Constipation in Stroke patients - Research Proposal Example

of Project The project runs under the “Constipation in Stroke patients. The project uses information gathered via interviews, questioners, and diverse academic publications. The research was conducted in nine Sussex Health Care homes. Four patient groups were represented: learning disabilities, elderly, mentally ill, and young disabled. Key Words Nursing discipline: Stroke and Constipation, Sussex Methodology: Interview, Questionnaire. Area of interest: Care of elderly. Summary of Project This project aims to assess the early recognition of constipation in patients suffering from stroke. Among the objectives is to educate nurses through focused education sessions on the effects of constipation using evidence based on the conducted research. The research aims to prevent constipation by establishing patient’s baseline of bowel pattern prior to admission. I have identified constipation as a serious problem which affects stroke patients. This is an area which requires practice and development since constipation is among the recurring complications in hospitalized acute stroke patients (Woolery, Bisanz, Lyons, & Gaido, 2008, p. 320). Along with other complications like deep vein thrombosis, loss of skin integrity, mobility related problems, faecal and urinary incontinence, they need to be actively managed in order to positively influence during the patient’s stay in the hospital. For this research to be a success, over thirty publications were used. In the project I have used several data collection techniques including questionnaires. To back up the mentioned research methods I used literature search on electronic databases, nursing journals among other literature. I also used internet abstract obtained from Google scholars and explored the references of literature related to management of constipation. The study related to stroke patients was limited therefore I focused on people above the age of 65. The project aims to come up with recommendations in establishing early assessment of bowel habits prior to admission. This will help in identifying patients at the risk of developing constipation and audit pre and post risk patients. Background of Project In the current clinical practice, chronic constipation is a frequent outcome secondary to cerebral-vascular accident leading to impaction and overflow incontinence in stroke patients (Apau, 2010, p. 24). It remains poorly understood leading to complications including haemorrhoids, faecal impaction, urinary incontinence, ladder outlet, obstruction, urinary tract infection, rectal bleeding, general weakness, and psychological disorders (Bracci, Badiali, Pezzotti and Scivoletto, 2007, p. 3970). Constipation has cost implication in terms of hospitalisation, medications, containment, equipment and nursing time (Bosshard, Dreher, Schnegg and Bola, 2004, p. 12). It was observed in the clinical setting that stroke took priority and constipation was overlooked and not considered until patients developed symptoms causing confusion, distress and restlessness. Measures were not taken until patients became constipated and this had an impact on the quality of life and prolonged the hospital stay (Dennison, Prasad, Lloyd, Bhattacharya, and Coyne, 2005, p. 464). Unfortunately constipation is often seen as less important than other conditions in general practice because it is not within an agreed management target. Patients were not assessed and an accurate history of the bowel pattern prior to admission was not obtained or established. Assessment of constipation continues to be poor, compared to other symptoms being rated as a higher priority. A full continence assessment undertaken by a competent health care professional will help to identify patient’s problem (Holman, Roberts and Nicol, 2008, p. 23). It is important to take a good history in order to identify pertinent information which might not be apparent in a physical examination. Prevention is better than cure. The objective for patients should be prevention of constipation rather than treatment of constipation (Haycox, Howard, Partridge, Wright, 2001, p. 94). Nurses should identify patients at risk and implement evidence based interventions. The goal of treatment and management of constipation basically aim at preventing symptom relief and improving quality of life (Castledine, Grainger, Wood, Dilley, 2007, p. 18). This can be accompanied by early assessment which identifies the underlying cause and determine the most effective treatment as management strategies. Nurses are in ideal position to provide preventive care and health promotion in conjunction with multidisciplinary team. Effective assessment provides nurses with the information on which advice and interventions, management can be planned, outcomes measured and evaluation of care made. A thorough medical history and physical examination are needed to exclude constipation secondary to any underlying condition (Foxley, 2008, p. 268). A complete history should be taken including relevant details in order to establish a regular bowel pattern which would aid in early assessment of constipation. An accurate history may be difficult to obtain if cognitive ability is compromised and it may be necessary to use information provided by relatives or carers. The accuracy of any assessment is dependent on the quality of the information gained. Managing constipation is