Constipation Nursing Diagnosis and Care Plan: Comprehensive Guide for Nurses

Constipation, characterized by infrequent bowel movements, difficult stool passage, and hard, dry stools, is a prevalent health issue affecting individuals across all age groups. It’s a common gastrointestinal complaint encountered in healthcare settings. While occasional constipation is often benign, chronic constipation can significantly impact quality of life and may indicate underlying health conditions. Certain populations are more susceptible, including the elderly, women (especially during pregnancy and postpartum), and individuals with neurological disorders.

Note on Terminology: It’s important to acknowledge that the nursing diagnosis “Constipation” has been updated to “Chronic Functional Constipation” by NANDA International. However, for clarity and broader recognition, this article will primarily use “Constipation” while recognizing the updated terminology.

Understanding the Root Causes of Constipation

Identifying the underlying causes of constipation is crucial for effective management. Constipation can stem from a variety of factors, broadly categorized as:

• Dietary Factors:

  • Low Fiber Intake: Insufficient dietary fiber reduces stool bulk, making it harder to pass. Diets lacking fruits, vegetables, and whole grains are common culprits.
  • High Consumption of Dairy Products: Excessive intake of milk and cheese can contribute to constipation in some individuals, possibly due to the fat content and lower fiber.
  • Processed Foods: Highly processed foods are often low in fiber and high in unhealthy fats, contributing to sluggish bowel function.
  • Dehydration: Inadequate fluid intake leads to harder stools as the body absorbs more water from the colon.

• Activity and Lifestyle:

  • Sedentary Lifestyle: Lack of physical activity slows down metabolism and reduces muscle strength in the digestive tract, hindering bowel movements.
  • Changes in Routine: Travel, altered work schedules, or changes in daily habits can disrupt regular bowel patterns.
  • Limited Mobility: Bed rest, chronic disability, or conditions limiting physical activity significantly increase the risk of constipation.
  • Ignoring the Urge: Regularly suppressing the urge to defecate can desensitize the bowel to signals, leading to constipation.

• Psychological and Social Factors:

  • Stress: Psychological stress can significantly affect bowel function, contributing to constipation in some individuals.
  • Poor Oral Health: Dental issues can limit food choices, potentially leading to a lower fiber intake and subsequent constipation.

• Physiological Factors:

  • Pregnancy and Postpartum: Hormonal changes during pregnancy and after childbirth, along with the physical pressure of the growing fetus on the intestines, can slow down bowel transit.
  • Chronic Pain: Pain, especially chronic pain, can lead to reduced mobility and medication use, both of which can contribute to constipation.

• Medications:

  • Pain Medications:
    • Narcotics (Opioids): Opioids are notorious for causing constipation by slowing down bowel motility.
    • NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): While less constipating than opioids, NSAIDs can still contribute to constipation in some individuals.
  • Antidepressants: Certain antidepressants can have anticholinergic effects, leading to constipation.
  • Antacids (Calcium or Aluminum-based): These antacids can cause constipation as a side effect.
  • Iron Supplements: Iron supplements are a common cause of constipation, particularly in pregnant women.
  • Allergy Medications (Antihistamines): Some antihistamines have anticholinergic effects that can contribute to constipation.
  • Blood Pressure Medications: Certain blood pressure medications, like calcium channel blockers and diuretics, can sometimes lead to constipation.
  • Psychiatric Medications: Similar to antidepressants, some psychiatric medications can have anticholinergic effects.
  • Antiemetics: Medications used to prevent vomiting can sometimes slow down bowel motility.
  • Anticonvulsants: Certain anticonvulsants can have constipation as a side effect.

• Underlying Medical Conditions:

  • Various medical conditions can manifest with constipation. These include hypothyroidism, irritable bowel syndrome (IBS), colorectal cancer, and neurological disorders like Parkinson’s disease and multiple sclerosis.

Alt text: Woman’s hands holding a variety of colorful high-fiber fruits and vegetables, promoting a diet rich in fiber to prevent constipation.

Recognizing the Signs and Symptoms of Constipation

Identifying constipation involves recognizing both subjective symptoms reported by the patient and objective signs observed by the nurse.

Subjective Symptoms (Patient-Reported)

• Infrequent Bowel Movements: Fewer than three bowel movements per week is a primary indicator.
• Hard or Dry Stools: Stools are difficult to pass and have a hard, dry consistency.
• Lumpy Stools: Stools may be described as lumpy or pebble-like.
• Straining During Defecation: Significant effort and straining are required to pass stool.
• Painful Bowel Movements: Defecation is accompanied by pain or discomfort.
• Abdominal Discomfort: Stomach pain, aches, cramps, or general abdominal discomfort.
• Bloating and Nausea: A sensation of fullness, bloating, and sometimes nausea.
• Incomplete Evacuation: Feeling that the bowels are not fully emptied after a bowel movement.

