Constipation, characterized by a decrease in the normal frequency of bowel movements, is a prevalent gastrointestinal complaint affecting individuals across all age groups. It’s often accompanied by difficulty or incomplete stool passage, resulting in hard, dry stools. While occasional constipation is common, chronic constipation presents a persistent challenge that requires comprehensive nursing assessment and intervention. This article delves into the nursing diagnosis of chronic constipation, providing an in-depth understanding of its causes, symptoms, assessment techniques, and evidence-based interventions to improve patient outcomes.
Understanding Chronic Constipation
Chronic constipation is more than just infrequent bowel movements; it significantly impacts an individual’s quality of life. Certain populations are more susceptible to chronic constipation, including:
- Elderly individuals: Age-related factors like reduced physical activity, slower metabolism, and decreased muscle strength in the digestive tract contribute to constipation in the elderly.
- Women: Hormonal fluctuations, particularly during pregnancy and postpartum, can disrupt bowel regularity. The physical pressure of the growing fetus on the intestines during pregnancy also plays a role.
- Individuals with neurological diseases: Neurological conditions can interfere with the nerve signals that control bowel function, leading to chronic constipation.
It’s important to note that the nursing diagnosis “Constipation” has been updated to “Chronic Functional Constipation” by NANDA International. While this article primarily uses “Chronic Constipation” for broader understanding and SEO purposes, healthcare professionals should be aware of the updated terminology in formal nursing documentation.
[alt]: Elderly individual experiencing constipation due to age-related factors.
Causes of Chronic Constipation
Identifying the underlying causes of chronic constipation is crucial for effective nursing management. Several factors can contribute to this condition:
- Dietary Factors:
- Low fiber intake: Insufficient dietary fiber reduces stool bulk, making it harder to pass.
- High dairy consumption: Increased intake of milk and cheese products can contribute to constipation in some individuals.
- Processed foods: Diets high in processed foods often lack fiber and essential nutrients, promoting constipation.
- Dehydration: Inadequate fluid intake leads to harder stools and difficult bowel movements.
- Lifestyle Factors:
- Sedentary lifestyle: Lack of physical activity slows down bowel motility.
- Changes in routine: Disruptions to daily routines, such as travel or hospitalization, can affect bowel habits.
- Limited mobility: Bed rest and poor mobility significantly increase the risk of constipation.
- Chronic disability: Physical limitations associated with chronic disabilities can contribute to constipation.
- Psychological Factors:
- Stress: Stress and anxiety can disrupt normal bowel function.
- Behavioral Factors:
- Ignoring the urge to defecate: Regularly suppressing the urge can lead to stool hardening and constipation.
- Medical Factors:
- Oral/dental health problems: Pain or difficulty chewing can lead to dietary changes that contribute to constipation.
- Pregnancy and childbirth: Hormonal changes and physical factors during pregnancy and postpartum can cause constipation.
- Chronic pain: Chronic pain can limit mobility and affect bowel habits.
- Medications:
- Pain medications: Narcotics and NSAIDs are common culprits of constipation.
- Antidepressants: Certain antidepressants can have constipating side effects.
- Antacids: Antacids containing calcium or aluminum can contribute to constipation.
- Iron supplements: Iron supplements are known to cause constipation.
- Allergy medications: Some antihistamines can have a drying effect, leading to constipation.
- Blood pressure medications: Certain antihypertensive drugs can cause constipation.
- Psychiatric medications: Some psychiatric medications can have constipating side effects.
- Antiemetics: Medications to prevent vomiting can sometimes cause constipation.
- Anticonvulsants: Certain anticonvulsant medications can contribute to constipation.
- Underlying Medical Conditions: Various medical conditions can manifest with chronic constipation as a symptom.
Signs and Symptoms of Chronic Constipation
Recognizing the signs and symptoms of chronic constipation is essential for prompt nursing intervention. Symptoms can be categorized as subjective (patient-reported) and objective (nurse-assessed):
Subjective Symptoms (Patient Reports)
- Infrequent bowel movements: Fewer than three bowel movements per week is a key indicator.
- Hard, dry stools: Patients often describe stools as difficult to pass and having a hard, dry consistency.
- Lumpy stools: Stool consistency may be described as lumpy or pebble-like.
- Straining during defecation: Significant effort and straining are often required to pass stool.
