Constipation and Bowel Obstructions Risk
P
r
e
s
e
n
t
e
d
b
y
:
T
h
e
V
i
r
g
i
n
i
a
D
e
p
a
r
t
m
e
n
t
o
f
B
e
h
a
v
i
o
r
a
l
H
e
a
l
t
h
a
n
d
D
e
v
e
l
o
p
m
e
n
t
a
l
S
e
r
v
i
c
e
s
T
h
e
O
f
f
i
c
e
o
f
I
n
t
e
g
r
a
t
e
d
H
e
a
l
t
h
H
e
a
l
t
h
S
u
p
p
o
r
t
s
N
e
t
w
o
r
k
1
C
o
n
s
t
i
p
a
t
i
o
n
a
n
d
B
o
w
e
l
O
b
s
t
r
u
c
t
i
o
n
s
R
i
s
k
A
w
a
r
e
n
e
s
s
T
r
a
i
n
i
n
g
(
R
A
T
)
Objectives
1.
Define constipation
2.
List (2) common causes of constipation
3.
State (2) complications of constipation
4.
Define bowel obstruction
5.
Identify (4) signs and symptoms of fecal
impaction
6.
Identify (3) caregiver recommendations
7.
List two medical professionals that can
help with assessing for bowel obstruction
Who benefits
from this
training?
3
Terms and Definitions
4
Normal bowel habits-
each person’s bowel habits are individualized. While
some may eliminate every day, others may only have a bowel movement 3
times a week. Many factors contribute to frequency of bowel movements
such as hydration, exercise, and mobility.
Constipation
- is defined as difficulty passing stool. Having fewer than three
(3) bowel movements a week. (Mayo Clinic, 2018)
Functional Constipation-
is defined as having no anatomical or genetic
defect that is the underlying cause. There is no organic cause. Cause may
be associated with inadequate fluid intake or lack or fiber in diet. (Talley,
2004)
Organic Constipation-
when there is an identifiable condition, disorder or
diagnosis causing constipation. (Pashankar, 2005).
Chronic Constipation
- is defined as painful bowel movements that are hard
and lumpy, with less than two movements a week, and may have feeling of
incomplete defecation of stool (Talley, 2004)
Signs and
Symptoms-
Adults
•
Passing fewer than (3) stools per
week or fewer bowel movements
than usual.
•
Straining/grunting
•
Stool smearing in underwear or
briefs
•
Extended periods of time sitting on
toilet trying to pass stool
•
Refusing to eat or drink
•
Hard or dry stool
•
Hard, protruding stomach
•
Abdominal pain, cramping, bloating
5
Signs and
Symptoms-
Children
•
Fear of the bathroom or toilets (public
bathrooms).
•
Toilet training problems in young children.
•
Older children ignoring the urge to pass stool.
•
Reduced stool from eating a low-fiber diet, not
eating often
•
enough or not drinking enough fluids.
•
Intolerance to cow's milk.
•
Lack of physical activity.
•
Side effects from certain medications.
•
Pain from hemorrhoids.
•
Examples of rare, but serious, causes of
constipation in children include:
•
Hirschsprung's disease: A genetic condition
that prevents the colon from
working normally.
•
Thyroid conditions.
•
Problems with the spinal cord (cerebral palsy).
•
Malformations of the anus and rectum.
•
(UVA Children’s, n.d.)
6
C
o
m
m
o
n
C
a
u
s
e
s
o
f
O
r
g
a
n
i
c
C
o
n
s
t
i
p
a
t
i
o
n
Hypothyroidism
Pseudo obstruction or rectal
tumors
Neurologic conditions such as
Cerebral Palsy
IBD- Inflammatory bowel disease
Diabetes Mellitus
Celiac disease
Dysphagia (inadequate
consumption of fiber and fluids)
Congenital disorders such as Tay
Sachs, Prader-Willi, Hirschprung
Disease, Spina Bifida, Trisomy 13,
Down Syndrome
Congestive Heart Failure
Organic Constipation-
there is an
identifiable condition, disorder or
diagnosis causing constipation
(Pashankar, 2005).
