until eliminated

Smooth muscle of colon contracts and relaxes in response to distension and mixing movements occur

Contents of colon enter the rectum usually q amSpinal reflex to defecate occurs and the anal

sphincter relaxes or contracts with pelvic and abdominal muscle movement

Risk Factors for Older Adults

Diet low in fibrePoor or reduces oral fluid intakeLow level of physical activity or immobilityAdvanced ageOveruse of laxativesEndocrine/metabolic disease (diabetes,

hypothyroid, hypercalcemia, hypokalemia)Neurologic disease (stroke, MS, parkinsons)Disease of the colon (diverticulitis, IBS)Medications (anticholinergic drugs)

Drug Induced Constipation

OPIOIDS Cause ConstipationCodeine, morphine, oxycodone, fentanyl patch

The Hand that Writes the Narcotic Writes the Cathartic

Drug Induced Constipation

Antinauseant Antiparkinson meds Alzheimers meds Iron supplements Incontinence meds Antacids Ulcer meds Antidepressants Antipsychotics Antihypertensives Lipid lowering drugs

Quality of Life

Pain, discomfort, bloatingLack of appetiteNauseaFatigueIrritabilityChange in behaviourHaemorrhoids, prolapseFecal impaction , diarrhea

Bowel Assessment

The most essential step is determining the etiology or cause Usual bowel pattern and measures currently usedHx of problemAbility to sense urge to defecateDaily fluid and fibre intakeRelevant medical/surgical hxFunctional abilities7 day bowel recordPhysical assessment

Treatment

First line acuteTreat underlying causeDiet and lifestyle measuresPrunes and /or stool softenerIf impacted , enema/suppository/disimpaction

and stimulant laxative

Ongoing Constipation

First lineTreat underlying causeDiet/lifestyle measuresBulk laxative (metamucil/psyllium) or prunes,

and/or stool softenerSecond lineDiet/lifestyle measuresOsmotic laxative (lactulose, mg containing

laxatives)

Third lineDiet/lifestyle measuresOsmotic laxative (lactulose, glycerin, PEG or mg containing products – MOM, citromag fleet)Stimulant laxative (senna, castor oil or dulcolax) if no BM x 3 days

Laxatives

Caution with bulk forming laxatives in elderly , may cause obstruction

Stool softeners are not to be used alone for constipation. Little value for chronic constipation. Help with pain and straining with defecating

Pharmacologic Considerations

Meds do have a place in the treatment of constipation

Short term, time limitedChoose laxatives based on resident symptoms

and hxUse homes bowel protocol

Summary

Focus is on preventionResident specific interventionsStaff communication ( 7 day bowel record

and ongoing monitoring)In house bowel protocolPharmacological interventions

The End