What are the nursing considerations for managing constipation?

Nursing Considerations for Constipation Management

Nurses should prioritize systematic assessment, implement evidence-based non-pharmacological interventions, initiate appropriate laxative therapy when needed, and monitor for complications—particularly fecal impaction and bowel obstruction.

Assessment Priorities

All patients should be routinely evaluated for constipation through targeted questioning about bowel patterns, stool consistency, and associated symptoms. 1

• Obtain a complete medication list and identify constipating agents (opioids, anticholinergics, calcium channel blockers, iron supplements) 1, 2
• Document current bowel movement frequency, consistency, straining, and sensation of incomplete evacuation 1
• Assess dietary fiber intake, fluid consumption, and activity level 2
• Review social factors including privacy, toilet access, and mobility limitations 1, 2
• Perform abdominal examination to assess for distension, tenderness, and palpable stool 1
• Conduct digital rectal examination (DRE) to identify rectal impaction or masses 1
• Consider plain abdominal X-ray if severe symptoms, sudden changes, or suspected obstruction 1
• Check corrected calcium and thyroid function if clinically indicated 1

Critical Red Flags

• Rule out fecal impaction if patient reports diarrhea with constipation (overflow incontinence) 3
• Suspect bowel obstruction with severe abdominal pain, distension, vomiting, or absence of flatus 1
• Recognize complications: urinary retention, rectal bleeding, stercoral ulcers, perforation 1

Non-Pharmacological Interventions

Implement environmental and lifestyle modifications as foundational management, though these alone are insufficient for symptom control and must be combined with pharmacological therapy when needed. 2

Environmental Modifications

• Ensure privacy and comfort during toileting to allow normal defecation patterns 1, 2
• Position patient with small footstool to assist gravity and facilitate easier straining 1, 2
• Maintain regular toileting schedule, especially for patients with decreased mobility 2

Dietary and Fluid Management

• Increase fluid intake to at least 2 liters daily, particularly for patients with low baseline consumption 2
• Only increase dietary fiber if patient has adequate fluid intake and physical activity—fiber without sufficient hydration worsens constipation 2
• Fiber supplements (psyllium) require 8-10 ounces of fluid per dose to prevent symptom exacerbation 2

Activity and Mobility

• Encourage increased mobility within patient limits, even simple bed-to-chair transfers 1, 2
• Promote 30 minutes of exercise daily when patient's condition allows 4

Patient Education Pitfalls

• Warn patients against home remedies or online over-the-counter products that may interfere with treatments 2
• Educate that lifestyle modifications have limited influence and should not be the sole management focus 2

Pharmacological Management

When laxatives are needed, initiate osmotic laxatives (polyethylene glycol) or stimulant laxatives (senna, bisacodyl) as first-line therapy. 1

First-Line Laxative Therapy

Polyethylene glycol (PEG) receives strong recommendation with moderate certainty of evidence from the American Gastroenterological Association and American College of Gastroenterology. 1, 5

• Administer PEG 3350: 17 grams (one heaping tablespoon) dissolved in 8 oz water twice daily 2, 5
• PEG increases complete spontaneous bowel movements by 2.90 per week compared to placebo 5
• Generally produces bowel movement in 1-3 days 6

Stimulant laxatives are equally appropriate first-line options, particularly for opioid-induced or medication-related constipation. 1, 3

• Senna: 2-3 tablets (8.6 mg each) two to three times daily, titrated to effect (maximum 8-12 tablets daily) 2, 3, 5
• Bisacodyl: 10-15 mg orally 2-3 times daily 1, 3
• Evidence shows senna alone is more effective than senna combined with docusate (stool softener) 3
• Produces bowel movement in 6-12 hours 7

Alternative Osmotic Agents

• Lactulose: standard dosing per protocol 1
• Magnesium hydroxide: 30-60 mL daily 5
• Magnesium citrate: 8 oz daily 5
• Use magnesium-based products cautiously in renal impairment due to hypermagnesemia risk 1, 5

Goal of Therapy

Educate patients that the treatment goal is one non-forced bowel movement every 1-2 days. 2, 3, 5

Rectal Interventions

Suppositories and enemas are preferred first-line therapy when DRE identifies full rectum or fecal impaction. 1

• Bisacodyl suppository: 10 mg once or twice daily 3
• Glycerin suppositories for mild cases 1
• Enemas are contraindicated in neutropenic or thrombocytopenic patients 1, 3

Fecal Impaction Management

In the absence of suspected perforation or bleeding, manage fecal impaction through digital disimpaction followed by maintenance bowel regimen. 1

• Perform digital fragmentation and extraction of stool 1
• Follow with suppositories and enemas to clear distal colon 1
• Administer oral PEG for proximal impaction once distal colon partially cleared 1
• Implement maintenance laxative regimen to prevent recurrence 1

Prophylactic Management

Initiate prophylactic laxatives when prescribing opioids rather than waiting for constipation to develop. 1, 2

• Start stimulant laxative (senna) or osmotic laxative (PEG) concurrently with opioid initiation 1, 2
• Patients do not develop tolerance to opioid-induced constipation, requiring ongoing prophylactic treatment 5
• Discontinue non-essential constipating medications when possible 2, 3, 5

Refractory Constipation

For persistent constipation despite first-line measures, escalate to combination therapy or specialized agents. 3

• Combine PEG with stimulant laxative if monotherapy insufficient 3, 5
• Add prokinetic agent (metoclopramide) if gastroparesis suspected 3
• Consider peripherally acting μ-opioid receptor antagonists (methylnaltrexone 0.15 mg/kg subcutaneously every other day) for opioid-induced constipation 3
• Lubiprostone or linaclotide for severe refractory cases 3

Monitoring and Safety

Monitor patients for adverse effects and treatment response, adjusting therapy within 2-4 days if inadequate response. 5

When to Stop and Reassess

• Stop PEG and consult physician if rectal bleeding, worsening nausea, bloating, cramping, or abdominal pain occurs 6
• Stop if diarrhea develops 6
• Stop if laxative needed longer than 1 week without medical evaluation 6
• Assess response after 2-4 days and titrate doses accordingly 5

Common Nursing Pitfalls to Avoid

• Do not use stool softeners (docusate) alone without stimulant laxatives—they are ineffective 3, 5
• Do not add fiber supplements for medication-induced constipation—they are ineffective and may worsen symptoms 5
• Do not fail to provide prophylactic treatment when starting constipating medications 3
• Do not rely solely on lifestyle modifications for symptom control 2

Special Populations

Elderly Patients

Pay particular attention to elderly patients who have 24-50% prevalence of constipation and enhanced risk of complications. 1

• Obtain complete medication list and withdraw inappropriate medications 1
• Assess living situation (home alone, with family, nursing home) 1
• Recognize degenerative changes in enteric nervous system increase risk of severe constipation and impaction 1

Cancer Patients

All cancer patients should be routinely evaluated for constipation given high prevalence and risk of complications. 1

• Implement anticipatory management when prescribing chemotherapy or opioids 1, 2
• Consider abdominal massage for patients with concomitant neurogenic problems 1, 2