Understanding Constipation: Causes and Management

Hey guys, Woodruff here. We're going to start out talking about constipation with a drag and drop, or again, and remember these drag and drops, they're not perfect, like, you know, where it's an actual, remember drag and drops are extended select all that applies. So just think of these as one that has a bunch of answer possibilities, and we were just kind of mentally dragging them over. So which statements by a client would be most indicative, which means some of these could possibly indicate, but are like, which of these are most closely tied? with an increased risk of constipation. So we're looking for risk factors here. So let's look at the first one. I am diabetic and my last hemoglobin A1C was 10.9. So diabetes seems to ruin everything. So it seems like the easy answer here is yes. But let's look at the whole thing. So they're diabetics, that maybe is one risk factor. And then how is their glucose control? Their hemoglobin A1C was 10.9, which is a sign of Poor glucose control. So because they have poor glucose control, they, they're going to be at higher risk, because here's the thing that you want to consider is, is that sugar, too much sugar, we accumulate extra sugar, what can happen is it can affect the blood vessels in the intestines into the rectum, other things that can affect the ability to have uh, you know, regular stools and things like that. So having diabetes and having, uh, unmanaged diabetes are both, uh, going to having diabetes in general, but especially diabetes that's poorly managed, it's going to be an increased risk for constipation. Next one is I have a history of coronary artery disease and I'm on a torvastatin. So then we have to sit there and be like, okay, cause this is really focused on. So like would having plaque in my arteries and being on a torvastatin increase my risk for constipation. So what do you call them? Believe it or not, this is one of the few times that we're going to say no, there are other meds that can cause constipation, but atorvastatin is not one of them. Then this is a great time to do some cumulative review and be like, hmm, what does atorvastatin affect? And atorvastatin affects your liver and then can also cause that muscle pain or rhabdose. You always want to ask about muscle pain. So liver function, muscle pain, and then it also can cause a rash. So that's, it's not necessarily related to constipation. Now I'm going to tell you this. The reason I put most indicative here is because if you Google all of these meds conditions, I'm sure you could find some way to tie it to constipation. Anyone can get constipated for a variety of reasons. I'm just thinking close ties. I'm in nursing school and have an exam next week. How exciting. Yes. This is also another indicator. Stress can lead to constipation. Any change in your routines. This is why like. When people travel, they get really constipated. They're out of their routine. They're out of their comfort zone, things like that. So definitely stress is another thing. So sugar, stress are two things. I have inflammatory bowel disease and take diphenoxalate atropine daily. So if you remember diphenoxalate atropine is lamodal. And am I saying that right? Yes, lamodal. I'm just making sure. I'm doubting in my head, but yes, lamodal it is. I'm not crazy. And so- you know, they have an inflammatory bowel disease, which one is already a risk factor for issues with like changes in your soul. So usually with inflammatory bowel, they have diarrhea. So that's why this patient is taking medication that's an anti-diarrheal. So we have to think about if I'm taking something that's going to slow my motility or my bowels or cause them to not be moving as much, what's the side effect there? I'm going to be higher risk for constipation. So sugar, stress, and anti-diarrheals. I have a history of hyperthyroidism. So some of the thyroid stuff seems like, yeah, that's a safe bet. And if this said I have a history of hypothyroidism, it would be true. Because in hypothyroidism, everything is slow and low. But with hyperthyroidism, everything is actually moving a lot faster. So they're less at risk for having constipation. But with hypothyroidism, they definitely are at risk for constipation. chronic back pain and taking hydrocodone daily. So having chronic back pain, definitely it's chronic back pain can put stress on you, which could lead to constipation. But let's look at the full sentence and they're taking hydrocodone. And what is hydrocodone? It is a opioid and opioids put you at increased risk for constipation. So it's another thing to consider. Last but not least, I have a history of Meniere's disease and take furosemide. So Meniere's disease, like, I don't think that having... lymphatic fluid being off in your ear can necessarily cause constipation. But if you're taking a medication that's going to dry you out, it can also dry you out to where you have less fluid available in your bowels in order to, you know, make things softer and easier to pass. So being on a diuretic is also a risk factor for constipation. So we got sugar, stress, antidiarrheals, opioids, and diuretics. come on Jesus let's go there we go so who gets or what is constipation who gets it um constipation is infrequent stools or difficult to pass stools or feeling like you're not emptying as much as you should and so um you know like where you're pooping but like it's like you feel like there's still some left so keep in mind constipation everyone hears constipation they're like oh they must not have pooped at all some people that are constipated are pooping but pooping normally. Or sometimes their people are pooping, and they're pooping regularly, but the stools are really hard. And so you always want to consider that constipation is not just no stool, sometimes it's abnormal stools. So some common cause is not enough fiber or fluid, a sedentary lifestyle, certain medications like we brought up, and pregnancy as well. So like I mentioned, a client that has constipation, they can have lack of stools, absent stools. They can also just have hard stools or difficult to pass stools. We may note that they have hemorrhoids as a result of their constipation, which we'll talk about. They can also have abdominal pain, bloating, gas, and general pressure in their rectal area. Priority assessments that we're going to do is assessing for their stool and bowel habits and patterns like how often do they normally go? What is their stool like? That kind of stuff. Have they ever had this problem before? I want to assess their diet and what their fluid and fiber intake is like, because those can be very critical factors to this. And then any other abdominal symptoms, like I talked about the pain, bloating, gas, pressure. And then specifically, I want to look in the rectal area, look for any skin breakdown or issues or things like hemorrhoids, which might be telling of constipation. So this is the Bristol stool scale. and, you know, can tell different types of like, you know, stool, like from liquid to solid. So you definitely want to kind of consider this, you