Constipation is the decrease in normal frequency of bowel movements. It is also typically accompanied by difficult or incomplete passage of stool and stool that is often extremely hard and dry. Constipation is very common and one of the most frequently seen gastrointestinal complaints. It can affect anyone however the following individuals are more prone to constipation:
- Elderly: typically, these individuals are less active, have slower metabolisms, and less muscle strength along the digestive tract
- Women (particularly pregnant women or shortly after childbirth): changes in hormones can cause constipation and for pregnant women the baby often pushes on the intestines resulting in a slower passage of stool
- Individuals with neurological disease
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
The following are the common causes of constipation:
- Diet:
- Low fiber diet
- Increased consumption of milk or cheese products
- Increased intake of highly processed food
- Decreased fluid intake or Dehydration
- Activity:
- Low exercise/activity level
- Changes in regular daily routine
- Limited physical activities (bedrest and poor mobility)
- Chronic disability
- Stress
- Resisting the urge to have a bowel movement
- Oral/ dental health problems
- Pregnancy and childbirth
- Chronic pain
- Medications
- Pain medications
- Narcotics
- NSAIDs
- Antidepressants
- Antacids with calcium or aluminum
- Iron supplements
- Allergy medications
- Some blood pressure medications
- Psychiatric medications
- Antiemetics
- Anticonvulsants
- Pain medications
- Conditions/ Diseases:
- Neurologic:
- Spinal cord injuries
- Stroke
- Parkinson’s disease
- Traumatic brain injury
- Multiple sclerosis
- Endocrine:
- Hypothyroidism
- Diabetes Mellitus
- Uric acid in the blood (uremia)
- Gastrointestinal:
- Colorectal cancer
- Irritable bowel syndrome (IBS)
- Diverticular Disease
- Intestinal obstruction
- Structural defects within the digestive tract
- Presence of diversion
- Neurologic:
Signs and Symptoms (As evidenced by)
The following are the common signs and symptoms of constipation. They are categorized into subjective and objective data based on patient reports and the assessment by the nurse.
Subjective (Patient reports)
- Less than three bowel movements per week
- Hard, dry stool
- Lumpy stool
- Difficulty/straining to pass stool, painful
- Stomach pain, aches, or cramps
- Sensation of feeling bloated or nauseous
- Sensation that you have not fully emptied your bowel after a bowel movement
Objective (Nurse assesses)
- Assess medical history related to potential constipation (history of constipation, activity level, medications used routinely for constipation)
- Assess for abdominal pain using an age-appropriate pain scale
- Location of pain
- Severity of pain
- Duration of pain
- Description of pain
- Specific actions that improve or worsen pain
- Complete the comprehensive abdominal assessment in the following sequence:
- Inspection
- Auscultation
- Percussion
- Palpation
- Assess stool characteristics per patient
- Color, consistency, amount
- Use appropriate tools as needed (Bristol Stool Chart)
Expected Outcomes
The following are the common nursing care planning goals and expected outcomes for constipation:
- Patient will report soft, formed stool during bowel movements.
- Patient will establish bowel movement three times a week to three times a day.
- Patient will verbalize being free of pain and straining during bowel movement.
- Patient will be able to identify actions to prevent constipation in the future
- Patient will be able to enumerate behavior or lifestyle changes to prevent constipation.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to constipation.
1. Assess changes in bowel habits.
Note for the following changes in bowel movements and stool characteristics such as:
- Time of day
- Frequency
- Experience (presence of pain, straining, or difficulty while passing stool)
- Previous need for bowel aid such as a stool softener or laxative
2. Observe stool characteristics.
Monitoring for stool characteristics provides a baseline for comparison and evaluates the effectiveness of treatment. Assess the following stool characteristics:
- Amount
- Consistency
- Color
- Odor
3. Assess the patient’s lifestyle choices.
Identify the daily routine changes that can trigger constipation. It will also be the basis for developing a care plan for constipation or preventing it. Ask the patient about the following:
- Activity level
- Exercise
- Food preference
- Diet
4. Review the patient’s medical history and medication list.
Some medical conditions (such as hypothyroidism) or medications (such as narcotics) can cause constipation. Treat the underlying cause. Identifying these risk factors can help develop the appropriate treatment plan for constipation.
