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Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Constipation - Impaction; Obstipation
Marian D. Cachero-Salavrakos, RN, BSN
Audrey Klopp, RN, PhD, ET, CS, NHA

NANDA: The state in which an individual experiences a change in normal bowel habits characterized by a decrease in frequency and/or passage of hard, dry stools

Constipation is a common, yet complex problem; it is especially prevalent among the elderly. Constipation often accompanies pregnancy. Diet, exercise, and daily routine are important factors in maintaining normal bowel patterns. Too little fluid, too little fiber, inactivity or immobility, and disruption in daily routines can result in constipation. Use of medications, particularly narcotic analgesics or overuse of laxatives, can cause constipation. Overuse of enemas can cause constipation, as can ignoring the need to defecate. Psychological disorders such as stress and depression can cause constipation. Because privacy is an issue for most, being away from home, hospitalized, or otherwise being deprived of adequate privacy can result in constipation. Because "normal" patterns of bowel elimination vary so widely from individual to individual, some people believe they are constipated if a day passes without a bowel movement; for others, every third or fourth day is normal. Chronic constipation can result in the development of hemorrhoids; diverticulosis (particularly in the elderly who have a high incidence of diverticulitis); straining at stool, which can cause sudden death; and although rare, perforation of the colon. Constipation is usually episodic, although it can become a lifelong, chronic problem. Because tumors of the colon and rectum can result in obstipation (complete lack of passage of stool), it is important to rule out these possibilities. Dietary management (increasing fluid and fiber) remains the most effective treatment for constipation.

Related Factors

Defining Characteristics

Expected Outcomes

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Assess usual pattern of elimination; compare with present pattern. Include size, frequency, color, and quality.
"Normal" frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is "normal" for each individual.
(i) Evaluate laxative use, type, and frequency.
Chronic use of laxatives causes the muscles and nerves of the colon to function inadequately in producing an urge to defecate. Over time, the colon becomes atonic and distended.
(i) Evaluate reliance on enemas for elimination.
Abuse or overuse of cathartics and enemas can result in dependence on them for evacuation, because the colon becomes distended and does not respond normally to the presence of stool.
(i) Evaluate usual dietary habits, eating habits, eating schedule, and liquid intake.
Change in mealtime, type of food, disruption of usual schedule, and anxiety can lead to constipation.
(i) Assess activity level.
Prolonged bed rest, lack of exercise and inactivity contribute to constipation.
(i) Evaluate current medication usage,
Which may contribute to constipation. Drugs that can cause constipation include the following: narcotics, antacids with calcium or aluminum base, antidepressants, anticholinergics, antihypertensives, and iron and calcium supplements.
(i) Assess privacy for elimination (i.e., use of bedpan, access to bathroom facilities with privacy during work hours).
Many individuals report that being away from home limits their ability to have a bowel movement. Those who travel or require hospitalization may have difficulty having a bowel movement away from home.
(i) Evaluate fear of pain.
Hemorrhoids, anal fissures, or other anorectal disorders that are painful can cause ignoring the urge to defecate, which results over time in a dilated rectum that no longer responds to the presence of stool.
(i) Assess degree to which patient's procrastination contributes to constipation.
Ignoring the defecation urge eventually leads to chronic constipation, because the rectum no longer senses, or responds to, the presence of stool. The longer the stool remains in the rectum, the drier and harder (and more difficult to pass) it becomes.
(i) Assess for history of neurogenic diseases, such as multiple sclerosis, Parkinson's disease.
Neurogenic disorders may alter the colon's ability to perform peristalsis.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Encourage daily fluid intake of 2000 to 3000 ml per day, if not contraindicated medically.
Patients, especially the elderly, may have cardiovascular limitations, which require that less fluid is taken.
(i) Encourage increased fiber in diet (e.g., raw fruits, fresh vegetables); a minimum of 20 gm of dietary fiber per day is recommended.
Fiber passes through the intestine essentially unchanged. When it reaches the colon, it absorbs water and forms a gel, which adds bulk to the stool, and makes defecation easier.
(i) Encourage patient to consume prunes, prune juice, cold cereal, and bean products.
These are "natural" cathartics because of their high-fiber content.
(i) Encourage physical activity and regular exercise.
Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitate defecation.
(i) Encourage a regular time for elimination.
Many persons defecate following first meal or coffee, as a result of the gastro-colic reflex; depending on the person's usual schedule, any time as long as it is regular, is fine.
(i) Encourage isometric abdominal and gluteal exercises
To strengthen muscles needed for evacuation unless contraindicated.
(i) Digitally remove fecal impaction.
Stool that remains in the rectum for long periods becomes dry and hard; debilitated patients, especially the elderly, may not be able to pass these stools without manual assistance.
(i) Suggest the following measures to minimize rectal discomfort:
(i) For hospitalized patients, the following should be employed:

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(c) Consult dietitian if appropriate.
Persons unaccustomed to high-fiber diet may experience abdominal discomfort and flatulence; a gradual increase in fiber intake is recommended.
(i) Explain or reinforce to patient and caregiver the importance of the following:
(i) Teach patients and caregivers to read product labels
To determine fiber content per serving.
(c) Teach use of pharmacological agents as ordered, as in the following:

NIC

Constipation/Impaction Management; Bowel Training; Teaching: Prescribed Medication

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