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Simple treatments for constipation in residential care

Lynn Freeman, Brenda Ferguson and Miriam Forster reflect on how a change in practice and a few simple treatments can transform the management of constipation within nursing homes

Lynn Freeman
RGN
Clinical Nurse Lead, North Tyneside PCT/Northumberland Care Trust

Brenda Ferguson
RGN
Specialist Nurse Continence, North Tyneside PCT

Miriam Forster
RGN
Specialist Nurse Continence, Northumberland Care Trust

With the introduction of the Health and Social Care Act, trusts are charged with supplying continence products to self-funding and local authority-assisted clients within nursing homes.1 To ensure that prescribed incontinence products meet clients' needs and to allow nursing homes to facilitate the development of evidence-based continence care for residents, there is now a dedicated specialist nurse for many trusts.

Even if a nurse attends a teaching session it may be difficult for them to change culture and practice. This article will review some simple measures that nurses can put into place and regularly use to treat constipation. It is by no means comprehensive but will hopefully give an overview of what can be achieved using good evidence-based assessments and treatments.

Definition and prevalence
There is no single, accepted definition of constipation.2 Despite the discrepancies in definition, the cost is high in both monetary terms (£27m on over-the-counter laxatives in the UK) and quality of life.2

Documented estimates of prevalence in long-term care range from 50–90%.3 Constipation and faecal impaction are regarded as important causes of faecal incontinence within long-term care. Both faecal incontinence and laxative use are higher in nursing homes than in older people living in their own homes.3

Primary constipation (no underlying causative illness) is usually associated with lifestyle factors, eg, dietary fibre and environmental changes. Secondary constipation is the result of physiological/psychological diseases or conditions that affect bowel function, such as MS and dementia. It is important to remember that latrogenic constipation is induced as a result of pharmacological agents; for example, opioid medication, and five or more medications are a particular risk.2 It is clear that people living in nursing homes may indeed fit into all of the above categories and why assessment and knowledge-based treatments are vital.

Assessment
An indepth knowledge and understanding of bowel function, dysfunction and treatment is essential; therefore, assessment should be carried out by trained and competent professionals. A structured approach using evidence-based guidelines is also important.4

Although using a patient's own account can be useful and highly recommended, clients who cannot communicate should not be excluded from a thorough assessment. The authors are aware and acknowledge the importance that following the primary assessment some clients may need to be referred for further investigations, eg, sigmoidoscopy or surgical medical consultations.

Treatments
Advice on diet
One of the first steps in the treatment of simple constipation should be advice on diet. During assessment, possible food intolerance should have been reviewed and, if found, changes made. An increase in dietary fibre is often required but should be increased slowly to avoid possible bloating. While most nurses and healthcare assistants are aware of foods that can increase motility, such as heavily spiced food and the recommendation of five portions of fruit and vegetables daily,5 they may not be knowledgeable about the amount of fibre in everyday foods.5

With knowledge of both fibre and the individual's likes and dislikes, it is possible to sustain a well-balanced diet.

There is little point trying to get people to eat foods that are high in fibre if they do not like them. The cook within the nursing home should be involved from the outset. While introducing Essence of Care to one home, the cook reflected that although there were fruit bowls throughout the home, the contents were often not touched.6 She now cuts up a range of fruit and offers small portions to the residents, who now eat more as a result. Another cook reflected that the soft or pureed dishes given to the residents were not visually appetising and bought moulds to present meals that now look more appealing.

Often, simple measures that encourage people to eat are the most effective. Individual plans may be needed for specific medical conditions and appropriate help for residents to eat and drink should be at hand. As laxative use is often high within nursing homes,3 when diet is changed a medication review for those residents is needed (see Case study 1). Fluid advice should also be given; a minimum of 1.5 litres of mixed fluid intake per day is recommended (unless contraindicated).5

Case study 1
When carrying out some continence training with carers within a nursing home, they commented that many residents had become faecally incontinent. When asked what had changed within the home, they identified that they had a new chef who had changed the menu. He was now making home-made lentil or vegetable soup in the evening. The residents were really enjoying this meal option. Carers had mentioned this to the qualified staff who had not re-evaluated medication being given.

Appliances
The act and time of defecation can have a significant impact on constipation. The process of rectal emptying is completed by adapting the correct posture, which facilitates a rise in abdominal pressure. Some residents will inevitably find it difficult getting on and off a toilet. Raised toilet seats can be obtained, which will change the position – a simple footstool can help.

Assistance with placing and removing the footstool may be necessary and the risks should be evaluated. Grip rails and other appliances can be valuable tools in allowing the use of toilets.

Lack of privacy and dignity while using commodes can result in constipation and should, therefore, be avoided if possible.2
Suppressing the urge to defecate can lead to constipation, and it is vital that residents access toilets in a timely manner.2

Bowel retraining programmes
Advice to homecare staff regarding use of bowel routines can help to improve bowel control for many residents. The use of a bowel diary can indicate the most useful times to sit clients on the toilet. While it is accepted that using the half hour after breakfast each morning to maximise the gastrocolic reflex can be very effective, one rule doesn't fit all. A referral to a specialist incontinence service for a gentleman with "faecal incontinence" who was regularly taken to the toilet at 7am with little effect was reviewed. A simple diary revealed defecation at around 7pm. With a great number of staff on different shifts and no set review process, staff were not aware that toileting at 7pm would promote continence. This simple diary and change to routine produced the desired effect.

