ENGLISH IN NURSING NURSING CARE TO CONSTIPATION CASE

BY: Group 10

Septi Nursanindah Sasikirana 131111161 Dewi Sulistyorini Ertina Anggraini Andi Rahmi Endah Lusi 131111171 131111142 131111128 131111151

FACULTY OF NURSING AIRLANGGA UNIVERSITY SURABAYA 2011

CHAPTER 1 INTRODUCTION
1.1 Background Constipation is the most common digestive complaint in the United States. Worldwide, approximately 12% of people suffer from self-defined constipation. In Indonesia based on Cipto Mangunkusumo Hospital in 2005, 9% of the patient on that hospital has Gastrointestinal disorder Constipation. Other research result that the most familiar gastrointestinal disorder is constipation. It is a symptom rather than a disease and, despite its frequency, often remains unrecognized until the patient develops sequelae, such as anorectal disorders or diverticular disease. Constipation occurs when the stool is hard, dry, and difficult to pass. It maybe happen in every people. When the central role of the intestinal tract and accessory organs of digestion have a problem, the most usual gastrointestinal disorder is constipation. It makes study about constipation is very important to every nurses.

1.2

Problem Question What is the definition of constipation? How about the physiology of GI tract? How constipation can happen? How about the nursing process of constipation case?

1.3

Objectives The students can explain about the definition of constipation The students can explain about the physiology of GI tract The students can explain about how constipation can happen The students can explain about the nursing process of constipation case

CHAPTER 2 STUDY LITERATURE

2.1. Clinical Definition Constipation is occurs when the stool is hard, dry and difficult to pass. there may be a bloated feeling and pain may be experienced when the patient attempts to defecate. (Dewit, 2009) Constipation is a gastrointestinal disorder when a human or animal have a hard stool and make pain when defecate. Constipation is a condition of digestive system in which a person experiences hard feces that are difficult to expel.

2.2. Anatomy And Physiology Anatomy GI tract

Physiology The teeth and tongue are instrumental in the chewing (mastication process, and they help break down food into smaller pieces that can be acted upon by various enzymes. food moves from the mouth through the pharynx down the esophagus to the stomach, where mixing movements occur. Muccus, hydrochloric acid (HCL), intrinsic factor, pepsinogen, and gastrin are secreted into the stomach from cells within its walls and are mixed into the food to break down further the particles for absorption. The mixture produced is

called chyme. The small intestine receives the chyme from the stomach, adds more digestive enzymes and fluids, receives bile and pancreatic enzymes from common duct, and further digests the chyme into a more liquid state. Substance are moved along the intestinal track by the peristaltic action of the intestinal smooth muscle. Digested food particles are absorbed into the bloodstream from the villi on the walls of small intestine. the large intestine reabsorbs water and electrolytes, formulated some vitamin K and eliminates waste products. The large intestine is populated with bacteria that aid in the breakdown fo waste products. The rectum stores fecal material until it is eliminated through the anus. The internal anal sphincter at the top of the anal canal is under involuntary control. The external anal sphincter at the end of the anal canal is under voluntary control. The gastrocolic reflex initiates elimination. it is stimulated by the ingestion of food. by tightening the voluntary anal sphincter, the reflex emptying of the rectum can be stopped. (Dewit, 2009)

2.3. Etiology The main causes of constipation include : Hardening of the feces Insufficient intake of dietary fiber Dehydration from any cause or inadequate fluid intake Paralysis or slowed transit, where peristaltic action is diminished or absent, so that feces are not moved along Hypothyroidism (underactive thyroid gland) Hypokalemia Injured anal sphincter (patulous anus) Medications, such as loperamide, opioids, diuretics and those containing iron, calcium, aluminum (e.g., codeine and morphine) and certain tricyclic antidepressants Lactose Intolerance

