Attachment 10.Constipation in an adult.pdf

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1.  Purpose of guideline
The purpose of this guideline is to facilitate the safe and effective care of an adult patient with
constipation within Auckland District Health Board (Auckland DHB).
This guideline excludes those patients with chronic constipation, spinal cord injury and those
where there is no clear diagnosis.
2.  Guideline management principles and goals
Bowel management should be based on current evidence based practice and assessment should
be initiated within 24 hours.
3.  Definitions
Constipation
A change in the individual’s normal bowel habits, characterised by:
  A decrease in the frequency of bowel movements compared with their ambulatory baseline
  The absence of sensation of complete evacuation
  Reported need for increased straining with defecation.

Faecal impaction
Retention of hardened or putty-like stool in the rectum and colon, which cannot be passed by the
patient as a result of incomplete evacuation over time. Often associated with watery, loose stools
around the impacted mass.
  Faecal incontinence
An involuntary passage of stool at an inappropriate place or time. This may be related to cortical
lesions, spinal cord lesions, injury to sphincter, perineal muscle relaxation, over use of laxatives,
and functional status (e.g. cognitive impairment and impaired mobility).
4.  Risk factors
  Reduction in fluid intake
  Needing assistance to be able to drink
  Dislike of available fluids e.g. is on thickened fluids
  Is worried about urinary frequency and/or incontinence
  Lack of knowledge about importance of fluids
  Functional status e.g. cognitive or physical impairment.
  Reduction in dietary fibre intake
  Poor dentition, decreased saliva production, or other chewing difficulties
  Available diet is low in fibre
  Decreased motivation to eat
  Poor memory
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  Lack of knowledge about importance of dietary fibre or foods that contain it.
  Reduction in physical activity
  Increasing frailty makes activity difficult, unsafe or impossible without assistance
  Sudden change in physical condition or health status
  Change in environment or usual routine
  Lack of knowledge about importance of regular physical activity.
  Access to toilet facilities
  Need help getting to toilet and/or removing clothing
  Toilet seat wrong height, room too cold, lack of privacy, having to wait for others, having to
use bedpan etc.
  Medical condition
The following medical conditions can slow or obstruct the passage of stool through the gut, or
makes it difficult or painful to pass stool:

  Neurological deficits e.g. stroke, multiple sclerosis, Parkinson’s disease, brain/spinal cord injury
  Bowel obstruction e.g. adhesions, tumour
  Painful anal conditions e.g. haemorrhoids, fissures
  Irritable bowel disease
  Diverticulosis
  Megacolon, hypotonic bowel.
  Medications
  Aluminium
  Antihistamines
  Antipsychotics (e.g. clozapine, phenothiazines)
  Tricyclic antidepressants
  Calcium antagonists e.g. diltiazem, verapamil
  Calcium supplements
  Cholestyramine
  Clonidine
  Diuretics
  Iron
  Levodopa
  Opioid analgesics (including codeine)
  Ondansetron.
5.  Assessment
Patient assessment involves discussion about some or all of the following:
  Identifying risk factors
  Normal bowel pattern and history of constipation
  Medication review
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  Abdominal assessment with rectal examination (if required)
  Use of a bowel chart and clear descriptions e.g. Bristol Stool Chart.
6.  Management
  Gastrocolic reflex
When a person smells, sees or eats food, gut mobility increases and moves food along the
digestive tract. Usually within 30 minutes following stimulation, a person feels the need to
defecate. Even if sensation is impaired due to paraplegia, defecation may still occur at this time. It
can also be effective in the confused patient.
It is therefore important in bowel management to establish regular timed defecation. Once the
urge to defecate is recognised, it should not be delayed, providing the place and time is
appropriate. If the urge to defecate is deferred it may not return for 24 hours.
The longer faeces remains in the bowel, the dryer and harder it becomes and progressively more
difficult to pass. It may take up to 4 weeks for regular timed defecation to become established.
  Laxatives
Type of laxative
Use
Action and onset
Nursing points
Bulking agents
Suitable first time
Increase the volume  Dose should be taken
e.g. Metamucil,
treatment for the
of the stool by
with a large glass of
Normacol,
mobile less frail
absorbing water.
water.
Psyllium
older person
The increased
Should not be given when
Often used to treat
volume stimulates
nausea, vomiting
diarrhoea secondary  peristalsis.
undiagnosed abdominal
to nasogastric

pain or faecal impaction
feeding.
Onset 12-24 hours
are present.
Osmotic laxative
Lactulose is often
Lactulose syrup is
Lactulose can be mixed
e.g. Lactulose
the first choice of
poorly absorbed in
with water, milk or fruit

treatment in the frail  the gastro-intestinal  juice to make it more

and/or immobile
tract. It is broken
palatable.

elderly person
down in the colon by  Lactulose is more
bacteria to form

effective when used
acetic and lactic
consistently.

acids. These acids
The patient on galactose

stimulate peristalsis
and/or lactose-free diets

and also exert a local  may experience intestinal

osmotic effect,
obstruction.

drawing water into
Needs adequate fluid

the colon.
intake to work properly

Can cause bloating.