C
o
m
m
o
n
c
a
u
s
e
s
o
f
F
u
n
c
t
i
o
n
a
l
C
o
n
s
t
i
p
a
t
i
o
n
Inadequate fluid intake
Inadequate fiber intake
Disruption of regular diet
Disruption of routine
Inactivity or immobility
Poor body alignment
Absence of upright standing
Consumption of large amounts
of dairy products
Stress
Resistance to bowel
movements
Overuse of laxatives
Depression
Eating disorders
Functional Constipation-
is
defined as having no anatomical
or genetic defect that is the
underlying cause. There is no
organic cause (Talley, 2004)
C
o
m
p
l
i
c
a
t
i
o
n
s
o
f
C
o
n
s
t
i
p
a
t
i
o
n
Hemorrhoids
Rectal bleeding
Anal fissures (tears in skin around
the anus)
Rectal prolapse (the large
intestine detaches inside the body
and pushes out of the rectum)
Fecal impaction (hard, dry stool is
stuck in the body and unable to be
expelled naturally)
Diverticulitis
9
Fecal Impaction vs Bowel Obstruction
F
e
c
a
l
I
m
p
a
c
t
i
o
n
Fecal impaction occurs
when hard, dry stool
cannot pass through the
colon or rectum. Fecal
impaction may be caused
by using laxatives too
often, using certain types
of pain medicines, little or
no physical activity over a
long period, diet changes,
or constipation that is not
treated (NCI, n.d.).
B
o
w
e
l
O
b
s
t
r
u
c
t
i
o
n
A bowel/intestinal
blockage or obstruction
occurs when something
prevents the contents of
the intestines from
passing normally through
the digestive tract. The
problem causing the
blockage can be inside
or outside the intestine.
10
Signs & Symptoms
F
e
c
a
l
I
m
p
a
c
t
i
o
n
Constipation.
Rectal discomfort.
Anorexia
Nausea and vomiting
Abdominal pain
Paradoxical diarrhea (
Liquid stool
leaks around the fecal mass,
imitating incontinence)
Urinary frequency and/or urinary
overflow incontinence.
Abdominal distention and
tenderness.
Fever.
B
o
w
e
l
O
b
s
t
r
u
c
t
i
o
n
Cramping.
Abdominal pain.
Nausea and vomiting.
No gas passing through the rectum.
A “tight” or firm and/or bloated abdomen,
sometimes with abdominal tenderness.
Rapid pulse and rapid breathing during
episodes of cramps.
Colon tumor
Diarrhea resulting from liquid stool leaking
around a partial bowel obstruction.
11
Importance of
reporting
change
P
r
e
v
a
l
e
n
c
e
o
f
c
o
n
s
t
i
p
a
t
i
o
n
i
n
t
h
e
g
e
n
e
r
a
l
p
o
p
u
l
a
t
i
o
n
i
s
d
i
f
f
i
c
u
l
t
t
o
a
s
c
e
r
t
a
i
n
d
u
e
t
o
i
n
a
c
c
u
r
a
t
e
r
e
p
o
r
t
i
n
g
.
(
G
a
r
r
i
g
u
e
s
,
e
t
a
l
.
,
2
0
0
4
)
e
s
t
i
m
a
t
e
s
t
h
a
t
t
h
e
g
e
n
e
r
a
l
p
u
b
l
i
c
h
a
s
a
n
i
n
c
i
d
e
n
c
e
r
a
t
e
b
e
t
w
e
e
n
2
%
-
3
4
%
.
T
h
e
i
n
c
i
d
e
n
c
e
a
m
o
n
g
f
e
m
a
l
e
s
a
n
d
e
l
d
e
r
l
y
a
r
e
h
i
g
h
e
r
(
G
a
r
r
i
g
u
e
s
,
e
t
a
l
.
,
2
0
0
4
)
.
P
r
e
v
a
l
e
n
c
e
o
f
c
o
n
s
t
i
p
a
t
i
o
n
w
i
t
h
i
n
t
h
e
i
n
t
e
l
l
e
c
t
u
a
l
d
i
s
a
b
i
l
i
t
y
p
o
p
u
l
a
t
i
o
n
i
s
a
s
h
i
g
h
a
s
5
0
%
(
R
o
b
e
r
t
s
o
n
,
B
a
i
n
e
s
,
E
m
e
r
s
o
n
,
&
H
a
t
t
o
n
,
2
0
1
7
)
.
I
n
c
r
e
a
s
e
i
n
b
e
h
a
v
i
o
r
s
c
a
n
a
l
s
o
b
e
a
n
i
n
d
i
c
a
t
i
o
n
o
f
c
o
n
s
t
i
p
a
t
i
o
n
.
Any changes noted in bowel habits should be
reported. Individuals that take medications for
constipation should be monitored. To report a change
contact the nurse. If nursing is not available, contact the
PCP or an Urgent Care if issue is found on a
weekend. Delay in seeking care can result in
complications.
