Constipation

Difficulty in passing stools or an incomplete emptying of the rectum

Causes

Simple constipation - No underlying pathology

Low residue diet Dehydration

Environment, (type and availability of toilet) Incomplete emptying or delayed defaecation

Factors include, poverty, education, dentition, lack of exercise,

Motility disorders

Increased transit time, (normal 3-7 days). Idiopathic slow transit time can lead to megacolon. Older people have slower transit times (up to 8 - 15 days). Often the lower colon is never completely emptied causing terminal distension.

Irritable bowel syndrome Idiopathic megacolon

Increasing age, ("terminal reservoir syndrome")

Remember reduced frequency of defaecation can be normal with increasing age and does not usually require "medical" treatment

Psychiatric disorder

Depression Confusion Anorexia nervosa

Remember in the elderly constipation may cause confusion, (ie differentiate between cause and effect)

Local pathology

Anal fistula Prolapse Haemorrhoids Any painful condition may inhibit defaecation

Diverticulitis Hirschsprung's disease, (aganglionic congenital megacolon)

Systemic pathology

Endocrine disorders, (diabetes autonomic neuropathy and hypothyroid) Carcinoma

Iatrogenic

Drug induced Immobility Nursing management, (eg use of bed pans) Laxative abuse

Drugs include, analgesics, (especially opiate), codeine, anticholinergics and anti-Parkinsonian.

Nursing observations

Frequency Volume Change Unduly offensive smell Blood, (frank, fresh, altered, occult) Pus Pain Straining History of laxative use/abuse

Urgency Diet Incontinence PR Peri-anal problems

Preoccupation Anxiety Hypochondriasis

Assessment

Natural variation Regular daily bowel action is desirable 3 times per day to 3 times per week Therefore establish the normal for the individual Consider changes to factors necessary to the maintance of the normal rhythm.

Factors effecting variation

Diet Exercise Fluid intake Normal pattern Anxiety Depression

Record normal pattern and frequency

Nature of the faeces, soft? well formed? associated pain or discomfort?

Does the faeces indicate diarrhoea which may be caused by constipation?

How long has there been a problem?

When were the bowels last opened?

Are the bowels normally stimulated by a particular event, eg. gastrocolonic reflex?

Are laxatives taken, any other drugs which may effect GI function taken, eg.

What is the normal fluid intake?

What is the nature of the diet? eg. re. non water soluble fibre

Rectal digital examination may be indicated

Possible radiological examination

Presence of abnormal components, eg blood, mucous. Blood in the faeces may indicate underlying pathology.

Faecal odour, check for changes, particularly offensive stools may indicate mal absorption.

Is there a need to defecate, how much notice do they have, does passing a motion leave the desire to pass more or a feeling of continued fullness.

What is the mental state of the individual.

Your key decision is,

a. to educate and treat yourself.

b. to refer for medical opinion

Factors discovered in your assessment which merit a medical opinion are,

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Specific Treatments

Management clearly depends on the cause,

Enemas, suppositories, access to toilet, manual evacuation, medication drugs, surgery.

Diet

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Overflow

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Constipation

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Acute diarrhoea

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Chronic diarrhoea

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Psychological management

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Social management, (including relationships)

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Laxatives

Bulking agents

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Stool softeners

* liquid paraffin

* Castor oil

Irritant/chemical

* Senna

* Bisacodyl

Combined softener/irritant

* Dorbanex (carcinogenic)

Others

* Lactulose

Per Rectum

* Glycerine, bisacodyl suppositories

* Phosphate, microenemas