Effect of Nursing Instructions on Reducing Selected Functional Gastrointestinal Disorders among Elderly Patients

Introduction

The changes that occur along the process of ageing in Gastrointestinal (GI) alteration in the elderly are common. (Igor Dumic, et al.,2019)Constipation is a common gastrointestinal disorder that negatively affects people's quality of life and burdens healthcare services worldwide. It is estimated that constipation affects between 6 and 18% of community-dwelling older adults and more than 60% of older adults in long-term care settings. In older adults, constipation is associated with frailty and decreased quality of life. Therefore, prevention and treatment of constipation should be a priority for nurses who look after older adults in long-term care settings. (Murray, et al.,2020)

Constipation is defined as the presence of two or more of the following symptoms: straining to evacuate more than 25% of defecations, lumpy or hard stools in more than 25% of defecations, fewer than three spontaneous bowel movements per week,…etc. (lacy, et al.,2016)  

Nurses are first-line professionals in long-term care settings, hence the importance of them implementing non-pharmacological interventions that improve constipation amongst older adults in long-term care settings. (White, et al.,2020) The gerontological nurse should educate the elderly on recognizing and responding to any urge to defecate, a regular daily routine, starting with light physical activity and the optimal times to have a bowel movement are soon after waking and after meals when the normal colon accentuates its motor activity. So, the nurse should educate the patients to try defecation first thing in the morning and in the post-prandial intervals to profit most from the gastro-colic reflex. Nurses can suggest a gradually increasing intake of fluids and fibres up to 30 g/day. This goal can be achieved by recommending the patient to integrate the diet with more fruits, vegetables, and nuts in addition to adding varying amounts of bran.  (Lucak, et al.,2021)

The management of constipation in the elderly aims to relieve the symptoms associated with constipation, to restore normal bowel habits, which is defined as the  passage of a soft, formed stool at least three times a week without straining, and to restore the quality of life without any significant adverse effects. There is no difference in the treatment of constipation between the elderly and younger adults. Treatment should be started with non-pharmacological approaches, including lifestyle changes, dietary changes, and physical activity. Within the pharmacological approaches, fibre and laxatives are the most commonly used as the initial treatment, according to several recent studies. (Lundberg, et al.,2020)

If lifestyle interventions are ineffective, medications are necessary; osmotic or stimulant laxatives are first-line therapy. These agents are at least as effective and less expensive than newer agents for treating chronic constipation in adults. (Chassagne, et al.,2017)It is advisable to start treatment with organic osmotic laxatives (polyethylene glycol with electrolytes, lactitol, or lactulose); if they are not effective, continue with inorganic osmotic laxatives (magnesium salts),  lubricants (glycerin suppositories), and as the last step: stimulating laxatives (bisacodyl). This last group should be administered with caution since their long-term use can cause an atonic colon. (Serra, et al.,2017)

Significance of the study 

Constipation is a chronic gastrointestinal condition that has a detrimental impact on people's quality of life and places a strain on healthcare systems across the world. Constipation affects between 6 -18% of community-dwelling older adults, as well as more than 60 % of those in long-term care facilities. Constipation is linked to frailty and a lower quality of life in the elderly.  (Murray, et al.,2020)

Functional constipation can have many different causes, ranging from changes in diet, physical activity, or lifestyle to primary motor dysfunctions due to colonic myopathy or neuropathy. (Sanaa & Samah,2017)

the researcher went to the practical settings with the students and observed that a large number of elderly patients suffer from constipation for a long duration. For this reason, the researcher felt the importance of giving nursing instructions about lifestyle modifications for the elderly to help them control and prevent constipation.

Aim of the Study                                             

The current study aims to:

• evaluate the effect of the nursing instructions on reducing the selected functional gastrointestinal disorders among elderly patients. 

Research Hypothesis

•  The frequency and severity of constipation among elderly patients post receiving the nursing instructions will be less than pre instructions.

Subjects and Method

Study Design:

Quasi-experimental (Pre–posttest) research design was utilized in the current study.

Setting:

This study was carried out at the Geriatric Home  )Dar Al Hana(, Geriatric Club, the outpatient clinic (Gastrointestinal clinic) at Qena & University Hospital Qena Public Hospital- Qena Government - Egypt 

Subjects:

The study sample was taken in one year (consecutive sample) who were 100 elderly patients.

Tools of data collection

The data of this study was collected by using two tools

1.  First Tool:

Questionnaire sheetwas developed by the researchers to collect the necessary data from the patients based on the literature review. It was collected by the researcher at the first interview. It was constituted of two main parts:

• Part (I): personnel characteristics: that includes (age, gender, phone number, marital status, level of education, …etc.
• Part (II): Patient's medical data: that includespatients’ awareness of risk factors for constipation.

2. Second Tool:(The Patient Assessment of Constipation-Symptoms (PAC-SYM) Questionnaire ) 

It was developed by (Frank, et al, 1999); to assess symptoms severity of chronic Constipation. It includes 12-symptoms it is divided into three subscales: abdominal (four items); rectal (three items); and stool (five items).  

Scoring System  

• Items are scored on 5-point Likert scales ; they ranged from 0 to 4 (0 = meaning "symptoms absent , 1 = meaning "mild , 2 = meaning " moderate , 3 = meaning " severe’ and 4 = meaning " very severe ).
• A mean total score in the range of 0-4 is generated by dividing the total score by the number of questions completed; the lower the total score, the lower the symptom burden.
• A total score for the PAC-SYM ranged from zero, which means no constipation symptoms, to forty-eight, which means very severe constipation symptoms.     