- Painful bowel movements: Defecation may be accompanied by pain or discomfort.
- Abdominal discomfort: Stomach pain, aches, or cramps are common complaints.
- Bloating and nausea: Patients may experience a sensation of bloating or nausea.
- Incomplete evacuation: A persistent feeling that the bowels are not fully emptied after a bowel movement.
Objective Symptoms (Nurse Assessment)
- Medical History Review: Assess for pre-existing conditions or medications known to cause constipation. Inquire about past history of constipation, activity levels, and routine laxative use.
- Abdominal Pain Assessment: Utilize an age-appropriate pain scale to assess abdominal pain. Document:
- Location: Where is the pain felt?
- Severity: How intense is the pain?
- Duration: How long does the pain last?
- Description: What does the pain feel like (e.g., cramping, sharp, dull)?
- Aggravating/Relieving factors: What makes the pain worse or better?
- Comprehensive Abdominal Assessment: Perform a systematic abdominal assessment in the following order:
- Inspection: Visually examine the abdomen for distention, scars, or masses.
- Auscultation: Listen for bowel sounds in all four quadrants. Note frequency and character (e.g., active, hypoactive, hyperactive, absent).
- Percussion: Assess for tympany (air-filled) or dullness (fluid or solid).
- Palpation: Gently palpate all quadrants to assess for tenderness, masses, or organomegaly.
- Stool Characteristics Assessment: Evaluate stool characteristics for:
- Color: Note any unusual colors (e.g., black, red, pale).
- Consistency: Use the Bristol Stool Chart to objectively categorize stool consistency.
- Amount: Estimate the volume of stool.
[alt]: Bristol Stool Chart for assessing stool consistency in chronic constipation.
Expected Outcomes for Chronic Constipation
Nursing care planning for chronic constipation aims to achieve specific, measurable, achievable, relevant, and time-bound (SMART) outcomes. Common expected outcomes include:
- Regular bowel movements: Patient will establish a bowel movement frequency ranging from three times per week to three times per day, as individually appropriate.
- Soft, formed stools: Patient will report passing soft, formed stools during bowel movements, indicating improved stool consistency.
- Pain-free defecation: Patient will verbalize being free of pain and straining during bowel movements, reflecting improved comfort.
- Self-management strategies: Patient will be able to identify and implement actions to prevent future episodes of constipation.
- Lifestyle modifications: Patient will be able to enumerate and adopt behavior and lifestyle changes that promote bowel regularity.
Nursing Assessment for Chronic Constipation
A thorough nursing assessment is the cornerstone of effective management of chronic constipation. It involves gathering comprehensive data to identify contributing factors and guide individualized care.
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Assess Changes in Bowel Habits:
- Time of day: When do bowel movements typically occur?
- Frequency: How often are bowel movements?
- Experience: Are bowel movements painful, difficult, or associated with straining?
- Bowel aids: Does the patient routinely use stool softeners or laxatives?
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Observe Stool Characteristics:
- Amount: How much stool is typically passed?
- Consistency: Use the Bristol Stool Chart for objective assessment.
- Color: Note any abnormal colors.
- Odor: Note any unusual or foul odor.
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Assess Lifestyle Choices:
- Activity level: How physically active is the patient?
- Exercise: Does the patient engage in regular exercise?
- Food preferences: What types of foods does the patient typically consume?
- Dietary habits: Describe the patient’s usual diet, focusing on fiber and fluid intake.
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Review Medical History and Medications:
- Medical conditions: Identify any underlying medical conditions that could contribute to constipation (e.g., hypothyroidism, irritable bowel syndrome).
- Medications: Review the patient’s medication list for drugs known to cause constipation (see list above).
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Check for Emotional Distress:
- Stress levels: Assess the patient’s current stress levels.
- Mental health: Screen for symptoms of anxiety or depression, as these can impact bowel function.
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Utilize Bristol Stool Scale: Employ the Bristol Stool Chart as a standardized tool to assess and document stool consistency objectively.
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Assess for Laxative Abuse:
- Frequency of laxative use: How often does the patient use laxatives?
- Type of laxative: What type of laxative is used (e.g., stimulant, osmotic)?
- Dependence: Does the patient feel they cannot have a bowel movement without laxatives?
