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Nursing Diagnosis: Constipation Application of NANDA, NOC, NIC


Nursing Diagnosis: Constipation
Betty J. Ackley and Kathie D. Hesnan

NANDA Definition: A decrease in a person's normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool

Defining Characteristics: Change in bowel pattern; bright red blood with stool; presence of soft paste-like stool in rectum; distended abdomen; dark, black, or tarry stool; increased abdominal pressure; percussed abdominal dullness; pain with defecation; decreased volume of stool; straining with defecation; decreased frequency; dry, hard, formed stool; palpable rectal mass; feeling of rectal fullness or pressure; abdominal pain; unable to pass stool; anorexia; headache; change in abdominal growing (borborygmi); indigestion; atypical presentation in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature); severe flatus; generalized fatigue; hypoactive or hyperactive bowel sounds; palpable abdominal mass; abdominal tenderness with or without palpable muscle resistance; nausea and/or vomiting; oozing liquid stool

Related Factors:
Functional
Recent environmental changes; habitual denial/ignoring of urge to defecate; insufficient physical activity; irregular defecation habits; inadequate toileting (e.g., timeliness, positioning for defecation, privacy); abdominal muscle weakness
Psychological
Depression; emotional stress; mental confusion
Pharmacological
Antilipemic agents; laxative overdose; calcium carbonate; aluminum-containing antacids; nonsteroidal antiinflammatory agents; opiates; anticholinergics; diuretics; iron salts; phenothiazides; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers
Mechanical
Rectal abscess or ulcer; pregnancy; rectal anal fissures; tumors; megacolon (Hirschsprung's disease); electrolyte imbalance; rectal prolapse; prostate enlargement; neurological impairment; rectal anal stricture; rectocele; postsurgical obstruction; hemorrhoids; obesity
Physiological
Poor eating habits; decreased motility of gastrointestinal tract; inadequate dentition or oral hygiene; insufficient fiber intake; insufficient fluid intake; change in usual foods and eating patterns; dehydration