know, a lot of times people that are having more of this like corn on the cob or a bunch of grapes or rabbit droppings, they can have that really hard stool that can be hard to pass. So mostly we just get a history. But one thing to consider is constipation can be a sign of something a lot worse, we want to check maybe an occult stool look for bleeding. And then also look for any signs of blood loss, like with an H&H or iron labs. We also, because a lot of times with this, like constipate, like changes in stool habits, whether it's diarrhea or constipation, bleeding in the stool and stuff like that, these can be early signs or earlier-ish signs of colorectal cancer. So we definitely want to make sure it goes beyond just, hey, I need more fluid and fiber. Sorry, want to make sure it doesn't go beyond. Like just we need lifestyle changes. And you know, I talk about it more when I talk about colorectal cancer videos, which you learn about in complex or your last semester. But it's just really important to note that colorectal cancer is making a surge. It's much more common, especially in younger women. And you want to be super careful and not just think like, oh, yeah, cancer, that's something to worry about as I get older. Um, there's a lot of times these subtle changes can make a big difference. I'm not saying that to scare you, but it's a lot of the lack of awareness that a lot of people don't know how much more common colorectal cancer is becoming. So constipation is better, less episodes, um, excuse you, um, less episodes of constipation, more softer stools are easy to pass stools, um, less or no other symptoms, no complications. But if they're having more episodes, harder, difficult to pass stools. um, increasing other symptoms like they're, they're starting, they didn't have abdominal pain and now they do, or they had abdominal pain, but it's getting worse, um, or complications and the complications they can experience. We're going to talk about hemorrhoids separately. Um, but it's effectively, if you remember varicose veins, that's what hemorrhoids are. They're varicose veins, but in the rectal area, it's pretty much just these dilated torturous veins, but in your rectum, and you can imagine it's really surface level. So it can lead to a lot of pain and discomfort, especially with hard stools. But they're a result of too much pressure straining. Bageling. So this is... Vagaling is what happens. It's a cardiovascular response. I like to say it's a cardiovascular response. There's more that goes into it. But pretty much what happens is that if you're sitting on the stool, you're straining, you're working hard, you're building up a lot of intra-abdominal pressure. And when you're building up intra-abdominal pressure, your body has these things called baroreceptors. And there's also chemoreceptors and stuff inside. And with the baroreceptors, when they sense, hey, there's this extra pressure going on, What they do in response is, is that they try to compensate for that, you know, intense, what do you call them? Where there's like too much pressure, you know, in the body. It's like, hey, I'm going to compensate for that. So they're trying to help to make it better. So what your body does is it, it tries to decrease your heart rate, blood pressure and stuff like that. Cause it's like, hey, there's too much pressure. What can happen is your heart rate can go so low with this that you can pass out. So this is where like when they find people passed out by their toilets. this is usually what happened. And I mean, it happens at the hospital too, where people pass out on the toilet. That's why you never leave a patient alone. Always check on them because if they're, especially if they're constipated, trying to have a bowel movement, even a healthy patient, this is just a natural human response, very cardiovascular response. Impaction. So, signs of those like hardwall stools, which can lead to like an obstruction, and then also diverticulosis or diverticulitis. So this is like another thing kind of like hemorrhoids. It's like pouches that are on the outside of the intestines, usually on the lower left quadrant. And they can get infected, inflamed and be very dangerous. We'll talk about those later. So again, too much pressure in the blood vessels of the rectum, we can get hemorrhoids, it can get clogged with impaction. Too much pressure could also lead to perforation of the bowels, which leads to those three P's, the pain, perforation, peritonitis. We can also have breakdown of the skin and tissues of the rectum, also known as fissures, really uncomfortable. And, you know, kind of think of it like it's like skin breakdown, but in the tissue. And then if you have stool that gets in there, it burns like hell. And then also, like I mentioned, passing out from that vagal stimulation. So let's get into hemorrhoids now. So hemorrhoids are, this is a separate topic that you do need to know about. Hemorrhoids are swollen or inflamed. Well, part of me is like, should I do a different video on this? But it all goes together. So we'll just keep it together. Hemorrhoids are swollen or inflamed blood vessels of the anal area. It's a result of straining, increased pressure. And what do you call it? You know, like from sitting on the toilet for too long. And again, they start, these blood vessels, they start to get stretched out. And it's from too much pressure. Like, you know, it's just kind of like. you know, it leaves these outpocketed blood vessels in your rectum. So they cause like itching, pain, burning, especially if they get broken down, have sores on them, or like with constipation or frequent stools, they can get worse. So from sitting on a toilet for a long time, chronic GI problems, like lots and lots of bowel movements, any sort of increased abdominal pressure like obesity or pregnancy. or a low fiber diet can definitely be causes all the constipation kind of stuff. So what we do for this patient is we want to soften their stool, which we'll talk about stool softener soon, we want to take away pain, irritation, there is stuff like preparation H like local ointments and creams, there's some inter rectal stuff that you can stick up suppositories, tons of stuff that you can use. Additionally, you can also use NSAIDs for pain. It's an inflammation, so it can definitely help. Sitz baths, which is what's in this picture. And what this is like, if you've ever given birth, you might've seen one like this. You can put like Epsom salts and things in these little, okay, sorry. And you can do Epsom salts and other things like this in these baths. And then you just kind of soak your rectal area in this. Like you can sit on the toilet and do these and things like that. And it allows for the Epsom salts and stuff to decrease inflammation and can increase inflammation. prove your comfort. Provide comfort and dignity to this patient. Like, you know, it's very painful and uncomfortable for them. So try to be kind human being and understand that even though it seems minor to you, it can be super painful. We want to increase fluids and fiber, all the stuff we want to