Even when some clients have a fear of toilets, with caring, well-trained staff, clients who have been deemed "incontinent" for years can be helped. A lady with Down's syndrome who was new to a home protested vigorously at going to a toilet. Staff completed a diary and recorded stools according to the Bristol Stool Chart. Staff were asked to offer the client the toilet at appropriate times on a daily basis, initially for her to become used to the toilet itself. Behaviour therapy was used, and with lots of praise and encouragement the lady now requests the toilet and is faecally continent. Challenging behaviour in clients with dementia is sometimes interpreted as being caused by the dementia process, but this is not always the case. Correct interpretation of what is happening and a good knowledge of bowel care can have a profound effect (see Case study 2).

Case study 2
A female resident in elderly mental nursing care who was previously faecally continent had began to manually self-evacuate. She was walking up the corridors with faeces in her nails and on her hands, approaching staff for help. It was requested that staff complete a Bristol Stool Chart, which identified type 1–2 stool. Staff were informed that this lady was very distressed when having a stool movement, but they had not informed the GP regarding this or taken the matter further.
Staff were informed of the importance of the Bristol Stool Chart indicating type 1–2. The lady was becoming distressed due to the discomfort she was experiencing and was trying to relieve this by manual evacuation. In consultation with the GP and after prescribing appropriate medication she began presenting with type 3–4 stools. She ceased manually evacuating and remains faecally continent. Staff were advised of the importance of maintaining a Bristol Stool Chart.

Medication
Medication is often the first or only treatment given for constipation. Brocklehurst et al also found this in other long-term care settings.3 Their findings suggest that alternative treatments help to reduce not only laxative use, but also faecal incontinence. If medication is to be used, consultation with a GP should elicit the most appropriate type for the individual. There are oral as well as rectal medications to consider and nurses must be aware of contraindications. All medication should be regularly reviewed, especially when trialling other treatments. Bowel diaries and the use of the Bristol Stool Chart can inform usage, particularly for "when necessary" prescriptions.

Skincare
As faeces can affect the integrity of skin, all staff should have knowledge of skincare and factors that cause pressure damage. Factors such as frailty, immobility, loss of sensation, diabetes, lack of nutrition and dry skin can all have an effect.4 The National Institute for Health and Clinical Excellence (NICE) guidelines provide advice on both cleaning and barrier products.4 A mild pH balance soap or cleanser, warm water and soft wipes are recommended. Drying should be gentle. Creams and lotions should not be used routinely as they can make the area moist. If barrier cream is used, old cream should be removed first, and then applied according to the manufacturer's recommendations.

Where sacral pressure sores are present, great care must be taken. Tissue viability nurses and our continence team often work together with home staff to care for individuals. Good bowel care is essential in the healing process (see Case study 3).

Case study 3
A 66-year-old male resident, Mr S, was admitted to a nursing home following amputation. He presented with faecal incontinence. On admission he had a grade three sacral pressure sore and one to his remaining heel. He was not always compliant and had a history of self-neglect.
In discussion with Mr S, the importance of promoting his faecal incontinence was stressed, which would help prevent infection to his pressure sore, promote healing and reduce the number of dressings required. The dressings required changing more frequently due to soiling and Mr S was not happy with this due to discomfort.
A bowel diary and Bristol Stool Chart were completed, the GP prescribed appropriate medication and, following discussion, Mr S agreed to be toileted daily according to the diary. Although initially reluctant, he began to comply. Within three weeks he was faecally continent. His pressure sore was healing and required fewer dressings. Mr S stated he was more comfortable and he began requesting the toilet and agreed that although initially he did not want to go through the process he was happy with the outcome.

Conclusion
A partnership between the continence service and independent nursing homes is changing practice, and after comprehensive assessment, simple treatments are having a positive effect on many residents. This work can easily be transferred to district nurses working in residential homes. There are certainly benefits to be gained from collaborative developments.

References
1. Department of Health (DH). Health and Social Care Act. London: DH; 2003.
2. Kyle G. Constipation: an examination of the current evidence. Continence UK 2008;2:361–7.
3. Brocklehurst J, Dickinson E, Windsor J. Laxatives and faecal incontinence in long-term care. Nurs Stand 13(52):32–6.
4. National Institute for Health and Clinical Excellence (NICE). Faecal incontinence: The management of faecal incontinence in adults. London: NICE; 2007.
5. Royal College of Nursing (RCN). Bowel care, including digital rectal examination and manual removal of faeces. London: RCN; 2008.
6. Department of Health (DH). The Essence of Care: Patient-focused benchmarking for health care practitioners. London: DH; 2001. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...