Nursing Manual

Fatal Four Topic: Constipation

1. Neuromuscular degenerative disorders that impair the central nervous system (CNS) responses needed for elimination.
2. Spinal cord injuries or birth defects such as spina bifida that affect the CNS responses needed for elimination.
3. Hypotonia in individuals with syndromes such as Down syndrome, Prader-Willi and cerebral palsy; may lack muscular strength and tone needed for adequate bowel function.
4. Diet textures that contain little fiber and roughage.
5. Dysphagia or aspiration problems that make it difficult to consume adequate amounts of fluid and fiber.
6. Inadequate or inconvenient access to and privacy in the bathroom.
7. Immobility and contractures which may slow the natural digestive process.
8. Immobility and contractures may not allow for physiologic positioning for bowel elimination.
9. Medications that slow down gastric motility time or draw too much fluid from the GI tract.
10. Hemorrhoids or other conditions that make bowel elimination painful.
11. Repression of the urge to defecate.
12. Poor toileting habits and routines or lack of privacy and time for toileting.
13. History of bowel stimulants leading to decreased bowel reactivity.

Nursing assessment

• Physician has written the diagnosis.
• Hospitalization or outpatient treatment for constipation, obstipation or impaction.
• Person takes medication that has anticholenergic side effects, affects the body's hydration status, or has constipating side effects.
• Person has a diet that has an altered texture, low in fiber and/or fluids.
• Person has a constipation protocol.
• Person has increased dietary fiber (prunes, bran, psyllium, etc.).
• Staff documentation indicates that the person is having hard B.M.s or B.M.s more than 2-3 days apart.
• Staff documents indicate that the person complains of stomach discomfort, straining with elimination or abdominal distention, frequent trips to bathroom, or rectal digging.
• Person has a routine order for bowel medications and/or treatments.
• Increased usage of P.R.N. bowel medications.
• Decrease or discontinuance of routine bowel medication.

• Bloating, distention
• Pain with palpatation
• Absence or presence of bowel sounds and tones
• Flatulence
• Quality of stool, color, consistency, frequency
• Diarrhea or liquid stool
• Anorexia or change in food or fluid intake
• Vomiting or nausea
• Fecal odor on breath

• Malaise, lethargy
• Change in verbalization
• Change in routine

• Hydration status
• Anal irritation (scratching, digging)
• Rectal hemorrhoids (straining with stool)

• Privacy and availability of bathroom
• Scheduled time of availability for access to the bathroom

• Is based on a professional assessment of the individuals health care:
  • Problems
  • Support needs
  • Identifies
  • Measurable and appropriate goals
  • Specific interventions
  • By whom and how frequently the data will be monitored
• Refers to an individualized constipation protocol that contains:
  • The individuals bowel/toileting routine
  • If, when, how, where B.M.s recorded
  • Prevention strategies
  • Signs and symptoms of constipation
  • Interventions specific to the individual
  • Remind the staff to call 911 if they believe the individual appears gravely ill or they are concerned about their immediate health and safety.

• No increase in use of bowel medications to maintain regularity.
• Individual eliminates without straining or discomfort.
• Decrease use of enema, laxatives or suppositories.
• Elimination patterns remain baseline.
• Individual consumes a varied diet adequate in fiber and fluid.

• Dietician Consultation: regarding amount and type of food, texture and fiber content, and fluid requirements.
• Individualized constipation protocol.
• Physical activity or exercise to increase muscle strength and facilitate gastric functioning.
• Positioning schedule for non-mobile individuals to facilitate normal physiologic functioning throughout the day with considerations for positions as upright as possible.
• Physical therapy consultation to look at positioning schedules and equipment to promote the digestive and elimination process.
• Pharmacy or medication analysis for potential medications contributing to constipation.
• Establish toileting routines and schedule in conjunction with normal physiologic processes of elimination, for example:
  1. Responding to urge to defecate
  2. Hot drink on an empty stomach
  3. Instructions to take deep slow breaths to increase intra-abdominal pressure during toileting
  4. Small step stool while person sits on commode to raise position of legs to increase intra-abdominal pressure
• Implement other nursing actions, abdominal massage, rectal check (if indicated), digital stimulation (if prescribed by physician).
• Administer or train staff in giving routine prescribed medications or P.R.N. bowel meds and or treatments.
• Implement training programs or develop methods so the person can perform tasks themselves around monitoring or implementation of interventions.
• Report observations and/or data to the physician as needed.

• Analysis and review of above interventions on appropriate data collection sheets used by RN or staff
• Review the person's and staff's training needs.
• Review as needed and continue to monitor person's responses.