Constipation Related Nursing Diagnosis: Comprehensive Guide for Nurses

Constipation, characterized by infrequent bowel movements, difficult stool passage, and hard, dry stools, is a prevalent gastrointestinal issue affecting a wide range of individuals. While it can impact anyone, certain populations are more susceptible, including the elderly, women (especially during and after pregnancy), and individuals with neurological conditions. Understanding constipation and its related nursing diagnoses is crucial for effective patient care.

In this comprehensive guide, we will delve into the nursing diagnosis of constipation, exploring its causes, signs and symptoms, assessment strategies, nursing interventions, and care plans. This article aims to provide a deeper understanding of constipation within the nursing context, enhancing your ability to provide optimal care for patients experiencing this common yet often distressing condition.

Causes (Related Factors)

Constipation is not a disease itself but rather a symptom with various underlying causes. Identifying these contributing factors is essential for accurate diagnosis and targeted interventions. Common causes of constipation can be broadly categorized as follows:

• Dietary Factors:

  • Low Fiber Intake: Insufficient consumption of dietary fiber, found in fruits, vegetables, and whole grains, reduces stool bulk and slows transit time.
  • High Intake of Processed Foods: Processed foods are often low in fiber and high in unhealthy fats, contributing to constipation.
  • Dairy Overconsumption: Excessive intake of milk and cheese can lead to constipation in some individuals, particularly children.
  • Dehydration: Inadequate fluid intake results in harder stools, making them difficult to pass.

• Lifestyle Factors:

  • Sedentary Lifestyle: Lack of physical activity slows down bowel motility.
  • Changes in Routine: Travel, changes in work schedules, or hospitalization can disrupt regular bowel habits.
  • Ignoring Urge to Defecate: Habitually suppressing the urge to have a bowel movement can lead to constipation over time.

• Medical Conditions and Medications:

  • Neurological Disorders: Conditions like Parkinson’s disease and multiple sclerosis can affect bowel function.
  • Endocrine Disorders: Hypothyroidism can slow down metabolism and contribute to constipation.
  • Pregnancy: Hormonal changes and pressure from the growing fetus can cause constipation in pregnant women.
  • Medications: Numerous medications have constipation as a side effect, including:
    • Opioid Pain Relievers: Narcotics are notorious for causing constipation by slowing down bowel movements.
    • Nonsteroidal Anti-inflammatory Drugs (NSAIDs): While less common than opioids, NSAIDs can also contribute to constipation.
    • Antidepressants: Certain antidepressants can affect bowel motility.
    • Antacids (Calcium or Aluminum-Based): These can have a constipating effect.
    • Iron Supplements: Iron is known to cause constipation in some individuals.
    • Allergy Medications (Antihistamines): Some antihistamines can have anticholinergic effects, leading to constipation.
    • Blood Pressure Medications: Certain types of blood pressure medications can contribute to constipation.
    • Psychiatric Medications: Some antipsychotics and other psychiatric drugs can cause constipation.
    • Antiemetics: Medications to prevent vomiting can sometimes slow down bowel movements.
    • Anticonvulsants: Certain anticonvulsant medications may lead to constipation.

• Other Factors:

  • Stress and Anxiety: Psychological stress can impact bowel function.
  • Chronic Pain: Pain, especially in the abdominal or rectal area, can lead to withholding bowel movements and subsequent constipation.
  • Oral/Dental Issues: Painful oral conditions might lead to dietary changes that contribute to constipation.

Signs and Symptoms (Defining Characteristics)

Recognizing the signs and symptoms of constipation is crucial for nurses to accurately identify the problem and initiate appropriate interventions. These symptoms can be categorized as subjective (reported by the patient) and objective (observed or assessed by the nurse).

Subjective Data (Patient Reports)

• Infrequent Bowel Movements: Fewer than three bowel movements per week is a primary indicator.
• Hard, Dry Stools: Patients may describe their stools as difficult to pass and having a hard, pebble-like consistency.
• Lumpy Stools: Stools may be described as lumpy or resembling nuts.
• Straining During Defecation: Significant effort and straining are often required to pass stools.
• Painful Bowel Movements: Passing stools can be associated with pain or discomfort.
• Abdominal Discomfort: Patients may experience stomach pain, aches, cramps, or bloating.
• Feeling of Incomplete Evacuation: The sensation that the bowels are not fully emptied after a bowel movement.
• Nausea: Constipation can sometimes be accompanied by nausea.

Objective Data (Nurse Assessment)

• Medical History Review: Assess for a history of constipation, medications known to cause constipation, low activity levels, and relevant medical conditions.
• Abdominal Pain Assessment: Use an age-appropriate pain scale to assess the location, severity, duration, and characteristics of abdominal pain. Identify factors that aggravate or relieve the pain.
• Abdominal Assessment: Perform a comprehensive abdominal assessment in the correct sequence:
  • Inspection: Observe for abdominal distention or visible masses.
  • Auscultation: Listen for bowel sounds in all four quadrants. Hypoactive bowel sounds may be present in constipation.
  • Percussion: Percuss the abdomen to assess for tympany (indicating gas) or dullness (indicating stool).
  • Palpation: Gently palpate the abdomen to identify areas of tenderness, masses, or firmness.
• Stool Characteristics Assessment: Evaluate stool color, consistency, and amount. Utilize the Bristol Stool Chart to standardize stool consistency assessment.

