National Institute for Health and Care Excellence. Constipation: Management. 2017. https://tinyurl.com/y9rmdzua (accessed 25 January 2018)
Nursing and Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018. https://tinyurl.com/gozgmtm (accessed 12 February 2018)
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Constipation is a common problem that can occur at any age. The incidence rate is 2-3 times higher in women than in men and prevalence increases with age; however, it is important to note that this may be underestimated due to the high proportion of self-management and treatment (National Institute for Health and Care Excellence (NICE), 2017). Constipation is more common in pregnancy and can be exacerbated by medication. Effective treatment of constipation relies on a thorough holistic assessment to identify the cause.
Constipation is defined as unsatisfactory defecation due to the infrequent passing of stools (NICE, 2017). It is a subjective disorder and is measured in patients according to their dissatisfaction with the frequency of defecation and the relevance of the symptoms to the individual (Woodward, 2012; Basilisco and Coletta, 2013; Dougherty and Lister, 2015). However, there can be wide variation between different individuals' perceptions of ‘normal’. Consequently, this has led to a lack of consensus around constipation definition (Kyle, 2011; Dougherty and Lister, 2015). The Rome IV diagnostic criteria for gastrointestinal disorders identify constipation as two of the following criteria in the preceding month: a spontaneous bowel movement that occurs less than 3 times a week, painful or hard stools, presence of faecal matter in the rectum, or a history of incomplete evacuation (Drossman, 2016). Chronic constipation is defined as symptoms that persist for more than 12 weeks in 6 months (NICE, 2017).
Causes of constipation
There is no pathological cause for primary constipation (Royal College of Nursing (RCN), 2012; Dougherty and Lister, 2015). Factors that lead to the development of primary constipation are extrinsic or related to lifestyle. These include inadequate fibre in the diet (a fibre-rich, well-balanced diet softens and increases the stool weight and accelerates transit time), a change in lifestyle, poor fluid intake, and ignoring or delaying the urge to defecate (Basilisco and Coletta, 2013; Dougherty and Lister, 2015). The causes of chronic constipation are multifactorial and relate to colonic motility and absorption, diet, sensory function, behavioural and psychological factors (Basilisco and Coletta, 2013).
Secondary constipation is caused by either a metabolic, neurological or psychological disorder. These include colonic tumours, irritable bowel syndrome, anal fissures and other neurological, myopathic and structural conditions (Dougherty and Lister, 2015). Constipation can also be a direct side effect of some medications, for example, opioid analgesics (RCN, 2012; Woodward, 2012).
Risk factors for constipation should be considered from a physical, psychological and social perspective (NICE, 2017). Diagnosis of constipation should be reached only following a full assessment, a detailed structured evaluation and rectal examination (Basilisco and Coletta, 2013).
Assessment
Assess the person's normal bowel habits (this may influence diagnosis)
Ask the patient how long they have they been constipated and whether this has occurred before. Also, what self-help methods have been previously tried and what the outcome was. Understanding a patient's bowel history is key to an accurate diagnosis. Withholding bowel movements following previous experiences of pain or discomfort is known to cause functional constipation, particularly in older people who are in hospitals or institutions (Basilisco and Coletta, 2013 joan.2019.8.2.)
Record the volume, colour and consistency of stools, for example: hard, small. Use the Bristol Stool Chart (Bristol Stool Form Scale) to assess this (a version is available on the NICE website: http://tinyurl.com/yxtr75dg). Constipation would be classified as types 1 or 2 (separate hard lumps or lumpy and sausage like) on the Bristol scale. Consider implementing a bowel diary to record the frequency of bowel evacuation, stool consistency, and to record any faecal incontinence (RCN, 2012). Ask the patient if they have any nocturnal symptoms (this may be an indication of impaction and overflow)
Assess for any associated symptoms, such as excessive straining, rectal discomfort or bleeding, feeling of incomplete evacuation, abdominal pain or distension. Ask the patient if they have any pain or discomfort on defaecation (Dougherty and Lister, 2015)
Assess for any symptoms of fever, vomiting, nausea, loss of appetite or weight loss. Use a validated tool to assess that patient's nutritional status
Ask the patient if they have any urinary symptoms such as incontinence, retention or dyspareunia? Large amounts of stool in the colon can put pressure on the bladder causing it not to fill or contract as it should (Basilisco and Coletta, 2013)
Assess the patient's diet, particularly fibre and fluid intake. A person's fibre intake should be approximately 30 g per day, and their diet should contain whole grains and fruits (including their juices) that have a high sorbitol content—for example, apples, apricots, strawberries, pears, plums/prunes and grapes/raisins (NICE, 2017). Sorbitol is a sugar alcohol that has a laxative effect. Consider not only insufficient fibre intake but also excessive fibre in the diet, which can cause bloating and abdominal pain particularly in patients who have a delayed colonic transit (Basilisco and Coletta, 2013). Use the Public Health England (2018) Eatwell Guide to provide patient information. Fibre intake must be increased slowly to minimise bloating and flatulence (NICE, 2017). Adults including older people are recommended to drink between 1600 ml and 2000 ml of water a day (Gandy, 2017). Ask the patient to use a food and fluid diary to monitor intake and refer to a dietitian if there are any concerns
Assess for a family history of inflammatory bowel disease or colorectal cancer. If any red flag symptoms are detected, such as hematochezia (fresh blood in the stool or anus), anaemia or a change in bowel habits, refer the patient for further investigation (NICE, 2017)
Assess the patient for the impact of constipation on quality of life and daily functioning. Does the patient have any mechanical aspects of faecal incontinence, such as regularly soiled underwear or loose stools (NICE, 2017)?
