What should the nurse include in the plan of care when establishing a bowel routine for an older adult?

According to the American Academy of Family Physicians, constipation is a common issue affecting up to 28% of adults, with the prevalence increasing with age. Therefore, understanding what should the nurse include in the plan of care when establishing a bowel routine for an older adult is a critical nursing skill for promoting patient comfort and preventing complications.

Quick Summary

A nurse's plan for an older adult's bowel routine should integrate dietary modifications, adequate hydration, and regular physical activity to stimulate natural peristalsis. Crucial elements also include establishing a consistent toileting schedule, promoting proper toileting posture, and evaluating the patient's medication regimen for constipating side effects. Patient privacy and effective communication are essential for success.

Key Points

• Assessment: Before starting a routine, assess the patient’s normal bowel habits, diet, fluid intake, mobility, and medication list to identify contributing factors.

• Hydration and Diet: Emphasize high-fiber foods and increase fluid intake to 1.5-2 L daily (unless contraindicated) to soften stools and stimulate motility.

• Physical Activity: Encourage and assist with regular, appropriate physical activity, such as walking or seated exercises, to stimulate the bowels.

• Scheduled Toileting: Establish a regular toileting schedule, ideally after a meal, to take advantage of the body's natural gastrocolic reflex.

• Optimal Positioning: Help the patient achieve a proper toileting position, either on a commode or with a footstool, to facilitate easier evacuation.

• Medication Management: Monitor medications for side effects, use laxatives judiciously and as prescribed, and avoid reliance on stimulants for long-term management.

Comprehensive Assessment and Baseline Establishment

Before establishing a bowel routine, a thorough assessment is crucial to identify the patient's normal bowel habits and any contributing factors to irregular elimination. The nurse must review the patient's medical history for conditions that affect bowel function, such as neurological disorders, and assess their current medication list for constipating side effects. It is also important to determine the patient's baseline for frequency, consistency, and any associated symptoms like bloating or straining.

A key part of this assessment involves a detailed dietary and fluid intake history. Many older adults experience constipation due to a lack of fiber and reduced fluid intake. Nurses should document the patient's typical fluid consumption and preference for high-fiber foods. Additionally, an evaluation of the patient's mobility level is necessary, as a sedentary lifestyle can significantly slow bowel motility. For bedridden patients, the nurse should note their ability to reposition themselves.

Nursing Interventions for Promoting Regularity

Effective nursing interventions combine lifestyle adjustments with targeted strategies to encourage healthy bowel function. The nurse's role involves both implementation and patient education to ensure adherence.

Dietary and Fluid Management

• Increase fiber intake: Gradually increase dietary fiber to 20-35 grams daily by incorporating whole grains, fruits, and vegetables. Examples include prunes, bran, and lentils, which can be easier for older adults to consume. Sudden increases in fiber can cause bloating, so a gradual approach is best.
• Ensure adequate hydration: Encourage a fluid intake of 1.5 to 2 liters per day, unless contraindicated by other health conditions. Water, juice, and herbal teas are excellent options. Excessive caffeine and alcohol should be limited due to their diuretic effect.
• Leverage natural stimulants: Offer a warm drink, such as prune juice, or a hot meal to stimulate the gastrocolic reflex, which increases intestinal motility.

Activity and Mobility Enhancement

• Promote regular exercise: Encourage safe and appropriate physical activity, such as walking or gentle chair exercises. For bedbound patients, passive or active range-of-motion exercises can help.
• Assist with mobility: Help the patient ambulate to the toilet or a bedside commode, which is more effective than using a bedpan. The upright position uses gravity to aid elimination.

Bowel Training and Environmental Support

• Establish a toileting schedule: Institute a regular schedule, such as 30 minutes after breakfast, to capitalize on the gastrocolic reflex. Consistency helps retrain the bowel.
• Provide privacy and comfort: Ensure the patient has privacy and a comfortable environment, as anxiety can inhibit defecation. A footstool can help achieve a squatting position, which eases straining.

Medication and Supplement Management

• Review medications: Continually monitor and review the patient's medication list for constipating side effects and collaborate with the provider on adjustments.
• Use pharmacological agents as ordered: When non-pharmacological interventions are insufficient, administer prescribed stool softeners, bulk-forming agents, or osmotic laxatives cautiously. Avoid chronic use of stimulant laxatives unless directed by a physician.

Comparison of Non-Pharmacological and Pharmacological Interventions

Nurses must understand the appropriate use of different interventions based on the patient's needs and underlying causes of constipation. The following table compares key approaches.