do to treat constipation, because we want to get to the bottom of the problem, no pun intended. And then with this certain people, if it gets so severe, we may need to do what's called a hemorrhoidectomy, which is where we're removing the hemorrhoid. And usually they do stuff like they do banding and stuff like that, where we literally just try to kind of cut off flow to that blood vessel so that we can get it and it's not one that you need. So like kind of like varicose veins, like how we can suck them out and stuff like that. Um, so, uh, post-op as the nurse, remember you don't need to know too in depth about how these procedures are done, but you want to focus on what are we going to do as the nurse after. So after as the nurse, we want to maintain packing. Um, so sometimes these, um, the rectum will be packed and you really want to be careful with this because you want to be looking, there's a very, um, not a very high chance, but there's a concerning risk for bleeding with these patients because it's a very vascular area in the anal area. So you want to maintain that pack. packing watch for excessive bleeding, or if you have to change the packing a lot, that's usually a sign that maybe there's something else going on. The pain with this can be severe, like your book talks about like sometimes they can dread their first bowel movement. And it's going to take a lot like where you have to maybe pre medicate them to convince them to have a bowel movement, some of that, but it's so important for them to go. And then doing this, it's best, like I talked about overall education for hemorrhoids, it's going to be to reduce straining, you know, fluids and fluids, fiber and movement. are going to be all helpful. So that's hemorrhoids, but let's get back to constipation. So for constipation, we want to, there's a few things we'll do. Of course, there's medications we can give like stool softeners, laxatives, fiber stuff, enemas. But we always want to start with the least invasive first. So if we can do lifestyle changes like fluid, fiber and movement increases, we want to start with that. And then another thing that a lot of people don't recognize is can be a problem. is the position that we use the restroom. So you know, the way that our bodies were designed, we were meant to poop in a squat. And the way that toilets are designed, our knees are not high enough for us to actually be in a good position for having a stool. So there's wonderful things like the squatty potty that was invented to help to increase the height of our knees to allow for a better stooling experience. So And then also just make sure to provide privacy and dignity. I always tell the funny story of the patient that, you know, they were a stroke patient, I just didn't trust them. So like, I put them on the on like the bedside commode. But then I'm standing right there. And I'm just talking to them and stuff. And like 1015 minutes goes by. And I'm like, Hey, still going. And they were like, Well, I haven't even started. They're like, How do you expect me to go? And you're standing here talking to me? Like, I'm just so used to being around people and they're pooping, they're doing whatever, you know, so I'm just like, Yeah, oh, okay. So you want privacy. So just Make sure some people can't go with you present. But you know, you have to always maintain their safety. But it's just about a balance trying to find a happy middle. So let's talk about these constipation meds. I know you're so excited that there's more meds. So we'll know these work if the patient poops, like that's the effectiveness. Especially like some of them, it's going to be like if they pooped or if their stool is more soft, because some of them it's just about making it more soft, necessarily making you stool. Keep in mind, all constipation meds should be taken with a full glass of water. Because again, it's kind of like with the cholesterol meds. Like if I'm going to give someone cholesterol meds, okay, but they also need to work on their diet. So same thing like constipation meds, they can help. But if they have poor fluid or poor fiber intake, long term, we're just going to keep having this problem. So since all these medications will cause you to poop, we're going to be worried about dehydration, skin irritation, electrolyte imbalances. So a lot of the stuff with like diarrhea and stuff like that kind of think up for this. There's a few different classes for constipation meds. There's what's called bulk forming laxative. These are like fiber. They make the stool more bulky. There's also what's known as emollients. This is like a stool softener. And these help to make things easier for you. It makes it easier for your stools to pass. It makes the stool itself softer. There's saline and osmotic laxatives that increase the amount of fluid. the retention of fluid that you're having in your intestines. And by doing this, it helps to make stools have a softer consistency. And then last but not least, the more invasive option is stimulants. These actually increase your peristalsis and get things moving, like if you have poor motility. So some considerations for these meds with the psyllium fiber or like metamucil, this is a ball forming laxative. Again, this is more like just fiber. And so it has very few side effects, but you want to mix it well. And, you know, because there's like, you want to mix it well, because it's going to be harder to take in and less effective. Again, this is something where we talk about, you know, you want it with a full glass of water. So usually like things like Metamucil, we can mix it with something else like juices or preferred water to get some more of that liquid intake in as well. And there's a very low risk of dependence. Like some of these other meds, I'm going to talk about dependence. And I'm not talking about dependence, like opioid dependence, but I'm talking about like that you're going to be dependent upon taking this in order to have a stool. And these like you can take stuff like the psyllium fiber, and it's not going to be like, oh my God, I have to have this in order to have a bowel movement. There's also what's known as emollients. That's like docusate or colase. These can help, again, to kind of make things a little bit softer. And one thing to consider, though, is that they can also block absorption of vitamins, specifically vitamin K. And this can also affect the effectiveness of your anticoagulation. Because remember, vitamin K works on or against warfarin. So... Just kind of keep that in mind when with medications like that. There's also I talked to you about the saline and hyperosmotic laxatives. You can just see some considerations here, like some of the saline laxatives, they have magnesium in them. And I talked before that magnesium and renal stuff doesn't go well together. So careful with magnesium products in renal patients. And then milk of magnesia is more of like a gentle, as gentle as you can get, I should say. Um, it's not necessarily a bowel prep, whereas magnesium citrate, or, um, you might see it called mag citrate. This is a very potent med. It's a