Constipation is a common condition that affects people of all ages. It may be described as a variation in an individual’s normal bowel habit with discomfort and diminished quality of life. Medical assessment is required as the underlying cause may be due to a serious medical condition. Managing patients with constipation presents many challenges to the health care professional, not only overcoming communication barriers associated with bowel habits but also because there is no universally accepted definition. Constipation is usually multifactorial, often with complicated underlying patho-physiology and it can be influenced by physical, psychological, physiological, emotional and environmental factors.
Chronic constipation is one of the most common lower gastrointestinal disorders affecting people in America and is a key health concern for healthcare providers. This is mainly accurate for patients in high-risk groups such as the elderly, patients suffering from immobility, neurologically impaired patients and those with multiple health-care needs, as well as and those admitted to the hospital or residing in a healthcare facility. Unfortunately, constipation may be regarded as less important than other conditions commonly seen in general practice. Constipation has cost implications in terms of medications, containment equipment and nursing time. The following paper will investigate a patient suffering from constipation while developing a better understanding and approach of management for such ailment.
Health Assessment and Promotion Plan
Mrs. Burns a 64 years old female presents with chief complaint of being “constipated”. She states she has a bowel movement about every 3 to 4 days, feels the need to strain at defecation and her stools are hard and painful to excrete. She also has stated having frequent headaches, fatigue, a feeling of bloatedness and loss of appetite. As mention in the book, “Physical Examination and Health Assessment” by Jarvis, the aging adult frequently reports constipation signs and symptoms, such as reduced stool frequency (less than 3 bowel movements per week), and other common and troubling associated symptoms like straining, lumpy or hard stool, feeling of incomplete evacuation, feeling of anorectal blockage and use of manual maneuvers. Common causes of constipation include decrease in physical activity, inadequate intake of water, a low-fiber diet, side effects of medications (opioids, tricyclic antidepressants, and antacids), irritable bowel syndrome, bowel obstruction, hypothyroidism, and inadequate toilet facilities. Upon obtaining subjective data it was found that Mrs. Burns lives by herself after the death of her husband 6 months ago.
She states no longer being able to eat as she used to when her husband was still alive and she cooked every day; now she usually eats by herself. She stated she has lost over 20 lbs. since her husband’s dead. She also reported usually feeling lonely and very sad. Client also stated her usual meals of the day include breakfast starting with a cup of coffee and a slice of toast, lunch is usually eaten between 1 and 2 pm and include can soup or a tuna sandwich if she feels hungry and for dinner tea. Anorexia is a loss of appetite, and the purpose for obtaining information about signs and symptoms of anorexia is vital to prevent the dangerous psychological and behavioral effects on all aspects of an individual’s life. The individual can become seriously underweight, irritable and easily upset which can lead to depression and social withdrawal. Anorexia can also affect sleep and lead to fatigue during the day, as well as decrease attention and concentration (Prynn, 2011).
Mrs. Burns does not often consume fruits and vegetables or other additional source fiber. She does not like the taste of water, so is very rare for her to consume it. She states not having trouble chewing, swallowing, or feeling nauseous or vomiting, but she likes to take naps after eating. Mrs. Burns also reported having signs and symptoms of abdominal pain located in the right and left lower quadrants of the stomach. The pain usually starts after the third day of constipation, which she describes as cramping (colic type) and usually relieved after she ambulates or has a bowel movement. Mrs. Burns describes her bowel habits as changed from going on a daily basis to only having a bowel movement every 3 to 4 days with a hard consistency. In her past abdominal history she reports not ever having an abdominal surgery.
She brought an abdominal x-ray report, which concludes fecal matter to be present. She reports her list of medications including calcium, iron supplements and antacids, which she takes on a daily basis. The patient reports that being constipated all the time makes it really difficult for her to have a normal life. She reports her coping mechanisms as taking over-the-counter preparations especially laxatives, the use of digital stimulation and taking ibuprofen as necessary to relieve the pain when food or ambulation are not effective. A throughout functional assessment was performed and found that Mrs. Burns is able to ambulate, perform activities of daily living, including instrumental activities of daily living and has no problems with mobility. In the other hand, she has reported that she used to be much more active while her husband was alive and remembers walking the park for at least 20 minutes three times per week.
Upon physical examination the following anthropometric measures and vital signs were obtained: Height: 162 cm (5′4′′), Weight: 65 kg (143 lbs.), Temperature: 36.2°C (97.2°F), Pulse: 82 BPM, Respirations: 20/minute, Blood pressure: 128/74 mm Hg, Active bowel sounds in all four quadrants and abdomen slightly distended without pain or tenderness at the present time. Gait and posture are normal for a patient of her age. There are no complaints related to lower back symptoms, perineal area observed free of any abnormalities or redness, perineal movement and anal sphincter squeeze noted with moderate muscle coordination. Digital rectal examination performed: hard fecal material noted, anal sphincter tone was normal, no rectal prolapse, no hemorrhoids, and no skin tags or anal lesions were noted. Labs results for hemoglobin, 11.8 and urinalysis, negative.
Effective assessment provides nurses with the relevant information on which advice, interventions and management can be planned. In addition, it contributes to the path of outcomes measured and evaluation of care. Assessing patients with constipation presents many challenges to the health professional, not only by overcoming communication barriers associated with bowel habits and the embarrassment associated with an intimate rectal examination, but also because constipation may not result from a single straightforward cause. The subjective nature of constipation adds to the difficulty of the assessment, especially as nurses tend to use the objective measurement of bowel frequency rather than using a subjective symptom tool (Kyle, 2011).
Assessment is based on a consideration of all the possible causes, while particularly assuring that it is not caused by an underlying undiagnosed medical condition. The aim of assessment is to establish a symptom profile in order to plan individualized bowel care. The main goal of treatment and management for constipation is prevention and relief. Establishing an ideal bowel action should prevent recurrence. Therefore, effective assessment provides nurses with the information on which advice and interventions of management can be planned effectively. Establishing a symptom proﬁle assist in identifying the most likely causes for the bowel symptoms based in the context of a more relevant medical/surgical/obstetric history and functional ability. Three main components have been identified as part of the plan of care developed for Mrs. Burns’ current chief complaint.
These primary components include: the implementation of an exercise routine, as well as a dietary regimen that will include more ﬂuids and ﬁber. This is better known as lifestyle advice or step one of a stepped approach to bowel care, which is often recommended for promoting a healthy bowel and is still considered the ﬁrst-line treatment for constipation (Kyle, 2010). The implementation of this approached will be monitor by a dietitian, along with the nurses who will provide Mrs. Burns with dietary education and lifestyle modification strategies. In addition, other very important components will be included as well. Mrs. Burns will have a psychological consult as she is at risk for depression as evidenced by her husband’s recent death and feelings of loneliness and sadness.
Nurses should develop a more proactive and evidence-based approach to the prevention of constipation rather than continuing with the existing reactive response to this distressing symptom. Such an approach is dependent primarily on improving the education and the skill-base of nursing and those with whom they work. Finally, further research and discussions will add to the knowledge framework of such a significant condition, since so many complications are rooted from unhealthy digestive systems.
Jarvis, C. (2012). Physical Examination. (6th edition ed.). St. Louis: W B Saunders Co. Kyle, G. (2011). Risk assessment and management tools for constipation. British Journal of Community Nursing,16(5), 224-230.
Kyle, G. (2010). Considering the options for treating constipation. Practice Nursing, 21(3), 124. Prynn, P. (2011). Managing adult constipation. Practice Nurse, 41(17), 23-28.