Constipation and bowel health

awareness session. Kirklees

LD Community Nursing Team
What is constipation?
• Constipation is when your stools become hard and you find
it more difficult or painful to go to the toilet.

NHS (2017) explain constipation as: -

• Not opening your bowels 3 times in one week
• Your stools being difficult and large to pass
• Your stools being hard and lumpy.
 3 Categories of constipation
Primary – no underlying cause
and largely associated with lifestyle
factors

Secondary – Exacerbated by
physiological /medical conditions
such as; cerebral palsy, diabetes,
hypothyroidism, depression.

iatrogenic- Due to side effects of

medications such as opiates
The digestive system and journey of food
(easy and quick version!)
Symptoms of constipation
• Abdominal pain/cramps
• Bloating
• Beware of when the wind stops (obstruction)
• Loss of appetite
• Nausea
• Overflow diarrhoea
• Faecal impaction
• Faecal vomiting
• Rectal bleeding when defecating. Anal fissures are associated
with chronic constipation
• Twisting of the bowel leading to severe complications
• Constipation can be dangerous and life threatening if left
untreated
Faecal impaction
A faecal impaction is a
solid, immobile bulk of
faeces that can develop in
the rectum as a result of
chronic constipation
Prevalence of constipation in
people with learning disabilities
• People with LD are more likely to suffer from constipation
• Some studies identify rates of 50%
• 25% on repeat prescription for laxatives
• 18.8% of people with downs syndrome prescribed
laxatives (compared to 3.4% of general population).
• Health problem for 59.8% of profound and multiple
disabilities
• Reference ‘Making reasonable adjustments for people with learning
disabilities in the management of constipation’ (DoH 2016).
Commonly prescribed
laxatives
• Bulk forming laxatives – i.e . Fibogel – increase bulk of the
stool to stimulate the bowel

• Osmotic laxatives i.e lactulose, macrogols (Laxido, Movicol) –

draw water from the rest of body into the bowel to soften poo
and make it easier to pass

• Stimulant laxatives i.e Senna, Bisocodyl – stimulate gut

muscles to move the poo along

• Poo softener laxatives i.e Docusate sodium – increases the

amount of water the stool absorbs
(reference nhs.uk/conditions/laxatives)
What contributes to constipation for our
client group?
• Poor diet and fluid intake
• Reduced physical mobility
• Being prescribed medications such as antipsychotics,
antidepressants and anticonvulsants.
• Body shape distortion
• Abnormal muscle tone
• Environmental factors such as lack of privacy/poor facilities/lack of
suitable adaptations
• Changes to care/routine causing negative effect on bowel habits
• Challenging behaviour
• Lack of understanding
• Sensory issues
• Communication issues with poor reporting of problems/symptoms
SERIOUS CASE REVIEW
• Richard Handley – 33 years of age, Down’s syndrome,
associated health problems and lifelong constipation

• https://www.bing.com/videos/search?q=richard+handley+you+
tube&view=detail&mid=E9081F7040FCAF7924C0E9081F70
40FCAF7924C0&FORM=VIRE
AVOIDING CONSTIPATION
• Diet – promoting a healthy balanced diet which includes
adequate fibre. Insoluble and soluble fibre which helps to bulk
and soften stools
• Fluid intake – Recommended amount of fluid for average
person 2 – 2.5 litres daily. Needed to avoid hard stools
• Exercise – Exercising regularly helps to keep your digestive
system healthy . Any exercise is better than nothing. Being
sedentary contributes to constipation.
• Toileting – Routine and good toilet habits. Adequate support
provided with necessary aids and adaptions for good
positioning if needed
Our role
• GP/medical consultation on constipation should always be sought to
rule out underlying causes. A baseline assessment should be
completed. A physical examination is usually necessary. Further
investigation may be required such as CT scan/ultrasound scan.
• Having detailed history of problems, frequency and consistency of
bowel movements, childhood constipation? Good awareness and
knowledge to recognise signs and symptoms of constipation. Good
monitoring and assessment. Clear bowel management/care plans in
place which are reviewed regularly.
• Be aware and record behaviour/mood changes that could indicate a
problem
• Support to increase the SUs awareness and encourage self reporting.
Use easy read/videos, pictoral charts etc.
• Knowledge of risk factors/history of individual
• Effective monitoring allows us to take appropriate action
Effective monitoring
Effective monitoring
• Appropriate physical examination/investigation by relevant medical
professional
• Observation for changes in presentation
• Pain when going to the toilet?
• Soiled underwear? – could be overflow? – caution when considering
stopping laxatives!!!
• Diet charts – having enough fibre?
• Fluid charts – drinking enough fluid?
• Stool charts – no bowel movement in 3 days?
• Bowel management protocols – a plan of what to do -
• Be aware of normal bowel habits and to recognise when there is a
problem for the individual
• Review bowel management/care plans regularly
• Review advice/bowel medication with the GP
• Assessment of toileting equipment/correct positioning
Effective positioning
Case Studies
• Laura – Autism and challenging behaviour. Lives at home with
parents. Persevered with monitoring. Identified constipation as a
trigger to escalation in behavioural incidents. Reviewed with GP.
Bowel care plan put into place.
• Christopher – Mild LD and Autism. Involved increasing awareness,
self reporting. Used Youtube videos to explain constipation and how
you can help avoid this. Used a bowel chart with pictures to tick each
day. Currently bowels are well managed.
• Alfie – change in diet and toileting times. Profound physical
disabilites, severe LD. Diet improvements through increase in fibre
and fluid intake. Identified opening bowels regularly after eating,
then provided time on toilet at effective time. Introduced to passive
bowel exercises by physiotherapist. New toileting equipment
provided by OT. At discharge bowels were well managed.
• (names changed for confidentiality).
Increasing individual’s
awareness
• Videos
• Easy read resources
• Journey of the cheeseburger
• Pictures
• Social stories
• Make self reporting easier – use photos, pictures, tick charts
etc.
To recap
• Increased risk for our service users
• Causes
• Constipation can become a serious health issue if left
untreated
• The carer has a key role in providing awareness and promoting
effective monitoring
NHS England leaflets on
constipation
References and Resources
References
‘Making reasonable adjustments for people with learning disabilities in the
management of constipation’ (DoH 2016).
‘Faecal Incontinence in adults:Management’ (2007) available at nice.org.uk
‘Constipation’ (2019) NHS UK available at nhs.uk/conditions/constipation
ERIC, The children’s bowel and bladder charity.
Links to NHS England constipation information
https://www.england.nhs.uk/wp-content/uploads/2019/05/constipation-resources-easy-
read.pdf
https://www.england.nhs.uk/wp-content/uploads/2019/05/constipation-resources-hcp-
31-print-ready.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/05/constipation-resources
-families-carers-stage-31-print-ready.pdf