bowel prep. We use it for people that are getting colonoscopies and stuff like that. And so we definitely want to consider like, this is not something to take lightly. Um, some people take the mag citrate and stuff, and this is actually very unsafe before, um, when they're pregnant to try to speed up, um, labor and stuff like that. Super dangerous. So. be very careful or you know, there's, you know, it's very, it's going to cause you to go go go go go like for for a while and can cause a lot of diarrhea and loss of water and stuff like that. So kind of keep a close eye. Another med that's like that is what's called polyethylene glycol, I can speak polyethylene glycol, which is go lightly. And so just know with this one, there's nothing light about go lightly. It's very potent. It's about prep. They get like a big jug and have to drink the whole thing. I try to always make it like as a joke, like fun, like, hey, this is like margaritas, but it sure don't taste like margaritas. So it's definitely no fun. I think they have flavors, but trust me, it's not good. There's also for hyperosmotic, that's a little bit less, what do you call them? Less, I guess I would say potent is going to be Miralax. It still can work really well. So in other words, like most of the time in the hospital, what you're going to see given, they might give them. fiber, but they'll usually do stuff like Miralax is a go-to, stool softeners and things like that, like the Docusate are used as well. We only usually use the MagCit Tray to go lightly if they're literally about to have a colonoscopy or some sort of bowel prep. Other things that you'll see used is like stuff like Senna, which is considered a stimulant. Again, that's the one that causes more bowel contractions. Now getting to stimulant laxatives, these work better. by causing contractions in the bowel. And they work by contracting in the bowel, but they also can lubricate as well, which sounds great. But anything that's a stimulant laxative, it's training the body to go when you're giving it, but it can actually cause dependence where some people end up, they overuse these. Your book actually goes into it a lot about how there's been such a issue now with dependence. on these meds, like with these meds for people, where they're becoming dependent upon them in order to have a bowel movement. So we really try to avoid doing stimulants until like if unless it's like last ditch efforts like that, or like that's the it's more of the later ones that we want to use. We want to try other least invasive things first. There's also enemas. No enemas can work rapidly. They also people can come dependent upon these enemas as well. The patient has to have the ability to clench. In other words, they have to have rectal tone. If they don't have rectal tone, like if there's spinal or neurological injury, they're not going to be able to use these. We want to turn them on their left side. This promotes them to have a better ability to have their, to get their stool out. It just has to do with the way, like with peristalsis and how things work. Left side is how we want to position them. And then because of the way that like, literally, if you've never given an enema, you're sticking the stube up their butt. There's a bunch of either. water, it can have mineral oil in it, it can have milk of molasses, stuff like that is pretty much what we're squirting in them. It just helps to loosen any stool that's in like that last area and kind of just helps to make things easier to pass. But we're sticking a bunch of fluid up them. So it can cause irritation, inflammation. They also can have water intoxication, which means like that water is meant to grab the stool and then leave the body. But sometimes we can accidentally absorb too much, which can lead to issues. And then also electrolyte imbalances from the excess stool. Sorry, excess like stool losses or loss of fluid and stuff. As the nurse, we want to protect this patient's skin, watch closely, because a lot of times with constipation, again, they can have the fissures or with the medications we give, they can be pooping a lot. So we want to watch closely for their skin. And we want to teach them risks of chronic laxative use, especially those stimulant laxatives. So really, like, I mean, laxatives are meant to be used until they can have a stool, but they're not meant to be like, hey, I have to take this in order to go. We want to use the medications as prescribed, not above how they're prescribed. Because people just like sometimes like people are very set. I'm like, I have to have a bowel movement every day at this time, this way. This doesn't always work out that way. Long term, like it says here, they can have decreased tone in their rectum, which can make things worse and again, dependence. Lifestyle changes. So two liters of fluid a day, 20 to 30 grams of fiber and exercising at least three times per week. So those lifestyle changes in conjunction with meds, hopefully only as needed. can be super helpful. Other things to teach about is not to wait. So holding it in is really bad for rectal tone and stuff like that. You want them to go when they need to go. And then creating a routine and schedule because the body is a very big inhabit. So and then this picture kind of shows like at 90 degrees, it's a lot harder to get stool out. Whereas if you're at more of this 35 degree angle with your knees up, it can lead for easier stooling. I think that's it. Okay. All right. So the only thing else I have here is just some questions, some food for thought questions, no pun intended food for thought, but just think about like what foods or liquids would we encourage a client with constipation to eat or drink or what foods or liquids should we discourage? So we want to think of what are our high fiber foods and liquids and what are the ones that are not going to be as helpful. So when you think of high fiber, most of the time you want to think of your roughage, like your fruits and vegetables, your whole grains, stuff like that. that are definitely going to help. What do you call them? Because really, so we want to think as a whole, high fiber is good, low fiber is not as good. And low fiber foods are going to be things like things that are like white rice, white breads, things like that. So we want things that are going to help to form bulk, and then help to get things to pass better. And so definitely this is something there's a lot more there. I'm going to just get you started with that. But definitely want to kind of start going through and thinking a lot of the GI disorders that we're going to get into. It's like this food is good. This food is not good. Or this type of food is good. Or this is not good. So making a table or something like that and think of what's going to help and what's going to hurt for this patient, whether it's food, other treatments, kind of like I talked about making a indicated contraindicated for each disease process will be super helpful, especially because these can all start to get mixed up in your head. Anyway. I will see you for the next one. Have a good night.