 Tumors, either of the bowel or surrounding tissues Psychosomatic constipation, based on anxiety or unfamiliarity with surroundings. Smoking cessation (nicotine has a laxative effect) Abdominal surgery, other types of surgery, childbirth Some causes are with particular respect to infants: o Switching from breast milk to bottle feeds, or to solid meals o Hirschsprung's disease - a condition from birth where the child has a nerve cell defect that affects communication between the brain and bowels 2.4 Pathophysiology Constipation is divided, with considerable overlap, into issues of stool consistency (hard, painful stools) and issues of defecatory behavior (infrequency, difficulty in evacuation, straining during defecation). Although hard stools frequently result in defecatory difficulties, soft bulky stools may also be associated with constipation, particularly in elderly patients with anatomic abnormalities and in patients with impaired colorectal motility. Constipation may originate primarily from within the colon and rectum or may originate externally. Processes involved in constipation originating from the colon or rectum include the following: Colon obstruction (neoplasm, volvulus, stricture) Slow colonic motility, particularly in patients with a history of chronic laxative abuse Outlet obstruction (anatomic or functional) - Anatomic outlet obstruction may derive from intussusception of the anterior wall of the rectum on straining, rectal prolapse, and rectocele; functional outlet obstruction may derive from puborectalis or external sphincter spasm when bearing down, short-segment Hirschsprung disease, and damage to the pudendal nerve, typically related to chronic straining or vaginal delivery Hirschsprung disease in children Chagas disease

Factors involved in constipation originating outside the colon include poor dietary habits (the most common factor, generally involving inadequate fiber or fluid intake and/or overuse of caffeine or alcohol), medications, systemic endocrine or neurologic diseases, and psychological issues. Constipation results in various degrees of subjective symptoms and is associated with abnormalities (eg, colonic diverticular disease, hemorrhoidal disease, anal fissures) that occur secondary to an increase in colonic luminal pressure and intravascular pressure in the hemorrhoida l venous cushions. Nearly 50% of patients with diverticular or anorectal disease, when asked, deny experiencing constipation. On careful questioning, however, nearly all of these patients report having symptoms suggestive of defecatory straining or infrequency, mostly constipation related, although occasionally diarrhea related in patients with irritable bowel or other chronic diarrheal disorders. 2.5 Signs and Symptoms Constipation is a symptom, not a disease, and can be caused by many factors. Each individual may experience symptoms of constipation differently. However, some of the most common symptoms include: The inability to have a bowel movement for several days or passing hard, dry stools Abdominal bloating, cramps or pain Decreased appetite Lethargy 2.6 Diagnostic Assessment 1. Barium Enema Radiographic examination of the colon using fluoroscopy to lacate tumors, obtruction,and ulseration. 2. Colonoscopy Non invasive methode of the determining if there are polips or abnormalities in the colon. Does not allow for biopsy of suspicious areas. 3. Ultrasonography Obtains images of soft tissue that indicate density changes. Use to diagnose gallstones, tumor, cysts, abses, etc.

Laboratory test 1. Fecal analysis (stool examination) Analysis for presents of mucus, elevated fat, content, blood, bacteria or parasites.

2.7

Treatments In people without medical problems, the main intervention is to increase the intake of fluids (preferably water) and dietary fiber. The latter may be achieved by consuming more vegetables and fruit and whole meal bread, and pulses such as baked beans and chick peas and by adding linseeds to one's diet. The routine non-medical use of laxatives is to be discouraged as this may result in bowel action becoming dependent upon their use. Enemas can be used to provide a form of mechanical stimulation. However, enemas are generally useful only for stool in the rectum, not in the intestinal tract. Lactulose, a nonabsorbable synthetic sugar that keeps sodium and water inside the intestinal lumen, relieves constipation. It can be used for months together. Among the other safe remedies, fiber supplements, lactitiol, sorbitol, milk of magnesia, lubricants, etc., may be of value. Electrolyte imbalance, e.g., hyponatremia may occur in some cases especially in diabetics. In alternative and traditional medicine, colonic irrigation, enemas, exercise, diet, and herbs are used to treat constipation. The mechanism of the herbal, enema, and colonic irrigation treatments often includes the breakdown of impacted and hardened fecal matter.
1. Laxatives

Laxatives may be necessary in people in whom dietary or other interventions are not effective or are inappropriate. Laxatives should be used with caution and only as necessary. The following sequence of laxative use is recommended: bulk forming, then stool softeners, then osmotic, then stimulants, then suppositories, and finally enemas (only as a last resort). The reason for this cautious use is because laxatives can lead to dependence, and like all medications they have side effects. Laxatives should not be used if there are signs and/or symptoms of a bowel obstruction.