12
DSP's connect the dots....
•
Situation:
James lives with his parents. His communication skills are
limited. He is incontinent of bowel and bladder and requires total
assistance with hygiene. He has a history of chronic constipation and
fecal impaction. The PCP has ordered Miralax daily to help soften and
promote bowel movements. James' mother does not like to give Miralax
because it makes hygiene more difficult and he often will have leakage
from his adult brief. She prefers that it remain hard. James attends day
support.
Example of a progress note
: 4/16/20 8:20am James arrives at DS with a frown on his
face. Staff asked his mother about bowel movements in the last 2 days, since he has not
had one while at DS. His mother states, he has not had one at home since last Friday,
today is Wednesday. Mother states that she had not given him Miralax either. James'
stomach appears bloated and he is refusing all food and drink. Staff reported to DS
manager.
Way to go DSP! You
recognized a change in status.
DSP's connect the dots...
14
Use the RAT tool to help staff
recognize risks and prompt
changes within plans and support
instructions. The RAT can help
providers be proactive
.
You are the boots on the ground! Based
on your daily observations you may
recognize a change in status that would
require evaluation. If you notice any of
the risk factors listed below for bowel
obstruction, report and document quickly.
Caregiver
Recommendations
The main management response to constipation in people with intellectual disability is laxative use,
despite limited effectiveness. An improved evidence base is required to support the suggestion that
an individualized, integrated bowel management program may reduce constipation and associated
health conditions in people with intellectual disability (Robertson, Baines, Emerson, & Hatton, 2017).
I
n
i
t
i
a
t
e
a
b
o
w
e
l
m
a
n
a
g
e
m
e
n
t
p
r
o
g
r
a
m
t
h
a
t
i
n
c
l
u
d
e
s
:
1) Having a consistent schedule in place for taking medicines regularly to prevent or relieve
constipation
2) Monitoring of bowel movement frequency, consistency, and volume.
3) Documenting the findings of monitoring by utilizing a tool such as a bowel diary to record stool
frequency and consistency.
Discuss treatment strategies with the individual’s primary care physician (PCP), including
implementation of a bowel management guideline or protocol to ensure the individual receives the
prescribed treatment and proper monitoring for prevention of complications.
15
Diagnosis
•
Diagnosing of constipation may require physical
exams, lab tests and bowel monitoring. The
following questions are usually considered, when
observing a person’s condition and treatment
options:
•
What is the individual’s normal bowel habits?
•
How long has the individual had difficulty with
bowel movements?
•
When was the last time the individual had a
bowel movement?
•
Is the individual passing gas?
•
Does the individual complain about abdominal
or rectal pain when defecating/having a bowel
movement?
•
Does the individual grimace or appear to be in
pain when they are defecating/having a bowel
movement?
•
Always contact the primary care physician
(PCP) if the individual has not had a bowel
movement in 3 days.
Diagnostic
Tests
D
i
a
g
n
o
s
t
i
c
T
e
s
t
s
A general physical exam.
A digital rectal exam.
B
l
o
o
d
t
e
s
t
s
.
T
h
e
p
r
i
m
a
r
y
c
a
r
e
p
h
y
s
i
c
i
a
n
(
P
C
P
)
m
i
g
h
t
c
h
e
c
k
f
o
r
a
n
u
n
d
e
r
l
y
i
n
g
c
o
n
d
i
t
i
o
n
s
u
c
h
a
s
l
o
w
t
h
y
r
o
i
d
l
e
v
e
l
s
(
h
y
p
o
t
h
y
r
o
i
d
i
s
m
)
(
M
a
y
o
C
l
i
n
i
c
,
2
0
1
8
)
.
E
x
a
m
i
n
a
t
i
o
n
o
f
t
h
e
r
e
c
t
u
m
a
n
d
l
o
w
e
r
o
r
s
i
g
m
o
i
d
c
o
l
o
n
(
s
i
g
m
o
i
d
o
s
c
o
p
y
)
.
E
x
a
m
i
n
a
t
i
o
n
o
f
t
h
e
r
e
c
t
u
m
a
n
d
e
n
t
i
r
e
c
o
l
o
n
(
c
o
l
o
n
o
s
c
o
p
y
)
.
Evaluation of anal sphincter muscle
function (anorectal manometry).
M
R
I
(
m
a
g
n
e
t
i
c
r
e
s
o
n
a
n
c
e
i
m
a
g
i
n
g
)
.