Check the patient's position on the toilet seat. This should be a squatting position for defecation (Figure 1). Assess their toilet habits. Do they feel hurried or withhold the urge to defecate, what toilet access do they have and to what level of privacy? Consider current lifestyle and habits, and ask the patient whether they allow sufficient time for defecation (NICE, 2017)?
Ask the patient if there have been any changes in their mobility or reduction in exercise (Dougherty and Lister, 2015)
Assess for any psychological conditions including any adverse life events, depression, anxiety, eating disorders, somatisation disorders or a history of abuse (Basilisco and Coletta, 2013, NICE, 2017).
Review the patient's current medication and treatment with underlying contraindications of constipation
Complete an abdominal examination to assess for any pain, distension, mass or palpable colon (which would indicate retained faecal masses) (Dougherty and Lister, 2015)
Assess the patient for secondary causes of constipation. The underlying and secondary causes of constipation need to be managed as part of the treatment to prevent recurrence (NICE, 2017)
Complete baseline observations to support the bowel assessment and aid differential diagnosis (RCN, 2012).
Figure 1. Correct toilet sitting position
Digital rectal examination
A digital rectal examination (DRE) should be performed only by nurses who have received suitable training and who have demonstrated a level of competence determined by the Nursing and Midwifery Council (NMC) (Dougherty and Lister, 2015; NMC, 2018). All patients with chronic constipation should undergo a DRE to look for causes of anal pain that may precipice secondary constipation (Basilisco and Coletta, 2013). Before undertaking a DRE nurses must observe the perineal areas for any abnormalities such as:
Rectal prolapse (this should be graded) (RCN, 2012)
Watching the patient while they strain may identify stool leakage, a gaping anus or a prolapse of internal haemorrhoids (Rao, 2011).
DRE is contraindicated when there is a lack of informed consent from the patient whether written, verbal or implied (RCN, 2012) or there is instruction from a doctor or senior physician that this procedure should not take place. Nurses should use caution if patients have acute inflammation of the bowel, including diverticulitis, Crohn's disease or ulcerative colitis.
Caution and discussion with the multidisciplinary team are also required if a patient has recently undergone radiotherapy on the pelvic area, and if the patient has had rectal surgery or experienced a trauma to the anal or rectal area in the past 6 weeks (RCN, 2012), if the patient is complaining of rectal or anal pain, or there are obvious signs of rectal bleeding. Other issues to consider are whether a patient has a known allergy to latex, a known history of abuse, or an injury above the sixth thoracic vertebra because this increases the risk of autonomic dysreflexia (RCN, 2012).
Procedure
Confirm the patient's identity, explain and discuss the full procedure
Assess the patients' specific requirements and the reason for intervention. If the patient is constipated a full physical, psychological and social assessment should be completed (NICE, 2017)
Wash hands and put on apron and gloves. This is to ensure that hygiene and infection control measures are maintained
Close the door or draw the curtains to maintain privacy and dignity (NMC, 2018).