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Identify Life Changes and Stressors:
- Recent life events: Inquire about recent changes such as pregnancy, travel, trauma, relationship changes, job changes, or financial difficulties.
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Investigate Causes of Painful Defecation:
- Hemorrhoids: Assess for the presence of hemorrhoids.
- Rectal fissures: Evaluate for rectal fissures or tears.
- Rectal prolapse: Assess for rectal prolapse.
- Skin breakdown: Inspect the perianal area for skin irritation or breakdown.
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Perform Abdominal Assessment: Conduct a systematic abdominal assessment as described in the “Signs and Symptoms” section.
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Perform Digital Rectal Examination (DRE):
- Rectal tone: Assess the tone of the anal sphincter.
- Pain or bleeding: Note any pain or bleeding during the examination.
- Fecal impaction: Check for fecal impaction, especially in patients at risk.
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Consider Extensive Work-up if Treatment Fails: If initial medical management is unsuccessful after 3-6 months, further investigation may be necessary. This may include:
- Anorectal testing: Anorectal manometry, balloon expulsion testing, surface anal electromyography (EMG).
- Colonic testing: Colonic manometry, colonic transit studies.
- Imaging studies: X-ray, ultrasound.
- Lower GI endoscopy: Colonoscopy or sigmoidoscopy.
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Assist with Imaging Studies: Prepare the patient for and assist with imaging studies as ordered to rule out underlying pathology.
Nursing Interventions for Chronic Constipation
Nursing interventions for chronic constipation are multifaceted and focus on promoting bowel regularity, alleviating symptoms, and preventing recurrence.
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Manual Disimpaction: For severe fecal impaction, manual disimpaction may be necessary. This should be performed gently and with appropriate lubrication.
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Administer Laxatives and Stool Softeners as Prescribed: Pharmacological interventions may be indicated, particularly for short-term relief. Common options include:
- Bulk-forming agents (fiber, psyllium): Increase stool bulk and promote peristalsis.
- Emollient stool softeners (docusate): Soften stool to ease passage.
- Rapidly acting lubricants (mineral oil): Lubricate the stool for easier elimination.
- Prokinetics (tegaserod): Stimulate bowel motility (use may be limited due to availability and specific indications).
- Stimulant laxatives (senna, bisacodyl): Stimulate bowel contractions (should be used cautiously and not for long-term management).
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Apply Lubricant or Anesthetic Ointment: For patients with painful defecation due to hemorrhoids or fissures, lubricant or anesthetic ointments can provide relief and facilitate stool passage.
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Emphasize Lifestyle Changes: Patient education is paramount. Focus on sustainable lifestyle modifications for long-term constipation management:
- Dietary modifications: Increase fiber intake, ensure adequate fluid intake.
- Regular physical activity: Encourage daily exercise.
- Establish regular bowel habits: Promote consistent toileting routines.
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Encourage High-Fiber Diet: Educate patients about incorporating fiber-rich foods into their diet:
- Whole foods: Fruits, vegetables, whole grains.
- Fiber supplements: Wheat bran, psyllium (if needed).
- Fiber-rich food examples:
- Fruits: Berries (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 low-fiber and high-fat foods: Ice cream, cheese, meats, processed meals, fast food.
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Promote Increased Fluid Intake: Advise patients to drink adequate fluids daily:
- Water: Aim for 6-8 glasses per day.
- High-fiber fruits: Fruits with high water content.
- Vegetable juices: Provide hydration and nutrients.
- Fruit and vegetable smoothies: Combine fiber and fluids.
- Popsicles: Contribute to fluid intake, especially for children or elderly.
- Warm liquids: Tea, hot water, decaffeinated coffee (can stimulate bowel motility).
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Avoid Caffeine and Alcohol: Educate patients about the potential dehydrating effects of caffeine and alcohol, which can worsen constipation.
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Advise Physical Activities: Encourage daily exercise tailored to the patient’s abilities. Even moderate activity like walking can improve bowel function.
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Encourage Elimination Diary: Suggest keeping an elimination diary to track bowel movements, stool characteristics, and medication use. This can help identify patterns and assess treatment effectiveness.
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Establish Regular Bowel Movements:
- Do not ignore the urge: Advise patients to respond to the urge to defecate promptly.
- Predictable timing: Establish a regular toileting schedule, ideally after meals when the gastrocolic reflex is stimulated.