17
Prevention is key
Ensure that individuals are receiving high-fiber foods in diet
(according to recommendations of 20-35grams per day)
Avoid eating highly processed foods with low fiber content
Drink plenty of fluids
Stay active and plan activities that promote movement
Assist individuals to establish a schedule (encourage bathroom
breaks 20-30 minutes after meals)
Allow plenty of time for bathroom breaks
Follow positioning protocol to promote natural bowel motility
Administer stool softeners and/or laxatives as prescribed by PCP
Track bowel movement frequency, consistency, and volume.
(See note)
*
A constipation protocol should be established for individuals taking stool
softeners, laxatives on a routine basis or history of bowel obstruction.*
Case Study
M
eet Joey. He is 34 years old with limited verbal
communication. He has a diagnosis of Cerebral Palsy, Autism,
constipation. He is incontinent of bowel and bladder.
Today Joey’s mother calls you to report that he is very
agitated, biting her when she gets close, and refusing to eat or
drink. She asks if REACH would be able to help her with his
behavior. You ask if she has taken his temperature or if he
appears to be in pain. She replies that he is angry with her and
will not allow her to touch him. Since you have a good
relationship with Joey, you tell her you will come by the home
shortly.
Upon arrival you notice that Joey is very agitated and
grimacing. You talk to him in a soothing voice and he allows you
to touch his hand. His skin feels normal temperature. You notice
a Miralax container sitting on the counter, and ask the mother if
Joey has taken his medications today. She states “yes, but I only
give him Miralax when he gets really constipated.” You ask about
his last bowel movement and she is unable to recall, but states
she prefers for his stool to be less messy and easier to clean
up. You notice that Joey’s stomach looks bloated, you try to
gently rub his stomach and he reacts by trying to bite you.
19
Apply what you have learned
State (3) caregiver recommendations to avoid the
complications of constipation the Individual
experienced in the case study.
20
1.______________________
2.______________________
3.______________________
21
SC's- as you are completing the RAT tool keep in mind there are key
diagnoses and situations you need to incorporate in discussion with
providers and caregivers to ensure risk factors are being recognized.
SC's connect the dots with the RAT Tool...
RAT
TOOL
Bowel
Management
Program
Positioning Protocol –
does the individual use a
stander?
Hydration Status-does
the individual require
prompting to drink?
Medications:
Antidepressants, Opioids,
Calcium Channel Blockers,
Iron supplements,
Anticholinergics,
Diuretics, and NSAIDS.
Laxative Use –
how often are
PRN's being used
for constipation
Rectal Prolapse
Rectocele
Anal Fissure
Colon Cancer
Behaviors
Increase in self-injurious
behaviors.
Postures that indicate the person
is withholding stool (standing
on tiptoes and then rocking back
on the heels of the feet,
clenching buttocks muscles, other
unusual “dancelike” behaviors.
22
Follow these steps to success…
Remember! Think about
all settings: home, Day
Support, Community
Engagement
Prior to ISP meeting, review
discharge summaries,
medical reports, and health
history for information.
Skip Step 2 and go to Section F
23
Follow these steps to success…
During the ISP meeting ask
all participants if they are
aware of any risk factors
listed in Step 2
Dr. Hopewell
Nov 15, 20
24
R
e
f
e
r
e
n
c
e
s
C
harlot, L., Abend, S., Ravin, P., Mastis, K., Hunt, A., & Deutsch, C. (2010). Non-psychiatric health problems
among psychiatric inpatients with intellectual disabilities.
Journal of Intellectual Disability Research
,
55
(2), 199–
209. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3646333/
Cleveland Clinic. (2019).
Improving your health with fiber. Retrieved from
https://my.clevelandclinic.org/health/articles/14400-improving-your-health-with-fiber
Forootan, M., Bagheri, N. & Darvishi, M. (2018). Chronic constipation: A review of literature.
Medicine
,
97
(20).
Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/29768326
Garrigues, V., Gálvez, C., Ortiz, V., Ponce, M., Nos, P., & Ponce, J. (2004). Prevalence of Constipation:
Agreement among Several Criteria and Evaluation of the Diagnostic Accuracy of Qualifying Symptoms and
Self-reported Definition in a Population-based Survey in Spain.
Am J Epidemiol
,
159
, 520-526.
Lewis, S. J., & Heaton, K. W. (1997). Stool form scale as a useful guide to intestinal transit time.
