NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Bowel Elimination
* Medication Response
* Self-Care Toileting
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Constipation/Impaction Management
* Bowel Training
* Teaching: Prescribed Medication
NANDA Definition: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool
Constipation is a common, yet complex problem; it is especially prevalent among elderly patients. 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 elderly patients 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.
* Defining Characteristics: 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
* Related Factors: 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
* Expected Outcomes 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.
* 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.
* 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.
* 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.
* 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.
* Assess activity level. Prolonged bed rest, lack of exercise, and inactivity contribute to constipation.
* Evaluate current medication usage that 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.
* Assess privacy for elimination (e.g., 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.
* Evaluate fear of pain. Hemorrhoids, anal fissures, or other anorectal disorders that are painful can cause ignoring the urge to defecate, which over time results in a dilated rectum that no longer responds to the presence of stool.
* 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.
* Assess for history of neurogenic diseases, such as multiple sclerosis or Parkinson’s disease. Neurogenic disorders may alter the colon’s ability to perform peristalsis.
* Encourage daily fluid intake of 2000 to 3000 ml/day, if not contraindicated medically. Patients, especially elderly patients, may have cardiovascular limitations, which require that less fluid is taken.
* Encourage increased fiber in diet (e.g., raw fruits, fresh vegetables); a minimum of 20 g 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.
* Encourage patient to consume prunes, prune juice, cold cereal, and bean products. These are "natural" cathartics because of their high-fiber content.
* Encourage physical activity and regular exercise. Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitate defecation.
* Encourage a regular time for elimination. Many persons defecate following first daily meal or coffee, as a result of the gastrocolic reflex; depending on the person’s usual schedule, any time, as long as it is regular, is fine.
* Encourage isometric abdominal and gluteal exercises. Exercises, unless contraindicated, strengthen muscles needed for evacuation.
* Digitally remove fecal impaction. Stool that remains in the rectum for long periods becomes dry and hard; debilitated patients, especially elderly patients, may not be able to pass these stools without manual assistance.
* Suggest the following measures to minimize rectal discomfort:
o Warm sitz bath
o Hemorrhoidal preparations These shrink swollen hemorrhoidal tissue.
* For hospitalized patients, the following should be employed:
o Orient patient to location of bathroom and encourage use, unless contraindicated. A sitting position with knees flexed straightens the rectum, enhances use of abdominal muscles, and facilitates defecation.
o 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 maneuver.
o Curtain off the area. This provides privacy.
o Allow patient time to relax.
Education/Continuity of Care
* Consult dietitian if appropriate. Persons unaccustomed to a high-fiber diet may experience abdominal discomfort and flatulence; a gradual increase in fiber intake is recommended.
* Explain or reinforce to patient and caregiver the importance of the following:
o A balanced diet that contains adequate fiber, fresh fruits, vegetables, and grains Twenty grams per day is recommended.
o Adequate fluid intake Drink 8 glasses/day or 2000 to 3000 ml/day.
o Regular meals Successful bowel training relies on routine.
o Regular time for evacuation and adequate time for defecation
o Regular exercise/activity
o Privacy for defecation
* Teach patients and caregivers to read product labels. It is important for patients and caregivers to determine the fiber content per serving.
* Teach use of pharmacological agents as ordered, as in the following:
o Bulk fiber (Metamucil and similar fiber products) These increase fluid, gaseous, and solid bulk of intestinal contents.
o Stool softeners (e.g., Colace) These soften stool and lubricate intestinal mucosa.
o Chemical irritants (e.g., castor oil, cascara, Milk of Magnesia) These irritate the bowel mucosa and cause rapid propulsion of contents of small intestines.
o Suppositories These aid in softening stools and stimulate rectal mucosa; best results occur when given 30 minutes before usual defecation time or after breakfast.
o Oil retention enema This softens stool.