5. Check the presence of emotional distress.
Stress and other emotions related to depression and anxiety can effects constipation. Identifying these risks and managing them can help to relieve constipation.
6. Assess using Bristol Stool Scale.
Bristol stool scale assesses stool consistency. Having the same scale allows all team members to use the same assessment tool to evaluate stool consistently.
7. Assess for signs of laxative abuse and misuse.
Look for indications of laxative misuse or excessive usage of stimulant laxatives. It is common among older patients due to aging and a high risk of constipation.
8. Identify the patient’s life changes or stressors.
Constipation can be caused or worsened by pregnancy, travel, trauma, changes in personal relationships, occupational factors, or financial worries. The client can neglect to schedule time for regular bowel movements and have gastrointestinal side effects from stress.
9. Investigate the cause of pain during defecation.
The client may be holding defecation or having difficulty passing stool due to the following:
- Hemorrhoids
- Rectal fissures or prolapse
- Skin breakdown
10. Perform abdominal assessment.
Perform abdominal assessment techniques in proper sequence. It ensures that the bowel movements are not altered during the examination. An accurate abdominal assessment provides the nurse with objective data for treatment. The techniques are the following:
- Inspection
- Auscultation of bowel sounds
- Percussion
- Palpation
11. Perform a digital rectum examination.
Assess rectal tone, look for pain or blood, or look for signs of fecal impaction by checking the digital rectum.
12. Perform an extensive work-up if treatment fails.
Conduct a thorough workup on an outpatient basis after 3-6 months of unsuccessful medical treatment for constipation. Anorectal testing checks for defecatory diseases if over-the-counter medications cannot ease constipation. These include:
- Anorectal manometry
- Colonic manometry
- Colonic transit studies
- Surface anal electromyography (EMG)
- Balloon expulsion testing
- Imaging studies such as X-ray and ultrasound
- Lower gastrointestinal (GI) endoscopy
13. Assist the patient in undergoing imaging studies as indicated.
Perform imaging tests to rule out underlying causes of colonic ileus or assess the causes of persistent constipation.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with constipation.
1. Perform manual disimpaction.
Manual disimpaction and transrectal enemas are two initial constipation treatments. A well-lubricated gloved finger may be necessary for patients with lower anorectal impactions.
2. Administer laxatives or stool softeners as prescribed.
Stool softeners and laxatives can be beneficial in the short term to assist with initiating the first bowel movement. It includes the following:
- Bulk-forming agents: fibers and psyllium
- Emollient stool softeners: docusate
- Rapidly acting lubricants: mineral oil
- Prokinetics: tegaserod
- Stimulant laxatives: senna
3. Apply lubricant or anesthetic ointment as ordered.
Lubricant facilitates stool passage and prevents further strain. Additionally, numbing (anesthetic) cream helps ease the discomfort of bowel motions.
4. Emphasize the importance of lifestyle changes.
Health teaching should focus on the prevention of constipation rather than medications. Patient education should include lifestyle changes such as proper diet, adequate hydration, regular physical activities, and exercise.
5. Encourage a high-fiber diet.
A balanced diet includes:
- Whole food: fruits, vegetables, and whole grains
- Fiber supplements: wheat bran and psyllium
- Fiber-rich foods:
- Fruit: raspberries, strawberries, blueberries, pears, apples, bananas
- Vegetables: peas, broccoli, brussels sprouts, potatoes, sweet corn, cauliflower, carrots
- Grains: barley, quinoa, bran, oatmeal, brown rice, whole wheat bread
- Legumes and nuts: split peas, lentils, baked beans, black beans, chia seeds
- Limit the intake of low-fiber foods and avoid high-fat food: ice cream, cheese, meats, processed meals, fast food
6. Promote increased fluid intake.
Encourage adequate intake of fluids, such as:
- Water
- High-fiber fruit
- Vegetable juices
- Fruit and vegetable smoothies
- Popsicles
- Warm, energizing liquids: tea, hot water, or decaffeinated coffee
7. Avoid caffeine and alcohol.
Alcohol and caffeine can aggravate the gastrointestinal tract. They can alter how the body absorbs water, causing dehydration.