Encourage the patient to empty their bladder first. A full bladder can create discomfort during the procedure (Peate, 2015)
Place a waterproof pad underneath the patient
Remove the patient's clothing from the waist down if they are unable to do this unaided
The patient should lie on their left side, knees flexed with the upper knee higher than the lower knee and buttocks near the edge of the bed. This supports the easy passage of the finger into the rectum (Dougherty and Lister, 2015). Note that patients with musculoskeletal conditions may not be able to lie in this position. Ensure that you have adequate lighting and that the patient is not at risk of falling (Pokorny, 2017)
Change gloves (as starting invasive procedure). Place lubricating jelly on a pad of sterile gauze and lubricate the index finger. Lubrication reduces friction, aids insertion and reduces anal mucosal trauma. Separate the buttocks and observe the perineal and perianal areas. Document any abnormalities for anything that may make assessment difficult, for example, haemorrhoids, rash, discharge or bleeding (Pegram et al, 2008; Peate, 2015)
Gently advance lubricated index finger into the patient's rectum. Assess the anal sphincter and tone. This can be achieved by asking the patient to squeeze the examining finger or push and bear down as if to defecate (Rao, 2011; Pokorny, 2017). The external anal sphincter is responsible for voluntary contraction of the sphincter. Weakening or disruption of the anal sphincter by trauma can result in faecal incontinence (RCN, 2012). At the same time explain to the patient what is happening and encourage the patient to relax if possible by taking deep breaths (Pegram et al, 2008)
Establish the content of the rectum, and the amount and consistency of faecal matter (use the Bristol Stool Chart). Assess anal and rectal sensation, assess for the presence of any foreign bodies, and review the rectum for any conditions that may cause discomfort (RCN, 2012). Perform 360° palpation of the rectal wall to identify any polyps or masses (Rao, 2011). Determine whether there is a need for digital removal of faeces prior to the administration of suppositories or an enema
Discontinue the procedure if the patient is complaining of pain or abdominal cramps. DRE may be uncomfortable, but the procedure should not be painful (Pokorny, 2017)
Slowly remove index finger. Examine the glove for any signs of blood, faecal consistency and colour (e.g. pale or melaena) (Pokorny, 2017). Dry the perineal area to prevent any discomfort or excoriation
Remove and dispose of all equipment according to local policy. Wash hands
Document assessment. If an enema or suppositories are required, ensure these are prescribed for the patient prior to administration. Document colour, consistency and amount of retained faeces using the Bristol Stool Chart. Avoid subjective descriptions such as ‘copious amounts’ or ‘+++’.
Considerations for prescribing
There are several options for the treatment of constipation. Initial self-management should be encouraged in the first instance. Encourage patients to increase fibre and fluid intake, and physical activity and exercise levels, if appropriate (NICE, 2017). Discuss toileting routines and advise patients to respond immediately to the sensation of needing to defecate (NICE, 2017). Ensure that access to supported seating is available if they are unsteady on the toilet.
For short-duration constipation consider management of underlying secondary causes and reduction in causative drugs or treatment to alleviate symptoms (NICE, 2017). If initial measures continue to be ineffective nurses should offer oral laxatives using a stepped approach. Bulk-forming laxatives should be considered as first-line treatment (NICE, 2017). Bulk-forming laxatives act by retaining fluid and increasing faecal mass which stimulates peristalsis. These should not be used if a patient has opioid-induced constipation. If treatment remains unsuccessful consider an osmotic laxative (which increases the amount of fluid in the large bowel), or if a stool is soft or difficult to pass consider a stimulant laxative (which causes peristalsis by stimulating colonic and rectal nerves) (NICE, 2017).
If the patient's response to oral laxatives is inadequate or does not achieve the desired results, the NICE (2017) management advice suggests considering a docusate sodium or sodium citrate enema. More detail on the various types of enemas and their administration can be found in a separate article (Mitchell, 2019).
Enemas should be used with caution and observing all the contraindications, for example, gastrointestinal obstructions or inflammatory bowel disease (NICE, 2017). Caution should be used in patients with ascites, congestive heart failure, older people or debilitated patients, patients with electrolyte disturbances or uncontrolled hypertension (a side effect of some enemas can be electrolyte disturbances) (NICE, 2017). Other side effects can include a local irritation. Nurses should advise patients and carers about adequate hydration particularly with osmotic enemas, and should ensure that the patients are warned about the potential for faecal overflow and diarrhoea during disimpaction (NICE, 2017).
Following treatment with an enema, regular laxatives should be considered to maintain bowel movements and the patient should be reviewed regularly to monitor their response to the treatment (Dougherty and Lister, 2015). If constipation fails to improve it is recommended that patients are referred to a specialist for further investigations (Basilisco and Coletta, 2013).
Conclusion
Holistic assessment is essential for the ongoing treatment and management of constipation. Whenever possible, patients should be encouraged to adopt early interventions and lifestyle changes to avoid chronic constipation.
LEARNING OUTCOMES
Increase knowledge of constipation and complications
Understand the holistic assessment of constipation in adults
Improve knowledge of rectal examination in context of constipation
