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Holistic Nursing Practice:
doi: 10.1097/HNP.0000000000000024
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Bowel Movement: The Sixth Vital Sign

Holl, Rita M. PhD, ND, RN

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School of Nursing, University of Indianapolis, Indianapolis, Indiana.

Correspondence: Rita M. Holl, PhD, ND, RN, School of Nursing, University of Indianapolis, Indianapolis, 1400 E Hanna, Ave, IN 46227 (hollr@uindy.edu).

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

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Abstract

Bowel movements provide vital information on how the body is functioning, and constipation among older adults is especially problematic. Although we do not like hearing the details of someone else's bowel movement, it is a function that nurses need to assess, support, and treat with the same attitude as when caring for patients with pain.

Bowel movement is a vital sign on how the body is functioning, just as blood pressure, heart rate, and respirations are. Without a bowel movement, the body retains toxic waste and pressure within the colon increases. Moreover, health problems such as anal fissure, fecal impaction, and hemorrhoids can occur.1 Although constipation often elicits jokes and is dismissed as trivial, it is a problem our society needs to discuss and understand so that effective prevention and treatment are possible.2

Constipation is especially common among older adults, and older adults may appear obsessed with their bowel movements.3 This so-called “obsession” is related to how constipation is defined. Although health care providers and patients are concerned about the frequency of bowel movements, health care providers tend to use more objective criteria for defining constipation, such as consistency of stools.4 Older adults, in contrast, are more concerned about how they feel, such as abdominal discomfort, feeling of incomplete evacuation, and the need to strain.4 Annells and Kock5 found that constipation is subjective and a personal experience. Older adults decide that they are constipated by how they feel and how their bodies feel is their reality. They sense whether there is a risk to their health and well-being. They know that the feeling is unpleasant and that the feeling needs to be addressed and treated. The discrepancies between health care providers' and patients' perceptions can lead to chronicity and decreased quality of life. Patients, especially older adults, feel patronized by health care workers who dismissed their need for a daily and adequate bowel movement.5

Thus, the issue of constipation is complex and without a universally accepted definition.5,6 Leung et al1 noted that there is no exact definition for normal bowel function and similarly may be interpreted differently by patients and health care workers. Fosnes et al7 defined normal bowel function as bowel movements from 3 times per week to 3 times per day and stool consistency 3 to 5 on Bristol Stool Form Scale.8 The Bristol Stool Form Scale describes 7 types of stools, ranging from very hard to watery.

In comparing older adults with other age groups, children and adolescents have 1 to 2 bowel movements per day.9 Infants have frequent bowel movements, and those who are breast-fed often pass stool after each feeding.10(p1347) Tangalos11 points out that this gastrocolic reflex present in infants is still present in adults, and adults can use this powerful physiological response to defecate after meals. Tangalos11 further explained that psychological preparedness and relaxation facilitate defecation. Conversely, not having a bowel movement can ruin the day.

Older adults are prone to constipation because of decreased abdominal muscle strength as well as other health problems that reduce their activity.12,13 Frequently, medications reduce peristalsis.14,15 Older adults may have little choice about what they eat, and the choices can lack fiber. Waiting for help when they have the urge because of physical disability is not unusual, and lack of privacy is often an issue for those who are dependent on others.16

Unfortunately, many older adults suffer from constipation and frequently seek treatment.5,13,17 Thus, laxative use is common,5,18 and tolerance and side effects of laxatives can become health issues.7,13 Common side effects of laxatives include flatulence, cramping, abdominal pain, bloating, fainting, and nausea.18,19 With long-term use, a person can develop a weakened bowel, thus complicating the situation.20(p1012) Moreover, Mihaylov et al21 found that satisfaction with laxatives is often low.

