Nursing Guide to Constipation: Nursing Diagnosis, Interventions, & Care Plans

Constipation Etiology and Epidemiology

Constipation is the infrequent or difficult evacuation of stool and usually results from a decrease in activity or dietary changes, such as inadequate intake of fluids and dietary fiber (DynaMed, 2018). Constipation that lasts longer than 3 months is considered to be chronic.

Common causes of constipation include:

• Irregular bowel habits
• Neurological conditions
• Chronic bowel dysfunction
• Stress
• Physical inactivity
• Medications
• Changes in routine
• Aging
• Chronic illness
• Surgery
• Psychosocial issues
• Diet

There are two types of constipation:

• Primary constipation is classified as a slow transit or outlet dysfunction.
• Secondary constipation is caused by dehydration, neurological disorders, structural abnormalities, or medications.

Primary constipation consists of three categories:

• Functional constipation: Relates to irritable bowel syndrome
• Slowed transit constipation: Delays in bowel movements
• Outlet dysfunction: Results from anal sphincter dysfunction, pelvic floor muscle weakness, or rectoceles

Secondary constipation relates to diet, lifestyle, and medications (e.g., opiates, antidepressants, anticholinergics, and clozapine). It also relates to a variety of conditions, such as:

• Neoplasia
• Diabetes
• Multiple sclerosis
• Parkinson’s disease
• Thyroid disease
• Pregnancy
• Scleroderma
• Amyloidosis
• Depression
• Anorexia

The prevalence of constipation is approximately 16% of the population in North America, with a higher incidence in adults 65 years and older (Jani & Marsicano, 2018). Constipation is more common in:

• Women
• Adults over age 65
• Non-White individuals
• Persons with lower socioeconomic status
• Smokers
• People that drink alcohol

Constipation Diagnosis

A thorough history and physical is completed. The focused history consists of:

• Effect on the person’s quality of life
• Severity and frequency of the constipation
• Change in stools, frequency, consistency, straining, or pain
• Anemia
• Weight loss
• Family history of colorectal cancer
• Current medications

Physical findings to look for are:

• Abdominal distension, discomfort with palpitation
• Surgical scars
• Right iliac fossa tenderness
• Palpable fecal mass
• Non-fecal masses
• Anal inspection for scars, fistulas, fissures, hemorrhoids
• Digital rectal exam, evaluate for rectocele, tenderness, and sphincter tone
• Watch perineum while the individual bears down to assess perineal descent

Signs that may cause alarm during examination include:

• Acute onset
• Fever, nausea, or vomiting
• Anemia
• Hematochezia or melena, positive fecal occult blood test

Evaluate individuals for the use of medications that can contribute to constipation. These include:

• Antipsychotics (both typical and atypical)
• Iron supplements
• Antidepressants
• Bismuth
• Anticholinergics
• Opioids
• Antacids
• Calcium channel blockers
• Anti-inflammatory drugs or NSAIDs
• Sympathomimetics

Diagnostic testing is not necessary to diagnose constipation. However, if there are any alarming findings on examination, X-rays, or blood tests, an endoscopy might be indicated.

Complications from constipation include overflow incontinence and fecal impaction. Laxatives are commonly used prophylactically for chronic constipation.

Management

Management of constipation includes:

• Changing lifestyle, such as a high fiber diet
• Adding psyllium supplements
• Increasing fluid intake
• Including prunes in diet
• Reducing the amount of red meat, fried/fatty foods, and dairy products
• Using laxatives such as polyethylene glycol (MiraLAX®) or lactulose (Enulose®)
• Adding stimulant laxatives such as bisacodyl (Dulcolax®) for chronic constipation
• Increasing physical activity

Laxatives are frequently used to manage constipation and are often used in older people to treat and prevent contipation (Point & Williams, 2019). There are many laxatives available, including:

• Bulk-forming agents which increase the weight of stool, leading to bowel stimulation (e.g., psyllium (Metamucil®)
• Stool softeners or emollients which allows water into the stool to make it easier to pass (e.g., docusate sodium (Colace®)
• Osmotic agents which draw water to the bowel to soften the stool (e.g., lactulose (Enulose® or Lactugal®)
• Stimulant laxatives which stimulate the muscles lining the gut to promote movement (e.g., senna (Senokot®).
• Prokinetic and secretory agents, which are used for severe constipation, to promote intestinal motility (e.g., metoclopramide (Reglan®) or cisapride (Propulsid®)

Laxatives are the foundation for managing constipation. They are often used in older adults for both treating and preventing constipation.

