Appendix H: Prevention of Appendix H: Prevention of ConstipationConstipation

Heather Woodbeck, Heather Woodbeck,

Regional Best Practice Regional Best Practice Guideline Coordinator for Guideline Coordinator for

Long Term Care Long Term Care

Northwestern OntarioNorthwestern Ontario

20072007

ImportanceImportance

Over ½ of residents in long term care Over ½ of residents in long term care use laxatives to have a bowel use laxatives to have a bowel movement (BM) movement (BM) (RNAO Constipation BPG 2004)(RNAO Constipation BPG 2004)..

Constipation contributes to: Constipation contributes to: – fecal impaction & fecal impaction & – urinary incontinenceurinary incontinence

PreventionPrevention

Constipation is preventable in most Constipation is preventable in most people.people.

Modifiable factors: Modifiable factors: – Low fluid intake, – Too little dietary fibre, – Lack of exercise, and – Ignoring the urge to defecate.

For Constipation - AssessFor Constipation - Assess

History of the resident’s bowel habits History of the resident’s bowel habits and constipation.and constipation.

Fluid and fibre intake levelsFluid and fibre intake levels Relevant medical & surgical history.Relevant medical & surgical history. Medications/polypharmacy.Medications/polypharmacy. Functional & cognitive issues.Functional & cognitive issues. Physical assessment.Physical assessment.

22ndnd Level Assessment Level Assessment

Use a 7 day bowel record to Use a 7 day bowel record to determine:determine:– Bowel pattern,Bowel pattern,– Episodes of continence/constipationEpisodes of continence/constipation– Toileting methodToileting method– Triggers for defecation. Triggers for defecation.

Constipation - PlanConstipation - PlanAddress Contributing Factors Address Contributing Factors

1. Insufficient fluid1. Insufficient fluid2. Decreased fibre in diet.2. Decreased fibre in diet.3. Decreased mobility due to lack of 3. Decreased mobility due to lack of exercise.exercise.4. Lack of recognition of urge to defecate. 4. Lack of recognition of urge to defecate. 5. Ineffective peristalsis5. Ineffective peristalsis6. Medications that cause constipation 6. Medications that cause constipation 

Monitor effect of interventions on Monitor effect of interventions on BM’s BM’s

Interventions - FluidInterventions - Fluid Encourage daily Encourage daily

fluid intake of fluid intake of 1500-2000 mls.1500-2000 mls.

Use sip and go Use sip and go method to method to encourage encourage drinkingdrinking

Interventions -FibreInterventions -Fibre

Encourage daily Encourage daily fibre intake of fibre intake of 25-30 gms. 25-30 gms.

Must drink fluid Must drink fluid to digest fibre!to digest fibre!

Flax flour, Flax flour, dynamite dynamite cookiescookies

Regular ToiletingRegular Toileting

Promote regular, Promote regular, consistent consistent toileting.toileting.

Individualize Individualize daily routine to daily routine to resident. resident.

Use the squat Use the squat position.position.

Interventions - ExerciseInterventions - Exercise

Encourage physical Encourage physical activity activity

Walking for mobile Walking for mobile clients.clients.

Upper body exercises Upper body exercises for those in for those in wheelchairs or in bed.wheelchairs or in bed.

Constipation - Laxative Use Constipation - Laxative Use

Use laxatives only after trying exercise, Use laxatives only after trying exercise, fluid, fibre, & toileting regimens.fluid, fibre, & toileting regimens.

Give bulk forming laxatives - metamucil Give bulk forming laxatives - metamucil and stool softeners – colace with caution in and stool softeners – colace with caution in residents prone to dehydrationresidents prone to dehydration

Ensure adequate fluids.Ensure adequate fluids.

Laxative/Suppository UseLaxative/Suppository Use

Use osmotic laxatives – Use osmotic laxatives – lactulose and stimulants lactulose and stimulants – senokot as ordered.– senokot as ordered.

Give suppository or Give suppository or enema only if laxatives enema only if laxatives are ineffective.are ineffective.

Long Term Care Constipation Long Term Care Constipation ProtocolProtocol

First try exercise, fluid, fibre, toileting First try exercise, fluid, fibre, toileting regimens.regimens.

Use bulk forming laxatives and stool Use bulk forming laxatives and stool softeners with caution. Ensure adequate softeners with caution. Ensure adequate hydration.hydration.

If no BM after 2 days, give osmotic If no BM after 2 days, give osmotic laxative such as lactulose.laxative such as lactulose.

If no BM after 3 days, give suppository.If no BM after 3 days, give suppository.

Protocol adapted from U. of Iowa Stepwise Approach to Constipation Protocol adapted from U. of Iowa Stepwise Approach to Constipation

InterventionsInterventions

Evaluate resident’s response to each Evaluate resident’s response to each intervention.intervention.

Educate staff, families and residents Educate staff, families and residents about the importance of fluid, fibre, about the importance of fluid, fibre, exercise.exercise.

Revise policies, procedures and Revise policies, procedures and nursing care plans to prevent nursing care plans to prevent constipation.constipation.

Plan/Do/Study/ActPlan/Do/Study/ActModel for ImprovementModel for Improvement

3. What change can you make that will result in improvement?

2. How will you know a change is an improvement?

1. What are you trying to accomplish?

ACT PLAN

STUDY DO

CYCLES for testing & implementing Change

Langley, Nolan, Nolan, Norman Provost;Improvement Guide, 1996

Set AIMS

Establish MEASURES

Select CHANGE

Successful ImplementationSuccessful Implementation

Management support Management support

Support and active involvement of Support and active involvement of

front line clinical stafffront line clinical staff

Plan for gradual implementation of Plan for gradual implementation of

protocol with 1 or 2 clients at a protocol with 1 or 2 clients at a

time.time.

Provide education and trainingProvide education and training

ConclusionConclusion

Constipation is everybody’s problem.Constipation is everybody’s problem. It is preventable. It is preventable. In long term care, constipation In long term care, constipation

requires adapting to the needs of requires adapting to the needs of residents rather than the residents residents rather than the residents adapting to the institution’s rules. adapting to the institution’s rules.

ReferencesReferences Folden, SL et al. 2002. Rehabilitation Nursing Foundation (RNF) Folden, SL et al. 2002. Rehabilitation Nursing Foundation (RNF)

Practice Guidelines for the Management of Constipation in Adults. Practice Guidelines for the Management of Constipation in Adults. RNF Glenview, Ill. RNF Glenview, Ill. http://www.rehabnurse.org/about/research.html..

Hinrichs, M & Huseboe, J. 2001. Management of Constipation. Hinrichs, M & Huseboe, J. 2001. Management of Constipation. University of Iowa Gerontological Nursing Interventions Research University of Iowa Gerontological Nursing Interventions Research Centre, Iowa City, Iowa. Centre, Iowa City, Iowa.

Joanna Briggs Institute for Evidence Based Nursing and Midwifery. Joanna Briggs Institute for Evidence Based Nursing and Midwifery. 1999. Management of Constipation in Older Adults. Adelaide, 1999. Management of Constipation in Older Adults. Adelaide, Australia. Australia. http://www.joannabriggs.edu.au/pdf/BPISEng_3_1.pdf..

Registered Nurses Association of Ontario. 2005. Prevention of Registered Nurses Association of Ontario. 2005. Prevention of Constipaton in the Older Adult Population, Nursing Best Practice Constipaton in the Older Adult Population, Nursing Best Practice Guideline. Toronto, Ontario. Guideline. Toronto, Ontario. http://www.rnao.org..