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
·         Bowel Elimination
·         Hydration
Client Outcomes
·         Maintains passage of soft, formed stool every 1 to 3 days without straining
·         States relief from discomfort of constipation
·         Identifies measures that prevent or treat constipation
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Constipation/Impaction Management
Nursing Interventions and Rationales
·         Observe usual pattern of defecation including time of day, amount and frequency of stool, consistency of stool, history of bowel habits or laxative use; diet including fluid intake; exercise patterns; personal remedies for constipation; obstetrical/gynecological history; surgeries; alterations in perianal sensation; present bowel regimen. There often are multiple reasons for constipation; the first step is assessment of usual patterns of bowel elimination.
·         Have the client or family keep a diary of bowel habits including time of day; usual stimulus; consistency, amount, and frequency of stool; fluid consumption; and use of any aids to defecation. A diary of bowel habits is valuable in treatment of constipation (Wong, Kadakia, 1999).
·         Review client's current medications. Many medications affect normal bowel function, including opiates, antidepressants, antihypertensives, anticholinergics, diuretics, anticonvulsants, antacids containing aluminum, iron supplements, and muscle relaxants (Wong, Kadakia, 1999).
·         Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds. In clients with constipation the abdomen is often distended with a palpable colon (Held, 1995).
·         Check for impaction; perform digital removal per physician's order. If impaction is present, use cleansing regimen until you obtain a very soft stool. If using an enema, the client must be able to bodily retain the fluid. If the client has poor sphincter tone, use a cone tip–irrigating bag to assist the client in retaining the fluids. This also decreases the amount of fluid necessary for cleansing.
·         Provide privacy for defecation. Assist the client to the bathroom and close the door if possible. Bowel elimination is a very private act, and a lack of privacy can contribute to constipation (Weeks, Hubbartt, Michaels, 2000).
·         Encourage fiber intake of 25 g/day for adults. Emphasize foods such as fresh fruits, beans, vegetables, and bran cereals. Add fiber     to diet gradually. Fiber helps prevent constipation by giving stool bulk. Add fiber to diet gradually because a sudden increase can cause bloating, gas, and diarrhea (Doughty, 1996). A daily fiber intake of 25 g can increase frequency of stools in clients with constipation (Anti, 1998). Dietary supplements of fiber in the form of bran or wheat fiber are helpful for women experiencing constipation with pregnancy (Jewell, Young, 2000).
·         Encourage a fluid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day). If oral intake is low, gradually increase fluid intake. Fluid intake must be within the cardiac and renal reserve. Adequate fluid intake is necessary to prevent hard, dry stools. Increasing fluid intake to 1.5 to 2 L/day along with fiber intake of 25 g can significantly increase frequency of stools in clients with constipation (Anti, 1998; Weeks, Hubbartt, Michaels, 2000).
·         Encourage client to be out of bed as soon as possible, and to own activities of daily living (ADLs) as able. Encourage exercises such as turning and changing positions in bed, lifting their hips off the bed, doing range of motion exercises, alternating lifting each knee to the chest, doing wheelchair lifts, doing waist twists, stretching arms away from body, and pulling in the abdomen while taking deep breaths. Activity, even minimal, increases peristalsis, which is necessary to prevent constipation (Yakabowich, 1990; Weeks, Hubbartt, Michaels, 2000).
·         At each meal, sprinkle bran over client's food as allowed by client and prescribed diet. Ensure that client receives adequate fluid (1500 ml/day) along with bran. The number of bowel movements is increased and the use of laxatives is decreased in a client who eats wheat bran (Schmelzer, 1990; Wong, Kadakia, 1999). A study done on institutionalized elderly male clients with chronic constipation demonstrated that with bran use, clients were able to discontinue use of oral laxatives (Howard, West, Ossip- Klein, 2000).
·         If sprinkling bran over the food is not effective, try this mixture: 1 cup Kellogg's All Bran cereal, 1 cup applesauce, 1 cup prune juice. Mix together, and give 2 tablespoons per day. Keep refrigerated. Always check with the primary care practitioner before initiating this intervention. It is important that the client also have sufficient fluids.
This mixture has been shown to be effective even with short-term use in elderly clients recovering from acute conditions. NOTE: Giving fiber without sufficient fluid has resulted in impaction/bowel obstruction (Gibson et al, 1995). A number of bran mixtures have been shown to effectively decrease constipation (Beverley, Travis, 1992; Gibson et al, 1995), including a mixture called power pudding (Neal, 1995).
·         Initiate a regular schedule for defecation, using the client's normal evacuation time whenever possible. Offer hot coffee, hot lemon water, or prune juice before breakfast, or while sitting on the toilet if necessary. An optimal time for many individuals is 30 minutes after breakfast because of the gastrocolic reflex. A schedule gives the client a sense of control, but more importantly it promotes evacuation before drying of stool and constipation occur (Doughty, 1992). Hot liquids can stimulate peristasis and result in defecation (Weeks, Hubbartt, Michaels, 2000).
·         Emphasize to the client the necessary ingredients for a normal bowel regimen (e.g., fluid, fiber, activity, and regular schedule for defecation). Help client onto bedside commode or toilet with client's hips flexed and feet flat. Have client deep breathe through mouth to encourage relaxation of the pelvic floor muscle and use the abdominal muscles to help evacuation.
·         Provide laxatives, suppositories, and enemas as needed and as ordered only; establish a client goal of eliminating their use. Avoid soapsuds enemas, or use a low concentration of castile soap only. Use of laxatives should be avoided (Schaefer, Cheskin, 1998). Soapsuds enemas can cause damage to the colonic mucosa (Schmelzer, Wright, 1993). The use of a soapsuds enema was shown to increase stool output as compared with tap water enemas in preoperative liver transplant patients; amount of mucosal irritation was unknown (Schmelzer et al, 2000).
·         For the stable neurological client, consider use of a bowel routine of Therevac enema or suppositories every other day, or performing digital stimulation with physician's permission. For persistent constipation, refer to physician for evaluation. Use of the Therevac SB mini-enema was found to cut time needed for bowel care by as much as one hour or more as compared with use of suppositories (Dunn, Galka, 1994).
Geriatric
·         Explain the importance of fiber intake, fluid intake, and activity for soft, formed stool. Fiber intake, fluid intake, and activity are often decreased in elderly clients. Increasing fiber and fluids can effectively prevent constipation in the elderly (Rodrigues- Fisher, Bourguignon, Good, 1993).
·         Determine client's perception of normal bowel elimination; promote adherence to a regular schedule. Misconceptions regarding the frequency of bowel movements can lead to anxiety and overuse of laxatives.
·         Explain Valsalva's maneuver and the reason it should be avoided. Valsalva’s maneuver can cause bradycardia and even death in cardiac patients.
·         Respond quickly to client's call for help with toileting.
·         Avoid regular use of enemas in the elderly. Enemas can cause fluid and electrolyte imbalances (Yakabowich, 1990) and damage to the colonic mucosa (Schmelzer, Wright, 1993).
·         Use opioids cautiously. If ordered, use stool softeners and bran mixtures to prevent constipation. Use of opioids can cause constipation (Schaefer, Cheskin, 1998).
·         Position client on toilet or commode and place a small footstool under the feet. Placing a small footstool under the feet increases intraabdominal pressure and makes defecation easier for an elderly client with weak abdominal muscles.
Home Care Interventions
·         Put client in bathroom to toilet when possible. Bowel elimination is a very private act, and a lack of privacy can contribute to constipation (Weeks, Hubbartt, Michaels, 2000).
·         Carefully monitor bowel patterns of clients under pain management with opioids. Introduce a bowel management program at first sign of constipation. Constipation is a major problem for terminally ill or hospice clients who may need very high doses of opioids for pain management.
·         When using a bowel program, establish a pattern that is very regular and allows client to be part of family unit. Regularity of program promotes psychological and/or physiological "readiness" to evacuate. Families of home care clients often cannot proceed with normal daily activities until bowel programs are complete.
Client/Family Teaching
·         Instruct client on normal bowel function and the necessity of fluid, fiber, and activity in a bowel program.
·         Encourage client to heed defecation warning signs and develop a regular schedule of defecation by using a stimulus such as a warm drink or prune juice. Most cases of constipation are mechanical and result from habitual neglect of impulses that signal appropriate time for defecation. This results in accumulation of a large, dry fecal mass (Wright, Thomas, 1995).
·         Encourage client to avoid long-term use of laxatives and enemas and to gradually withdraw from their use if used regularly.
·         If not contraindicated, teach client how to do bent-leg sit-ups to increase abdominal tone; also encourage client to contract abdominal muscles frequently throughout the day. Help client develop a daily exercise program to increase peristalsis.

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