Scandinavian
Journal of Gastroenterology,
32
(9), 920-924. Retrieved from
https://www.nice.org.uk/guidance/cg99/resources/cg99-constipation-in-children-and-young-people-bristol-stool-
chart-2
Mayo Clinic. (2018). Constipation.
Retrieved from
https://www.mayoclinic.org/diseases-
conditions/constipation/symptoms-causes/syc-20354253
Mayo Clinic. (2019).
Nutrition and healthy eating: Dietary fiber essential for a healthy diet
. Retrieved
from:
https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fiber/art-20043983
National Institute on Aging (NIA). (2013).
Concerned About Constipation?
https://www.nia.nih.gov/health/concerned-about-constipation
National Cancer Institute (n.d). NCI Dictionary of Cancer Terms, Fecal Impaction. Retrieved from
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/fecal-impaction
25
R
e
f
e
r
e
n
c
e
s
National Institute of Diabetes and Digestive and Kidney Diseases (n.d.). Let’s talk about
bowel control. Retrieved from
file:///C:/Users/dha92624/Downloads/Stool_Diary_508.pdf
Nikjooy, A., Jafari, H., Saba, M., Ebrahimi, N., Mirzael, R. (2018). Patient assessment of
constipation quality of life questionnaire: Tradition, cultural adaptation, reliability and validity of the
Persian version.
Iran J Med Sci 43
(3), 261-268.
Pashankar, D. S. (2005). Childhood constipation: evaluation and management.
Clinics in colon
and rectal surgery
,
18
(2), 120–127. doi:10.1055/s-2005-870894
Robertson, J., Baines, S., Emerson, E. & Hatton, C. (2018). Constipation management in people
with intellectual disability: A systematic review.
Journal of Applied Research in Intellectual
Disabilities
,
31
(5), 709-724. Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1111/jar.12426
Smith, M. A. & Escude, C. L. (2015). Intellectual and developmental disabilities.
Clinical
Advisor
,
18
(2), 48–59. Retrieved from
https://www.clinicaladvisor.com/home/cme-ce-
features/intellectual-and-%E2%80%A8developmental-disabilities/2/
Talley, N. J. (2004). Definitions, epidemiology, and impact of chronic constipation.
Reviews in
Gastroenterological Disorders
,
4
, S3-S10.
UVA Children’s (n.d.). Constipation in Children. Retrieved from
https://childrens.uvahealth.com/services/pediatric-digestive-health/constipation
26
This training program by The Virginia Department of Behavioral Health and Developmental Services focuses on defining constipation, identifying causes and complications, recognizing bowel obstructions, and understanding signs and symptoms of fecal impaction. Caregiver recommendations and the roles of medical professionals are highlighted to raise awareness about these important health issues.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author.If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
You are allowed to download the files provided on this website for personal or commercial use, subject to the condition that they are used lawfully. All files are the property of their respective owners.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author.
E N D
Presentation Transcript
Constipation and Bowel Obstructions Risk Awareness Training (RAT) Presented by: The Virginia Department of Behavioral Health and Developmental Services The Office of Integrated Health Health Supports Network 1
Objectives 1. Define constipation 2. List (2) common causes of constipation 3. State (2) complications of constipation 4. Define bowel obstruction 5. Identify (4) signs and symptoms of fecal impaction 6. Identify (3) caregiver recommendations 7. List two medical professionals that can help with assessing for bowel obstruction
3 DSP's and caregivers- you will learn important risk factors associated with constipation and bowel obstructions, learn to recognize signs and symptoms, and the importance of recognition and reporting. Who benefits from this training? Support Coordinators-you will learn important risk factors associated with constipation and bowel obsturction, understand the signs and symptoms that DSP's and caregivers are going to recognize and provide in documentation, and learn diagnosis that may be associated with risk factors.
