Understanding Bowel Problems in Older People: Part 2

By Wilson, Lesley A

By reading this article and writing a practice profile, you can gain a certificate of learning. You have up to a year to send in your practice profile. Guidelines on how to write and submit a profile are featured at the end of this article.

Summary

Bowel problems can be devastating for patients and those who care for them. Accurate assessment is essential in determining the cause of symptoms and deciding treatment and management strategies. Treatment can be complex, but with care and patience improvement or cure is possible. Part 1 of this two-part article offered an overview of bowel problems in older people and an introduction to assessment. Part 2 discusses specific components of assessment, treatment and management.

Key words

* Older people: nursing

* Constipation

* Faecal incontinence

* Bowel management

These key words are based on subject headings from the British Nursing Index. This article has been subject to double-blind review.

Aims and intended learning outcomes

This article aims to assist in increasing the understanding of bowel problems in older people and enable nurses to support their patients by providing advice and information to prevent problems developing and deal effectively with existing conditions. After reading this article and completing the activities you should be able to:

* discuss the incidence of constipation and faecal incontinence

* define constipation and faecal incontinence

* describe the causes of constipation and faecal incontinence

* describe the normal physiology of defecation

* list the components of a comprehensive assessment for bowel problems

* describe treatment and management strategies for bowel problems.

Now do Time out 1 and Time out 2

Fluid chart, food diary, stool chart

It is important to determine fluid and food intake, as this will help to identify dietary deficiencies, and may also identify specific substances that can exacerbate symptoms. Intolerance of certain foods is a common problem causing symptoms described as ‘irritable bowel syndrome’, where loose stools or constipation can be experienced. It is important to identify these foods and eliminate them from the diet. A fluid chart should include the frequency, quantity and type of fluid consumed. Charts can be obtained from some of the continence aid companies, or a specific chart can be devised to suit each patient. Food diaries should indicate all food consumed, the amount, and the times of meals or snacks. A stool chart should be kept to record bowel activity, enabling the stools to be observed for colour, consistency and odour. The Bristol Stool Form Scale is a useful tool that has been developed to assess objectively stool consistency (Figure 1).

Food diaries and fluid charts, together with stool charts, can be a significant aid to rectify problems with an individual’s dietary or fluid intake that may be causing or contributing to their symptoms.

Physical examination

Physical examination should include both abdominal palpation and rectal examination. Distension, pain or discomfort on abdominal examination may suggest the presence of gas, fluid or an obstruction, which could be a mass or loaded bowel. Rectal examination will confirm whether the rectum is loaded with faeces but will also assist in identifying an enlarged prostate or prolapse (Edwards et al 2003).

Before performing any invasive procedure, consent from the patient must be obtained, as proceeding without informed consent could be construed as abuse. Guidance can be found in the literature (McKee 1999, Wallace 2000, Willis 2000), and the RCN has published a guidance document on digital rectal examination and manual evacuation of faeces (RCN 2000).

Functional assessment

Functional assessment of such attributes as hearing, eyesight, mobility and dexterity is important, especially when assessing an older person whose functioning ability may compromise daily activities (Wilson 2003). It may also be possible to identify co- existent cognitive deficit that can contribute to the person’s difficulties. Mobility, especially, can be a significant factor when dealing with a patient who is constipated.

The outcome of the assessment process will be used to determine the treatment or management strategies to be implemented.

Treatment and management

The concept of treatment versus management strategies is a useful one, especially when caring for the older adult. Treatment is aimed at correcting or changing body functioning and is patient oriented. Conversely, management is a set of processes to improve the situation that does not effect a change in body functioning, and tends to be carer oriented (Ouslander and Schnelle 1993). Treatment or management strategies used for older people are the same as those for younger adults but, as improvement tends to be slower, it is often advisable to employ management strategies initially (Wilson 2003).

Figure 1 Bristol stool form scale

It is most important to base the treatment or management strategies on the findings from the assessment and to use strategies, such as diet or fluid intake modification, and behavioural techniques, such as pelvic floor exercises, before implementing more aggressive interventions such as laxatives, suppositories or enemas. It is likely that even when patients experience faecal incontinence, assessment will indicate constipation as the symptom requiring management.

A team approach to treatment and management should be used for patients with bowel problems. It may be necessary to enlist the help of dieticians, physiotherapists, occupational therapists, social workers and other health professionals as appropriate in each case, as well as medical and nursing staff being involved in the patient’s care (Winney 1998).

Management and treatment strategies are listed in Table 1. It may be appropriate to combine more than one intervention or lifestyle change to deal with the problem effectively.

