Constipation, characterized by a decrease in the normal frequency of bowel movements, is a prevalent gastrointestinal issue. It’s often marked by difficult or incomplete stool passage, resulting in stools that are hard and dry. While constipation can affect anyone, certain populations are more susceptible:
- Older Adults: Reduced physical activity, slower metabolism, and decreased muscle strength in the digestive tract contribute to constipation in the elderly.
- Women (especially during pregnancy or postpartum): Hormonal changes and the physical pressure of the fetus on the intestines can slow down stool passage.
- Individuals with Neurological Conditions: Neurological diseases can disrupt bowel function.
Note: The nursing diagnosis “Constipation” has been updated to “Chronic Functional Constipation” by NANDA International. However, for clarity and broader understanding, this article will continue to use “Constipation.”
Causes of Constipation (Related Factors)
Several factors can contribute to constipation. Understanding these causes is crucial for effective nursing care planning:
- Dietary Factors:
- Low Fiber Intake: Insufficient dietary fiber reduces stool bulk, making it harder to pass.
- High Consumption of Dairy Products: Milk and cheese can contribute to constipation in some individuals.
- Processed Foods: Diets high in processed foods are often low in fiber and can lead to constipation.
- Dehydration: Inadequate fluid intake can result in hard, dry stools.
- Activity Levels:
- Sedentary Lifestyle: Lack of physical activity slows down bowel motility.
- Changes in Routine: Disruptions to daily routines can affect bowel habits.
- Limited Mobility: Bed rest and poor mobility reduce physical activity and contribute to constipation.
- Chronic Disability: Conditions limiting mobility increase constipation risk.
- Psychological Factors:
- Stress: Stress can significantly impact bowel function and contribute to constipation.
- Ignoring the Urge to Defecate: Regularly suppressing the urge can lead to constipation.
- Physical Health:
- Oral/Dental Issues: Problems affecting chewing can lead to dietary changes that cause constipation.
- Pregnancy and Postpartum: Hormonal and physical changes.
- Chronic Pain: Pain can lead to reduced mobility and medication use that causes constipation.
- Medications: Certain medications are known to cause constipation as a side effect:
- Pain Medications:
- Narcotics (Opioids)
- NSAIDs (Nonsteroidal Anti-inflammatory Drugs)
- Antidepressants
- Antacids (Calcium or Aluminum-based)
- Iron Supplements
- Allergy Medications (Antihistamines)
- Some Blood Pressure Medications
- Psychiatric Medications
- Antiemetics (Anti-nausea medications)
- Anticonvulsants
- Pain Medications:
- Underlying Medical Conditions: Various diseases can manifest with constipation.
Signs and Symptoms of Constipation (As Evidenced By)
Recognizing the signs and symptoms of constipation is essential for accurate nursing diagnosis. These can be categorized into subjective (patient-reported) and objective (nurse-assessed) data.
Subjective Data (Patient Reports)
- Infrequent bowel movements (less than three per week)
- Hard, dry stools
- Lumpy stools
- Straining or pain during bowel movements
- Abdominal pain, aches, or cramps
- Bloating and nausea
- Feeling of incomplete bowel evacuation
Objective Data (Nurse Assessment)
- Medical History Review: Assess for pre-existing constipation, activity levels, and medications.
- Abdominal Pain Assessment: Use an age-appropriate pain scale to assess:
- Pain Location
- Pain Severity
- Pain Duration
- Pain Description
- Factors that worsen or relieve pain
- Comprehensive Abdominal Assessment: Perform in the correct sequence:
- Inspection
- Auscultation (bowel sounds)
- Percussion
- Palpation
- Stool Characteristics Assessment: Evaluate:
- Color, consistency, and amount of stool
- Use tools like the Bristol Stool Chart for consistency assessment.
Expected Outcomes for Constipation Nursing Care Plan
Setting realistic and measurable outcomes is vital for effective nursing care planning. Expected outcomes for patients with constipation include:
- Achieving soft, formed stools during bowel movements.