with an increased risk of constipation. So we're looking for risk factors here. So let's look at the first one.

I am diabetic and my last hemoglobin A1C was 10.9. So diabetes seems to ruin everything. So it seems like the easy answer here is yes.

But let's look at the whole thing. So they're diabetics, that maybe is one risk factor. And then how is their glucose control?

Their hemoglobin A1C was 10.9, which is a sign of Poor glucose control. So because they have poor glucose control, they, they're going to be at higher risk, because here's the thing that you want to consider is, is that sugar, too much sugar, we accumulate extra sugar, what can happen is it can affect the blood vessels in the intestines into the rectum, other things that can affect the ability to have uh, you know, regular stools and things like that. So having diabetes and having, uh, unmanaged diabetes are both, uh, going to having diabetes in general, but especially diabetes that's poorly managed, it's going to be an increased risk for constipation.

Next one is I have a history of coronary artery disease and I'm on a torvastatin. So then we have to sit there and be like, okay, cause this is really focused on. So like would having plaque in my arteries and being on a torvastatin increase my risk for constipation.

So what do you call them? Believe it or not, this is one of the few times that we're going to say no, there are other meds that can cause constipation, but atorvastatin is not one of them. Then this is a great time to do some cumulative review and be like, hmm, what does atorvastatin affect?

And atorvastatin affects your liver and then can also cause that muscle pain or rhabdose. You always want to ask about muscle pain. So liver function, muscle pain, and then it also can cause a rash.

So that's, it's not necessarily related to constipation. Now I'm going to tell you this. The reason I put most indicative here is because if you Google all of these meds conditions, I'm sure you could find some way to tie it to constipation. Anyone can get constipated for a variety of reasons. I'm just thinking close ties.

I'm in nursing school and have an exam next week. How exciting. Yes.

This is also another indicator. Stress can lead to constipation. Any change in your routines. This is why like. When people travel, they get really constipated.

They're out of their routine. They're out of their comfort zone, things like that. So definitely stress is another thing.

So sugar, stress are two things. I have inflammatory bowel disease and take diphenoxalate atropine daily. So if you remember diphenoxalate atropine is lamodal.

And am I saying that right? Yes, lamodal. I'm just making sure. I'm doubting in my head, but yes, lamodal it is.

I'm not crazy. And so- you know, they have an inflammatory bowel disease, which one is already a risk factor for issues with like changes in your soul. So usually with inflammatory bowel, they have diarrhea.

So that's why this patient is taking medication that's an anti-diarrheal. So we have to think about if I'm taking something that's going to slow my motility or my bowels or cause them to not be moving as much, what's the side effect there? I'm going to be higher risk for constipation.

So sugar, stress, and anti-diarrheals. I have a history of hyperthyroidism. So some of the thyroid stuff seems like, yeah, that's a safe bet. And if this said I have a history of hypothyroidism, it would be true. Because in hypothyroidism, everything is slow and low.

But with hyperthyroidism, everything is actually moving a lot faster. So they're less at risk for having constipation. But with hypothyroidism, they definitely are at risk for constipation.

chronic back pain and taking hydrocodone daily. So having chronic back pain, definitely it's chronic back pain can put stress on you, which could lead to constipation. But let's look at the full sentence and they're taking hydrocodone. And what is hydrocodone?

It is a opioid and opioids put you at increased risk for constipation. So it's another thing to consider. Last but not least, I have a history of Meniere's disease and take furosemide. So Meniere's disease, like, I don't think that having...

lymphatic fluid being off in your ear can necessarily cause constipation. But if you're taking a medication that's going to dry you out, it can also dry you out to where you have less fluid available in your bowels in order to, you know, make things softer and easier to pass. So being on a diuretic is also a risk factor for constipation. So we got sugar, stress, antidiarrheals, opioids, and diuretics. come on Jesus let's go there we go so who gets or what is constipation who gets it um constipation is infrequent stools or difficult to pass stools or feeling like you're not emptying as much as you should and so um you know like where you're pooping but like it's like you feel like there's still some left so keep in mind constipation everyone hears constipation they're like oh they must not have pooped at all some people that are constipated are pooping but pooping normally.

Or sometimes their people are pooping, and they're pooping regularly, but the stools are really hard. And so you always want to consider that constipation is not just no stool, sometimes it's abnormal stools. So some common cause is not enough fiber or fluid, a sedentary lifestyle, certain medications like we brought up, and pregnancy as well.

So like I mentioned, a client that has constipation, they can have lack of stools, absent stools. They can also just have hard stools or difficult to pass stools. We may note that they have hemorrhoids as a result of their constipation, which we'll talk about. They can also have abdominal pain, bloating, gas, and general pressure in their rectal area.

Priority assessments that we're going to do is assessing for their stool and bowel habits and patterns like how often do they normally go? What is their stool like? That kind of stuff. Have they ever had this problem before? I want to assess their diet and what their fluid and fiber intake is like, because those can be very critical factors to this.

And then any other abdominal symptoms, like I talked about the pain, bloating, gas, pressure. And then specifically, I want to look in the rectal area, look for any skin breakdown or issues or things like hemorrhoids, which might be telling of constipation. So this is the Bristol stool scale. and, you know, can tell different types of like, you know, stool, like from liquid to solid.

So you definitely want to kind of consider this, you know, a lot of times people that are having more of this like corn on the cob or a bunch of grapes or rabbit droppings, they can have that really hard stool that can be hard to pass. So mostly we just get a history. But one thing to consider is constipation can be a sign of something a lot worse, we want to check maybe an occult stool look for bleeding.