Intervention Type	Examples	Primary Mechanism	Benefits	Considerations
Non-Pharmacological	High-fiber diet, increased fluids, regular exercise, bowel training	Natural stimulation of peristalsis and softening of stool	Promotes long-term bowel health; minimizes dependency on medications	Requires consistent effort from patient and caregiver; slower results
Bulk-Forming Laxatives	Psyllium (Metamucil), methylcellulose (Citrucel)	Absorbs water to increase stool bulk, stimulating bowel movement	Safe for long-term use; mimics natural fiber effect	Requires adequate fluid intake; may cause bloating or gas
Osmotic Laxatives	Polyethylene glycol (MiraLAX), lactulose	Draws water into the colon, softening stools	Gentle action, generally well-tolerated	Potential for dehydration if fluid intake is insufficient
Stool Softeners	Docusate sodium (Colace)	Lowers surface tension of stool, allowing water to penetrate and soften it	Prevents straining and is useful for painful defecation	Not effective for severe, chronic constipation
Stimulant Laxatives	Bisacodyl (Dulcolax), Senna	Stimulates intestinal muscle contractions	Fast-acting; useful for short-term, acute constipation	Risk of dependency and cramping with long-term use

Conclusion

Creating an effective bowel routine for an older adult requires a multi-faceted approach centered on assessment, education, and consistent application of interventions. The nursing care plan must be individualized, considering the patient's specific health status, mobility, and lifestyle. By prioritizing non-pharmacological strategies like diet, hydration, and activity, nurses can help restore regular bowel habits and improve the patient's quality of life. For situations where natural methods are insufficient, a careful, monitored use of appropriate pharmacological agents can be incorporated, with ongoing evaluation to prevent dependency and address side effects. A collaborative effort between the nursing staff, patient, and other healthcare providers is key to achieving successful, long-term outcomes.

How-to Guide for Establishing a Bowel Routine

1. Assess and Plan: Interview the patient about their current bowel habits and review their health history and medications. Establish a baseline and identify risk factors.
2. Hydrate and Fiber Up: Gradually increase fluid intake to 1.5-2 L daily (unless contraindicated). Incorporate fiber-rich foods like fruits and whole grains into the diet.
3. Encourage Movement: Promote regular physical activity tailored to the patient's abilities, such as daily walks or seated exercises.
4. Set a Schedule: Establish a consistent time for toileting, typically 30 minutes after a meal, to take advantage of the gastrocolic reflex.
5. Create a Supportive Environment: Ensure the patient has privacy and a comfortable setting for toileting. Use a footstool to promote proper positioning and reduce straining.
6. Administer Medications (If Needed): Use stool softeners or osmotic laxatives as prescribed. Monitor for effectiveness and side effects, and avoid prolonged use of stimulant laxatives.
7. Monitor and Evaluate: Keep a stool diary to track progress. Reassess the plan and make adjustments as needed based on the patient's response.

What to Monitor When Establishing a Bowel Routine

• Fluid intake: Track daily fluid consumption to ensure the patient is meeting hydration goals.
• Dietary fiber: Monitor the types and amounts of fiber-rich foods being consumed daily.
• Bowel movement pattern: Record frequency, consistency (using a stool chart), and ease of defecation.
• Patient comfort: Assess for any abdominal discomfort, bloating, or cramping.
• Medication side effects: Watch for and document any adverse reactions from laxatives or other medications.

Troubleshooting Common Issues

• Problem: Patient complains of bloating after increasing fiber. Solution: Increase fiber intake more gradually and ensure fluid intake is adequate.
• Problem: Bowel movements remain infrequent despite interventions. Solution: Re-evaluate the effectiveness of interventions, potentially consulting the healthcare provider for a change in pharmacological agents or further assessment.
• Problem: Patient is reluctant to use a bedpan. Solution: Encourage the use of a bedside commode or toilet if mobility allows, as a seated position is more conducive to elimination.
• Problem: Patient is confused or uncooperative. Solution: Involve family or caregivers in the process, provide simple, clear instructions, and offer reassurance and support.

Signs of Improvement

• Regularity: Consistent bowel movements occurring on or near the established schedule.
• Stool consistency: Softer, formed stools without excessive straining.
• Patient comfort: Reduction in complaints of bloating, abdominal pain, or fullness.
• Increased independence: Patient may become more independent in managing their bowel routine.

Frequently Asked Questions

Why do older adults often experience constipation?

Constipation in older adults is often caused by several factors, including slowed peristalsis due to aging, decreased fluid and fiber intake, reduced physical activity, and side effects from medications.

What is the gastrocolic reflex and how is it used in a bowel routine?

The gastrocolic reflex is the body's natural response to eating, which stimulates increased movement in the gastrointestinal tract. A nurse can use this by scheduling toileting sessions for the older adult about 30 minutes after meals.

Are bulk-forming laxatives safe for older adults?

Yes, bulk-forming laxatives like psyllium are generally safe for older adults when taken with adequate fluid. They work similarly to dietary fiber by increasing stool bulk. However, they should be introduced gradually to prevent gas and bloating.

What if an older adult is bedridden?

For bedridden older adults, the plan of care should include repositioning, passive range-of-motion exercises, a high-fiber diet, and increased fluids. Assisting them to a semi-squatting position on a bedpan can also help gravity with elimination.

How can a nurse manage constipation caused by medications?

The nurse should review the patient's medication list for constipating agents and collaborate with the healthcare provider to determine if any adjustments can be made. A daily stool softener may also be initiated for patients on certain pain medications, such as opioids.

How can the nurse ensure the patient's privacy during toileting?

To ensure privacy, the nurse should close doors or curtains, use a bedside commode out of direct view, and avoid rushing the patient during elimination. A calm and respectful approach helps reduce anxiety.

How long should it take to establish a new bowel routine?

Most people can establish a new bowel routine within a few weeks of consistently applying the interventions. Patience and consistent reinforcement are important during this period.