Objective Signs (Nurse Assessment)

• Medical History Review: Assess the patient’s history for pre-existing constipation, activity levels, and medications known to cause constipation.
• Abdominal Pain Assessment: Utilize an age-appropriate pain scale to assess abdominal pain, noting:
  • Location: Where is the pain felt in the abdomen?
  • Severity: How intense is the pain? (e.g., using a 0-10 scale).
  • Duration: How long has the pain been present?
  • Description: What does the pain feel like? (e.g., sharp, cramping, dull).
  • Aggravating/Relieving Factors: What makes the pain worse or better?
• Comprehensive Abdominal Assessment: Perform a systematic abdominal assessment in the correct sequence:
  • Inspection: Observe the abdomen for distension, scars, or visible peristalsis.
  • Auscultation: Listen to bowel sounds in all four quadrants to assess bowel activity.
  • Percussion: Percuss the abdomen to assess for tympany (air) or dullness (fluid/masses).
  • Palpation: Gently palpate the abdomen to assess for tenderness, masses, or organomegaly.
• Stool Characteristics Assessment: Evaluate stool characteristics, noting:
  • Color: Normal stool color is brown. Note any variations like black (upper GI bleed), red (lower GI bleed), or pale/clay-colored (biliary obstruction).
  • Consistency: Use the Bristol Stool Chart to objectively classify stool consistency.
  • Amount: Estimate the volume of stool.
  • Odor: Note any unusual or foul odor.
• Bristol Stool Chart: Utilize the Bristol Stool Chart as a standardized tool for assessing stool consistency. This visual aid helps patients and healthcare providers communicate stool form effectively.

Alt text: Bristol Stool Chart illustrating seven types of stool consistency for constipation assessment, ranging from hard, lumpy stools to watery diarrhea.

Expected Outcomes for Constipation Management

Nursing care for constipation aims to achieve the following patient outcomes:

• Regular Bowel Movements: Patient will establish a bowel movement frequency within the normal range (three times a week to three times a day), as appropriate for their individual baseline.
• Soft, Formed Stools: Patient will report passing soft, formed stools without difficulty or straining.
• Pain-Free Defecation: Patient will verbalize being free of pain and straining during bowel movements.
• Understanding of Prevention: Patient will be able to identify actions and lifestyle modifications to prevent future episodes of constipation.
• Behavioral and Lifestyle Changes: Patient will demonstrate an understanding of and implement necessary behavior or lifestyle changes to manage and prevent constipation.

Comprehensive Nursing Assessment for Constipation

A thorough nursing assessment is the foundation of effective constipation management. It involves gathering subjective and objective data to understand the patient’s specific situation and guide the care plan.

1. Bowel Habit History: Assess for changes in bowel habits, including:

• Time of Day: Usual time of bowel movements.
• Frequency: How often bowel movements occur.
• Experience: Presence of pain, straining, or difficulty during defecation.
• Bowel Aids: Previous or current use of stool softeners or laxatives.

2. Stool Characteristics Observation: Monitor and document stool characteristics:

• Amount: Quantity of stool passed.
• Consistency: Use Bristol Stool Chart for classification.
• Color: Note any deviations from normal brown color.
• Odor: Observe for any unusual or strong odors.

3. Lifestyle Assessment: Identify lifestyle factors that may contribute to constipation:

• Activity Level: Level of physical activity and exercise.
• Dietary Habits: Food preferences and typical diet, focusing on fiber intake.
• Fluid Intake: Daily fluid consumption.

4. Medical History and Medication Review: Explore medical history and current medications:

• Medical Conditions: Identify conditions known to cause constipation (e.g., hypothyroidism, IBS).
• Medications: List all medications, noting those with constipating side effects (e.g., opioids, anticholinergics).

5. Emotional and Psychological Assessment: Assess for emotional distress:

• Stress Levels: Evaluate current stress levels.
• Mental Health: Screen for symptoms of depression or anxiety, as these can impact bowel function.

6. Bristol Stool Scale Application: Utilize the Bristol Stool Scale to consistently assess and document stool consistency.

7. Laxative Abuse Assessment: Evaluate for signs of laxative misuse or overuse, particularly in older adults or individuals with a history of constipation.