And then also look for any signs of blood loss, like with an H&H or iron labs. We also, because a lot of times with this, like constipate, like changes in stool habits, whether it's diarrhea or constipation, bleeding in the stool and stuff like that, these can be early signs or earlier-ish signs of colorectal cancer. So we definitely want to make sure it goes beyond just, hey, I need more fluid and fiber. Sorry, want to make sure it doesn't go beyond. Like just we need lifestyle changes.

And you know, I talk about it more when I talk about colorectal cancer videos, which you learn about in complex or your last semester. But it's just really important to note that colorectal cancer is making a surge. It's much more common, especially in younger women.

And you want to be super careful and not just think like, oh, yeah, cancer, that's something to worry about as I get older. Um, there's a lot of times these subtle changes can make a big difference. I'm not saying that to scare you, but it's a lot of the lack of awareness that a lot of people don't know how much more common colorectal cancer is becoming.

So constipation is better, less episodes, um, excuse you, um, less episodes of constipation, more softer stools are easy to pass stools, um, less or no other symptoms, no complications. But if they're having more episodes, harder, difficult to pass stools. um, increasing other symptoms like they're, they're starting, they didn't have abdominal pain and now they do, or they had abdominal pain, but it's getting worse, um, or complications and the complications they can experience. We're going to talk about hemorrhoids separately. Um, but it's effectively, if you remember varicose veins, that's what hemorrhoids are.

They're varicose veins, but in the rectal area, it's pretty much just these dilated torturous veins, but in your rectum, and you can imagine it's really surface level. So it can lead to a lot of pain and discomfort, especially with hard stools. But they're a result of too much pressure straining.

Bageling. So this is... Vagaling is what happens.

It's a cardiovascular response. I like to say it's a cardiovascular response. There's more that goes into it. But pretty much what happens is that if you're sitting on the stool, you're straining, you're working hard, you're building up a lot of intra-abdominal pressure. And when you're building up intra-abdominal pressure, your body has these things called baroreceptors.

And there's also chemoreceptors and stuff inside. And with the baroreceptors, when they sense, hey, there's this extra pressure going on, What they do in response is, is that they try to compensate for that, you know, intense, what do you call them? Where there's like too much pressure, you know, in the body.

It's like, hey, I'm going to compensate for that. So they're trying to help to make it better. So what your body does is it, it tries to decrease your heart rate, blood pressure and stuff like that. Cause it's like, hey, there's too much pressure.

What can happen is your heart rate can go so low with this that you can pass out. So this is where like when they find people passed out by their toilets. this is usually what happened. And I mean, it happens at the hospital too, where people pass out on the toilet. That's why you never leave a patient alone.

Always check on them because if they're, especially if they're constipated, trying to have a bowel movement, even a healthy patient, this is just a natural human response, very cardiovascular response. Impaction. So, signs of those like hardwall stools, which can lead to like an obstruction, and then also diverticulosis or diverticulitis.

So this is like another thing kind of like hemorrhoids. It's like pouches that are on the outside of the intestines, usually on the lower left quadrant. And they can get infected, inflamed and be very dangerous. We'll talk about those later.

So again, too much pressure in the blood vessels of the rectum, we can get hemorrhoids, it can get clogged with impaction. Too much pressure could also lead to perforation of the bowels, which leads to those three P's, the pain, perforation, peritonitis. We can also have breakdown of the skin and tissues of the rectum, also known as fissures, really uncomfortable. And, you know, kind of think of it like it's like skin breakdown, but in the tissue. And then if you have stool that gets in there, it burns like hell.

And then also, like I mentioned, passing out from that vagal stimulation. So let's get into hemorrhoids now. So hemorrhoids are, this is a separate topic that you do need to know about.

Hemorrhoids are swollen or inflamed. Well, part of me is like, should I do a different video on this? But it all goes together. So we'll just keep it together. Hemorrhoids are swollen or inflamed blood vessels of the anal area.

It's a result of straining, increased pressure. And what do you call it? You know, like from sitting on the toilet for too long. And again, they start, these blood vessels, they start to get stretched out. And it's from too much pressure.

Like, you know, it's just kind of like. you know, it leaves these outpocketed blood vessels in your rectum. So they cause like itching, pain, burning, especially if they get broken down, have sores on them, or like with constipation or frequent stools, they can get worse.

So from sitting on a toilet for a long time, chronic GI problems, like lots and lots of bowel movements, any sort of increased abdominal pressure like obesity or pregnancy. or a low fiber diet can definitely be causes all the constipation kind of stuff. So what we do for this patient is we want to soften their stool, which we'll talk about stool softener soon, we want to take away pain, irritation, there is stuff like preparation H like local ointments and creams, there's some inter rectal stuff that you can stick up suppositories, tons of stuff that you can use.

Additionally, you can also use NSAIDs for pain. It's an inflammation, so it can definitely help. Sitz baths, which is what's in this picture. And what this is like, if you've ever given birth, you might've seen one like this.

You can put like Epsom salts and things in these little, okay, sorry. And you can do Epsom salts and other things like this in these baths. And then you just kind of soak your rectal area in this.

Like you can sit on the toilet and do these and things like that. And it allows for the Epsom salts and stuff to decrease inflammation and can increase inflammation. prove your comfort. Provide comfort and dignity to this patient. Like, you know, it's very painful and uncomfortable for them.

