GROUP 5 :

Constipation
A. Definition
According to potter & perry (2005), constipation is a symptom and not a disease.
Constipation is a decrease in frequency of defecation, followed by spending long or hard
stool and dry. The effort of straining during defecation is a sign that is associated with
constipation. If the small intestine motility slows, feces longer period of exposure to the
intestinal wall and most of the water content in the feces is absorbed. A small amount of
water left to soften and lubricate the stool. Spending dry and hard feces that can cause pain in
the rectum.
B. Causes
1. Unhealthy diet
2. Less of fiber
3. Irregular habit of defecation
4. Excessive absorption of water in colon
C. Sign and Symptom
Signs and symptoms will differ from person to someone else, but usually signs and
symptoms that are commonly found in most or sometimes a few sufferers are as follows:
1. The stomach feels full and even stiff as a pile of feces (if the stool has accumulated
approximately 1 week or more, the stomach of patients can be seen as being
pregnant).
2. Stool becomes tougher, heat, and darker than usual and fewer in number than usual
(even may take the form of small round if it is severe).
3. At the time of defecation stool is difficult to remove or discarded, sometimes have to
push or squeeze the stomach beforehand in order to issue a stool.
4. The frequency of flatus increases with odor worse than usual.
5. The reduced frequency of defecation and increased transit time of defecation.
D. Diagnosis
Risk of constipation related to irregular defecation habits.

E. Nursing Care
1. Intervention according to NANDA NIC NOC
Diagnosis : Constipation related to irregular defecation habits. (00011)
Domain 3 : Elimination and Exchange Class
Class 2
: Gastrointestinal function
a. Goals and Criteria Results :
NOC:
1) bowel Elimination
2) Hydration
After the nursing intervention for 3 x 24 hours constipation patients overcome
with expected outcomes:
1)
2)
3)
4)
5)

Defecation pattern within normal limits

Stool soft
Adequate fluid and fiber
Adequate activity
Adequate hydration

b. Intervention
NIC:
1) Management of constipation
2) Identification of factors that cause constipation
3) Monitor signs of bowel rupture / peritonitis
4) Explain the causes and rationalization measures in patients
5) Consult with your doctor about the increase and decrease in bowel sounds
6) Collaboration if there are signs and symptoms of constipation persist
7) Explain to patients the benefits of a diet (fluids and fiber) to elimination
8) Explain to the client the consequences of using laxatives for a long time
9) Collaboration with nutritionist diet high in fiber and fluids
10) Push the optimal increase in activity
11) Provide privacy and security during defecation
2. According to ScienceDirect journals on chronic constipation: A critical review,
nursing management of patients with constipation is :
There are many evidence-based therapeutic approaches to the treatment of chronic
constipation, including biofeedback, osmotic and stimulant laxatives, and new
pharmacological therapies that have different mechanisms of action and side effects.
a. Fiber supplements
Fiber supplements are traditionally considered the first-line treatment, although
deficient fiber intake in patients with chronic constipation has not been demonstrated

at referral centres, and there is little evidence that insoluble fibers are beneficial. Fiber
supplements are less effective in patients with slow transit constipation or defecatory
disorders that in those with normal transit constipation, they are generally safe, but
may increase bloating, flatulence and abdominal pain, and may interfere with the
absorption of some drugs. A soluble fiber (psyllium) may benefit some patients with
chronic constipation but, unlike osmotic and stimulant laxatives and the newer
pharmacological agents, this treatment is supported by poor quality data, and one
study has found that treatment with polyethylene glycol (PEG) was faster and more
effective. Taken together, these observations suggest that, rather than fiber
supplementation, osmotic and stimulant laxatives should be considered for the firstline treatment of patients with chronic constipation seen at referral centres.
b. Biofeedback
This represents a behavioural treatment in which patients learn the physiological
mechanisms of defecation, and how to use their diaphragms and abdominal and
pelvic floor muscles in order to evacuate. Sensory retraining may also be provided.
Patient motivation and the expertise of the therapist are critical but not standardised
factors that affect therapeutic responses. Randomised clinical trials have shown that
biofeedback is more effective than both sham feedback and laxatives, particularly in
the sub-group of patients with defecation disorders as 76% responded to bio-feedback
and only 46% to standard laxative therapy. However, experienced therapists are not
widely available, and some experts have suggested that biofeedback should only be
proposed after all of the other available treatments have been tried, although others
indicate it as the first-line treatment for patients with defecation disorders.
Interestingly, the instrumental feedback might be less important than the interaction
with the therapist, which suggests that verbal instructions from dedicated physicians
or other techniques of home training may prove to be effective in the future.
c. Evidence-based pharmacological approaches
A recent systematic review and meta-analysis has found that polyethylene glycol
(PEG), sodium picosulfate, bisacodyl, prucalopride, lubiprostone and linaclotide are