challenging due to the open discussion of bowel habits. Due to sensitive nature of the symptoms and the accompanying social and psychological implications, even cognitively intact individuals may be reluctant to provide an accurate history. Bowel habits should be discussed at the initial assessment on admission (Grainger, Castledine, Wood, Dilley, 2007, p. 1213). In the authors concern this is primarily where the problem lies. Nurses perhaps avoid asking questions to shun away from embarrassment to both oneself and patients. If bowel habits were discussed properly the nurses may be able to predict any potential problems and thus implement prophylactic non-invasive measures such as flagging the patients chart, diet list and the name of the patient on the board and over the bed for high fibre diet, encouraging increased mobility with the involvement of physiotherapy, occupational therapist and maintaining adequate fluid intake. Modification of lifestyle, exercise, fluid and fibre are known as step one of a stepped approach to bowel care and is still considered the first line treatment for constipation. Constipation is multi-factorial with many underlying reasons. It can be influenced by physical, psychological, physiological, emotional and environmental factors. The fear of constipation and the need for regular bowel movements is a major concern. Equally, the embarrassment associated can be genuine threat to personal dignity and quality of life. The symptoms experienced are both distressing and disabling causing significant deterioration in lifestyle and health status. Constipation is rarely a life threatening symptom yet the distress it causes leads to reduced patient comfort and diminished quality of life (Christer, 2003, p. 27). Lack of attention to privacy and dignity results in an unfavourable environment for every defecation. It can be devastating and demoralising for the patient and can impact significantly on daily activities and quality of life. Accurate assessment is essential to determine the cause of symptoms, and to decide effective strategies of management and treatment. If not treated on time can lead to serious problems and can be precipitating factors for hospital admissions. Interventions should be individualised for patients according to history, disease process and plan of care. Due to ineffective management, patients are prone for negative consequences which can be uncomfortable and life threatening. Constipation is common in stroke patients due to physiologic changes and poly pharmacy. Secondary constipation is usually treated by way of correcting the respective underlying pathology or lowering pre disposing factors. Primary constipation is amenable to dietary adjustable, education, behavioural training and laxatives when necessary. Project Objectives The aim of this project was to assess early recognition of constipation in stroke patients and educate nurses through focused education sessions on the effects of constipation using evidence based the research. It aims to prevent constipation by establishing patient’s baseline of bowel pattern prior to admission to a hospital by taking history. It encourages pre and post patients audit so as to examine and improve patients care and prevent constipation n and its reoccurrence. Prevention of constipation is of prime importance. This project aims at the treatment and management of constipation. Constipation is complex at times but with care and patience improvement is possible. The project aims at educating patients, families, and nurses on this topic. It aims at giving nurses a different approach. This will help in reducing cases of revolving patients and cut medical costs. “Poorly managed constipation can lead to disabling complications for the patients” (Wald, 2010 p. 1). Description of Plan of Research to be undertaken Management of constipation is a problem in any health care setting. To investigate and improve the management of constipation (Grainger et al, 2007) performed research in nine homes from Sussex health care (SHC). The action research will highlight the importance of giving up to date information to the members of care team for appropriate management of bowel care. For the research study, nine SHC care homes were selected ensuring four groups of patients were represented: learning disabilities, elderly, mentally ill, young disabled. Initial stage researchers provided leaflets to provide information about constipation (Wang, Wu, He, Yan, Dong, 2009, p. 5). Different questionnaires were designed for staff and patients. After pilot studies, they were asked to complete questionnaires. The Elton scale risk assessment was considered by the research group to predict constipation. Staff from nine SHC homes attended the training session conducted by a qualified representative from the drug company in bowel product. It included Bristol stool chart and methods of prevention. A flow chart was developed for bowel management and further alterations were made in the flow chart according to Elton assessment chart. It was piloted over a three weak period. Six weeks after the training session and introduction of assessment tool and management patients, relatives, and carers and staff completed the questionnaires again. Pre and post intervention were compared. There was great variation in the use of laxatives reflecting type of patient/care setting, age and staff preferences. Two care homes showed a significant