Volume 32, Issue 1 (1-2022)                   JHNM 2022, 32(1): 29-39 | Back to browse issues page


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Alijanpour S, Alimohamadi N, Khafri S, Khorvash F. New-onset Constipation After Stroke: Caspian Nursing Process Projects. JHNM 2022; 32 (1) :29-39
URL: http://hnmj.gums.ac.ir/article-1-1790-en.html
1- PhD Candidate (Nursing), Education, Research and Planning Unite, Pre-hospital Emergency Organization and Emergency Medical Service Center, Babol University of Medical Sciences, Babol, Iran - 2- Nursing (MSN), Students Research Committee, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
2- Associated professor, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
3- Assistant Professor of Biostatic, Department of Biostatistics and Epidemiology, Babol University of Medical Sciences, Babol, Iran.
4- Professor, Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
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Introduction 
Stroke is the second leading cause of death worldwide [1]. The complications of a stroke in the early days of hospitalized patients significantly increase the mortality rate [2, 3, 4]. One of the most common complications of acute stroke is constipation. Constipation status and laxative use are independently associated with a higher risk of all-cause mortality and incident of stroke [5]. It has been reported to occur in 22.9%-79% of patients with stroke [6]. In the acute stage, the incidence of constipation ranged from 33% to 55% and was associated with poor stroke outcomes among clients with strokes of moderate severity at baseline [6, 7].
The risk factors for new-onset constipation and its impacts on acute stroke complications have remained unclear [8]. However, new-onset stroke constipation is secondary constipation due to several factors after cerebrovascular accidents. These factors include medication use (antidepressants, antiepileptics, antihistamines, antispasmodics, anticholinergics, calcium channel blockers, calcium and iron supplements), metabolic diseases (hypothyroidism, hypoparathyroidism, hypercalcemia, hypokalemia, hypomagnesemia, diabetes mellitus, uremia, and heavy metal poisoning), neuropathies (due to cerebrovascular disease, medullar lesions or neoplasia, multiple sclerosis, autonomic neuropathy, and Parkinson disease) and other conditions (cognitive impairment, immobility, Chagas disease) [9].
Constipation, as a distressing symptom, is traditionally managed by nurses. Ambiguity concerning the descriptions of the nurse’s role in managing constipation exists, and guidelines are scarce. Management of constipation is typically based on experience and anecdotal evidence. There is a range of treatment modalities: diet modification, fluid intake, bowel training, abdominal massage, and increased mobility in older adults [10]. According to Fekri et al. study, the abdominal massage is in line with gastrointestinal peristalsis, confirming that a shallow abdominal massage might be the reason for the reduction of constipation improvement [11].
For constipation, little evidence is available to assist nurses in carrying out an appropriate clinical assessment, taking a proper treatment choice, or considering all constipation factors in a structured care plan [12]. Given the high prevalence of constipation among stroke clients, its adverse effects, the nurse’s responsibility, the lack of studies in this regard, it seems helpful to conduct a study that prioritizes and updates the role of nursing interventions in constipation after stroke. Therefore, we aimed to define a care plan for post-stroke constipation.

Materials and Methods
The current multi-stage evolutionary study elaborates the protocol study and method of Caspian Nursing Process Projects (CNP2), conducted in 2019 with the combination of Delphi and RAND (Research And Development) Methods (RAM) in Isfahan City, Iran. This project was used a scientific method to plan, collect, and implement a structural plan by nursing-led intervention for stroke complications such as new-onset constipation. This method was designed by the RAND Institute and the University of California in Los Angeles (UCLA). It has been used in many studies in North America and Europe. RAM involves generating clinical scenarios or criteria [13]. The research study consisted of several phases according to similar studies as follows: 
1. Searching for scientific sources
2. formal-content validity
3. RAM and Delphi methods
4. Results and changes made at the Delphi stage
5. The panel of experts [14]

Searching for scientific sources
The inclusion criteria for scientific resources have two sections: first, searching for resources, and second, authorities who participated in the study. Clinical articles and guidelines on constipation management after stroke, available as English language full texts between January 2004 and December 2019, were extracted first. Also, the relevant authorities were selected with at least 5 years of experience in clinical practice, willingness to cooperate, and having sufficient time to collaborate in research. The exclusion criteria were unwillingness or lack of time to cooperate. 
First, we systematically searched databases, such as Cochran database, MEDLINE, Science Direct, PubMed, Elsevier, Scopus, and library resources with keywords and MeSH terms, such as “post-stroke constipation”, “constipation”, “new-onset constipation” in combination with the “stroke” and “cerebrovascular accident” terms using OR & AND operators. Figure 1 shows the steps of research in the current study.