more effective than placebo in treating chronic constipation.The definition of, and
clinical approach to patients with difficult, refractory or intractable
constipation is still unclear. The degree of patient dissatisfaction may be due to
efficacy and/or the side effects of treatments, or psychological alterations, but it is not
known what the relative role of these factors is most studies have not defined patient
sub-types, and so it is unknown whether a better response can be obtained in certain
sub-groups. Suppositories, enemas and other concomitant laxatives have been
allowed as rescue therapies during pharmacological trials, but how to optimise
combined therapies with different mechanisms of action, or how and when to use
rectal therapies, has been poorly investigated. How long the patients should be treated
and the long-term safety profile of treatments remain relatively unknown, although
PEG and prucalopride have been safely used for more than two years.
d. Other approaches
In highly selected patients treatment strategies may include sacral nerve
stimulation or surgery. However, the substantial morbidity and variable outcomes
associated with these treatments should limit their use, with special arrangements
being made for consent, audits or research.
Sacral nerve stimulation is based on the continuous low-amplitude electrical
stimulation of sacral nerve roots, and has been claimed to be effective in patients with
intractable constipation. However, other studies with a median follow-up of more
than two years have reported successful outcomes in only 29% of patients, and at
least one event leading to failure in 58% (surgery in 33%).
Of the surgical procedures, colectomy with ileorectal anastomosis is performed in
patients with refractory slow transit constipation in whom a concomitant defecation
disorder has been excluded or treated. Between 39% and 100% of patients have said
they were satisfied with the procedure. A number of side effects have been reported,
including abdominal pain, small bowel obstruction and re-operation, with prevalence
rates varying from 0% to 90%. The outcome may be worse in patients with coexisting psychiatric disturbances and disordered motility in the higher segments of the
gastrointestinal tract.

Stapled transanal rectal resection (STARR) of the redundant rectal mucosa has
been proposed for patients with defecation disorders associated with the presence of
rectoceles or internal rectal prolapse at defecography. However the causal relationship
between these conditions and symptoms remains uncertain as rectoceles and internal
rectal prolapse can also be encountered in normally defecating subjects. One
randomised trial found that STARR was superior to bio-feedback, with success rates
of respectively 81% and 33%; however, there was an unusual drop-out rate of 50% in
the bio-feedback arm. The results seem to be less encouraging after a longer followup. An overall post-procedural morbidity rate of 36% has also been reported,
including faecal urge incontinence, severe anorectal pain and anorectal sepsis.
Laparoscopic ventral rectopexy has been used as an alternative with promising shortterm results in patients with a defecation disorder and internal rectal prolapse.

Source :
Bulechek, Gloria M, Howard K. Butcher, dan Joanne McCloskey Dochterman. Nursing
Interventions Classification (NIC) Sixth Edition. Mosby
Carpenito, L.J. 2009. Diagnosis Keperawatan Aplikasi pada Praktik Klinis Edisi 9. Jakarta:
EGC.
Herdman, T. H. and Kamitsuru, S (Eds). 2014. NANDA International Nursing Diagnosis:
Defitions & Classification, 2015-2017. Oxford: Wiley Blackwell
Kozier, Barbara dan Erbs.2009. Buku ajar praktik Keperawatan Klinis edisi 5.Jakarta:EGC.
Moorhead, Sue, Marion Johnson, Meridean L. Maas, dan Elizabeth Swanson. Nursing Outcomes
Classification (NOC) Measurement of Health Outcomes Fifth edition. Elsevier
http://www.sciencedirect.com/science/article/pii/S1590865813001163