Older adults' concerns about their bowel movements are as important as concerns about pain. Margo McCaffery, an internationally known nurse expert on pain, is often quoted: “pain is whatever the person says it is, and exists whenever he says it does.”22(p1205) In comparing the fifth vital sign with the sixth vital sign, pain versus bowel movement, pain is described as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”23(p1205) Berman and Snyder10(pp1210–1211) explain that uncontrolled pain contributes to other health problems such as insomnia, infections, stress, and depression and suggest that nurses are culturally incompetent if they disregard the pain observed in others. Similarly, constipation is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.13,24 Constipation creates pressure within the colon and increases the risk of impaction, bowel perforation, organ prolapse, and hemorrhoids.1 Just as pain can cause other psychological problems, the effects of constipation can lead to insomnia, depression, anxiety, and embarrassment.5,25,26

When pain is undertreated, a condition known as pseudoaddiction can occur.10(p1224) Clients may become so focused on obtaining medications for pain relief that they become demanding, may “clock watch,” and seem to inappropriately be “drug seeking.”10(p1224) Similarly, individuals, especially older adults, can appear obsessed with their bowel movements because they also are undertreated. Nursing literature informs nurses and nursing students that older adults should be advised that normal patterns for bowel elimination vary considerably and wrongfully suggest that they do not need a bowel movement everyday.3,10(p1348) Since normal transit time for food to pass through the colon is 12 to 24 hours,19 a minimum of 1 bowel movement per day is a reasonable expectation.

The longer the stool remains in the colon, the more water is absorbed and the harder the stool becomes20(p1012) The harder the stool becomes, the more straining is required.20(p1012) We know that many older people have problems with decreased fluid intake, limited mobility, decreased abdominal muscle strength and peristalsis, possibly a low-fiber diet, difficulty getting to the bathroom when the urge occurs, experiencing side effects from medications,18,26 and having less privacy when in a dependent situation.16 Thus, older adults' concerns about regular bowel movements should be taken seriously.

It is important to treat older adults who suffer from constipation in the same manner as patients with pain. Berman and Snyder10(p1225) stated that patients with pain should be acknowledged and their pain accepted, misconceptions about pain should be reduced, as well as their fear and anxiety. Emphasis should be placed on preventing pain and their needs should be attended to promptly. Similarly, individuals who express the need to have a bowel movement everyday should also be acknowledged, their needs attended to promptly, and their fear and anxiety reduced. Older adults know the pain and discomfort that comes with constipation. They know that when they do not have regular bowel movements, problems occur.

The body needs to be clean on the inside and outside.27 Florence Nightingale talked about natural things such as sunlight, fresh water, and cleanliness. Her environmental theory included diet and its effect on the body.28(p75) Similarly Jensen29 emphasized the importance of right eating, exercise, fresh air, and sunshine and pointed out that with “right” living bowel problems are not likely to occur. Daily bowel movements are needed to keep the colon clean and rid the body of toxins.27 Individuals well versed in natural health know that a healthy bowel system is the first step to a healthy body.29 In order for all the other organs and systems to function well, they must be fed healthy food and cleansed of toxins.29

Healthy bowels and regular bowel movements can be accomplished without excessive use of laxatives.27 Bowel movements can be supported by a variety of therapies. Healthy eating, exercises, adequate fluids, and privacy should be part of everyone's daily activities. As much as possible processed foods, sugar, salt, white flour, and caffeine should be avoided.29 Foods high in fiber should be offered and encouraged. The high-fiber food may need to be introduced gradually depending on the individual's tolerance. Drinking adequate amounts of water is important to keep the body hydrated.30 When that urge occurs, assist the individual to the rest room11 and provide needed privacy.16

As pointed out by Tangalos,11 the gastrocolic reflex is strongest early in the day. Helping individuals to the bathroom when they cannot help themselves an hour or so after breakfast can help establish regularity. Schnelle et al31 found that continent bowel movements increased significantly with assisted toileting.

The nursing profession can do much to relieve constipation among older adults and promote healthy colons in all individuals. The plan of care must be individualized and provided with a sense of empathy. Supporting healthy bowels and regular bowel movements and preventing constipation constitute an independent nursing area.

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bowel movement; constipation; older adult

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