8. Life Changes and Stressors Identification: Explore recent life changes or stressors that may be contributing to constipation:

• Pregnancy: Assess for pregnancy-related constipation.
• Travel: Changes in routine during travel.
• Trauma: Physical or emotional trauma.
• Relationship Changes: Changes in personal relationships.
• Occupational Factors: Work-related stress or changes.
• Financial Worries: Financial stress.

9. Pain During Defecation Investigation: Determine the cause of pain during bowel movements:

• Hemorrhoids: Assess for presence of hemorrhoids.
• Rectal Fissures: Evaluate for rectal fissures or tears.
• Rectal Prolapse: Check for rectal prolapse.
• Skin Breakdown: Inspect for perianal skin breakdown.

10. Abdominal Assessment Performance: Conduct a complete abdominal assessment in the correct sequence (Inspection, Auscultation, Percussion, Palpation).

11. Digital Rectal Examination (DRE): Perform a DRE (if indicated and within scope of practice) to assess:

• Rectal Tone: Muscle tone of the anal sphincter.
• Pain or Bleeding: Presence of pain or blood.
• Fecal Impaction: Presence of impacted stool.

12. Advanced Work-up Considerations: If initial treatments fail, consider further investigations:

• Anorectal Testing: Anorectal manometry, colonic manometry, colonic transit studies, surface anal electromyography (EMG), balloon expulsion testing to assess anorectal function.
• Imaging Studies: X-rays, ultrasound to rule out structural abnormalities or obstruction.
• Lower GI Endoscopy: Colonoscopy or sigmoidoscopy to visualize the colon and rectum.

13. Imaging Study Assistance: Assist patients in undergoing imaging studies as ordered to rule out underlying causes of constipation.

Effective Nursing Interventions for Constipation

Nursing interventions are crucial in alleviating constipation and promoting regular bowel function.

1. Manual Disimpaction: For fecal impaction, manual disimpaction may be necessary. This involves using a gloved, lubricated finger to gently break up and remove impacted stool from the rectum. Transrectal enemas may also be used initially.

2. Laxatives and Stool Softeners Administration: Administer laxatives or stool softeners as prescribed by a physician. These can provide short-term relief and help initiate bowel movements. Types include:

• Bulk-Forming Agents (Fiber, Psyllium): Increase stool bulk and water content.
• Emollient Stool Softeners (Docusate): Soften stool by increasing water and fat penetration.
• Rapidly Acting Lubricants (Mineral Oil): Lubricate the intestinal tract to ease stool passage. (Use with caution and under medical supervision due to potential side effects).
• Prokinetics (Tegaserod – specific use cases, consult guidelines): Stimulate bowel motility.
• Stimulant Laxatives (Senna, Bisacodyl): Increase bowel contractions to propel stool. (Use short-term due to potential dependence).
• Osmotic Laxatives (Polyethylene Glycol, Lactulose, Milk of Magnesia): Draw water into the bowel to soften stool and increase volume.

3. Lubricant or Anesthetic Ointment Application: Apply lubricant or anesthetic ointment to the perianal area as ordered to facilitate stool passage and reduce discomfort, especially in cases of hemorrhoids or fissures.

4. Lifestyle Modification Education: Emphasize the importance of lifestyle changes for long-term constipation management. Patient education should focus on:

• Dietary Changes: Increasing fiber intake, adequate hydration, and balanced nutrition.
• Hydration: Maintaining adequate fluid intake.
• Regular Physical Activity: Incorporating exercise into daily routines.

5. High-Fiber Diet Promotion: Encourage a diet rich in fiber:

• Whole Foods: Fruits, vegetables, and whole grains.
• Fiber Supplements: Consider fiber supplements like wheat bran or psyllium if dietary intake is insufficient (with adequate fluid intake).
• Fiber-Rich Foods Examples:
  • Fruits: Raspberries, strawberries, blueberries, pears, apples, bananas, prunes.
  • Vegetables: Peas, broccoli, Brussels sprouts, potatoes (with skin), sweet corn, cauliflower, carrots, leafy greens.
  • Grains: Barley, quinoa, bran, oatmeal, brown rice, whole wheat bread, whole grain pasta.
  • Legumes and Nuts: Split peas, lentils, baked beans, black beans, chia seeds, flax seeds, almonds.
• Limit Low-Fiber and High-Fat Foods: Reduce intake of ice cream, cheese, meats, processed foods, and fast food.

6. Increased Fluid Intake Promotion: Encourage adequate fluid intake:

• Water: Primary source of hydration.
• High-Fiber Fruits and Vegetables: Contribute to both fiber and fluid intake.
• Vegetable Juices and Fruit Smoothies: Healthy fluid and nutrient sources.
• Popsicles: Can be a palatable way to increase fluid, especially for children or older adults.
• Warm Liquids: Tea, hot water with lemon, or decaffeinated coffee can stimulate bowel motility in some individuals.