Twenty-one articles from 2009 to 2019 were identified and selected after reviewing their titles and abstracts. In this process, we used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. In the next step, seven studies were excluded because of not meeting the inclusion criteria, and three studies were excluded because of not being written in English (1 article) and not having their full texts (2 articles). In the end, 11 articles were entered the study. Also, by systematically searching for the care plan at specialized sites such as the World Gastroenterology Organization (https://www.worldgastroenterology.org) [15], the American Gastroenterology Association (https://www.gastro.org) [16], and the British Institute of Health and Care Excellence (https: //www.nice.org.uk) [17] on the subject of constipation management, six guidelines were found. These guidelines were appraised by AGREE II (The Appraisal of Guidelines for Research & Evaluation), and three guidelines were passed. Finally, 14 articles and guidelines were included in the study (Table 1). 

Formal-Content validity
First, initial recommendations were extracted from the articles and guidelines. During this step, the original text was translated into Persian, and references were written on the right-hand side of a table. Then, faculty members in the formal-content validity team (5 faculty members of the Isfahan University of Medical Science) were asked to modify, reject or approve the translation and determine the relative content to structure on the left side of the table. 

RAM and Delphi methods
The RAM includes priority, benefits, applicability, conceptualization, and authorization to provide service [14]. A list of recommendations in the new-onset constipation care plan was compiled according to credible sources and articles, arranged by nursing process, and divided into four tables (assessment, goals and outcomes, nursing diagnosis, intervention, and evaluation). A total of 22 authorities from different professions 11 Nurses (50%), Neurologist (18.2%), 2 Fellowships of Intensive Care (9.1%), Internal Medicine (9.1%), Surgen 1 (4.5%), Nutrition (4.5%), and Emergency Medicine (4.5%) of Isfahan, Tehran and Babul universities of Medical Sciences, who were expert in constipation management after stroke were selected. Also, due to ethical considerations in the research, the participants were assured that all information was confidential and that the contributor’s name and comments were provided only to the researcher. Based on the Delphi technique for obtaining expert’ opinions, a written version of the clinical guideline was completed in person, delivered to the participants who had mentioned their readiness. They were asked to complete a 5-point Likert scale clinical guideline draft, and if required, note further care or advice in a proposal form. As the RAM technique, the rating was (1 to 5) applied in four domains (priority, benefits, applicability, and conceptualization) of each recommendation. Then they could comment on the recommendation in the relevant column.
The priority areas were determined on a 5-point Likert scale: score 1, in my opinion, this care is not necessary at all; score 2, I don’t think this care is necessary; score 3, in my opinion, this care is relatively necessary; score 4, in my opinion, this care is necessary; and score 5, in my opinion, this care is absolutely necessary.
The applicability of each recommendation can be tailored to the hospital conditions and equipment, with a maximum score of 5 and a minimum of 1. 
The conceptualization means whether this sentence is understood by the nurse; score 5 refers to the full understanding, vs score 1 that means not be understood. Finally, the experts were asked to identify eligible nurses in the program, including a BSc nurse, Stroke Nurse (SN), or Critical Care Nurse (CCN), who can provide services.

Results and changes made at the Delphi stage
In this stage, the results obtained from the experts and the services with 70% agreement and above were maintained in the project. The rest with less than 70% agreement was separated to prepare the subsequent questionnaire and comments and suggestions by some professors and users in writing. According to the experts’ opinions, those services with less than 50% agreement were not suggested.

The panel of experts
In this stage, each item in care plan which not acquired agreement upper than 70% according to authorities opinion, should be discussed and finally modified or removed from care plan. 
The experts’ opinions in each column and degrees of the agreement were analyzed on a 5-point Likert scale for each item using descriptive statistics in Excel in Microsoft Office 2019 and SPSS v. 23 software. 

Results
The current study results showed that all 22 experts provided their feedback comments in a written format; in other words, we had 100% participation by experts. Most of them were 16 men (72.7%), 15 cases (68.2%) had a PhD, and the highest profession belonged to Nursing with 11 cases (50%). All recommendations had reached over 70% agreement in all four areas of the initial draft (priority, benefits, applicability, and conceptualization). After that, the initial draft was revised and confirmed by experts; because of high agreement, the panel phase of experts was not held.
 Data by RAM technique was categorized in priority, benefits, applicability, and conceptualization items. Regarding the priority, the highest agreement was found on patient and companion education (98%) and the lowest on disability in daily activity (75.6%). In terms of benefits, the patient’s education again achieved the highest agreement with 97.2% and use of the Bartel index (an ordinal scale used to measure performance in activities of daily living in approximately three weeks that could predict activities of daily living disabilities in 6 months) [18] with 73.6%, obtained the lowest agreement. In the applicability area, reporting the water and electrolyte impairment and an educational booklet with 93.6% agreement got the highest, and performing exercises such as pelvic lifting got the least applicability with 70%. Also, in terms of conceptualization, reporting water and electrolyte impairment obtained the highest agreement. On the other hand, the initiation of the constipation management protocol and prevention of bowel dysfunction received the least attention from the experts.
Considering the nursing process, according to each step, the recommendation was defined. According to experts’ opinions, people who provide services with less than 50% agreement were BSc nurses, so it was suggested that this care should be taken by stroke nurses or MSc in Critical Care Nursing (CCN). In the assessment section, the highest percentages of agreement belonged to constipation diagnosis by IV Rome criteria, constipation risk by the Norgine instrument, tenderness in physical examination, taking client medication (Table 2).