8. Advise the patient to do physical activities.
Encourage daily exercise and physical activities. Exercise improves the muscles’ flexibility and aids in digestion.
9. Encourage the patient to have an elimination diary.
An elimination diary helps the healthcare team track long-term issues easier. Note any medications used to assess the treatment’s efficacy and appropriateness for the patient.
10. Establish regular bowel movements.
Encourage the patient not to resist or ignore the urge to defecate. Promote predictable interval timing for toileting or colostomy irrigation.
11. Promote a bowel management program.
Give the patient privacy and a regular time to defecate or irrigate their colostomy. Ask the patient’s preference, such as using a toilet, commode, or bedpan.
12. Promote pain relief during defecation.
Encourage taking a sitz bath before stool defecation to relax the sphincter. Relaxation of the rectal muscles relieves the pain. It makes the passage of stool easy without forceful strain.
13. Apply a gentle abdominal massage.
Abdominal massage encourages rectal loading by increasing intra abdominal pressure.
14. Ask the patient to demonstrate proper abdominal massage.
Allows the patient to learn ways to perform abdominal massage at home independently.
15. Refer to the primary healthcare provider.
Advise the patient to consult the healthcare provider before using any medical therapy (such as additional emollient, saline, hyperosmolar laxatives, enemas, or suppositories) to prevent laxative abuse and misuse.
16. Assist the patient with surgery.
Surgery is performed to treat patients who have failed treatment. At least 10% of children with functional constipation require surgical intervention. Surgical treatment aims to evaluate the underlying cause, remove the bowel obstruction, and reduce symptoms. Surgical interventions are:
- Anal procedures
- Antegrade enemas
- Colorectal resection
- Intestinal diversion
17. Stimulate the sacral nerve.
Sacral nerve stimulation is effective for some children with functional constipation. The stimulation helps improve defecation frequency. Further research and evidence-based data are still needed to support sacral nerve stimulation.
18. Stay with the patient for emotional support.
Assist the patient with managing any current or possible difficulties from long-term bowel control. Offer social and emotional assistance.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for constipation.
Care Plan #1
Diagnostic statement:
Constipation related to opioid analgesics as evidenced by lack of bowel movement post-surgery.
Expected outcomes:
- Patient will pass soft, formed stools every 1 to 3 days without straining.
- Patient will perform measures to relieve opioid-induced constipation.
Assessment:
1. Review medication history.
Opioid-induced constipation occurs in approximately 60% of patients without cancer taking opioids for pain relief. Note if the patient takes the medication according to the prescription.
2. Assess the perceived normal pattern of defecation of the patient.
The normal frequency of defecation varies from twice daily to once every 3 to 4 days. However, hard, dry feces is characteristic of constipation. The nurse may utilize Rome Criteria IV in evaluating functional constipation. The patient is constipated if they satisfy two of the following for the last three months:
- Hard stools in at least 25% of bowel movements
- Straining in at least 25% of bowel movement
- A feeling of incomplete evacuation in at least 25% of defecations
- <3 bowel movements per week
- Use of manual measures to help move or remove the stools from the rectum
Interventions:
1. Administer laxatives as indicated.
All patients prescribed opioids should be prescribed with laxatives, except the bulk-forming type, as prophylaxis for constipation.
2. Encourage early physical mobility.
Aside from preventing constipation, early physical mobility after surgery decreases the risk of postoperative complications, hastens recovery and ambulation capacity, and reduces hospital length of stay.