7. Caffeine and Alcohol Avoidance: Advise limiting or avoiding caffeine and alcohol, as they can dehydrate and irritate the gastrointestinal tract.

8. Physical Activity Encouragement: Promote daily exercise and physical activity, tailored to the patient’s abilities. Exercise improves muscle tone, aids digestion, and stimulates bowel function.

9. Elimination Diary Recommendation: Suggest keeping an elimination diary to track bowel movements, stool characteristics, and any interventions used. This helps monitor progress and identify patterns.

10. Regular Bowel Movement Establishment: Encourage establishing a regular toileting schedule and not ignoring the urge to defecate. Promote predictable timing, especially after meals when the gastrocolic reflex is most active.

11. Bowel Management Program Promotion: Develop a personalized bowel management program, especially for individuals with chronic constipation or specific needs. This includes:

• Privacy: Ensure privacy during toileting.
• Regular Time: Establish a consistent time for attempting bowel movements.
• Preferred Toileting Method: Determine patient preference for toilet, commode, or bedpan.

12. Pain Relief During Defecation Promotion: Encourage sitz baths before defecation to relax the anal sphincter and reduce pain, especially in cases of hemorrhoids or fissures.

13. Gentle Abdominal Massage Application: Perform gentle abdominal massage, following the direction of the colon (clockwise), to stimulate peristalsis and encourage stool movement.

14. Abdominal Massage Technique Education: Teach patients or caregivers proper abdominal massage techniques for self-management at home.

15. Healthcare Provider Referral: Advise patients to consult their healthcare provider before using any new medical therapies (laxatives, enemas, suppositories) to prevent misuse and ensure appropriate treatment.

16. Surgical Intervention Assistance: In rare cases of severe, intractable constipation unresponsive to medical management, surgery may be considered. Surgical options include:

• Anal Procedures: For structural issues like fissures or strictures.
• Antegrade Enemas (ACE procedure): For severe constipation, especially in children with neurological conditions.
• Colorectal Resection: Removal of part of the colon in specific cases of colonic inertia.
• Intestinal Diversion (Colostomy/Ileostomy): Rarely indicated for severe, refractory constipation.

17. Sacral Nerve Stimulation Consideration: Sacral nerve stimulation may be considered for some individuals with chronic functional constipation, particularly in specialized centers.

18. Emotional Support Provision: Offer emotional support and address any anxieties or frustrations related to chronic bowel control issues. Provide social and emotional assistance as needed.

Nursing Care Plans for Constipation: Examples

Nursing care plans provide structured frameworks for addressing constipation, outlining diagnoses, expected outcomes, assessments, and interventions. Here are examples of care plans for different constipation etiologies.

Care Plan #1: Opioid-Induced Constipation

Diagnostic Statement: Constipation related to opioid analgesics, as evidenced by lack of bowel movement post-surgery and patient report of hard stools.

Expected Outcomes:

• Patient will pass soft, formed stools every 1 to 3 days without straining within 48 hours of intervention.
• Patient will verbalize understanding of measures to prevent and relieve opioid-induced constipation before discharge.

Assessments:

1. Medication History Review: Note opioid medication, dosage, frequency, and duration. Assess for other constipating medications. Rationale: Opioids significantly slow bowel motility. Understanding medication regimen is crucial.
2. Usual Bowel Pattern Assessment: Determine pre-operative bowel habits and expectations. Rationale: Establishes baseline for comparison and realistic goal setting.
3. Rome IV Criteria Assessment: Evaluate for functional constipation using Rome IV criteria if appropriate. Rationale: Provides standardized criteria for diagnosing functional constipation.

Interventions:

1. Laxative Administration as Prescribed: Administer prophylactic laxatives (stimulant or osmotic, not bulk-forming initially) as ordered, typically alongside opioid prescription. Rationale: Prophylactic laxatives are recommended to prevent opioid-induced constipation.
2. Early Mobilization Encouragement: Promote early ambulation post-surgery. Rationale: Physical activity stimulates bowel motility and reduces post-operative complications.
3. Patient and Family Education on Opioid-Induced Constipation: Educate on the common side effect of constipation with opioids and available management strategies (laxatives, diet, mobility). Rationale: Reduces anxiety and promotes self-management.
4. Avoidance of Long-Term Stimulant Laxative Use Education: Counsel against routine, long-term use of stimulant laxatives to prevent dependence. Rationale: Long-term stimulant laxative use can lead to bowel dependence.