reduction in usage where as one showed a significant increase. After the training session a significant improvement in staff’s knowledge in prevention of constipation was noted. Staff accurately recorded enema and laxative and bowel movement. There was overall reduction of lactulose. The study concluded by suggesting the need for staff knowledge and regular up to date audits of the assessment of constipation. Winsten and Messner (2005) did randomised control trial to study the effects of a daily consumption of a fruit and fibre rich porridge on stool frequency, perceived well being and the costs for laxatives in geriatric patients. Twenty patients were randomized into an intervention group and a controlled group for a time frame of three weeks. Patients were admitted mainly with diagnosis of stroke, degenerative joint disease and Parkinson’s disease. The average age of participants involved is above 80 years. The ethics committee approved the study and the patients gave consent. Patients were assessed for abdominal discomfort like pain, flatulence using analogue scale from 1 to 10 with no abdominal discomfort. Most of the patients were on drugs including constipation. Participants in intervention group were given laxatives when needed. Intervention group was served porridge for breakfast that had daily defecation without laxatives on average of 76% in comparison with 23% in the non-porridge group (Fullbrook, 2003, p. 100). ‘The discomfort was less in the porridge group. The cost of laxatives was 93% lower in the intervention group for the two week study” (Fullbrook, 2003, p. 100). Winsten and Messner concluded that a daily fibre rich meal to be included in the treatment strategies of constipation in hospital wards. Quigley, Vandeplassche, Kerstens and Ausma (2009, p. 320) conducted a randomized, double-blind, placebo controlled trial to evaluate the efficacy and safety of prucalopride (selective high affinity 5 –HT4 receptor agonist) in patients with chronic constipation. The study enrolled men and women over 18 years of age excluding women who were pregnant and breast feeding. 651 patients were randomized, 641 received study medication and 567 completed the study and the 12 week diary (Harari, Norton, Lockwood, Swift, 2010, p. 2550). Patients were allocated to receive prucalopride 2mg or 4mg or placebo, and were instructed to take one tablet before breakfast. All study personal and patients were blinded to the treatments. Patients were assessed over 2, 3, 8 and 12 weeks using the five point likert scale. “Higher scores reflected greater severity” (Wald, 2010, p. 1). Prucalopride treated patients achieved significantly greater satisfaction with bowel function and improved perception of constipation severity and reported using fewer laxatives than placebo. Research Method 1 During the initial project stages leaflets were used to provide information about constipation. Different questionnaires were used to gather information from patients, relatives, and carers and staff. They were supposed to be filled after pilot studies. Six weeks after the training session they filled the questionnaires again for pre and post intervention comparison. Questionnaires are of many forms including; factual, opinion based, tick boxes, and free text. Whatever the questionnaire form, they are viewed as easy and quick to do. For useful responses, cost effectively, clarity about the questionnaire’s aim is important. It should be clear how responses are going to help improve the implementation (Wald, 2010, p. 1). Data analysis and the results should come to mind when designing the questionnaire. The research used questionnaires as they are cost effective as compared to other forms of research methodologies. This is much evident when involved in large data samples. Written questionnaires are more cost effective since the questions increase. They are easily analyzed as tabulation and data entry can be done with computer packages. I did not encounter any difficulties as most people were familiar with questionnaires. Nearly all the people had experience in completing a questionnaire. They do not make the subjects apprehensive. They reduce bias as they have uniform representation of questions. As a researcher, my own opinions did not influence in any way the answers given. There were no visual or verbal clues which could influence respondents. Unlike other methods of research, questionnaires do not interrupt the respondent. Piloting process was conducted before the questionnaires were used. The questionnaires were revised, tested, and revised. This is an iterative process which included consulting different researchers with diverse experience and knowledge to comment on the draft. After the questionnaire was revised, piloting was conducted with a non expert group. A further questionnaire revision was piloted among nurses and care takers before the main trial. Sometimes in-depth interviewing which is cognitive provides insights about how some participants recall and process information, comprehend the questions, and decide on the answers to give. This involves reading each question to the participants and asked to either 'think aloud' considering their answer to be, or the interviewer asks them questions which are ‘further 'probing'. The piloting process is usually used to make the required adjustments in relation to an assortment of study aspects. This can include a time frame assessment of a