Diet or fluid manipulation

It is important to correct fluid intake problems and adjust dietary fibre (dependent on assessment findings), and eliminate problem foods where identified. Older people can find it difficult to eat the recommended five portions of fruit and vegetables each day, but fruit juices introduced to the diet will increase fibre content as well as fluid intake. Prune juice has a laxative effect as it contains magnesium salts (Newman 1999). Older people seem to get out of the habit of drinking sufficient fluid each day. One and a half to two litres a day is usually considered to be adequate (Madden 2000, Morrison 2000). When a person’s intake is considerably less than this, they should be encouraged to increase their intake gradually, as they will find it difficult to do this in one step. Dramatic increases in fluid may cause nausea and make the patient less inclined to persevere. If holding cups is a problem, as normal cups or glasses can be heavy when full, consider using lighter, plastic cups or only half-filling the glass, refilling frequently.

Now do Time out 3

Table 1 Management and treatment strategies for bowel problems

Behavioural interventions

Active participation by the patient is necessary, so comprehensive assessment, including cognitive ability and motivation, must be carried out in order to recommend the most appropriate strategy. Success can be improved when a knowledgeable and willing carer is involved (Fonda et al 1999). Behavioural interventions include:

* pelvic floor exercises – to strengthen the muscles of the pelvic floor. This approach can be effective in treating faecal incontinence. Even when there is damage to the anal sphincters, some improvement can be gained. Where there is major damage to the sphincter, exercises will not improve the situation and surgical repair will be necessary (Kamm 2003)

* habit training – to educate the bowel and establish routine. The patient should sit on the toilet about 30 minutes after a meal whether they have an urge or not. After breakfast or the evening meal may be the most convenient times. Eating will stimulate peristaltic action and this may give them the urge to evacuate the bowel. It will also allow them to focus and establish a routine (Edwards et al 2003). This may be combined with the bracing technique.

* the bracing technique – to ensure correct positioning and evacuation. The most effective way for the patient to locate the muscles in the abdomen necessary for bracing is to place the hands either side of the waist and cough. The waist should expand (Edwards et al 2003). Grunting can also have the same effect. If it is necessary to teach the bracing technique, it is usually recommended that this is combined with habit training and should be performed while sitting on the toilet. The bracing technique is taught to correct paradoxical contraction of the external sphincter (anismus) when the anal muscles contract preventing evacuation (Edwards etal 2003)

* biofeedback – with the use of specialist equipment biofeedback aims to train the patient to become aware of the muscles involved with defecation and to use them correctly. The patient learns to recognise rectal distension, to strain correctly and to contract and relax the muscles. The underlying principle is Operant conditioning’ or ‘learning through reinforcement’ (Storrie 1997)

* electro-stimulation – an electrical stimulus causes contraction of the weak muscles, strengthening them until the patient can join in with contractions and even\tually do them without needing stimulation.

Digital stimulation

Stimulation of the anal area can provoke expulsion of stool (the administering of suppositories will involve stimulation as well as the effect of the suppository itself).

Abdominal massage

This can be taught to the patient or carer, and can be beneficial in retraining the bowel by stimulating peristalsis in the colon, which will help to relieve flatulence (Richards 1998). Slow massage will also relieve tension in the muscles, increasing blood circulation and lymphatic drainage (Edwards et al 2003).

Laxatives and aperients

Often a first-line management but laxatives should be used with caution and, when used, chosen carefully. The main groups of laxatives fall into four main groups:

* bulking agents such as Fybogel and Normacol – can be counter- productive especially when peristalsis is impaired (Winge et al 2003)

* stimulants – it has been suggested that prolonged use of stimulant laxatives such as senna or bisacodyl can lead to colonie inertia due to nerve damage (Winney 1998, Norton 1996)

* stool softeners – can exacerbate the problem by rendering the stool so soft that evacuation is made more difficult

* osmotic agents – work by maintaining the fluid content of the stool. These are often the first choice. These agents, such as Lactulose and Movicol, are considered to be more gentle with fewer side effects.

Enemas/suppositories

Care should be taken in the use of enemas and suppositories as with oral laxatives. These can be stimulant (glycerol, bisacodyl), osmotic (rectal phosphates), rectal sodium citrate (micro-enemas) and stool softening (docusate sodium, arachis oil). Glycerine suppositories are widely used. These lubricate the anorectum as well as having a stimulant effect and no significant side effects (Edwards et al 2003).

Manual evacuation of faeces

In some conditions, especially when there is nerve damage (for example, in multiple sclerosis), regular manual bowel evacuation is important to maintain the patient’s regime. It is important that the person performing this procedure is suitably trained (RCN 2000). In recent years, with an increasing awareness of the risk of litigation, reluctance has grown within clinical areas for staff to perform this procedure. This can cause tremendous problems to patients who have an established bowel regime based on manual evacuation, and staff should ensure this is maintained wherever possible. It may be necessary for special arrangements to be put in place such as inviting the usual carer into the clinical area during the patient’s stay in hospital. The RCN guidance sets out the professional and legal framework for this procedure (RCN 2000).