Care Plan #2: Constipation Related to Immobility

Diagnostic Statement: Constipation related to immobility, as evidenced by bloating, abdominal discomfort, and decreased bowel sounds.

Expected Outcomes:

• Patient will pass Bristol Stool Type 3 or 4 within 3 days of intervention.
• Patient will report relief from abdominal discomfort (bloating, pain) within 24-48 hours of intervention.
• Patient will demonstrate measures to promote bowel function within their mobility limitations before discharge.

Assessments:

1. Usual Bowel Pattern Assessment: Detailed assessment of pre-immobility bowel habits (frequency, consistency, diet, fluid intake, exercise). Rationale: Establishes baseline and identifies contributing factors.
2. Mobility Level Assessment: Determine patient’s current mobility limitations and capabilities for exercise. Rationale: Guides appropriate activity and exercise recommendations.

Interventions:

1. High-Fiber Diet Promotion: Advise and provide fiber-rich foods (prune juice, leafy greens, whole grains) appropriate for patient’s diet and swallowing ability. Rationale: Fiber increases stool bulk and stimulates peristalsis.
2. Adequate Fluid Intake Promotion: Encourage 1.5-2 L of fluids daily (if not contraindicated). Rationale: Hydration softens stool and prevents impaction.
3. Physical Activity Encouragement within Limitations: Encourage range-of-motion exercises, bed exercises (knee-to-chest, waist twists), or ambulation as tolerated. Rationale: Physical activity stimulates bowel motility.
4. Gentle Abdominal Massage Demonstration and Application: Perform and teach gentle abdominal massage techniques. Rationale: Massage can stimulate peristalsis and promote bowel movement.
5. Enemas or Disimpaction as Needed: Consider enemas or manual disimpaction if other interventions are ineffective and impaction is suspected (physician order required). Rationale: Enemas and disimpaction can provide immediate relief for severe constipation.

Care Plan #3: Constipation Related to Poor Dietary Habits

Diagnostic Statement: Constipation related to poor dietary habits (low fiber intake), as evidenced by straining during bowel movements and fewer than three stools per week.

Expected Outcomes:

• Patient will maintain passage of soft, formed stool without straining within one week of dietary changes.
• Patient will identify dietary measures to prevent and treat constipation by discharge.

Assessments:

1. Dietary Regimen Review: Detailed review of daily diet, focusing on fiber intake (fruits, vegetables, whole grains, processed foods). Rationale: Identifies dietary fiber deficits.
2. Oral/Dental Health Assessment: Note any oral or dental issues that may affect food choices and fiber intake. Rationale: Dental problems can limit fiber-rich food consumption.
3. Fluid Intake Assessment: Determine daily fluid intake. Rationale: Inadequate fluid intake exacerbates constipation.

Interventions:

1. Laxative and Enema Use Discussion: Discuss appropriate and limited use of laxatives and enemas, emphasizing lifestyle modifications as primary management. Rationale: Laxatives are short-term solutions; lifestyle changes are crucial for long-term management.

2. Bowel Activity Stimulating Factors Identification: Identify individual factors that stimulate or inhibit bowel activity (caffeine, exercise, medications). Rationale: Tailors recommendations to individual needs.

3. Lifestyle Changes Promotion:

   • Dietary Fiber Education: Instruct on increasing dietary fiber intake through fruits, vegetables, and whole grains. Recommend fiber supplements if needed (with fluids).
   • Limit Low-Fiber, High-Fat Foods Education: Advise limiting processed foods, fast food, high-fat meats, and dairy.
   • Fluid Intake Education: Promote adequate fluid intake (water, juices, smoothies).
   • Warm Stimulating Fluids Recommendation: Suggest warm beverages (decaffeinated coffee, tea, hot water with lemon).
   • Daily Activity and Exercise Encouragement: Promote regular physical activity.
   • Regular Toileting Schedule Encouragement: Advise establishing a regular toileting time and not ignoring the urge to defecate.

4. Sitz Bath Encouragement: Recommend sitz baths for comfort and relaxation of sphincter, especially if straining or hemorrhoids are present. Rationale: Sitz baths can soothe and promote relaxation.

References

1. 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.
2. 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
3. Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
4. 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/
5. 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.
6. Cleveland Clinic (2019). Constipation. https://my.clevelandclinic.org/health/diseases/4059-constipation
7. Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
8. Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b-0000-000928
9. Mayo Clinic (2021). Constipation. https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/syc-20354253
10. Mayo Clinic (2021). Nutrition and healthy eating. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/high-fiber-foods/art-20050948
11. Sizar, O., Genova, R.,& Gupta, M. (2022). Opioid-induced constipation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK493184/
12. 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