CONSTIPATION,

DIARRHEA, AND FECAL

INCONTINENCE
Module 4
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can:
1. Identify the risk factors of the disorders.
2. Determine the pharmacologic therapy of the disorders.
3. Enumerate nursing interventions of the disorders

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CONSTIPATION
Constipation is a term used to describe an
abnormal infrequency or irregularity of
defecation, abnormal hardening of stools
that makes their passage difficult and
sometimes painful, a decrease in stool
volume, or retention of stool in the rectum
for a prolonged period.

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CONSTIPATION
Risk Factors
1. Medications (tranquilizers, anticholinergics, 7. Weakness, immobility, debility, fatigue,
antidepressants, antihypertensives, opioids, and an inability to increase intra-abdominal
antacids with aluminum, and iron) pressure
2. Rectal or anal disorders (hemorrhoids,
fissures) 8.Delaying or ignoring the urge to defecate
3. Obstruction (cancer of the bowel) 9.Dietary habits (low consumption of fiber
4. Neuromuscular conditions (hirschsprung’s
disease) and inadequate fluid intake)
5. Endocrine disorders (hypothyroidism, 10. Lack of regular exercise, and a stress-
pheochromocytoma) filled life
6. Irritable bowel syndrome (IBS), diverticular 11. Chronic laxative use
disease, appendicitis
12. Aging
CONSTIPATION
Pathophysiology
1. Constipation includes interference with one of three major functions of the colon:
mucosal transport (mucosal secretions facilitate the movement of colon contents),
myoelectric activity (mixing of the rectal mass and propulsive actions), or the
processes of defecation (pelvic floor dysfunction).
2. The urge to defecate is stimulated normally by rectal distention that initiates a
series of four actions: stimulation of the inhibitory rectoanal reflex, relaxation of the
internal sphincter muscle, relaxation of the external sphincter muscle and muscles in
the pelvic region, and increased intra- abdominal pressure. Interference with any of
these processes can lead to constipation.
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CONSTIPATION
Pathophysiology
3. If all organic causes are eliminated, idiopathic constipation is diagnosed.
4. When the urge to defecate is ignored, the rectal mucous membrane and musculature
become insensitive to the presence of fecal masses, and consequently a stronger
stimulus is required to produce the necessary peristaltic rush for defecation.

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CONSTIPATION
Pathophysiology
5. The initial effect of fecal retention is to produce irritability of the colon, which at this
stage frequently goes into spasm, especially after meals, giving rise to colicky mid
abdominal or low abdominal pains.
6. After several years of this process, the colon loses muscular tone and becomes
essentially unresponsive to normal stimuli (similar to an overstretched balloon).
7. Atony or decreased muscle tone occurs with aging. This also leads to constipation
because the stool is retained for longer periods.

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CONSTIPATION
Clinical Manifestations
1. Abdominal distention
6. Fatigue
2. Borborygmus (gurgling or
7. Indigestion
rumbling sound caused by
passage of gas through the 8. A sensation of incomplete
intestine) emptying

3. Pain and pressure 9. Straining at stool,

4. Decreased appetite 10. Elimination of small-volume,

lumpy, hard, dry stools
5. Headache 8
CONSTIPATION
Assessment and Diagnostic Tests
Complications: 1. Barium enema or Sigmoidoscopy -
determine whether symptom results
1. Hypertension from spasm or narrowing of the bowel
2. Stool testing for occult blood
2. Fecal impaction
3. Anorectal manometry – to assess
3. Hemorrhoids malfunction of the sphincter
4. Defecography and colonic transit
4. Megacolon studies – assess active anorectal
function
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 CONSTIPATION
Medical Management 6. If laxative use is necessary: one of the
following may be prescribed: bulk-
1. Bowel habit training
forming agents, saline and osmotic
2. Increase fiber and fluid intake agents, lubricants, stimulants, or fecal
3. Discontinuing laxative abuse softeners
4. Routine exercises to strengthen abdominal
7. If long term laxative use is necessary:
muscles
a bulk-forming agent in combination
5. Daily addition to the diet of 6 to 12
with an osmotic laxative
teaspoonfuls of unprocessed bran, especially for
the treatment of constipation in the elderly
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CONSTIPATION
Nursing Management :
1. Assess on the following: onset and duration of constipation,
current and past elimination patterns, the patient’s expectation of
normal bowel elimination, and lifestyle information.