Anal plug

This is an occlusive device and is used with faecal leakage. It can enable the patient to be comfortable and confident when going out.

Now do Time out 4

Care pathways

Care pathways are widely used to guide the management of many conditions. The advantage of care pathways is that non-specialist nurses can treat a greater number of conditions with confidence before having to enlist the help of specialists, and patients can be treated by a nurse they already know and trust. Care pathways have been developed for bowel problems (Bayliss 2000). Many areas are now using bowel care pathways, either developing the North Hampshire pathways to suit their client group or producing their own. Figure 2 is an example and Figure 3 shows the accompanying constipation guidelines.

Figure 2 Bowel care pathway

Surgery

In some cases, conservative treatments are not effective and surgical techniques have to be used. With damage to the anal sphincters, often obstetric in origin, overlap sphincter repair is usually performed. Short term, the results are good but not so satisfactory in the long term. Other surgical interventions include artificial bowel sphincters or repositioning of the gracilis muscle around the anus to form a sphincter (Kamm 2003). Alternatively, stimulation of the sacral nerves by the insertion of electrodes subcutaneously can be successful (Kamm 2003).

Now do Time out 5

Prevention

In order to prevent older people developing bowel problems, it is essential to be aware of the risk factors such as reduced mobility, poor diet, loss of appetite and poor fluid intake. Episodes of ill health can precipitate bowel problems, and bowel functioning should be sensitively observed and monitored as routine. Early treatment of a condition, before it becomes a significant problem, is always easier and less distressing for the individual.

Now do Time out 6

Figure 3 Constipation guidelines

Conclusion

Bowel problems can be devastating for the patient and for their carers and families. Faecal incontinence in older people, most commonly due to overflow leakage as a result of constipation, can often mean the breakdown of care at home causing older people to be prematurely admitted to a residential facility.

The treatment and management of bowel problems can be complex and difficult but, in many cases, much can be done to alleviate symptoms and improve the situation with care and patience.

Accurate assessment is essential to determine the cause of the symptoms experienced by the patient, to indicate whether further referral is appropriate and to ensure the implementation of the most appropriate intervention.

It is the responsibility of all nurses, especially those working with older people, to develop an understanding of constipation and faecal incontinence to enable them to identify symptoms early and prevent them from becoming serious problems.

Now do Time out 7

Practice profile

What do I do now?

* Using the information in section 1 to guide you, write a practice profile of between 750 and 1,000 words – ensuring that you have related it to the article that you have studied. see the examples in section 2.

* Write ‘Practice Profile’ at the top of your entry followed by your name, the title of the article, which is: ‘Understanding bowel problems in older people: part 2′, and the article number, which is NOP549.

* Complete all of the requirements of the cut-out form provided and attach it securely to your practice profile. Failure to do so will mean that your practice profile cannot be considered for a certificate.

* You are entitled to unlimited free entries. Using an A4 envelope, send for your free assessment to: Practice Profile, RCN Publishing Company, Freepost PAM 10155, Harrow, Middlesex HAI 3BR by December 2006. Please do not staple your practice profile and cut- out slip – paper-clips are recommended. You can also email practice profiles to practiceprofile@rcnpublishing.co.uk. You must also provide the same information that is requested on the cut-out form. Type ‘Practice Profile’ in the email subject field to ensure you are sent a response confirming receipt.

* You will be informed in writing of your result. A certificate is awarded for successful completion of the practice profile.

* Feedback is not provided: a certificate indicates that you have been successful.

* Keep a copy of your practice profile and add this to your professional profile – copies are not returned to you.

1. Framework for reflection

* Study the checklist (section 3).

* What have I learnt from this article?

* To what extent were the intended learning outcomes met?

* What do I know, or can I do, now, that I did not/could not before reading the article?

* What can I apply immediately to my practice or client/patient care?

* Is there anything that I did not understand, need to explore or read about further, to clarify my understanding?

* What else do I need to do/know to extend my professional development in this area?

* What other needs have I identified in relation to my professional development?

* How might I achieve the above needs? (It might be helpful to convert these to short/medium/long-term goals and draw up an action plan.)

2. Examples of practice profile entries

Example 1 After reading a CPD article on ‘Communication skills’, Jenny, a practice nurse, reflects on her own communication skills and re-arranges her clinic room so that she will sit next to her patients when talking to them. She makes a conscious decision to pay attention to her own body language, posture and eye contact, and notices that communication with patients improves. This forms the basis of her practice profile.

Example 2 After reading a CPD article on ‘Wound care’, Amajit, a senior staff nurse on a surgical ward, approached the nurse manager about her concerns about wound infections on the ward. Following an audit which Amajit undertook, a protocol for dressing wounds was established which led to a reduction in wound infections in her ward and across the directorate. Amajit used this experience for her practice profile and is now taking part in a region-wide research project.

