Constipation - Impaction; Obstipation
D. Cachero-Salavrakos, RN, BSN
Audrey Klopp, RN, PhD, ET, CS,
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.
- Inadequate fluid intake
- Low-fiber diet
- Inactivity, immobility
- Medication use
- Lack of privacy
- Fear of pain
- Laxative abuse
- Tumor or other obstructing mass
- Neurogenic disorders
- Infrequent passage of stool
- Passage of hard, dry stool
- Straining at stools
- Passage of liquid fecal seepage
- Frequent but nonproductive desire to defecate
- Abdominal distention
- Nausea and vomiting
- Dull headache, restlessness, and depression
- Verbalized pain or fear of pain
- Patient passes soft, formed stool at a frequency perceived as
"normal" by the patient.
- Patient or caregiver verbalizes measures that will prevent
recurrence of constipation.
- (i) independent
- (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
- 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
- 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
- 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
- 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
- (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
- (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
- (i) independent
- (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
- (i) Encourage physical activity and
- Ambulation and/or abdominal exercises strengthen abdominal
muscles that facilitate defecation.
- (i) Encourage a regular time for
- 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
- To strengthen muscles needed for evacuation unless
- (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:
- Warm sitz bath
- Hemorrhoidal preparations
- Which shrink swollen hemorrhoidal tissue.
- (i) For hospitalized patients, the following
should be employed:
- Orient patient to location of bathroom and encourage use,
- A sitting position with knees flexed straightens the
rectum, enhances use of abdominal muscles, and facilitates
- Offer a warmed bedpan to bedridden patients; assist patient to
assume a high Fowler's position with knees flexed.
- This position best uses gravity and allows for
effective Valsalva's maneuver.
- Curtain off the area
- Allow patient time to relax.
Education/Continuity of Care
- (i) independent
- (c) Consult dietitian if appropriate.
- Persons unaccustomed to high-fiber diet may experience
abdominal discomfort and flatulence; a gradual increase in fiber intake is
- (i) Explain or reinforce to patient and
caregiver the importance of the following:
- A balanced diet that contains adequate fiber, fresh fruits,
vegetables, and grains
- Twenty gm/day is recommended.
- Adequate fluid intake
- Eight glasses per day or 2000-3000 ml per day
- Regular meals
- Successful bowel training relies on routine.
- Regular time for evacuation and adequate time for
- Regular exercise/activity
- Privacy for defecation
- (i) Teach patients and caregivers to read
- To determine fiber content per serving.
- (c) Teach use of pharmacological agents as
ordered, as in the following:
- Bulk fiber (Metamucil and similar fiber products)
- These increase fluid, gaseous, and solid bulk of
- Stool softeners (e.g., Colace)
- These soften stool and lubricate intestinal
- Chemical irritants (e.g., castor oil, cascara, Milk of
- These irritate the bowel mucosa and cause rapid
propulsion of contents of small intestines.
- These aid in softening stools and stimulate rectal
mucosa; best results occur when given 30 min before usual defecation time or
- Oil retention enema
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