Expected Outcomes (Goals)

The primary goals of nursing care for patients with constipation are to restore normal bowel function, alleviate symptoms, and prevent recurrence. Expected outcomes include:

• Regular Bowel Movements: Patient will achieve bowel movements with a frequency ranging from three times per week to three times per day, appropriate for their individual pattern.
• Soft, Formed Stools: Patient will pass soft, formed stools without excessive straining.
• Pain-Free Defecation: Patient will verbalize the absence of pain or straining during bowel movements.
• Understanding of Prevention: Patient will be able to identify lifestyle and dietary 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.

Nursing Assessment

A thorough nursing assessment is the foundation for developing an effective care plan for constipation. Key assessment areas include:

1. Bowel Habit History: Elicit detailed information about the patient’s usual bowel patterns, including frequency, timing, and stool characteristics. Inquire about any recent changes.

2. Stool Characteristics Observation: Monitor and document stool amount, consistency, color, and odor. Use the Bristol Stool Chart for consistent assessment of stool form.

3. Lifestyle and Dietary Assessment: Assess the patient’s typical diet, focusing on fiber and fluid intake. Evaluate activity levels and exercise habits. Identify any recent changes in routine.

4. Medical and Medication Review: Obtain a complete medical history, including any conditions that could contribute to constipation (e.g., hypothyroidism). Review all current medications, noting those with constipation as a potential side effect.

5. Emotional and Psychological Factors: Assess for stress, anxiety, and depression, as these can impact bowel function.

6. Bristol Stool Scale Assessment: Utilize the Bristol Stool Scale to objectively assess and document stool consistency.

7. Laxative Use History: Assess for any history of laxative abuse or misuse, particularly in older adults.

8. Life Changes and Stressors: Explore recent life changes, stressors, or events (e.g., pregnancy, travel, relationship changes, financial worries) that might be contributing to constipation.

9. Pain During Defecation Investigation: If the patient reports pain with bowel movements, investigate potential causes such as hemorrhoids, anal fissures, or rectal prolapse.

10. Abdominal Assessment (Comprehensive): Perform inspection, auscultation, percussion, and palpation of the abdomen in the correct sequence to avoid altering bowel sounds.

11. Digital Rectal Examination (DRE): Perform a DRE to assess rectal tone, check for pain or bleeding, and evaluate for fecal impaction.

12. Further Diagnostic Work-up: If initial treatments are unsuccessful, prepare the patient for potential outpatient diagnostic testing, which may include anorectal manometry, colonic transit studies, imaging studies (X-ray, ultrasound), or lower GI endoscopy.

13. Assistance with Imaging Studies: Assist the patient in undergoing ordered imaging studies to rule out underlying pathology or assess the cause of persistent constipation.

Nursing Interventions

Nursing interventions for constipation are aimed at promoting bowel regularity, softening stools, and alleviating discomfort. These interventions range from lifestyle modifications to medical treatments.

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

2. Laxatives and Stool Softeners Administration: Administer laxatives or stool softeners as prescribed by the physician. Different types of laxatives work in various ways:

• Bulk-Forming Agents (Fiber, Psyllium): Increase stool bulk and promote peristalsis.
• Emollient Stool Softeners (Docusate): Soften stool by increasing water and fat penetration.
• Lubricant Laxatives (Mineral Oil): Lubricate the intestinal walls and stool mass.
• Osmotic Laxatives (Polyethylene Glycol, Lactulose): Draw water into the bowel to soften stool.
• Stimulant Laxatives (Senna, Bisacodyl): Stimulate bowel contractions to promote movement.
• Prokinetic Agents (Tegaserod): Enhance bowel motility (used in specific cases and under medical supervision).

3. Topical Anesthetic or Lubricant Ointment: Apply lubricant or anesthetic ointment to the anal area as ordered to ease discomfort and facilitate stool passage, particularly with hemorrhoids or anal fissures.

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

• Dietary Changes: Increasing fiber intake, consuming whole foods, limiting processed foods and high-fat foods.
• Hydration: Drinking adequate fluids, especially water, throughout the day.
• Regular Physical Activity: Engaging in daily exercise to promote bowel motility.