2. Patient education and health promotion.

3. Restore or maintain a regular pattern of elimination, ensure

adequate intake of fluids and high-fiber foods, learn about
methods to avoid constipation, relieve anxiety about bowel
elimination patterns, and avoid complications.
CONSTIPATION
PREVENTION
1. Emphasize the importance of responding to the urge to defecate.
2. Teach how to establish a bowel routine, and explain that having a regular time for defecation (best time
is after a meal) may aid in initiating the reflex.
3. Provide dietary information; suggest eating high-residue, high-fiber foods, (fruits, vegetables) adding
bran daily (must be introduced gradually), and increasing fluid intake (unless contraindicated).
4. Explain how an exercise regimen, increased ambulation, and abdominal muscle toning will increase
muscle strength and help propel colon contents.
5. Describe abdominal toning exercises (contracting abdominal muscles 4 times daily and leg-to-chest lifts
10 to 20 times each day).
6. Explain that the normal position (semisquatting) maximizes use of abdominal muscles and force of
gravity.
7. Avoid overuse or long-term use of stimulant laxatives (bisacodyl) because they can weaken colonic
function.
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DIARRHEA
Diarrhea is increased frequency of
bowel movements (more than three
per day), increased amount of stool
and altered consistency (looseness) of
stool. Diarrhea can be acute or
chronic. Acute diarrhea is most often
associated with infection and is usually
self-limiting; chronic diarrhea persists
for a longer period and may return
sporadically.
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 Types
1. Secretory diarrhea
Usually high-volume diarrhea. Often associated with bacterial toxins
and neoplasms, it is caused by increased production and secretion of
water and electrolytes by the intestinal mucosa into the intestinal
lumen.
2. Osmotic diarrhea
Occurs when water is pulled into the intestines by the osmotic pressure
of unabsorbed particles, slowing the reabsorption of water. It can be
caused by lactase deficiency, pancreatic dysfunction, or intestinal
hemorrhage. 18
3. Malabsorptive diarrhea
Combines mechanical and biochemical actions, inhibiting effective
absorption of nutrients manifested by markers of malnutrition that
include hypoalbuminemia. Low serum albumin levels lead to
intestinal mucosa swelling and liquid stool.
4. Infectious diarrhea
Results from infectious agents invading the intestinal mucosa.
Clostridium difficile is the most commonly identified agent in
antibiotic-associated diarrhea in the hospital.
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5. Exudative diarrhea
Caused by changes in mucosal integrity,
epithelial loss, or tissue destruction by radiation
or chemotherapy.

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Risk factors
1. Irritable bowel syndrome (IBS),
2. Inflammatory bowel disease (IBD)
3. Lactose intolerance
4. Medications (thyroid hormone replacement, stool
softeners and laxatives, antibiotics, chemotherapy,
antacids),

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5. Tube feeding formulas
6. Metabolic and endocrine disorders (diabetes,
Addison’s disease, thyrotoxicosis)
7. Viral or bacterial infectious processes
(dysentery, shigellosis, food poisoning)
8. Nutritional and malabsorptive disorders (celiac
disease)
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Clinical Manifestations
6. Thirst
1. Increased frequency and
fluid content of stools 7. Painful spasmodic contractions
of the anus and ineffectual
2. Abdominal cramps
straining (tenesmus)
3. Abdominal distention
8. Watery stools are characteristic
4. Intestinal rumbling of small bowel disease, whereas
(borborygmus)
loose, semisolid stools are
5. Anorexia associated more often with
disorders of the colon

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Complications
1. Fluid and electrolyte loss
2. Dehydration
3. Cardiac dysrhythmias
4. Urinary output of less than 30 mL per hour for 2 to 3
consecutive hours
5. Hypokalemia (less than 3.5 mEq/L
6. Muscle weakness, paresthesia, hypotension, anorexia,
and drowsiness (due to hypokalemia)

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Assessment and Diagnostic Tests
1. Complete blood cell count
2. Urinalysis
3. Routine stool examination, and stool examinations
for infectious or parasitic organisms, bacterial toxins,
blood, fat, and electrolytes
4. Endoscopy or barium enema – assist in identifying
the cause
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Medical Management
Primary management is directed at controlling symptoms,
preventing complications, and eliminating or treating the
underlying disease. Certain medications (antibiotics, anti-
inflammatory agents) may reduce the severity of the diarrhea
and treat the underlying disease.