Regarding goal setting and outcome, the highest percentages of the agreements were seen in the prevention of bowel dysfunction, stable water and electrolyte status, client placement in types III and IV of the Bristol criteria (The Bristol stool scale is a diagnostic medical tool designed to classify the form of human feces into seven categories, which is used in both clinical and experimental fields) [19], and no evidence of constipation according to the Rome IV criteria (Table 3).

Regarding nursing diagnosis and intervention, the highest percentages of agreements belonged to initiating constipation management protocol, identifying patterns of excretion, fiber intake, adjusting the patient physical activity, walking, pursuing constipation remedies, laxative use, training manual and educational booklet and pamphlet (Table 4).

About evaluation, the highest degree of agreement belonged to evaluating the client’s response to interventions, the level of awareness of intestinal care, evaluation of care performed, and using the Barthel index (Table 5).

Discussion
Stroke and its complications, such as constipation, can lead to mortality and disability [20, 21]. For the management of constipation, scientific methods, such as formal consensus development (including RAM), provide a timely and efficient solution when evidence is insufficient [22]. We used RAM for the management of new-onset constipation after stroke. All recommendations had reached over 70% agreement in all four areas of the initial draft.
Regarding the RAM sections, the highest agreement was found on the patient’s and companion’s education, reporting the water and electrolyte impairment and educational booklet. On the other hand, disability in daily activity, use of Barthel index, performing exercises, such as pelvic lifting, initiation of the constipation management protocol, and prevention of bowel dysfunction acquired the lower agreement in each item. According to the Farouki Far et al. study, patient education is one of the quality standards of nursing care and affects the costs, recovery, and cure rate of the patients [23]. Nurses know that immobilization, inadequate intake of water and fiber, emotional disturbance, reduced consciousness, and side effects of medication are the factors that contribute to constipation in stroke clients [24]. So, they should be enrolled in the patient education programs. As nurses are always the first line of dealing with the stroke patients in the hospital [11], they should implement interventions, such as patient and companion education, reporting the water and electrolyte impairment, and educational booklet to alleviate the patient’s constipation and gastrointestinal complications. 
Fekri et al. reported that massage and lifestyle training could improve constipation and distension and reduce patients’ need for taking laxative drugs. However, abdominal massage is a simple and inexpensive procedure, and anyone can be trained to do it [11]. Meta-analysis results imply that massage therapy could be a beneficial complementary treatment for a patient suffering constipation after stroke [25]. Lifestyle training, such as consuming fiber-containing foods, movement, and activity, could significantly improve gastrointestinal complications [11].
Considering that less than 50% agreement is being reached with the BSc nursing in some items, it was suggested that this care be taken by stroke nurses or MSc in CCN. 

Conclusion
Our results indicated that all recommendations had reached over 70% agreement in all four areas of the initial draft, but some care should be taken by a stroke nurse or MSc in CCN. The study findings can be used for the management of new-onset constipation after stroke. The study results can be used for developing national guidelines or criteria for this problem. This study had some limitations. We could not access other centers to invite other authorities in this field to increase the quality. Also, this study was limited to Iran, which focuses on new-onset constipation management with the structural and scientific method.

Ethical Considerations
Compliance with ethical guidelines

The proposal of this study was approved by The Vice-Chancellor in Research and the Ethics Committee of Isfahan University of Medical Science (Code: IR.MUI.RESEARCH.REC.2018.320). Cooperation in this research was not obligatory, and the purpose of the study was explained to all participants.

Funding
The current study was supported by Vice-Chancellery for Research of Isfahan University of Medical Sciences. 

Author's contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
All author want to thank Professor Alijan Ahmadi Ahangar and Payam Saadat (Mobility Impairments Research Center of Babol), Dr. Abasi (Head of ICU2 of Alzahra Hospital of Isfahan), Dr. Shahriary (Faculty of Nursing and Midwifery of Isfahan) for their cooperation, which made this research possible. 


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Article Type : Research | Subject: General
Received: 2021/08/23 | Accepted: 2021/09/29 | Published: 2022/01/1

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