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The Eton Scale: a tool for risk assessment for constipation.

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VOL: 101, ISSUE: 18, PAGE NO: 50

Gaye Kyle, BA, DipEd, RGN, is senior lecturer, Faculty of Health and Human Science, Thames Valley University, Berks

Phil Prynn, BA, RN, ONC, CertEd, is continence services manager, Wokingham Primary Care Trust, Wokingham, Berks; Hilary Oliver, RN, is head of continence services, Kensington and Chelsea Consortium, London; Terri Dunbar, BA, RGN, PGDip in Primary Care, is continence specialist nurse, Wokingham PCT, Wokingham, Berks

Why is a tool needed for risk of constipation?

Why is a tool needed for risk of constipation?
Constipation is a major health concern in patients in high-risk groups such as older, less mobile patients, those with neurological impairment and multiple health care needs, and people in institutional care.

Constipation is rarely a life-threatening symptom, yet the distress it causes leads to reduced patient comfort and diminished quality of life (Sweeny, 1997). Constipation remains an overlooked symptom in acute care, seldom getting attention until it is a significant problem (Ross, 1998). It has been estimated that 10 per cent of district nursing time is spent in bowel management (Poulton and Thomas, 1999), while Petticrew et al (1997) suggest that the cost of laxatives is more than £43 million a year. It would seem, therefore, that nurses need to adopt a more proactive approach to constipation, with a focus on prevention.

Assessment
An emerging theme from much of the nursing literature is the importance of assessing patients to identify any who might be at risk of developing constipation (Richmond, 2003; Hyde et al, 1999; Maestri-Banks and Burns, 1996). This view is further endorsed by the Royal College of Physicians (Potter et al, 2002) who state that identifying risk factors for constipation in older patients is critical to achieving effective management, because once health care professionals recognise those at risk, preventive measures can be implemented to meet each patient's individual needs. Yet, until now, there has been no such risk assessment tool in the nursing domain. The Eton Scale should encourage nurses to adopt a more proactive approach to the prevention and management of constipation.

The categories of risk assessment - The contributory factors (risks) leading to constipation have been brought together in the Eton Scale. Once the risks have been identified, they are given a numerical rating score. The total risk score for each patient is then categorised as follows: 'high', 'medium', 'at risk', or 'monitor'.

Figure 1 shows the front side of the tool. A stepped approach to assessment is used, each category having corresponding advice and suggested actions. These are printed on the back of the risk assessment document.

A multidisciplinary approach is inherent in the advice/actions given because of the variety of causative and risk factors involved in the development of constipation. (See the footnote opposite for details of how to obtain a copy of the scale.)

Evidence - Not all the risk factors for constipation that have been identified in the nursing literature have been subjected to the rigours of research and they often refer to personal opinion or anecdotal evidence. This is reflected in the paucity of research on constipation in the United Kingdom. The risk factors identified in the Eton Scale, however, are those that are mainly supported by research, although much of this is not recent.

The research evidence used throughout the Eton Scale is based on the recommendations of the Oxford Centre for Evidence-based Medicine (Potter et al, 2002). A few risk criteria have relied on level 5 evidence; for example, the condition of breathlessness. Level 5 includes expert opinion, where an opinion is based not on evidence but on 'first principles' (for example, physiological or anatomical) bench research. While there is no research that supports the view that patients with breathlessness are at risk of developing constipation, physiological evidence suggests that these patients will find it difficult to raise their intra-abdominal pressure in order to defecate competently.

To ensure reliability of the Eton scale the identified risk categories are predominantly objective and therefore not open to differing interpretation. However, evaluation of inter-rater reliability will be tested in the screening test validation study.

The risk categories identified in the Eaton scale are considered in the main to be constant or persistent factors, although variable or fluctuating factors such as hospitalisation, a sudden period of immobility and dietary changes are also taken into account. It is intended that the total score reflects the patient's current condition when the assessment is carried out.

Using the scale
To ensure correct use of the Eton Scale, an educational pack in the form of a CD PowerPoint presentation will be distributed, along with copies of the scale. Both the scale and a teaching CD should become an integral part of bowel management courses. The pack clearly outlines how to use the scale, and emphasises the importance of an adequate fluid and fibre intake, and correct positioning on the lavatory. Provision of the pack will enable those with an interest in bowel management to facilitate teaching sessions on the use of the tool, with a view to incorporating it into benchmarking activities.

The purpose of the Eton Scale and the educational pack is to enhance nursing practice rather than develop nursing knowledge. Further research studies into the efficacy of the scale will ensure its reliability, sensitivity and place in the bowel management of patients.

Footnotes
- Copies of the Eton Scale can be obtained from Norgine. Your name, job title and postal address should be e-mailed to: mss@norgine.com

- The Eaton scale is supported by an education grant from Norgine.

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