Terms and Definitions Normal bowel habits- each person s bowel habits are individualized. While some may eliminate every day, others may only have a bowel movement 3 times a week. Many factors contribute to frequency of bowel movements such as hydration, exercise, and mobility. Constipation- is defined as difficulty passing stool. Having fewer than three (3) bowel movements a week. (Mayo Clinic, 2018) Functional Constipation- is defined as having no anatomical or genetic defect that is the underlying cause. There is no organic cause. Cause may be associated with inadequate fluid intake or lack or fiber in diet. (Talley, 2004) Organic Constipation- when there is an identifiable condition, disorder or diagnosis causing constipation. (Pashankar, 2005). Chronic Constipation- is defined as painful bowel movements that are hard and lumpy, with less than two movements a week, and may have feeling of incomplete defecation of stool (Talley, 2004) 4
Signs and Symptoms- Adults Passing fewer than (3) stools per week or fewer bowel movements than usual. Straining/grunting Stool smearing in underwear or briefs Extended periods of time sitting on toilet trying to pass stool Refusing to eat or drink Hard or dry stool Hard, protruding stomach Abdominal pain, cramping, bloating 5
Fear of the bathroom or toilets (public bathrooms). Toilet training problems in young children. Older children ignoring the urge to pass stool. Reduced stool from eating a low-fiber diet, not eating often enough or not drinking enough fluids. Intolerance to cow's milk. Lack of physical activity. Signs and Symptoms- Children Side effects from certain medications. Pain from hemorrhoids. Examples of rare, but serious, causes of constipation in children include: Hirschsprung's disease: A genetic condition that prevents the colon from working normally. Thyroid conditions. Problems with the spinal cord (cerebral palsy). Malformations of the anus and rectum. (UVA Children s, n.d.) 6
Common Causes of Common Causes of Organic Constipation Organic Constipation Hypothyroidism Pseudo obstruction or rectal tumors Neurologic conditions such as Cerebral Palsy IBD- Inflammatory bowel disease Diabetes Mellitus Celiac disease Dysphagia (inadequate consumption of fiber and fluids) Congenital disorders such as Tay Sachs, Prader-Willi, Hirschprung Disease, Spina Bifida, Trisomy 13, Down Syndrome Congestive Heart Failure Organic Constipation- there is an identifiable condition, disorder or diagnosis causing constipation (Pashankar, 2005).
Common causes of Common causes of Functional Constipation Functional Constipation Inadequate fluid intake Inadequate fiber intake Disruption of regular diet Disruption of routine Inactivity or immobility Poor body alignment Absence of upright standing Consumption of large amounts of dairy products Stress Resistance to bowel movements Overuse of laxatives Depression Eating disorders Functional Constipation- is defined as having no anatomical or genetic defect that is the underlying cause. There is no organic cause (Talley, 2004)
Complications Complications of of Constipation Constipation Hemorrhoids Rectal bleeding Anal fissures (tears in skin around the anus) Rectal prolapse (the large intestine detaches inside the body and pushes out of the rectum) Fecal impaction (hard, dry stool is stuck in the body and unable to be expelled naturally) Diverticulitis 9
Fecal Impaction vs Bowel Obstruction Fecal Impaction Bowel Obstruction Fecal impaction occurs when hard, dry stool cannot pass through the colon or rectum. Fecal impaction may be caused by using laxatives too often, using certain types of pain medicines, little or no physical activity over a long period, diet changes, or constipation that is not treated (NCI, n.d.). A bowel/intestinal blockage or obstruction occurs when something prevents the contents of the intestines from passing normally through the digestive tract. The problem causing the blockage can be inside or outside the intestine. 10
Signs & Symptoms Bowel Obstruction Fecal Impaction Constipation. Rectal discomfort. Anorexia Nausea and vomiting Abdominal pain Paradoxical diarrhea (Liquid stool leaks around the fecal mass, imitating incontinence) Urinary frequency and/or urinary overflow incontinence. Abdominal distention and tenderness. Fever. Cramping. Abdominal pain. Nausea and vomiting. No gas passing through the rectum. A tight or firm and/or bloated abdomen, sometimes with abdominal tenderness. Rapid pulse and rapid breathing during episodes of cramps. Colon tumor Diarrhea resulting from liquid stool leaking around a partial bowel obstruction. 11
Importance of reporting change Prevalence of constipation in the general population is difficult to ascertain due to inaccurate reporting. (Garrigues, et al., 2004) estimates that the general public has an incidence rate between 2%-34%. The incidence among females and elderly are higher (Garrigues, et al., 2004). Prevalence of constipation within the intellectual disability population is as high as 50% (Robertson, Baines, Emerson, & Hatton, 2017). Increase in behaviors can also be an indication of constipation. Any changes noted in bowel habits should be reported. Individuals that take medications for constipation should be monitored. To report a change contact the nurse. If nursing is not available, contact the PCP or an Urgent Care if issue is found on a weekend. Delay in seeking care can result in complications. 12
DSP's connect the dots.... Situation: James lives with his parents. His communication skills are limited. He is incontinent of bowel and bladder and requires total assistance with hygiene. He has a history of chronic constipation and fecal impaction. The PCP has ordered Miralax daily to help soften and promote bowel movements. James' mother does not like to give Miralax because it makes hygiene more difficult and he often will have leakage from his adult brief. She prefers that it remain hard. James attends day support. Way to go DSP! You recognized a change in status. Example of a progress note: 4/16/20 8:20am James arrives at DS with a frown on his face. Staff asked his mother about bowel movements in the last 2 days, since he has not had one while at DS. His mother states, he has not had one at home since last Friday, today is Wednesday. Mother states that she had not given him Miralax either. James' stomach appears bloated and he is refusing all food and drink. Staff reported to DS manager.