questionnaire or interview, compared to a scheduled length of an interview or the time scheduled to complete a questionnaire. More piloting checks can be performed on the timing and appropriateness of the study. This can be done in relation to events which are contemporary. Questionnaires offer objective information collecting means about people's beliefs, knowledge, behaviour, and attitudes. Questionnaire design depends on the researcher’s wish to collect quantitative information (testing specific hypotheses generated previously) or exploratory information (information that is qualitative for the better understanding purposes or a subject’s hypotheses generation). Research Method 2 If the mode of questionnaire administration changes, it should be piloted first before being used. After developing a new questionnaire, testing is established to measure the necessary reliability. The project’s questionnaires were assessed by the quantification of agreement strength between the measured outcomes using the same questionnaire on one patient during different times. Some open-ended questions were used in offering participants a chance to answer by the use of text writing. These were used when there were a number answers possible. It was important to have all provided information details captured. Since open ended questions increase participant’s burden and are not factual, they were limited. Text responses were subsequently reviewed and assigned one or codes categorising the response before analysis. This was done whilst ignoring patient’s treatment allocation. This can be done by the application of a dictionary of adverse event. Participants needed sufficient space for the accurate and full information to be provided. Closed end questions which contained options which were mutually exclusive and others which included clear instructions for participants to select multiple responses were among the questions used. There is clear evidence that answers given in response to closed questions are highly influenced by investigator’s value of choice for the response categories offered. This increases the probability of respondents avoiding categories which are extreme. Closed-ended questions in which participants are given the choice to 'tick all that apply' are alternatively presented separately, with a 'no' or 'yes' response to each question. This is suitable design if the planned analysis treats each category in response as a binary variable (0 or 1). Ethics People in the healthcare field are confronted by ethical issues all the time. However, the ethical issues magnitude increases when it is involving public officials. Medicine and health industry holds highest ethics since it involves human life. Health care practitioners including nurses and doctors face dilemmas associated with ethics in their profession. Healthcare practitioners are trained to manage this kind of issues. This can sometimes have long impacts on their personal or professional lives. The public perception about their rights in a medical procedure conflicts with healthcare industry morals. Patients have rights as well. A patient has the right of being informed by the doctor about the medical consequences resulting from his or her decisions and actions to refuse treatment in an extent the law permits. This only applies when the patient is in position which he/she can understand his/her treatment consequences. Senile, incompetent patients do have neither the correct judgment nor understanding of the implications of their treatment. In such a situation a patient’s will to grant or deny any consent does not dictate treatment course. For patients who are mentally sound, the patient’s families fail to often understand that nurses and doctors are experts than themselves. It is unethical to deny consent for effective treatment that can cost the life of a patient. This situation is also common in constipation patients and becoming worse by day especially in elderly patients. The elderly sometimes have no one to think for them and are in no position to think for own selves either. Other ethical issues erupt from patient rights the conflict with professional ethics for doctors and in nurses. It is mandatory for medical practitioners to tell the patient about the ailment and the form along with its course and the treatment that follows. This is a clash with the doctors and nursing professional ethics. Medical practitioners should maintain high confidentiality degree regarding patient's treatment and health. In some situations, patients and their families do not comprehend the consequences of the information the nurse or doctor may provide. This sometimes leads to unnecessarily panic and misunderstanding. Although, information is not harmful it is necessary to keep it in the dark for the good of the patient. Oftentimes, elderly patients seek repeated treatment for constipation cases again and again. As a result they end up being admitted in hospitals for the same condition with no much improvement. Constipation patients tend to shy away form discussing their condition with other people and therefore end up spending more tax payer’s money in repetitive treatment. This is not an issue since every patient deserves the best treatment possible. However, practitioner’s opinion may change when they find out that it is a self induced issue. This might boomerang on the patient. This is among the biggest dilemmas in health practitioner’s