2. Physical intervention Constipation that resists all the above measures requires physical intervention. ''Manual dissimpaction'' (the physical removal of impacted stool) is done for those patients who have lost control of their bowels secondary to spinal injuries. Manual dissimpaction is also used by physicians and nurses to relieve rectal impactions. Finally, manual dissimpaction can occasionally be done under sedation or a general anestheticthis avoids pain and loosens the anal sphincter. Many of the products are widely available over-the-counter. Enemas (clysters) are a remedy occasionally used for hospitalized patients in whom the constipation has proven to be severe, dangerous in other ways, or resistant to laxatives. Sorbitol, glycerin and arachis oil suppositories can be used. Severe cases may require phosphate solutions introduced as enemas. 3. aediatrics/Pediatrics Lactulose and milk of magnesia has been compared to PEG (polyethylene glycol) in children. They had similar side effects but PEG was more effective at treating constipation. Osmotic laxatives are recommended over stimulant laxatives. P

2.8

Prevention Constipation is usually easier to prevent than to treat. The relief of constipation with osmotic agents, i.e., lactulose, polyethylene glycol (PEG), or magnesium salts, should immediately be followed with prevention using increased fibre (fruits, vegetables, and grains) and a nightly decreasing dose of osmotic laxative. With continuing narcotic use, for instance, nightly doses of osmotic agents can be given indefinitely (without harm) to cause a daily bowel movement. Recent controlled studies have questioned the role of physical exercise in the prevention and management of chronic constipation, while exercise is often recommended by published materials on the subject.

In various conditions (such as the use of codeine or morphine), combinations of hydrating (e.g., lactulose or glycols), bulk-forming (e.g., psyllium) and stimulant agents may be necessary to prevent constipation.

WOC (Web of Causation)

Insufficient dietary fiber Medication / drug hipokalemia Decreased of peristaltic action increased of water absorption hipotiroid Decreased of metabolism Hardening of feces Constipation Accumulated feces in colon Not able to expel Injured anal Sphincter Lost of laxative effect Fear to expel Smoking cessation

hisprung

Abdominal surgery

Abdominal pain Accumulated of microorganism in rectum

Nausea

Acute Pain

Altered Nutrition: less than body requirement

Risk for Infection

CHAPTER 3 NURSING CARE

3.1 Assessment A focused assessment of the GI system includes the collection of both objective and subjective data. Assessment for problems of organs of digestive system begins during history taking. 1. Nursing History History of medication, drugs and smoking. History of activity and stress patient, aged, dietary fiber. History of illness and medical procedures. 2. Physical Examination Examine about the abdominal distention, peristaltic action, abdominal pain

3.2 1.

Nursing Diagnosis Constipation related to side effect of medication, loss of ability to initiate defecation, or other cause.

2. 3. 4.

Imbalanced nutrition: less than body requirements related to nausea Acute Pain related to difficulties to defecate, hard stool Risk for infection related to accumulated microorganism on colon.

3.3

Nursing Intervention

a. Constipation related to side effect of medication, loss of ability to initiate defecation, or other cause Goals: Patient will have normal bowel movement regularly within 2 wk Nursing Intervention: Increase fluid intake to 2500 mL/day unless contraindicated Add fruit juices to diet Increase fiber in diet add slowly to prevent excessive gas formation Increase exercise on a daily basis Encourage patient to heed gastrocolic reflex not delay defecation Administer stool softener or bulk laxative as ordered Monitor for fecal impaction

b. Altered Nutrition: Less than body requirements related to nausea Goals: Patient will ingest at least 2000 calories per day

Nursing Intervention: Offer mouth care before meals Provide six small meals a day plus small high calories snack between meals Weight for 3 days and record keep room odor free provide company and quiet atmosphere for mealtime

c. Acute Pain related to difficulties to defecate, hard stool. Goals: Patient will have decrease pain. Nursing Intervention: Provide analgesic as indicated Administer relaxation technique Monitor characteristic of pain Monitor vital sign

d. Risk of Infection related to accumulated microorganism on colon. Goals: there is no infection in patient body Nursing Intervention: Monitor vital sign Administer the patient to have routine bowel Administer the patient to increase intake fluid

CHAPTER 4 CONCLUSIONS AND RECOMMENDATIONS

4.1. Conclusions Constipation is an an extremely common gastrointestinal disorder that happen in every people. Life style and activity have a significant effect in bowel include constipation.

4.2. Recommendations Constipation is very familiar intestine disorder but it needs a good managements. as a professional nurse we can't forget patients bowel comfort, so we must understand about constipation and the nursing process to provide the best interventions.

BIBLIOGRAPHY

Dewit, Susan C. 2009. Medical-Surgical Nursing: Concepts & Practice. Missouri:Saunders Elsevier.

Gulanick, Meg,. Myers Judith L. 2003. Nursing Care Plans: Nursing Diagnosis & Intervention. Fifth Edition. Philadelphia: Mosby