- Establishing regular bowel movements, ranging from three times per week to three times per day, depending on individual norms.
- Experiencing bowel movements without pain or straining.
- Identifying and implementing strategies to prevent future constipation.
- Verbalizing understanding of lifestyle and behavioral modifications to prevent constipation.
Nursing Assessment for Constipation
A thorough nursing assessment is the foundation of a successful nursing care plan.
1. Assess Bowel Habit Changes: Inquire about changes in:
- Time of day of bowel movements
- Frequency of bowel movements
- Experience during bowel movements (pain, straining, difficulty)
- Prior use of bowel aids (stool softeners, laxatives)
2. Observe Stool Characteristics: Monitor and document:
- Amount of stool
- Consistency of stool
- Color of stool
- Odor of stool
3. Evaluate Lifestyle Choices: Identify factors that may contribute to constipation:
- Activity level
- Exercise habits
- Food preferences
- Dietary habits (fiber intake)
4. Review Medical History and Medications: Identify predisposing conditions and medications that can cause constipation, such as:
- Hypothyroidism
- Narcotic pain medications
5. Check for Emotional Distress: Assess for stress, anxiety, and depression, as these can impact bowel function.
6. Utilize the Bristol Stool Scale: Employ this standardized tool to consistently assess stool consistency across the healthcare team.
7. Assess for Laxative Misuse: Be vigilant for signs of laxative overuse, especially in older adults at higher risk for constipation.
8. Identify Life Changes and Stressors: Explore potential triggers such as pregnancy, travel, trauma, relationship changes, work-related factors, or financial concerns.
9. Investigate Pain During Defecation: Determine potential causes of pain such as:
- Hemorrhoids
- Rectal fissures or prolapse
- Skin breakdown
10. Perform Abdominal Assessment: Conduct a systematic abdominal assessment (Inspection, Auscultation, Percussion, Palpation) to gather objective data.
11. Digital Rectal Examination: Perform a digital rectal exam to assess rectal tone, check for pain or bleeding, and identify potential fecal impaction.
12. Extensive Work-up if Treatment Fails: If initial treatments are ineffective, consider further investigation, including:
- Anorectal manometry
- Colonic manometry
- Colonic transit studies
- Surface anal electromyography (EMG)
- Balloon expulsion testing
- Imaging studies (X-ray, ultrasound)
- Lower gastrointestinal (GI) endoscopy
13. Assist with Imaging Studies: Facilitate imaging tests as ordered to rule out underlying conditions.
Nursing Interventions for Constipation
Nursing interventions are crucial for managing and resolving constipation.
1. Manual Disimpaction: For fecal impaction, manual disimpaction or transrectal enemas may be necessary.
2. Administer Laxatives and Stool Softeners: Administer as prescribed, considering different types:
- Bulk-forming agents (fiber, psyllium)
- Emollient stool softeners (docusate)
- Rapidly acting lubricants (mineral oil)
- Prokinetics (tegaserod)
- Stimulant laxatives (senna)
3. Apply Lubricant or Anesthetic Ointment: Use to ease stool passage and reduce discomfort, especially for painful defecation.
4. Emphasize Lifestyle Modifications: Educate patients on the importance of:
- High-fiber diet
- Adequate hydration
- Regular physical activity
- Exercise
5. Promote a High-Fiber Diet: Encourage consumption of:
- Whole foods: Fruits, vegetables, whole grains
- Fiber supplements: Wheat bran, psyllium
- Fiber-rich foods: Berries, pears, apples, bananas, peas, broccoli, lentils, oats, brown rice, etc.
- Limit low-fiber and high-fat foods: Ice cream, cheese, meats, processed foods, fast food.
