1. Assessment and Management of Constipation
Emily Booth RN BScN MN PHC-NP
NURSE LED OUTREACH TEAM

2. Agenda Definition Types/Classification Causes Anatomy and Physiology
Bowel Assessment
Treatment
Summary/Conclusion

3. What is Constipation?

4. One or more of… Excessive straining with bowel movement
Sense of incomplete emptying with BM
Failed or lengthy attempts to defecate
Hard stools
Decreased stool frequency

5. Prevalence Most common digestive complaint
4.53 million people per year
2.5 million physician visits per year
Twice as common in women than men
2 fold increase in LTC residents

6. Types of Constipation

7. Types of Constipation Primary Causes:
Disorder of neuromuscular function and brain- gut function
Slow 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)

8. Types of Constipation Secondary Causes: other conditions
Dietary – inadequate fluid intake and dietary fibre
Behavioural – decrease physical activity, failure to respond to initial urge to defecate, chronic use of stimulant laxatives
Metabolic – hypercalcemia, hypothyroid
Neurologic – parkinsons, spinal cord lesions, DM
Disease of the colon – strictures, fissures, ca

9. Anatomy and Physiology

10. 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

11. 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 am
Spinal reflex to defecate occurs and the anal sphincter relaxes or contracts with pelvic and abdominal muscle movement

12. Risk Factors for Older Adults

13. Diet low in fibre
Poor or reduces oral fluid intake
Low level of physical activity or immobility
Advanced age
Overuse of laxatives
Endocrine/metabolic disease (diabetes, hypothyroid, hypercalcemia, hypokalemia)
Neurologic disease (stroke, MS, parkinsons)
Disease of the colon (diverticulitis, IBS)
Medications (anticholinergic drugs)

14. Drug Induced Constipation
OPIOIDS Cause Constipation Codeine, morphine, oxycodone, fentanyl patch The Hand that Writes the Narcotic Writes the Cathartic

15. Drug Induced Constipation
Antinauseant
Antiparkinson meds
Alzheimers meds
Iron supplements
Incontinence meds
Antacids
Ulcer meds
Antidepressants
Antipsychotics
Antihypertensives
Lipid lowering drugs

16. Quality of Life Pain, discomfort, bloating Lack of appetite Nausea
Fatigue
Irritability
Change in behaviour
Haemorrhoids, prolapse
Fecal impaction , diarrhea

17. Bowel Assessment
The most essential step is determining the etiology or cause
Usual bowel pattern and measures currently used
Hx of problem
Ability to sense urge to defecate
Daily fluid and fibre intake
Relevant medical/surgical hx
Functional abilities
7 day bowel record
Physical assessment

18. Treatment First line acute Treat underlying cause
Diet and lifestyle measures
Prunes and /or stool softener
If impacted , enema/suppository/disimpaction and stimulant laxative

19. Ongoing Constipation First line Treat underlying cause
Diet/lifestyle measures
Bulk laxative (metamucil/psyllium) or prunes, and/or stool softener
Second line
Osmotic laxative (lactulose, mg containing laxatives)

20. Third line
Diet/lifestyle measures
Osmotic laxative (lactulose, glycerin, PEG or mg containing products – MOM, citromag fleet)
Stimulant laxative (senna, castor oil or dulcolax) if no BM x 3 days

21. 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

22. Pharmacologic Considerations
Meds do have a place in the treatment of constipation
Short term, time limited
Choose laxatives based on resident symptoms and hx
Use homes bowel protocol

23. Summary Focus is on prevention Resident specific interventions
Staff communication ( 7 day bowel record and ongoing monitoring)
In house bowel protocol
Pharmacological interventions

24. The End