Tools Validity and Reliability 

The two tools and scale content validity were done to identify the degree to which the used tools measure what was supposed to be measured. It was examined by a panel of five expert's opinions in the field of the study (Faculty of Nursing Medical-Surgical Nursing department) and necessary modifications were done. Tools were tested for content reliability using Alpha Cronbach’s test.  It was (0.91) for the second tool.

Study Procedure

The researcher contacted the studied subjects two days a week. Every session included an average of 2-3 elderly people. The researcher visited both hospital and the elderly home during the morning shift, but she went to the geriatric club in the evening. The researcher interviewed studied subjects who were admitted to hospitals clinics in the waiting room. They were informed by the researcher individually about the purpose and nature of the study through the interviewing method.

The first session: - the researcher began the pre-assessment baseline data by filling in the first tool (personal dataand medical data)

The Second session: - for education and giving nursing instructions regarding constipation. This session contains two parts.

Part1:-Regard knowledge giving information about themeaning, signs & symptoms, causes of constipation, …etc. teach patients how to prevent constipation by educating them the dietary measures such as a high fibre diet and increased fluid intake, increased regular daily physical activity and regular toilet routine, …etc.

Part 2: -Regard practice teaches the patient how to perform Brace Exercise and the good functional position when sitting on a toilet, (emulating a squat on the toilet)with the knees above the hips and the feet elevated.  

The third and last session was conducted for evaluating the study subjects after giving the nursing instructions and after following them for three months. Each session lasted between (15 - 20) minutes. After each session, there were 10 minutes for discussion and giving feedback. Reinforcement of teaching was performed according to patients' needs to ensure their understanding. Each patient obtained a copy of the nursing instructions booklet which was prepared in the Arabic language. The researcher used pictures in it for illustration and more clarification of the studied subjects. The researcher followed -up with every patient weekly by telephone for three months to follow the bowel habits of each patient, ensure the patient's compliance with the instructions, and ask about any complaints.

Pilot Study

A pilot study was carried out on 10% (10 patients) of the total sample to test the feasibility, objectivity, and applicability of the data collection tools& scale. The pilot study sample was not included in the study sample because some necessary modifications were done.

Ethical Consideration

v  An official letter regarding the study's approval was obtained from the manager of the geriatric home (El Hana home), geriatric club, and gastrointestinal outpatient clinics to conduct the study; then the aim of the study was explained to them to obtain their cooperation.

v  Patients were informed about the purpose, procedure, benefits, nature of the study, and follow-up, and they had the right to withdraw from the study at any time without any rationale. Strict confidentiality and anonymity of each subject were ensured through coding of all data and protecting the obtained data, then oral consents were obtained from subjects.

Statistical Analysis

The obtained data were reviewed, prepared for computer entry, coded, and analyzed by using SPSS (version 25). Descriptive statistics (frequencies, percentage, mean and standard deviation) were done. The Chi-square test and Fisher exact test were used to compare between the pre and post categories of constipation and personal data. A nonparametric test named the Wilcoxon signed ranks test was also used. Paired Samples Test, the independent sample T-test, the Pearson correlation test were used for testing the associations between continuous variables. It was considered significant when P-values were less than (0.05).

Results:

Table (1):  Distribution of the study subjects according to their personal data (n = 100)

Table (1) shows that the mean age of the studied elderly was (77.3± 7.5   years). Also, 59%, 44% and 41% of them were females, married, working as housewives respectively. Regarding education ,48% were illiterate. Lastly, regarding social life, they lived with their families in the rural areas, constituting (68%,53%) respectively.

Table (2): Distribution of the study subjects according to their awareness regarding constipation risk factors     

Table (2): demonstrates that 91%,88% and 81% have good awareness that a low fibre diet, limited fluid intake, and lack of mobility, respectively, are risk factors of constipation.64% and 27% have poor awareness that fear of pain with defecation and ignoring the urge to defecate, respectively, are risk factors for constipation. 

Table (3): comparison of overall total scores of constipation severity among studied subjects during pre and post nursing instructions implementation (n=89)

Table (3): represents that there is a highly statistically significant difference in total mean average score and SD (20.4 ±8.3, 10.8 ±8.3) of constipation symptom severity during pre and post nursing instructions implementation. p-value ≤0.05

Figure (1): distribution of the defecation frequency of the studied subjects during the three months after nursing instructions implementation for constipated subjects.  (n=89)

Figure (1): clarifies that in the first week there were only four subjects who defecated every three days, while twenty-five subjects defecated every four days, twenty-seven subjects defecated every five days, thirteen subjects defecated every six days and twenty subjects defecated every seven days. in the 6^th week and following, there were three subjects who defecated every two days, seventeen subjects defecated every three days, thirty-two subjects defecated every four days, seventeen subjects who defecated every five days, eleven subjects defecated every six days, and sixteen subjects defecated every seven days. But in the 12^th week, three subjects who defecated every day, twenty-five subjects defecated every two days, thirty-three subjects defecated every three days, eleven subjects defecated every four days, nine subjects were defecated every five days, five subjects defecated every six days, and only three subjects defecated every seven days. 

Table (4): correlation among the studied subjects between constipation severity and their data post nursing instruction implementation after three months

P≤0.05

Table (4): illustrates that there is a highly statistically significant correlation between the constipation severity and the study subjects' age and educational level p-value ≤0.05. while there is nostatistically significant correlation between constipation and the study subjects’ sex and marital status.