DSP's connect the dots... Use the RAT tool to help staff recognize risks and prompt changes within plans and support instructions. The RAT can help providers be proactive. You are the boots on the ground! Based on your daily observations you may recognize a change in status that would require evaluation. If you notice any of the risk factors listed below for bowel obstruction, report and document quickly. 14
Caregiver Recommendations The main management response to constipation in people with intellectual disability is laxative use, despite limited effectiveness. An improved evidence base is required to support the suggestion that an individualized, integrated bowel management program may reduce constipation and associated health conditions in people with intellectual disability (Robertson, Baines, Emerson, & Hatton, 2017). Initiate a bowel management program that includes: 1) Having a consistent schedule in place for taking medicines regularly to prevent or relieve constipation 2) Monitoring of bowel movement frequency, consistency, and volume. 3) Documenting the findings of monitoring by utilizing a tool such as a bowel diary to record stool frequency and consistency. Discuss treatment strategies with the individual s primary care physician (PCP), including implementation of a bowel management guideline or protocol to ensure the individual receives the prescribed treatment and proper monitoring for prevention of complications. 15
exams, lab tests and bowel monitoring. The following questions are usually considered, when observing a person s condition and treatment options: What is the individual s normal bowel habits? How long has the individual had difficulty with bowel movements? When was the last time the individual had a bowel movement? Is the individual passing gas? Does the individual complain about abdominal or rectal pain when defecating/having a bowel movement? Does the individual grimace or appear to be in pain when they are defecating/having a bowel movement? Always contact the primary care physician (PCP) if the individual has not had a bowel movement in 3 days. Diagnosing of constipation may require physical Diagnosis
Diagnostic Tests A general physical exam. A digital rectal exam. Blood tests. The primary care physician (PCP) might check for an underlying condition such as low thyroid levels (hypothyroidism) (Mayo Clinic, 2018). Examination of the rectum and lower or sigmoid colon (sigmoidoscopy). Examination of the rectum and entire colon (colonoscopy). Evaluation of anal sphincter muscle function (anorectal manometry). MRI (magnetic resonance imaging). Diagnostic Tests 17
Prevention is key Ensure that individuals are receiving high-fiber foods in diet (according to recommendations of 20-35grams per day) Avoid eating highly processed foods with low fiber content Drink plenty of fluids Stay active and plan activities that promote movement Assist individuals to establish a schedule (encourage bathroom breaks 20-30 minutes after meals) Allow plenty of time for bathroom breaks Follow positioning protocol to promote natural bowel motility Administer stool softeners and/or laxatives as prescribed by PCP Track bowel movement frequency, consistency, and volume. (See note) *A constipation protocol should be established for individuals taking stool softeners, laxatives on a routine basis or history of bowel obstruction.*
Case Study Meet Joey. He is 34 years old with limited verbal communication. He has a diagnosis of Cerebral Palsy, Autism, constipation. He is incontinent of bowel and bladder. agitated, biting her when she gets close, and refusing to eat or drink. She asks if REACH would be able to help her with his behavior. You ask if she has taken his temperature or if he appears to be in pain. She replies that he is angry with her and will not allow her to touch him. Since you have a good relationship with Joey, you tell her you will come by the home shortly. Today Joey s mother calls you to report that he is very grimacing. You talk to him in a soothing voice and he allows you to touch his hand. His skin feels normal temperature. You notice a Miralax container sitting on the counter, and ask the mother if Joey has taken his medications today. She states yes, but I only give him Miralax when he gets really constipated. You ask about his last bowel movement and she is unable to recall, but states she prefers for his stool to be less messy and easier to clean up. You notice that Joey s stomach looks bloated, you try to gently rub his stomach and he reacts by trying to bite you. Upon arrival you notice that Joey is very agitated and 19
