13.5/15 see comments

Case Study Four
Jessica Hetrick
Lakeview College of Nursing
N309 B
February 8, 2012

1.	According to Dictionary.com, constipation is infrequent or difficult evacuation of the bowels, with hard feces, caused by functional, organic disorders, or improper diet (2011). 
2.	Constipation is the most common bowel problem in older adults. Since it is a private topic, when elders have problems with constipation they do not like to talk about it. Patterns vary with each person, but constipation is usually determined if there hasn’t been a bowel movement in two days. The results of normal aging contribute to the slowing of intestinal peristalsis and decrease the fluid mechanism, resulting in less fluid intake. In Mr. Grady’s case, the most probably cause of his constipation is dehydration and cognitive impairment. Also, the normal processes of aging do make a contribution. His peristalsis was slowed any way, then he limited his fluids to stop urgency and constipation resulted (Mauk, 2010). 
3.	An older adult has a decrease in the thirst mechanism resulting in less fluid intake. Other causes for constipation include dehydration due to the lack of fluid. Also, decreased activity can cause constipation. Another cause is the lack of fiber in anyone’s diet. Constipation may be a side effect of other medications like opioids. It can also be a neurogenic bowel or other disease (Mauk, 2010). 
4.	One type of medication known to cause constipation is opioids. Morphine and fentanyl are two opioids known to cause constipation. Ultram, hydromorphone, oxycodone narcan, and staldol all are opioids that can cause constipation as well. The antidepressant/antianxiety amitriptyline can cause constipation. The antihypertensive Clonidine can also cause constipation. The anti-parkinson’s bromocriptine, the cholesterol lowering-agent cholestyramine, the duodenal ulcer treatment sucralfate, and iron supplements have been shown to cause constipation in any patient (Medications that Cause Constipation, 2011). Looks like there are a lot of meds that cause constipation in the elderly
Medications known to cause constipation are as follows: • ACE inhibitors,• aluminum containing antacids
• antiarrhythmia medications,• anticholinergics/antihistamines• antidepressants• antispasmodics
• antiparkinsonian agents• antipsychotics• benzodiazepines• beta-blockers• calcium channel blockers
• calcium supplements• diuretics• iron sulfate• muscle relaxants• neuroleptics• opiates

5.	Constipation can lead to fecal impactment or even bowel obstruction. Fecal impaction occurs when you accumulate a mass of hardened stool that can't be eliminated by a normal bowel movement. The patient may need to have impacted stool removed manually. This can also lead to rectal and colon dilation in the elderly. Rectal prolapse occurs when a small amount of rectal tissue pushes out through the anus. This condition may lead to a secretion of mucus from the anus. This allows large amounts of stool to accumulate with little or no sensation from the anus. Lazy bowel syndrome may occur if you use laxatives frequently, causing the bowels to become dependent on them for proper function. Laxative use can also lead to other problems, including poor absorption of vitamins and other nutrients and damage to the intestinal tract (Mayo Clinic, 2011). 
6.	Two types of medications used to treat constipation are laxatives and cathartics. Bulk forming laxatives act when water is added they swell and become gellike. The added bulk stimulates defecation. Surfactant laxatives are also called stool softners. These decrease surface tension of the fecal mass to allow water to come in and penetrate into the stool. Salin laxatives are not well absorbed from the intestine. They increase osmotic pressure and cause water to be retained.  The stool is semifluid. Stimulant cathartics are the strongest and most abused laxative. They irritate the GI mucosa and pull water in. The feces are moved through the bowel too rapidly to allow absorption of water. Mineral oil is the only lubricant laxative used clinically. It lubricates the fecal mass. Lactulose is a disaccharide not absorbed well in the intestines. It exerts laxative effect by pulling water into the lumen. Lubiprostone is for chronic idiopathic constipation in adults. Oral aloe can be used as a laxative, however it is not recommended because it is a strong stimulant laxative.  Suppositories can be sued. They are used to administer sedatives, analgesics, and laxatives. Also, enemas can be used for constipation. They can also be used for chronic inflammatory bowel disease (Abrams, Lammon, & Pennington, 2009)
  Treatments for constipation can be dietary approaches, behavioral changes, medication reviews for causative factors, and enemas and/or laxatives.

7.	The nurse should encourage the patient to increase exercise to promote peristalsis. Also, when you increase the fluid, you increase the peristalsis as well. Another technique is to increase the amount of fiber in the patient’s diet. A 3-7 day meal diary can tell whether the patient is eating appropriately. Increasing fresh fruits and vegetables can also help (Mauk, 2010). 
8.	This drug is used when rapid bowel evacuation is necessary. It is useful for short-term constipation. It is not safe for prolonged use. The patient and his family need to be aware that this drug can affect the fluid electrolyte balance in the body. The family needs to encourage increased fluids. Also, since this drug is used for rapid evacuation, the family should assist the patient with a bedside commode. This can help with the falls the patient has been experiencing. Also, the patient should not remain on this drug for a long period of time due to the side effects of fluid electrolyte imbalance and possible G.I. irritation (Abrams, Lammon, & Pennington, 2009).
should include the following: • take the medication with 8 oz of water • establish a clear plan for fluid and dietary intake • make sure his MOM is taken at the same time every other day, results usually occur within 3–6 hours, so stools can be predictable after initial dosing • make sure this medication is not taken within 2 hours of other medications unless recommended by his nurse practitioner, because it can interfere with absorption of other medications

References

Constipation. (2011). Retrieved February 8, 2012, from Dictionary.com: http://dictionary.reference.com/browse/Constipation
Constipation Complications. (2011). Retrieved February 8, 2012, from May Clinic.com: http://www.mayoclinic.com/health/constipation/DS00063/DSECTION=complications
Medications that Cause Constipation. (2011). Retrieved February 8, 2012, from Get Constipation Relief.com: http://www.getconstipationrelief.com/medications-causing-constipation
Abrams, A., Lammon, C., & Pennington, S. (2009). Laxatives and Cathartics. In Clinical Drug Therapy (pp. 972-977). Philadelphia: Lippincott Williams & Wilkins.
Mauk, K. L. (2010). Constipation. In Gerontological Nursing Competencies for Care (p. 411). Sudbury: Jones and Bartlett Publishers.