3. Educate the patient and family about the use of opioid analgesics.
Constipation is a common side effect of opioids. Reassure the patient that this concern is addressable through intake of a stimulant (senna/bisacodyl), stool softener (docusate), or an osmotic laxative (polyethylene glycol) accompanied by physical mobility after surgery.
4. Encourage them to avoid long-term use of laxatives.
Long-term use of stimulant laxatives can lead to dependence on defecation.
Care Plan #2
Diagnostic statement:
Constipation related to immobility as evidenced by bloating and abdominal discomfort.
Expected outcomes:
- Patient will pass Bristol Stools Type 3 (sausage-shaped with cracks on the surface) or Type 4 (sausage-shaped but smooth and soft).
- Patient will report relief from the discomfort of constipation as evidenced by the absence of the following symptoms:
- Bloating
- Abdominal discomfort
- Abdominal distension
- Anorexia
- Nausea
- Vomiting
- Patient will demonstrate measures to relieve discomfort brought on by constipation.
Assessment:
1. Assess the usual pattern of defecation, including time of day, stool amount, frequency, consistency, history of laxative use, diet, exercise patterns, and fluid intake.
Each person has their perceived “normal” bowel pattern. A detailed assessment of usual bowel habits will provide a baseline for evaluating planned nursing interventions.
2. Assess the level of mobility.
Knowing the extent of the patient’s capacity to move would help plan appropriate exercise or physical activity.
Interventions:
1. Advise a fiber intake of 18 to 25 g daily and suggest fiber-rich foods (e.g., prune juice, leafy green vegetables, wholemeal bread, and pasta).
Fiber creates bulky feces and stretches the bowel wall to stimulate peristalsis, thus shortening bowel transit time.
2. Advise a fluid intake of 1.5 to 2 L per day (ideally, 6 to 8 glasses of water) unless contraindicated by comorbidities like kidney or heart disease.
Water passes into the gut to promote the formation of a softer fecal mass and provides lubrication to prevent gut blockage.
3. Encourage physical activity within the client’s current ability to mobilize.
Encourage turning and changing position in bed if immobile. Encourage knee-to-chest raises, waist twists, and arms stretching away from the body for clients with reduced mobility.Physical activity can help stimulate peristaltic waves in the colon and encourage the transit of feces to the rectum.
4. Demonstrate gentle external abdominal massage using aroma therapy oils, following the direction of colon activity.
Abdominal massage encourages rectal loading by increasing intra-abdominal pressure, and in some cases, it may elicit rectal waves, stimulating the somatic-autonomic reflex and enhancing bowel sensation.
5. Perform enemas or disimpaction.
Consider using enemas if other natural interventions are ineffective. Enemas help in cleansing and stimulating bowel emptying.
References
- Ackley, B.J., Ladwig, G.B., Flynn Makic, M.B., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing diagnosis handbook: An evidence-based guide to planning care (12th edition). Mosby.
- Basson, M. D. (2021, October 17). Constipation treatment & management: Approach considerations, dietary measures, pharmacologic therapy. Diseases & Conditions – Medscape Reference. Retrieved July 2023, from https://emedicine.medscape.com/article/184704-treatment#showall
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Diaz, S., Bittar, K., & Mendez, M. D. (2023, January 31). Constipation – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved July 2023, from https://www.ncbi.nlm.nih.gov/books/NBK513291/
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions and rationales (15th ed.). F. A. Davis Company.
- Cleveland Clinic (2019). Constipation. https://my.clevelandclinic.org/health/diseases/4059-constipation
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Mayo Clinic (2021). Constipation. https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/syc-20354253
- Mayo Clinic (2021). Nutrition and healthy eating. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/high-fiber-foods/art-20050948
- Sizar, O., Genova, R.,& Gupta, M. (2022). Opioid-induced constipation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK493184/
- Tazreean, R., Nelson, G., & Twomey, R. (2022). Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements. Journal of comparative effectiveness research, 11(2), 121–129. https://doi.org/10.2217/cer-2021-0258