So try to be kind human being and understand that even though it seems minor to you, it can be super painful. We want to increase fluids and fiber, all the stuff we want to do to treat constipation, because we want to get to the bottom of the problem, no pun intended. And then with this certain people, if it gets so severe, we may need to do what's called a hemorrhoidectomy, which is where we're removing the hemorrhoid. And usually they do stuff like they do banding and stuff like that, where we literally just try to kind of cut off flow to that blood vessel so that we can get it and it's not one that you need.

So like kind of like varicose veins, like how we can suck them out and stuff like that. Um, so, uh, post-op as the nurse, remember you don't need to know too in depth about how these procedures are done, but you want to focus on what are we going to do as the nurse after. So after as the nurse, we want to maintain packing.

Um, so sometimes these, um, the rectum will be packed and you really want to be careful with this because you want to be looking, there's a very, um, not a very high chance, but there's a concerning risk for bleeding with these patients because it's a very vascular area in the anal area. So you want to maintain that pack. packing watch for excessive bleeding, or if you have to change the packing a lot, that's usually a sign that maybe there's something else going on. The pain with this can be severe, like your book talks about like sometimes they can dread their first bowel movement.

And it's going to take a lot like where you have to maybe pre medicate them to convince them to have a bowel movement, some of that, but it's so important for them to go. And then doing this, it's best, like I talked about overall education for hemorrhoids, it's going to be to reduce straining, you know, fluids and fluids, fiber and movement. are going to be all helpful. So that's hemorrhoids, but let's get back to constipation.

So for constipation, we want to, there's a few things we'll do. Of course, there's medications we can give like stool softeners, laxatives, fiber stuff, enemas. But we always want to start with the least invasive first.

So if we can do lifestyle changes like fluid, fiber and movement increases, we want to start with that. And then another thing that a lot of people don't recognize is can be a problem. is the position that we use the restroom.

So you know, the way that our bodies were designed, we were meant to poop in a squat. And the way that toilets are designed, our knees are not high enough for us to actually be in a good position for having a stool. So there's wonderful things like the squatty potty that was invented to help to increase the height of our knees to allow for a better stooling experience. So And then also just make sure to provide privacy and dignity.

I always tell the funny story of the patient that, you know, they were a stroke patient, I just didn't trust them. So like, I put them on the on like the bedside commode. But then I'm standing right there.

And I'm just talking to them and stuff. And like 1015 minutes goes by. And I'm like, Hey, still going.

And they were like, Well, I haven't even started. They're like, How do you expect me to go? And you're standing here talking to me? Like, I'm just so used to being around people and they're pooping, they're doing whatever, you know, so I'm just like, Yeah, oh, okay.

So you want privacy. So just Make sure some people can't go with you present. But you know, you have to always maintain their safety.

But it's just about a balance trying to find a happy middle. So let's talk about these constipation meds. I know you're so excited that there's more meds.

So we'll know these work if the patient poops, like that's the effectiveness. Especially like some of them, it's going to be like if they pooped or if their stool is more soft, because some of them it's just about making it more soft, necessarily making you stool. Keep in mind, all constipation meds should be taken with a full glass of water.

Because again, it's kind of like with the cholesterol meds. Like if I'm going to give someone cholesterol meds, okay, but they also need to work on their diet. So same thing like constipation meds, they can help. But if they have poor fluid or poor fiber intake, long term, we're just going to keep having this problem. So since all these medications will cause you to poop, we're going to be worried about dehydration, skin irritation, electrolyte imbalances.

So a lot of the stuff with like diarrhea and stuff like that kind of think up for this. There's a few different classes for constipation meds. There's what's called bulk forming laxative.

These are like fiber. They make the stool more bulky. There's also what's known as emollients. This is like a stool softener. And these help to make things easier for you.

It makes it easier for your stools to pass. It makes the stool itself softer. There's saline and osmotic laxatives that increase the amount of fluid.

the retention of fluid that you're having in your intestines. And by doing this, it helps to make stools have a softer consistency. And then last but not least, the more invasive option is stimulants.

These actually increase your peristalsis and get things moving, like if you have poor motility. So some considerations for these meds with the psyllium fiber or like metamucil, this is a ball forming laxative. Again, this is more like just fiber. And so it has very few side effects, but you want to mix it well. And, you know, because there's like, you want to mix it well, because it's going to be harder to take in and less effective.

Again, this is something where we talk about, you know, you want it with a full glass of water. So usually like things like Metamucil, we can mix it with something else like juices or preferred water to get some more of that liquid intake in as well. And there's a very low risk of dependence. Like some of these other meds, I'm going to talk about dependence. And I'm not talking about dependence, like opioid dependence, but I'm talking about like that you're going to be dependent upon taking this in order to have a stool.

And these like you can take stuff like the psyllium fiber, and it's not going to be like, oh my God, I have to have this in order to have a bowel movement. There's also what's known as emollients. That's like docusate or colase.

These can help, again, to kind of make things a little bit softer. And one thing to consider, though, is that they can also block absorption of vitamins, specifically vitamin K. And this can also affect the effectiveness of your anticoagulation. Because remember, vitamin K works on or against warfarin.

So... Just kind of keep that in mind when with medications like that. There's also I talked to you about the saline and hyperosmotic laxatives.

You can just see some considerations here, like some of the saline laxatives, they have magnesium in them. And I talked before that magnesium and renal stuff doesn't go well together. So careful with magnesium products in renal patients. And then milk of magnesia is more of like a gentle, as gentle as you can get, I should say. Um, it's not necessarily a bowel prep, whereas magnesium citrate, or, um, you might see it called mag citrate.

This is a very potent med. It's a bowel prep. We use it for people that are getting colonoscopies and stuff like that.