Onset 24 - 72 hours

e.g. Macrogols

Onset 0.5 - 3hours
Macrogols are licensed
(Molaxole)
for the treatment of
faecal impaction.
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Type of laxative
Use
Action and onset
Nursing points
Macrogols appear to be
at least as effective as
lactulose and may cause
less flatulence.

Faecal softeners

Lowers surface
Often combined with
e.g. Docusate
tension and allows
stimulants (such as senna
sodium
water to penetrate
in Laxsol tablets).
hard, dry faeces.
Stool softeners are
Also has some
unnecessary if stool is
stimulant activity
well hydrated and soft.

Oral docusate should be
Onset 6-12 hours
avoided in a patient with
intestinal obstruction.

Glycerine
Is a useful
Exert a local osmotic  Suppositories should be
suppositories
immediate option in  effect, drawing
inserted pointed end
the frail elderly
water into the
first.
person
rectum/lower colon.  Administer 1 - 2
Increasing the
suppositories as required
pressure within the
and hold for at least 20
bowel which
minutes.
stimulates
Should not be given if
peristalsis, resulting
patient is experiencing
in a bowel motion.
nausea, vomiting,

undiagnosed abdominal
Onset 5-30 minutes
pain or faecal impaction.

Enemas

Retains water in the
Contraindications –
Hyper osmolar

intestinal lumen by
nausea, vomiting,
e.g. Phosphate

osmosis, which
abdominal pain and/or
(fleet enemas)

results in increased
rectal bleeding

bulk and stimulates
Use with caution in a

peristalsis.
patient who has renal

impairment and/or bowel

Onset 2-30 minutes
stasis.

Only use Fleet enemas on

PRN basis.

Microlax®

Faecal softener,

which liberates the

water that is

present. This causes

a softening of the

stool and leads to a

gentle defecation

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Type of laxative
Use
Action and onset
Nursing points

(also contains

glycerol which

stimulates

peristalsis).

7.  Education for patients
Education to the patient and/or support person should include some or all of the following:
  A healthy bowel pattern
  The causes of constipation
  A well balanced diet, including adequate fibre and fluid
  Appropriate physical activity
  Optimising the gastro-colic reflex
  Use of natural laxatives or medications
  Providing the constipation hand-out prepared by Nutrition Services.
8.  Monitoring
All practitioners should monitor and review patient’s bowel status daily, and stop laxatives when
appropriate.
All nursing staff should monitor, record, review patient’s bowel status during every shift, and
notify the medical practitioner overseeing the patient’s care if loose stools are observed or the
patient has still not moved their bowels.
9.  Supporting evidence
  Allen-Dicker, J., Goldman, J. & Shah, B. (2015) Inpatient Constipation. Hospital Medicines
Clinics 4(1) 51-64.
  Gallegos-Orozco, J., Foxx-Orenstein, A., Sterler, S. & Stoa, J. (2012) Chronic Constipation in the
Elderly. Am J Gastroenterol 107, 18–25.
  Vasanwala, F. (2009) Management of Chronic Constipation in the Elderly. The Singapore Family
Physician 35(3) 87-92.
10.  Associated documents
  Bristol stool chart
  Constipation in Palliative Care - Adult
  Constipation in the Antenatal Patient
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  Medications - Administration
  Medications - Allergies & Adverse Drug Reactions (ADRs) Identification, Documentation &
Recording
  Medications - Prescribing

Clinical forms
  CR5504: Bowel Motion Chart
  CR5775: Bowel Chart Older People’s Health

Patient information leaflets

The following leaflets can be printed from the Auckland DHB intranet / Nutritional Services /
Nutrition information sheets.

  Constipation
  Fibre in your diet
11.  Disclaimer
No guideline can cover all variations required for specific circumstances. It is the responsibility of
the health care practitioners using this Auckland DHB guideline to adapt it for safe use within their
own institution, recognise the need for specialist help, and call for it without delay, when an
individual patient falls outside of the boundaries of this guideline.
12.  Corrections and amendments
The next scheduled review of this document is as per the document classification table (page 1).
However, if the reader notices any errors or believes that the document should be reviewed
before the scheduled date, they should contact the owner or Document Control without delay.
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