Nursing Care of Constipation in Older Person with Dementia - Essay Example

Nursing Care of Constipation in Older Person with Dementia Introduction: Constipation is more common in older people because of the loss of muscle tone in the bowel. The older persons often experience difficulty passing stools, and this can lead to the bowels being opened with a frequency less than in normal individuals. Constipation has many causes. In the in the elderly persons with dementia, these causes include poor appetite; inability to afford, shop for, or cook food; poor fluid intake; and lack of exercise. Dementia and depression can affect appetite and motivation to shop and cook (Hudson, 2003). Many older people take medications that can lead to constipation, and regular reviews of medication should be undertaken to avoid taking too many inappropriate medicines, which is often the case with these individuals. Constipation is usually treated by aperients; however excessive use of them may lead to other problems. Thus, the nursing care must include some plans to manage constipation other than laxatives or aperients. These include increased attention is given to activity, nutrition, fluids, and the minimisation of medicines that have constipating effects. Regarding medication use, nurses are uniquely placed to encourage the quality use of medicines. Every drug that is administered to people with dementia should have a clearly documented rationale, and should be monitored and evaluated carefully (Bradshaw and Merriman, 2007). Evidence from Current Literature: Constipation is also one of the biggest causes of confusion in older people, but is often overlooked. Moreover memory loss due to any reason may cause constipation. Constipation is one of the very common complaints of these patients for the reasons already explained, and this may pain or other physical discomforts. Sometimes there is a tendency of the healthcare personnel to ascribe physical discomfort as a normal part of ageing, and they tend to underestimate it (Saddichha and Pandey, 2008). In a care setting, quite frequently, the patients need a toilet, and they cannot find it, and consequently, they tend to neglect the complaint of constipation. The nurses should look for signs of discomfort due to constipation, and it is so common in healthy individuals, the nurses may also tend to ignore it as a complaint (Smith, Buckwalter, Kang, Ellingrod, and Schultz, 2008). The remaining aware of the constipation is an important part of the care plan for the nurses, and they should always ensure enough roughage and exercises are taken. Constipation is linked to nutrition and is one of the commonest causes of confusion amongst older people, especially those who are not very mobile. A preventative measure for constipation is ensuring that clients get plenty of exercise. This also helps clients overcome sleep problems (Jakobsson, Gaston-Johansson, hln, and Bergh, 2008). Recent studies have indicated that constipation shows significant correlation with both physical function and age, but not with cognitive function; however, deterioration of cognitive functions has been associated with constipation. In the care settings individuals who develop complaints of constipation are older, and this symptom is more common in individuals who are dependent on the activities of daily living (Jokinen, 2005). Consequently health monitoring and good care practices should aim to prevent and address the differing and behavioural health concerns and should prevent constipation and dehydration (Mentes, Chang, and Morris, 2006). In one study involving patients with dementia, the nurses found numerous treatable sources of pain and discomfort, and one of them was constipation or other painful bowel regimen associated problems, and these were addressed with care plans. These sources of discomforts leading to constipation were nurses' touching or moving body parts during washing or transfers, caregiver techniques such as moving too fast or leaving the patient in the toilet cold and uncovered, uncomfortable supplies and seats, and unpleasant aspects of physical environment (Sloane et al.,2007). Research has also demonstrated that in these patients, chronic dehydration may predispose to secondary condition such as constipation, urinary tract infection, or delirium (Mentes, Chang, and Morris, 2006). Usually constipation is habitual and long-term in these patients. Larkin et al. has presented their recommendations based on available literature. If the patient complains of constipation or defecates less than three times per week, a thorough patient history, physical examination, and assessment of bowel habits become necessary. A check list of key facts should be used to assess the causative factors in a particular patient, and the assessment and intervention must be continuous throughout the continuum of care. If necessary, investigations need to be done. Preventive measures such as ensuring privacy and comfort, encouraging activity and increasing fluid intake should be ongoing during the patient's care with care to prevent rectal interventions as much as possible. However, in some difficult cases of rectal impaction, oral medications may be unsuccessful, and rectal intervention may be necessary to establish a regular bowel pattern. Generally a combination of a softener and a stimulant laxative is recommended (Larkin et al, 2008). Care Plan Nursing Diagnosis: Constipation on an ongoing basis. May be related to: Disorientation, inability to recognise need, inability to locate toilet, lost neurologic functioning and muscle tone, changes in dietary and fluid intake, low fibre diet, side effects of medications, and lack of exercise, prostatic hypertrophy. Possibly evidenced by: Urgency, inappropriate toileting behaviours, constipation, pain and discomfort, loss of appetite, restlessness. Desired outcomes and Evaluation criteria: Adequate and appropriate bowel clearance pattern established. Care Plan 1. Assessment of prior pattern and comparison with current pattern, since the changes may be identified that may need further assessment or intervention (Doenges, Moorhouse, and Murr, 2006). 