And so we definitely want to consider like, this is not something to take lightly. Um, some people take the mag citrate and stuff, and this is actually very unsafe before, um, when they're pregnant to try to speed up, um, labor and stuff like that. Super dangerous.

So. be very careful or you know, there's, you know, it's very, it's going to cause you to go go go go go like for for a while and can cause a lot of diarrhea and loss of water and stuff like that. So kind of keep a close eye. Another med that's like that is what's called polyethylene glycol, I can speak polyethylene glycol, which is go lightly.

And so just know with this one, there's nothing light about go lightly. It's very potent. It's about prep. They get like a big jug and have to drink the whole thing. I try to always make it like as a joke, like fun, like, hey, this is like margaritas, but it sure don't taste like margaritas.

So it's definitely no fun. I think they have flavors, but trust me, it's not good. There's also for hyperosmotic, that's a little bit less, what do you call them?

Less, I guess I would say potent is going to be Miralax. It still can work really well. So in other words, like most of the time in the hospital, what you're going to see given, they might give them.

fiber, but they'll usually do stuff like Miralax is a go-to, stool softeners and things like that, like the Docusate are used as well. We only usually use the MagCit Tray to go lightly if they're literally about to have a colonoscopy or some sort of bowel prep. Other things that you'll see used is like stuff like Senna, which is considered a stimulant. Again, that's the one that causes more bowel contractions. Now getting to stimulant laxatives, these work better.

by causing contractions in the bowel. And they work by contracting in the bowel, but they also can lubricate as well, which sounds great. But anything that's a stimulant laxative, it's training the body to go when you're giving it, but it can actually cause dependence where some people end up, they overuse these.

Your book actually goes into it a lot about how there's been such a issue now with dependence. on these meds, like with these meds for people, where they're becoming dependent upon them in order to have a bowel movement. So we really try to avoid doing stimulants until like if unless it's like last ditch efforts like that, or like that's the it's more of the later ones that we want to use. We want to try other least invasive things first. There's also enemas.

No enemas can work rapidly. They also people can come dependent upon these enemas as well. The patient has to have the ability to clench.

In other words, they have to have rectal tone. If they don't have rectal tone, like if there's spinal or neurological injury, they're not going to be able to use these. We want to turn them on their left side. This promotes them to have a better ability to have their, to get their stool out. It just has to do with the way, like with peristalsis and how things work.

Left side is how we want to position them. And then because of the way that like, literally, if you've never given an enema, you're sticking the stube up their butt. There's a bunch of either.

water, it can have mineral oil in it, it can have milk of molasses, stuff like that is pretty much what we're squirting in them. It just helps to loosen any stool that's in like that last area and kind of just helps to make things easier to pass. But we're sticking a bunch of fluid up them.

So it can cause irritation, inflammation. They also can have water intoxication, which means like that water is meant to grab the stool and then leave the body. But sometimes we can accidentally absorb too much, which can lead to issues.

And then also electrolyte imbalances from the excess stool. Sorry, excess like stool losses or loss of fluid and stuff. As the nurse, we want to protect this patient's skin, watch closely, because a lot of times with constipation, again, they can have the fissures or with the medications we give, they can be pooping a lot. So we want to watch closely for their skin. And we want to teach them risks of chronic laxative use, especially those stimulant laxatives.

So really, like, I mean, laxatives are meant to be used until they can have a stool, but they're not meant to be like, hey, I have to take this in order to go. We want to use the medications as prescribed, not above how they're prescribed. Because people just like sometimes like people are very set.

I'm like, I have to have a bowel movement every day at this time, this way. This doesn't always work out that way. Long term, like it says here, they can have decreased tone in their rectum, which can make things worse and again, dependence.

Lifestyle changes. So two liters of fluid a day, 20 to 30 grams of fiber and exercising at least three times per week. So those lifestyle changes in conjunction with meds, hopefully only as needed. can be super helpful. Other things to teach about is not to wait.

So holding it in is really bad for rectal tone and stuff like that. You want them to go when they need to go. And then creating a routine and schedule because the body is a very big inhabit.

So and then this picture kind of shows like at 90 degrees, it's a lot harder to get stool out. Whereas if you're at more of this 35 degree angle with your knees up, it can lead for easier stooling. I think that's it.

Okay. All right. So the only thing else I have here is just some questions, some food for thought questions, no pun intended food for thought, but just think about like what foods or liquids would we encourage a client with constipation to eat or drink or what foods or liquids should we discourage?

So we want to think of what are our high fiber foods and liquids and what are the ones that are not going to be as helpful. So when you think of high fiber, most of the time you want to think of your roughage, like your fruits and vegetables, your whole grains, stuff like that. that are definitely going to help.

What do you call them? Because really, so we want to think as a whole, high fiber is good, low fiber is not as good. And low fiber foods are going to be things like things that are like white rice, white breads, things like that. So we want things that are going to help to form bulk, and then help to get things to pass better.

And so definitely this is something there's a lot more there. I'm going to just get you started with that. But definitely want to kind of start going through and thinking a lot of the GI disorders that we're going to get into. It's like this food is good.

This food is not good. Or this type of food is good. Or this is not good.

So making a table or something like that and think of what's going to help and what's going to hurt for this patient, whether it's food, other treatments, kind of like I talked about making a indicated contraindicated for each disease process will be super helpful, especially because these can all start to get mixed up in your head. Anyway. I will see you for the next one. Have a good night.

Transcript for:Understanding Constipation: Causes and Management

Transcript for:
Understanding Constipation: Causes and Management