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

• Fruits: Berries, pears, apples, bananas.
• Vegetables: Peas, broccoli, Brussels sprouts, carrots, sweet corn, cauliflower.
• Whole Grains: Barley, quinoa, oats, brown rice, whole wheat bread.
• Legumes and Nuts: Lentils, beans, chia seeds.
• Fiber Supplements: Wheat bran, psyllium.
• Limiting 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 through:

• Water: The primary source of hydration.
• High-Fiber Fruits and Vegetables: Contribute to both fiber and fluid intake.
• Fruit and Vegetable Juices and Smoothies: Healthy fluid and nutrient sources.
• Popsicles: Can be a palatable way to increase fluid intake.
• Warm Liquids: Tea, hot water, decaffeinated coffee (can stimulate bowel movement in some individuals).

7. Avoidance of Caffeine and Alcohol: Advise patients to limit or avoid caffeine and alcohol, as they can dehydrate and irritate the gastrointestinal tract.

8. Physical Activity Encouragement: Promote daily exercise and physical activity to improve muscle tone and aid digestion.

9. Elimination Diary Encouragement: Suggest keeping an elimination diary to track bowel movements, stool characteristics, and the effectiveness of interventions.

10. Regular Bowel Movement Establishment: Encourage patients to establish a regular toileting schedule and not to ignore the urge to defecate.

11. Bowel Management Program Promotion: Develop a bowel management program tailored to the patient’s needs, including privacy, scheduled toileting times, and preferred toileting method (toilet, commode, bedpan).

12. Pain Relief Promotion During Defecation: Recommend sitz baths before bowel movements to relax the anal sphincter and reduce pain.

13. Abdominal Massage Application: Perform gentle abdominal massage to stimulate peristalsis and encourage bowel movement. Teach patients how to perform self-massage.

14. Referral to Healthcare Provider: Advise patients to consult their healthcare provider before using new laxatives or enemas to prevent misuse and dependence.

15. Surgical Intervention Assistance: For severe, refractory constipation, assist with surgical interventions as needed, which may include anal procedures, antegrade enemas, colorectal resection, or intestinal diversion.

16. Sacral Nerve Stimulation: In specific cases of functional constipation, sacral nerve stimulation may be considered to improve defecation frequency.

17. Emotional Support Provision: Offer emotional support and address any anxieties or concerns related to long-term bowel management.

Nursing Care Plans: Examples

Nursing care plans provide a structured approach to patient care, outlining nursing diagnoses, expected outcomes, and specific interventions. Here are examples of care plans for constipation related nursing diagnoses.

Care Plan #1: Opioid-Induced Constipation

Nursing Diagnosis: 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.

Nursing Interventions:

1. Medication History Review: Confirm opioid use and dosage.
2. Normal Defecation Pattern Assessment: Determine the patient’s pre-opioid bowel habits.
3. Laxative Administration: Administer prescribed prophylactic laxatives (excluding bulk-forming agents initially).
4. Early Mobility Encouragement: Promote early ambulation post-surgery.
5. Patient and Family Education: Educate about opioid-induced constipation and management strategies (laxatives, stool softeners, mobility).
6. Avoid Long-Term Laxative Dependence Education: Caution against prolonged stimulant laxative use.

Care Plan #2: Immobility-Related Constipation

Nursing Diagnosis: Constipation related to immobility as evidenced by bloating and abdominal discomfort.

Expected Outcomes:

• Patient will pass Bristol Stools Type 3 or 4.
• Patient will report relief from constipation-related discomfort (bloating, abdominal pain, nausea).
• Patient will demonstrate measures to relieve discomfort.

Nursing Interventions:

1. Usual Bowel Pattern Assessment: Detailed assessment of pre-immobility bowel habits.
2. Mobility Level Assessment: Determine the patient’s current mobility limitations.
3. High-Fiber Diet Promotion: Recommend 18-25g fiber daily, suggest fiber-rich foods.
4. Fluid Intake Promotion: Encourage 1.5-2L fluid intake daily (unless contraindicated).
5. Physical Activity Encouragement: Promote activity within mobility limits (in-bed exercises, range of motion).
6. Abdominal Massage Demonstration: Teach and perform gentle abdominal massage.
7. Enemas or Disimpaction: Consider enemas if other interventions are ineffective.

Care Plan #3: Poor Dietary Habits-Related Constipation

Nursing Diagnosis: 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.

Nursing Interventions:

1. Dietary Regimen Review: Assess for fiber deficiency.
2. Oral/Dental Health Assessment: Note any oral health issues affecting diet.
3. Fluid Intake Assessment: Determine fluid intake levels.
4. Laxative and Enema Use Discussion: Discuss appropriate use and limitations.
5. Bowel Activity Stimulant Identification: Identify factors that stimulate or inhibit bowel movements for the patient.
6. Lifestyle Change Promotion:
   • Dietary Fiber Education: Emphasize fruits, vegetables, whole grains, fiber supplements.
   • Limit Low-Fiber/High-Fat Foods Education.
   • Fluid Intake Education.
   • Warm Stimulating Fluids Suggestion.
   • Daily Activity and Exercise Encouragement.
   • Regular Toileting Schedule Encouragement.
7. Sitz Bath Encouragement: Recommend sitz baths for comfort and relaxation.

References

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