The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [195]
The management of constipation depends on the cause and there are numerous possible causes, with many patients being affected by more than one causative factor (Figure 6.12). While constipation is not life-threatening, it does cause a great deal of distress and discomfort. Particularly, constipation can be associated with abdominal pain or cramps, feelings of general malaise or fatigue and feelings of bloatedness. Nausea, anorexia, headaches, confusion, restlessness, retention of urine, faecal incontinence and halitosis may also be present in some cases (Maestri-Banks 1998, Norton 1996b).
Figure 6.12 Classification of constipation: combined sources.
The effective treatment of constipation relies on the cause being identified by thorough assessment. Constipation can be categorized as primary, secondary or iatrogenic (Perdue 2005). Factors that lead to the development of primary constipation are extrinsic or lifestyle related and include:
an inadequate diet (low fibre)
poor fluid intake
a lifestyle change
ignoring the urge to defaecate (see Figure 6.13).
Figure 6.13 Correct positioning for opening your bowel.
Reproduced by kind permission of Ray Addison and Wendy Ness.
© Norgine Ltd.
Constipation that is attributed to an intrinsic disease process or conditions such as anal fissures, colonic tumours or hypercalcaemia is classified as secondary constipation, whereas iatrogenic constipation generally results from treatment or medication (Perdue 2005). Constipation of unknown cause must be investigated in order to ensure that appropriate treatment is instigated (Taylor 1997, Teahon 1999).
Preprocedural considerations
Assessment
Undertaking a detailed history from the patient is pivotal in establishing the appropriate treatment plan. At present, there is no comprehensive assessment tool that has been validated. It is of vital importance that nurses adopt a proactive preventive approach to the assessment and management of constipation. Kyle et al. 2005 have developed the Eton Scale, a constipation risk assessment tool.
There are a variety of factors that may affect normal bowel functioning which should be considered within an assessment, including:
nutritional intake/recent changes in diet
fluid intake
mobility, for example lack of exercise
medication, for example analgesics, antacids, iron supplements, tricyclic antidepressants
lack of privacy, for example having to use shared toilet facilities, commodes or bedpans
medical conditions, including disease process or symptoms, for example cancer, vomiting
radiological investigations of the bowel involving the use of barium
change in patient’s normal routine/lifestyle/home circumstances
change in psychological status, for example depression.
In addition to the identification of these risks/contributing factors, it is important to take a careful history of a patient’s bowel habits, taking particular note of the following.
Any changes in the patient’s usual bowel activity. How long have these changes been present and have they occurred before?
Frequency of bowel action.
Volume, consistency and colour of the stool. Stools can be graded using a scale such as the Bristol Stool Form Chart (see Figure 6.1) where constipation would be classified as types 1 or 2 (Longstreth et al. 2006).
Presence of mucus, blood, undigested food or offensive odour.
Presence of pain or discomfort on defaecation.
Use of oral or rectal medication to stimulate defaecation and its effectiveness.
A digital rectal examination (DRE) can also be performed, providing the nurse has received suitable training or instruction, to assess the contents of the rectum and to identify conditions which may cause discomfort such as haemorrhoids or anal fissures (Hinrichs and Huseboe 2001, Peate 2003, RCN 2006, Winney 1998).
Additional investigations such as an abdominal X-ray may be necessary to exclude bowel obstruction (Christer et al. 2003, Edwards