professional ethics. Ethical issues in physicians and nurses are somewhat similar as to the ones faced other health care workers. Constipation is prevalent in both the elderly and the very young (Wisten, & Messner, 2005, p. 71). As with small children and toddlers, the consequences of not treating cases of constipation in the elderly are very severe. The human body can sustain long periods without bowel movement in the early and mid adulthood (Lawrey, 2007, p. 26). However, the latter life stages are a different story. Ethical Issues and Vulnerable Groups Constipation affects and 34% of elderly women and 26% of elderly men (An Bord Altranais [The nursing Board 2000], 2000, p. 3). This is a disease that is sometimes related to a diminished perception of the quality of life one leads. Constipation can be a sign of a big problem like mass lesion, a systemic disorder like hypothyroidism, or side effects of a medication such as narcotics analgesics. Elderly patients suffering from constipation need to be questioned about food intake and fluid, medications, homeopathic remedies and supplements (Spinzi, Amato, Imperiali, Lenoci, Mandelli, Paggi, 2009, p. 470). This needs to be done with care since most patients do not like discussing this topic. They find it embarrassing and it gets more technical when dealing with the elderly. Sometimes physical examination reveals thrombosed hemorrhoids or local masses which may be a contributing factor to the constipation (Kyle, 2008, p. 60). The colon should be visually inspected when there is no obvious constipation cause. For the elderly, the abnormality should be treatment with much care. The use of chronic treatments, such as laxatives, is avoided at first. First-line therapy should be conducted including bowel retraining, increased fluid intake and dietary fibre, and possible exercise. Laxatives, non absorbable solutions, and stool softeners may be of need when handling chronic constipation patients. Constipation of the elderly is at time more severe than just simple hernia, laxative dependence, and haemorrhoids. This condition needs to administer more and more laxatives for the patient to have normal bowel movements. Bowel movement straining at the age of 55 and above can cause a condition of prolapsed uterus. This is whereby the organ turns outwards requiring immediate medical attention (Wilson, 2005, p. 26). This same problem occurs as a result of rectum constipation in both sexes, requiring immediate medical attention. Men with untreated constipation have high chances of developing Hydrocele, a very painful testicular swelling (Kyle, 2010, p. 125). Untreated and Chronic constipation among the elderly can cause urinary incontinence which needs the use of a catheter if there is straining, hence breaking down muscles. Publications to Support Hypothesis Rigby And Powell’s (2005, p. 45) journal ‘Primary health care’ was used as a health care professional guide to recognising the importance of practice and development and its essentiality component in order to provide high standards of care. It shows the aim of nursing profession and to offer the highest possible standards of health care to respective patients. As cited by Rigby and Powell (2005, p. 46), practice development is essentially about questioning practice in the context of evidence to support what it is we as practitioners do, why we do it so and how it can be done differently. It points out that the purpose of practice development is to improve health care of individuals, communities and populations. The 2008 journal by Briggs (3) was used to explain the correlation between variable age gaps and constipation. It highlighted on elderly patients and their treatment with a number of drugs, dehydration and immobility at admittance. Bed rest and immobility often give rise to constipation (Kyle, 2006, p. 45). Insufficient intake of dietary fibre in hemiplegic population and lack of attention to drinking fluids as a result of dysphagia is another problem leading to constipation. The journal focuses on people with neurological conditions such as Parkinson’s and stroke and their vulnerability. It also highlights all risk factors particularly affected by difficulties related to preparing and eating a high fibre diet and drinking adequate fluid. Quigley, Vandeplassche, Kerstens and Ausma (2009, p. 322) conducted a randomized, doubleblind, placebo controlled trial to evaluate the efficacy and safety of prucalopride (selective high affinity 5 –HT4 receptor agonist).in patients with chronic constipation. The study enrolled men and women over 18 years of age excluding women who were pregnant and breast feeding.651 patients were randomized,641 received study medication and 567 completed the study and the 12 week diary. Patients were allocated to receive prucalopride 2mg or 4mg or placebo, and were instructed to take one tablet before breakfast. All study personal and patients were blinded to the treatments. Patients were assessed over 2, 3, 8 and 12 weeks using the five point likert scale (Gruss & ULM, 2004, p. 149). Higher scores reflect greater severity.prucalopride treated patients achieved significantly greater satisfaction with bowel function and improved perception of constipation severity and reported using fewer laxatives than placebo. Enhancing Patient Care This paper aims at enhancing the management of constipation only by relieving the constipation state but also by