6. Promote Increased Fluid Intake: Advise drinking plenty of:
- Water
- High-fiber fruit and vegetable juices
- Smoothies
- Popsicles
- Warm liquids (tea, hot water, decaffeinated coffee)
7. Avoid Caffeine and Alcohol: These can dehydrate and irritate the GI tract.
8. Encourage Physical Activity: Promote daily exercise to improve muscle tone and digestion.
9. Elimination Diary: Recommend keeping an elimination diary to track bowel habits and medication effectiveness.
10. Establish Regular Bowel Movements: Advise patients not to ignore the urge to defecate and establish a consistent toileting schedule.
11. Bowel Management Program: Provide privacy and scheduled time for toileting, respecting patient preferences (toilet, commode, bedpan).
12. Pain Relief During Defecation: Suggest sitz baths before bowel movements to relax the sphincter and reduce pain.
13. Gentle Abdominal Massage: Perform or teach gentle abdominal massage to increase intra-abdominal pressure and stimulate bowel movement.
14. Patient Demonstration of Abdominal Massage: Ensure the patient can perform abdominal massage independently at home.
15. Referral to Healthcare Provider: Advise consultation with a healthcare provider before using medical therapies (laxatives, enemas) to prevent misuse.
16. Assist with Surgery (if needed): For severe cases unresponsive to other treatments, surgical interventions may be considered:
- Anal procedures
- Antegrade enemas
- Colorectal resection
- Intestinal diversion
17. Sacral Nerve Stimulation: Emerging therapy for functional constipation, but more research is needed.
18. Emotional Support: Provide emotional support and address any psychological distress related to bowel control issues.
Nursing Care Plans for Constipation
Here are examples of nursing care plans addressing different causes of constipation.
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 1-3 days without straining.
- Patient will implement measures to relieve opioid-induced constipation.
Assessment:
- Medication History Review: Assess opioid use and adherence to prescriptions. Note that opioid-induced constipation is common.
- Assess Normal Defecation Pattern: Determine the patient’s usual bowel habits. Utilize Rome Criteria IV for functional constipation assessment if needed.
Interventions:
- Administer Laxatives as Indicated: Prophylactic laxatives (except bulk-forming) are usually prescribed with opioids.
- Encourage Early Mobility: Promote postoperative mobility to prevent complications and aid bowel function.
- Educate Patient and Family about Opioid Analgesics: Explain constipation as a common side effect and reassure them it can be managed with laxatives and mobility.
- Discourage Long-term Laxative Use: Advise against prolonged stimulant laxative use to avoid dependence.
Care Plan #2: Constipation Related to Immobility
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 constipation discomfort.
Assessment:
- Assess Usual Bowel Pattern: Detailed assessment of frequency, consistency, laxative use, diet, exercise, and fluid intake to establish a baseline.
- Assess Mobility Level: Determine the patient’s ability to move to tailor interventions.
Interventions:
- Advise High-Fiber Diet (18-25g daily): Suggest fiber-rich foods like prune juice, leafy greens, whole grains.
- Advise Fluid Intake (1.5-2L daily): Unless contraindicated, encourage 6-8 glasses of water daily.
- Encourage Physical Activity: Promote mobility within patient’s capabilities, even simple in-bed exercises.
- Demonstrate Abdominal Massage: Teach gentle abdominal massage, potentially with aromatherapy oils.
- Perform Enemas or Disimpaction: Consider enemas if other interventions are ineffective.
Care Plan #3: Constipation Related to Poor Dietary Habits
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 for fiber deficiency and high processed food intake.
- Note Oral/Dental Health: Dental issues can impact dietary choices and fiber intake.
- Determine Fluid Intake: Identify fluid deficits.
Interventions:
- Discuss Laxative and Enema Use: Educate on their purpose but emphasize lifestyle changes as the primary solution.
- Identify Bowel Activity Stimulators: Explore factors that help or hinder bowel movements.
- Promote Lifestyle Changes:
- High-fiber diet (fruits, vegetables, whole grains, fiber supplements).
- Limit low-fiber, high-fat foods.
- Adequate fluid intake.
- Warm stimulating fluids.
- Daily activity and exercise.
- Do not ignore the urge to defecate; establish a routine.
- Encourage Sitz Baths: For comfort and sphincter 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.
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