2. Bed should be located near the bathroom with colour coded doors, adequate lighting, specially at night, since this promotes orientation and helps the client to find the bathroom. Sometimes, incontinence may be attributed to inability to find a toilet (Doenges, Moorhouse, and Murr, 2006). 3. The client should be taken to the toilet at regular intervals with dictation of each step at a time and with use of positive reinforcements, since very frequently, the problem with these patients is forgetting how to toilet. Moreover, adherence to a daily and regular schedule may prevent accidents and establish a habit (Doenges, Moorhouse, and Murr, 2006). 4. The bowel training programme should be established with promotion of client participation depending on the level of abilities, since this is known to stimulate awareness, enhance regulation of body functions, and helps to avoid accidents (Doenges, Moorhouse, and Murr, 2006). 5. The patient should be encouraged to have adequate fluid intake during the day to the extent of at least 2 L or as appropriate and diet high in fibre and fruit juices. The fluid intake should be limited during the late evening and at bedtime to limit nocturnal urination. These are necessary since these are deemed to be essential for bodily functions and are known to prevent potential dehydration and constipation. Restricting intake in evening is necessary to reduce frequency and/or incontinence during the night (Doenges, Moorhouse, and Murr, 2006). 6. The nurse must avoid hurrying or the patient being rushed, since hurrying may be perceived by the client as intrusion, which may lead to anger and lack of cooperation with activity (Doenges, Moorhouse, and Murr, 2006). 7. Nurse should be able to identify and hence should remain alert to nonverbal cues such as restlessness, holding self, or picking at clothes, since these may indicate urgency or inability to locate bathroom. Inattention to cues may lead to increased discomfort (Doenges, Moorhouse, and Murr, 2006). 8. The care must be discreet and respect person's privacy since although these clients are confused, a sense of modesty is often retained (Doenges, Moorhouse, and Murr, 2006). 9. Changing of clothes should be done promptly with good skin care, and acceptance is important to decrease the embarrassment and feelings of helplessness that may occur during the changing process. Prompt changing reduces risks of skin irritation and breakdown (Doenges, Moorhouse, and Murr, 2006). 10. Frequency of voiding and bowel movements should be recorded since this provides a visual reminder of elimination and may indicate a need for intervention when necessary (Doenges, Moorhouse, and Murr, 2006). 11. Monitoring is important of consistency of stool since detection of changes provides opportunity to alter interventions to prevent complications or acquire treatment as indicated. Since the client has a memory loss and he cannot remember, monitoring is essential to prevent constipation and potential for impaction (Doenges, Moorhouse, and Murr, 2006). 12. Stool softeners, bulk expanders, or glycerin suppository may be necessary to stimulate and facilitate regular bowel movement. Review of medications is necessary to detect if any agents are causing constipation (Doenges, Moorhouse, and Murr, 2006). Reference List Bradshaw, A. and Merriman, C.. Caring for the Older Person. John Wiley & Sons Ltd, London, 2007. Doenges, ME., Moorhouse, MF., and Murr, AC. Nursing Care Plans, F. A. Davis Company, Philadelphia, 2006. Hudson, R., Dementia Nursing A Guide to Practice. Ausmed Publications, Melbourne, Australia. 2003 Jakobsson, E., Gaston-Johansson, F., hln, J., and Bergh, I., (2008). Clinical problems at the end of life in a Swedish population, including the role of advancing age and physical and cognitive function. Scandinavian Journal of Public Health; vol. 36: pp. 177 - 182. Jokinen, N., (2005). The content of available practice literature in dementia and intellectual disability. Dementia; vol. 4: pp. 327 - 339. Larkin, PJ. et al. On behalf of The European Consensus Group on Constipation in Palliative Care (2008). The management of constipation in palliative care: clinical practice recommendations. Palliative Medicine; vol. 22: pp. 796 - 807 Mentes, JC., Chang, BL., and Morris, J., (2006). Keeping Nursing Home Residents Hydrated. Western Journal of Nursing Research; vol. 28: pp. 392 - 406. Saddichha, S. and Pandey, V., (2008). Alzheimer's and Non-Alzheimer's Dementia: A Critical Review of Pharmacological and Nonpharmacological Strategies. American Journal of Alzheimer's Disease and Other Dementias; vol. 23: pp. 150 - 161. Sloane, PD. et al., (2007). Provision of Morning Care to Nursing Home Residents With Dementia: Opportunity for Improvement American Journal of Alzheimer's Disease and Other Dementias; vol. 22: pp. 369 - 377. Smith, M., Buckwalter, KC., Kang, H., Ellingrod, V., and Schultz, SK., (2008). Dementia-Specific Assisted Living: Clinical Factors and Psychotropic Medication Use. Journal of the American Psychiatric Nurses Association; vol. 14: pp. 39 - 49. Read More