preventing its recurrence. In have explored various treatment options available for constipation, hence I have highlighted the need for improved management. Heitkemper and Wolff (2007, p. 41) asserts that enemas can be used when oral laxatives have not produced the desired affect and rapid evacuation is required. Administration of per rectum evacuants can potentially cause rectal or anal sphincter damage if not performed skilfully (Kalra, 2010, p. 24). There has been very little research evaluating their effectiveness .It has the potential to cause embarrassment and discomfort in patients. It is important to obtain informed consent from the patients and to provide with information about the procedure. This may alleviate an anxiety in patients. According to Kalish and Loven (2007, p. 1052), laxatives may be a necessary treatment option for severe constipation. Bowel problems can be linked to ineffective or inappropriate prescribing of laxatives. Bulk-forming laxatives are least harmful and can be used in conjunction with life style advice of increasing fibre in the diet. A common example is fibrogel sachets. This may take several days to work and not suitable for patients who require an immediate relief from constipation. They commonly cause bloating and flatulence in early stages of treatment. Stimulant laxatives include, docusate sodium, senna, dantron, bisacodyl, glycerol and. They are administered at bed time to produce stools in the morning. Although they have rapid effects they also have disadvantages. Stool softeners can exacerbate the problem by rendering the stool that evacuation is made more difficult. “One study found psylluim to be more effective than docusate compared with placebo. Docusate was more effective but, produced only modest improvement in constipation” (Wang, 2009, p. 4). However, Ghoshal (2005, p. 33) suggests other forms of therapy are preferable to softening agent. Osmotic agents work by maintaining the fluid content of the stool (Health service executive south, 2006, p. 38). These are often the first choice. Agents such as lactulose and movicol are considered to be gentler and have fewer side effects. Compared to placebo and lactulose, PEG (movicol) was more effective and potentially less costly (Woodward, 2002, p. 38). Project Outcomes This project aimed at assessing the early recognition of constipation in patients suffering from stroke. It will be able to educate nurses through focused education sessions on the effects of constipation using evidence based on the conducted research. The research will help to prevent constipation by establishing patient’s baseline of bowel pattern prior to admission. This will be achieved by looking at the patient’s history; examining and improving patients care to prevent recurrence. I have identified constipation as a serious problem which affects stroke patients. This is an area which requires practice and development since constipation is among the recurring complications in hospitalized acute stroke patients. Along with other complications like deep vein thrombosis, loss of skin integrity, mobility related problems, faecal and urinary incontinence, they need to be actively managed in order to positively influence during the patient’s stay in the hospital. The project was able to come up with recommendations in establishing early assessment of bowel habits prior to admission. This will help in identifying patients at the risk of developing constipation and audit pre and post risk patients. Bibliography An Bord Altranais (The nursing Board 2000), 2000, The code of professional conduct for each nurse and midwife. Pdf, 2-10. Apau, D., 2010, Assessing the cause of constipation and appropriate interventions. Gastrointestinal nursing 8(6), 24. Bosshard, W., Dreher, R., Schnegg, J. F., Bola, C.J., 2004, the treatment of constipation in elderly people: an update. PubMed 21(14)11-30. Bracci, F., Badiali, D., Pezzotti, P., Scivoletto, G., 2007, Chronic constipation in hemiplegic patients. World journal of Gastroenterology, 7(13) 3967-3972. Briggs, J., 2008, Management of constipation in older adults. Best practice, New Jersey: JBI Wiley- Blackwell publishing, 12(7), 1-4. Castledine, G., Grainger, M., Wood, N., Dilley, C., 2007, Researching the management of constipation in long-term care: part 1.British Journal of nursing 16(18). 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Spinzi, G., Amato, A., Imperiali, G., Lenoci, N., Mandelli, G., Paggi, S., 2009, Constipation in elderly: management strategies. Adis data information BV, 26(6), 469-474. Wald, A., 2010, Patient’s information: constipation in adults. Available at LY_BmnH_KO (Accessed 13 October 2010). Wang, B., Wu, T., He, P., Yan, Y., Dong, B. R., 2009, Polyethethylene glycol for chronic constipation in adults (protocol).The Cochrane library, Cochrane collaboration,1,1-8. Wilson, L., 2005, Understanding bowel problems in older people: part 1. Nursing older people, 17(8), 25-29. Wisten, A., & Messner, T., 2005, Fruit and fibre (pajala porridge) in prevention of constipation. Scand J caring, Nordic college of caring sciences.19, 71-76. Woodward, M.C., 2002, Constipation in older people pharmacological management issues. Geriatric therapeutics, 32, 37-43. Woolery, M., Bisanz, A., Lyons, H. F., & Gaido, L., 2008, Putting evidence into practice: evidence based interventions for management of constipation. 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