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Nursing Management
1. Assess and monitor the characteristics and pattern of
diarrhea, patient’s medication therapy, medical and
surgical history, and dietary patterns and intake.
2. Auscultate abdomen and palpate for abdominal
tenderness.
3. Assess hydration status

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4. Encourages bed rest and intake of liquids and foods low in bulk until the acute attack subsides.
5. When food intake is tolerated, recommend a bland diet of semisolid and solid foods.
6. Patient should avoid caffeine, carbonated beverages, and very hot and very cold foods,
because they stimulate
7. Restrict milk products, fat, whole-grain products, fresh fruits, and vegetables for several days.

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8. Administer antidiarrheal medications such as
Diphenoxylate (Lomotil) and Loperamide (Imodium)
9. Intravenous fluid therapy may be necessary for
rehydration
10. Closely monitor serum electrolyte levels.
11. Report evidence of dysrhythmias or a change in
the level of consciousness.
12. The patient should follow a perianal skin care
routine to decrease irritation and excoriation.
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Elderly persons can become dehydrated quickly and develop
low potassium levels (hypokalemia) as a result of diarrhea.
The older person taking digitalis must be aware of how
quickly dehydration and hypokalemia can occur with
diarrhea. The nurse instructs this person to recognize the
signs of hypokalemia, because low levels of potassium
intensify the action of digitalis, which can lead to digitalis
toxicity.

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FECAL
INCONTINENCE
Fecal incontinence describes the
involuntary passage of stool from the
rectum. Factors that influence fecal
continence include the ability of the
rectum to sense and accommodate
stool, the amount and consistency of
stool, the integrity of the anal sphincters
and musculature, and rectal motility.
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Risk factors
1. Trauma (after surgical procedures involving the
rectum)
2. Neurologic disorders (stroke, multiple sclerosis,
diabetic neuropathy, dementia)
3. Inflammation
4. Infection
5. Diarrhea
6. Chemotherapy
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Risk factors
7. Radiation treatment
8. Fecal impaction
9. Pelvic floor relaxation
10. Laxative abuse
11. Medications
12. Advancing age (weakness or loss of anal or rectal
muscle tone
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Clinical Manifestations
1. Minor soiling
2. Occasional urgency
3. Loss of control or complete incontinence
4. Poor control of flatus
5. Diarrhea or constipation

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Assessment & Diagnostic Tests
Rectal examination and Flexible sigmoidoscopy – to rule
out tumors, inflammation, or fissures 2. To identify
alterations in intestinal mucosa and muscle tone or in
detecting other structural or functional problems:
a. Barium enema
b. Computed tomography (CT)
c. Anorectal manometry

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Medical Management
1. If the cause is fecal impaction: impaction is removed
and the rectum is cleansed.
2. If the cause is decreased sensory awareness or
sphincter control: biofeedback therapy with pelvic floor
muscle training.
3. Bowel training programs can also be effective.

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Surgical Management
Surgical reconstruction, artificial sphincter implantation,
sphincter repair, or fecal diversion

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Nursing Management
1. Obtain a thorough health history, including information
about previous surgical procedures, chronic illnesses,
dietary patterns, bowel habits and problems, and current
medication regimen.
2. Initiate a bowel-training program that involves setting
a schedule to establish bowel regularity.
3. Therapeutic use of diet and fiber: foods that thicken
stool (applesauce) and fiber products (psyllium) help
improve continence. 38
Nursing Management
4. Maintain perineal skin integrity: incontinence
briefs/adult diapers are to be used only for brief periods
of time; encourage and teach meticulous skin hygiene
and use perineal skin cleansers and skin protection
products to protect perineal skin.
5. Fecal incontinence devices may be used.

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Thank you for listening!