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Promote Bowel Management Program:
- Privacy: Provide privacy during toileting.
- Preferred toileting method: Inquire about patient preference for toilet, commode, or bedpan.
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Promote Pain Relief During Defecation:
- Sitz bath: Recommend a sitz bath before defecation to relax sphincter muscles and reduce pain.
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Apply Gentle Abdominal Massage: Perform gentle abdominal massage in a clockwise direction to stimulate peristalsis.
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Teach Abdominal Massage Techniques: Instruct patients on how to perform abdominal massage independently at home.
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Refer to Healthcare Provider: Advise patients to consult their healthcare provider before using new medications or therapies for constipation, especially to avoid laxative misuse.
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Assist with Surgery (Rare): Surgical interventions are rarely needed for chronic functional constipation but may be considered in severe, refractory cases. Surgical options include:
- Anal procedures: For underlying anorectal issues.
- Antegrade enemas: For bowel irrigation in severe cases.
- Colorectal resection: In very rare cases of severe colonic inertia.
- Intestinal diversion: As a last resort in extreme cases.
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Sacral Nerve Stimulation (Emerging Therapy): Sacral nerve stimulation is being explored as a potential treatment for functional constipation, particularly in children, but further research is needed.
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Provide Emotional Support: Offer ongoing emotional support and address any psychological distress related to chronic bowel issues.
Nursing Care Plans for Chronic Constipation
Nursing care plans provide a structured framework for organizing assessments, interventions, and expected outcomes for patients with chronic constipation. Here are examples of nursing care plans addressing different contributing factors:
Care Plan #1: Opioid-Induced Constipation
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 implement measures to relieve opioid-induced constipation.
Assessment:
- Review medication history: Confirm opioid use and dosage.
- Assess normal bowel pattern: Determine the patient’s pre-operative bowel habits.
Interventions:
- Administer laxatives as indicated: Prescribe prophylactic laxatives (excluding bulk-forming agents initially with opioid use).
- Encourage early mobility: Promote ambulation as soon as medically appropriate post-surgery.
- Educate patient and family: Explain the link between opioids and constipation and reassure them about management strategies.
- Discourage long-term laxative use: Emphasize lifestyle modifications and avoid dependence on stimulant laxatives for prolonged periods.
Care Plan #2: Immobility-Related Constipation
Diagnostic statement: Constipation related to immobility as evidenced by bloating and abdominal discomfort.
Expected outcomes:
- Patient will pass Bristol Stool Type 3 or 4.
- Patient will report relief from constipation discomfort (bloating, abdominal pain, etc.).
- Patient will demonstrate measures to relieve discomfort.
Assessment:
- Assess usual bowel pattern: Establish baseline bowel habits.
- Assess mobility level: Determine the extent of the patient’s mobility limitations.
Interventions:
- Advise fiber intake: Recommend 18-25g daily, suggest fiber-rich foods.
- Advise fluid intake: Encourage 1.5-2L per day (unless contraindicated).
- Encourage physical activity: Promote mobility within patient’s limitations (bed exercises, turning, etc.).
- Demonstrate abdominal massage: Teach gentle abdominal massage techniques.
- Perform enemas or disimpaction: Consider if natural interventions are ineffective.
Care Plan #3: Poor Dietary Habits-Related Constipation
Diagnostic statement: Constipation related to poor diet habits as evidenced by straining to have bowel movements and less than three stools a week.
Expected outcomes:
- Patient will maintain passage of soft, formed stool without straining.
- Patient will identify measures to prevent or treat constipation.
Assessment:
- Review dietary regimen: Assess fiber intake.
- Note oral/dental health: Identify any issues affecting dietary intake.
- Determine fluid intake: Assess fluid consumption.
Interventions:
- Discuss laxative and enema use: Educate on appropriate use and limitations.
- Identify bowel activity stimulants: Explore factors that stimulate or inhibit bowel function for the patient.
- Promote lifestyle changes:
- Dietary modifications: Increase fiber, limit low-fiber/high-fat foods.
- Fluid intake: Increase water and hydrating fluids.
- Physical activity: Encourage daily exercise.
- Regular toileting: Establish a consistent schedule.
- Encourage sitz bath: Recommend for comfort and relaxation.
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.
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- 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