3. Portfolio submission

Checklist for submitting your practice profile

* Have you related your practice profile to the article?

* Have you headed your entry with: the title ‘Practice Profile’; your name; the title of the article; and the article number?

* Have you written between 750 and 1,000 words?

* Have you kept a copy of the practice profile for your own portfolio?

* Have you completed the cut-out form and attached it to your entry?

* Have you indicated whether you would like your practice profile to be considered for publication?

NOP549 Wilson L (2005) Understanding bowel problems in older people: part 2 Nursing Older People. 17, 9, 24-29. Date of acceptance: 14 September 2005

Online

For related articles visit our online archive at: www.nursingolderpeople.co.uk and search using the key words above.

Time out 1

What would you include in your assessment history of an older person experiencing bowel problems. Review the assessment forms used in your practice area. Evaluate these for comprehensiveness of cover and effectiveness in use.

Time out 2

Consider two people you are nursing who have bowel symptoms. Devise \fluid charts and food diaries for each of them to complete to ensure all the relevant information is obtained. If fluid charts and food diaries have already been completed, consider the information recorded. Is it comprehensive?

Are there any changes you would like to make to the charts to make it easier for the patient and improve the quality of the information?

Consider each person as an individual and reflect this in the way you ask them to record the information.

Time out 3

Consider what sort of advice you could give to patients who have poor diet, loss of appetite and poor fluid intake to improve their nutritional status and reduce their tendency to dehydration. What other health professionals could you involve to assist you?

Time out 4

Consider what simple changes you could make to help improve the functional ability of the patients you care for. Which health professionals would it be appropriate to involve in this strategy?

Time out 5

Reflect on two people you have nursed who developed bowel symptoms. Could you have prevented their bowel problems developing? What strategies could you employ to prevent patients developing bowel problems?

Time out 6

Reflect on what you have learned by reading this article and undertaking the Time out activities. Discuss this with your work colleagues and plan what changes could be made in your practice.

Time out 7

Now that you have read this article you might like to consider writing a practice profile. Guidelines to help you write and submit a profile are outlined on page 30

References

Bayliss V (2000) Worth Hampshire Bowel Care Pathway. Uxbridge, Norgine Ltd.

Edwards C et al (2003) Down, down and away! An overview of adult constipation and faecal incontinence. In Getliffe K, Dolman M (eds) Promoting Continence: A Clinical and Research Resource. Edinburgh, Bailliere Tindall.

Fonda D et al (1999) Management of incontinence in older people. In Abrams P et al (eds) Incontinence: 1st International Consultation on Incontinence. Plymouth, Health Publications.

Kamm MA (2003) Faecal incontinence. British Medical Journal. 327, 7427, 12991300.

Madden V (2000) Nutritional benefits of drinks. Nursing Standard. 15, 13, 4752.

McKee D (1999) The legal framework for informed consent. Professional Nurse. 14, 10,688-690.

Morrison C (2000) Helping patients to maintain a healthy fluid balance. Nursing Times Plus. 96, 31, 3-4.

Newman DK (1999) The Urinary Incontinence Sourcebook. Los Angeles, Lowell House.

Norton C (1996) The causes and nursing management of constipation. British Journal of Nursing. 5, 2, 1252-1258.

Ouslander JG, Schnelle JF (1993) Assessment, treatment and management of urinary incontinence in the nursing home. In Rubenstein LZ, Wieland D (eds) Improving Care in the Nursing Home: Comprehensive Reviews of Clinical Research. Newbury Park, Sage.

Richards A (1998) Hands on help. Nursing Times Supplement. 12, 32, 69-74.

Royal College of Nursing (2000) Digital Rectal Examination and Manual Removal of Faeces: Guidance for Nurses. London, Royal College of Nursing.

Storrie JB (1997) Biofeedback: a firstline treatment for idiopathic constipation. British Journal of Nursing. 6. 3, 152-158.

Wallace B (2000) Nurses and consent. Professional Nurse. 15, 11, 727-730.

Willis J (2000) Bowel management and consent. Nursing Times Plus. 96, 6, 7-8.

Wilson L (2003) Continence and older people: the importance of functional assessment. Nursing Older People. 15, 4, 22-28.

Winge K et al (2003) Constipation in neurological diseases. Journal of Neurology and Psychiatry. 74, 13-19.

Winney J (1998) Constipation. Nursing Standard. 13, 11, 49-53.

Author

Lesley A Wilson BSc (Hons), RGN, FETC is clinical manager, Snowdon Rehabilitation Centre, Southampton City Primary Care Trust

Copyright RCN Publishing Company Ltd. Dec 2005