Constipation Nursing Care Plan

Nursing Considerations

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for constipation are listed below.

Assessment

Assesses for signs and symptoms such as:

• Infrequent bowel movements (less than three times per week)
• Difficult to pass stool
• Hydration status (skin turgor, fluid intake)
• Painful or difficult bowel movements
• Dietary intake, especially for foods high in fiber
• Medications that cause constipation
• Less frequent stools or smaller volume of stool
• Abdominal tenderness or distension

Nursing Diagnosis/Risk For

• Lack of knowledge related to prevention of constipation, as evidenced by:
  • Chronic constipation
  • Recurrent constipation
  • Non-compliance with daily fluid and fiber intake
• Pain related to difficult bowel movements, as evidenced by:
  • Verbalizing pain
  • Irritability
  • Guarding of abdomen
  • Passing or hard stool
• Risk for dysfunctional gastrointestinal motility related to lack of peristaltic activity, as evidenced by:
  • Nausea and vomiting
  • Lack of regular bowel movements

Constipation Interventions

• Monitor frequency and characteristics of the individual’s stool.
• Provide privacy for effective elimination.
• Emphasize the importance of responding to the urge to defecate.
• Encourage ambulation and physical activity.
• Provide bowel training.
• Manage fecal impaction (digitally).
• Promote a high fiber diet.
• Encourage adequate fluid intake (at least 2000 mL per day).
• Administer fiber and bulk-forming laxatives, as ordered.
• Monitor medication list for medications that can lead to constipation.

Expected Outcomes

• Demonstrates an increase in fluid and fiber intake
• Verbalizes easy and complete evacuation of stools
• Verbalizes elimination pattern within normal limits
• Demonstrates an increase in overall activity

Patient/Caregiver Education

• Review risk factors for constipation
  • Age
  • Poor hydration
  • Diet low in fiber
  • Low physical activity
  • Irritable bowel syndrome
  • Sudden lifestyle changes, such as surgery or travel
  • Certain medications
• Educate individual on proper diet and hydration status
  • High fiber diet (e.g., fibrous fruits and vegetables such as prunes, brussel sprouts, spinach, and squash, along with whole grains, oats, and bran)
  • Minimum of 2 liters of fluid intake daily
• Review importance of regular activity to promote regular bowel movements
  • 10 to 15 minutes of steady activity a few times daily. This activity can include:
    • Performing yoga
    • Engaging in cardio-workouts
    • Walking/running
• Educate individuals on how to use laxatives appropriately
  • Take only as directed.
  • Take only as needed unless otherwise instructed by the healthcare provider.
  • Do not use to promote weight loss.
  • See a healthcare provider if constipation persists or they have not passed any stool for several days.
  • Seek emergency medical care if constipation is accompanied by:
    • Intense or constant abdominal pain
    • Vomiting
    • Abdominal distension
    • Blood in stool

Content Release Date

4/1/2022

Content Expiration

12/31/2027

Course Contributor

The content for this course was revised by Kathleen Koopmann, RN, BSN, PCCN. Kathleen earned her Associate Degree in nursing in 1987 at Mid-Michigan Community College and her Bachelor of Science in nursing in 2018 from Western Governor’s University. She has training from the North Carolina Statewide Program for Infection Control and Epidemiology through NCDHHS and the University of North Carolina. Kathleen has worked in long-term care, outpatient care, acute care, and nursing education. She has hospital experience in Med-Surg, OR/PACU, Critical Care, Telemetry, and outpatient experience in Occupational Health. Kathleen has experience as a clinical instructor for the LPN program at Susquehanna County Career and Technical Center in Pennsylvania. Most recently, she worked in long-term care as a Staff Development Coordinator and Infection Control Practitioner.

Resources

• American College of Gastroenterology https://gi.org/topics/constipation-and-defection-problems/

References

• DynaMed. (2018). Constipation in adults. https://www.dynamed.com/condition/constipation-in-adults
• Jani, B., & Marsicano, E. (2018). Constipation: Evaluation and management. Missouri Medicine, 115(3), 236–240. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140151/
• Pont, L. G., Fisher, M., & Williams, K. (2019). Appropriate use of laxatives in the older person.
• Drugs & Aging, 36(11), 999–1005. https://doi.org/10.1007/s40266-019-00701-9