Apply what you have learned State (3) caregiver recommendations to avoid the complications of constipation the Individual experienced in the case study. 1.______________________ 2.______________________ 3.______________________ 20
SC's connect the dots with the RAT Tool... SC's- as you are completing the RAT tool keep in mind there are key diagnoses and situations you need to incorporate in discussion with providers and caregivers to ensure risk factors are being recognized. Positioning Protocol does the individual use a stander? Hydration Status-does the individual require prompting to drink? Bowel Management Program RAT TOOL Medications: Antidepressants, Opioids, Calcium Channel Blockers, Iron supplements, Anticholinergics, Diuretics, and NSAIDS. Postures that indicate the person is withholding stool (standing on tiptoes and then rocking back on the heels of the feet, clenching buttocks muscles, other unusual dancelike behaviors. Laxative Use how often are PRN's being used for constipation Rectal Prolapse Rectocele Anal Fissure Colon Cancer Behaviors Increase in self-injurious behaviors. 21
Prior to ISP meeting, review discharge summaries, medical reports, and health history for information. Follow these steps to success Remember! Think about all settings: home, Day Support, Community Engagement Skip Step 2 and go to Section F 22
Follow these steps to success During the ISP meeting ask all participants if they are aware of any risk factors listed in Step 2 23 Dr. Hopewell Nov 15, 20
References References Charlot, L., Abend, S., Ravin, P., Mastis, K., Hunt, A., & Deutsch, C. (2010). Non-psychiatric health problems among psychiatric inpatients with intellectual disabilities. Journal of Intellectual Disability Research, 55(2), 199 209. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3646333/ Cleveland Clinic. (2019). Improving your health with fiber. Retrieved from https://my.clevelandclinic.org/health/articles/14400-improving-your-health-with-fiber Forootan, M., Bagheri, N. & Darvishi, M. (2018). Chronic constipation: A review of literature. Medicine, 97(20). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29768326 Garrigues, V., G lvez, C., Ortiz, V., Ponce, M., Nos, P., & Ponce, J. (2004). Prevalence of Constipation: Agreement among Several Criteria and Evaluation of the Diagnostic Accuracy of Qualifying Symptoms and Self-reported Definition in a Population-based Survey in Spain. Am J Epidemiol, 159, 520-526. Lewis, S. J., & Heaton, K. W. (1997). Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology, 32(9), 920-924. Retrieved from https://www.nice.org.uk/guidance/cg99/resources/cg99-constipation-in-children-and-young-people-bristol-stool- chart-2 Mayo Clinic. (2018). Constipation.Retrieved from https://www.mayoclinic.org/diseases- conditions/constipation/symptoms-causes/syc-20354253 Mayo Clinic. (2019). Nutrition and healthy eating: Dietary fiber essential for a healthy diet. Retrieved from: https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fiber/art-20043983 National Institute on Aging (NIA). (2013). Concerned About Constipation? https://www.nia.nih.gov/health/concerned-about-constipation National Cancer Institute (n.d). NCI Dictionary of Cancer Terms, Fecal Impaction. Retrieved from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/fecal-impaction 25
References References National Institute of Diabetes and Digestive and Kidney Diseases (n.d.). Let s talk about bowel control. Retrieved from file:///C:/Users/dha92624/Downloads/Stool_Diary_508.pdf Nikjooy, A., Jafari, H., Saba, M., Ebrahimi, N., Mirzael, R. (2018). Patient assessment of constipation quality of life questionnaire: Tradition, cultural adaptation, reliability and validity of the Persian version. Iran J Med Sci 43(3), 261-268. Pashankar, D. S. (2005). Childhood constipation: evaluation and management. Clinics in colon and rectal surgery, 18(2), 120 127. doi:10.1055/s-2005-870894 Robertson, J., Baines, S., Emerson, E. & Hatton, C. (2018). Constipation management in people with intellectual disability: A systematic review. Journal of Applied Research in Intellectual Disabilities, 31(5), 709-724. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/jar.12426 Smith, M. A. & Escude, C. L. (2015). Intellectual and developmental disabilities. Clinical Advisor, 18(2), 48 59. Retrieved from https://www.clinicaladvisor.com/home/cme-ce- features/intellectual-and-%E2%80%A8developmental-disabilities/2/ Talley, N. J. (2004). Definitions, epidemiology, and impact of chronic constipation. Reviews in Gastroenterological Disorders, 4, S3-S10. UVA Children s (n.d.). Constipation in Children. Retrieved from https://childrens.uvahealth.com/services/pediatric-digestive-health/constipation 26
