Constipation is one of the most common digestive complaints in the United States in ambulatory centers and a common cause of referral to gastroenterologists and colorectal surgeons. It is a symptom rather than a disease, and despite its frequency, it often remains unrecognized until the client develops sequelae, such as anorectal disorders (Basson & Anand, 2020).
Definition
Constipation is generally defined as when bowel movements occur three or fewer times a week and are difficult to pass. The Rome criteria, initially introduced in 1988 and subsequently modified three times to yield the Rome IV criteria, have become the research-standard definition of constipation (Basson & Anand, 2020). According to the Rome IV criteria for constipation, the client must have experienced at least two of the following symptoms over the preceding 3 months:
- Fewer than three spontaneous bowel movements per week
- Straining for more than 25% of defecation attempts
- Lumpy or hard stools for at least 25% of defecation attempts
- The sensation of anorectal obstruction or blockage for at least 25% of defecation attempts
- Manual maneuvering is required to defecate for at least 25% of defecation attempts
Pathophysiology
The cause of constipation is multifactorial. It may arise in the colon or rectum or it may be due to an external cause. In most people, slow colonic motility that occurs after years of laxative abuse is the problem. In a few clients, the cause may be related to an outlet obstruction like rectal prolapse or a rectocele. External causes of constipation may include poor dietary habits, lack of fluid intake, overuse of certain medications, an endocrine problem, or a type of emotional issue (MEW, 2022).
Etiology
The causes of constipation may be divided into the following broad categories:
- Functional (non-organic) or retentive: This includes constipation due to fecal withholding behaviors and when all organic causes have been ruled out.
- Anatomic causes: This includes anal stenosis or atresia, anteriorly displaced anus, imperforate anus, intestinal stricture, and anal stricture.
- Abnormal musculature: Related causes include prune belly syndrome, gastroschisis, Down syndrome, and muscular dystrophy.
- Intestinal nerve abnormality causes: The causes include Hirschsprung disease, pseudo-obstruction, intestinal neuronal dysplasia, spinal cord defects, tethered cord, and spina bifida.
- Drugs: Drugs like anticholinergics, narcotics, antidepressants, lead, and vitamin d intoxication can cause constipation.
- Metabolic and endocrine causes: This includes hypokalemia, hypercalcemia, hypothyroidism, diabetes mellitus, or diabetes insipidus.
- Other causes include celiac disease, cystic fibrosis, cow milk protein allergy, inflammatory bowel disease, and scleroderma among others.
Epidemiology
Chronic constipation is highly prevalent and affects approximately 15% of persons in the United States. In 2006, the number of constipation-related healthcare provider visits reached 5.7 million, and of these, 2.7 million visits had constipation as the primary diagnosis. About 2% of the population describes constant or frequent intermittent episodes of constipation. Worldwide, approximately 12% of people suffer from self-defined constipation. Female sex, age, and educational class were strongly associated with the prevalence of constipation (Basson & Anand, 2020).
An age-related increase in the incidence of constipation has been observed, with 30%-40% of adults older than 65 years citing constipation as a problem. Self-reported constipation and admissions to hospitals for constipation are more common in women than in men. The overall female-to-male ratio is approximately 3:1. The condition is seen fairly frequently during pregnancy and is common after childbirth (Basson & Anand, 2020).
Signs and symptoms
Basing the diagnosis on simply asking the clients whether they are constipated is associated with marked underreporting of the problem. A constipated client may be otherwise totally asymptomatic or may complain of one or more of the following:
- Abdominal bloating
- Pain on defecation
- Rectal bleeding
- Spurious diarrhea
- Low back pain
- A feeling of incomplete evacuation
- Straining
- Digital extraction
- Tenesmus
- Enema retention
The following signs and symptoms, if presented by the client, can be concerning:
- Rectal bleeding
- Abdominal pain
- Inability to pass flatus
- Vomiting and nausea
- Unexplained weight loss
- Fever
Interventions
Management for constipation includes medical supervision, dietary instructions, behavioral changes, and instructions regarding toilet training (MEW, 2022).
- Medical supervision: Medical care should focus on dietary change and exercise rather than laxatives, enemas, and suppositories, none of which really addresses the underlying problem. Potentially helpful measures include initiation of dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate; if necessary, these can be followed by intestinal secretagogues and/or prokinetic agents (Basson & Anand, 2020).
- Dietary instructions: The key to treating most clients with constipation is the correction of dietary deficiencies. This generally involves increasing the intake of fiber and fluid and decreasing the use of constipating agents, such as milk products, coffee, tea, and alcohol (Basson & Anand, 2020).
- Toilet training: In pediatric cases, long-term success in the management of constipation depends on the child establishing regular and routine toilet times. It is generally recommended that the child be encouraged to attend to the toilet twice daily for 5-10 minutes, preferably after breakfast and after supper to take advantage of the gastrocolic reflex. For school-aged children, it is preferable not to expect the child to attend the toilet while at school (Borowitz & Cuffari, 2022).
Nursing Diagnosis for Constipation
Nursing Diagnosis
Constipation
Assessment
Inappropriate toileting behaviors / elimination urgency / abdominal distention / pain on defecation / straining / rectal bleeding / low back pain / fever / rectal bleeding / abdominal pain / inability to pass flatus
Problem
Lost neurological functioning
Changes in dietary and fluid intake
Inability to recognize the need for elimination
Changes in the level of activity
Risk for imbalanced nutrition
Nursing Diagnosis
Acute Pain
Assessment
Communication of pain descriptors / Abdominal pain / pain on defecation / low back pain / abdominal guarding / facial grimacing / rigid body posture / tachycardia / restlessness / diaphoresis
Problem
Inability to perform activities of daily living
Social isolation
Decreased appetite
Weight loss
Nursing Diagnosis
Risk for Chronic Functional Constipation
Assessment
Small, hard stools / infrequent, large bowel movements / bright, red blood on the stool / weakness / abdominal pain / vomiting / urinary symptoms / obesity
Problem
Ineffective toilet training
Limited physical activity
A general feeling of malaise
Self-medicating with laxatives
Nursing Diagnosis
Risk for Dysfunctional Gastrointestinal Motility
Assessment
Abdominal pain and distention / difficulty swallowing / gastric content reflux / nausea / vomiting / weight loss / constipation / excessive flatus
Problem
Risk for constipation
Abdominal discomfort
Limited physical activity
Nursing Diagnosis
Deficient Knowledge
Assessment
Verbalization of questions / statement of misconception / inaccurate follow-through of instructions / development of preventable complications / request for information
Problem
Development of complications
Information misinterpretation
Unfamiliarity with terms and procedures
Lack of cooperation and poor adherence to treatment
Nursing Diagnosis
Impaired Comfort
Assessment
Reports of discomfort / distraction behaviors / anxiety / restlessness / irritability / tachycardia / abdominal guarding
Problem
Muscle tension
Utilization of ineffective coping methods
Diminished ability to complete tasks
Social isolation
Nursing Diagnosis
Risk for Injury
Assessment
Laxative dependency / Rectal pain and bleeding / Rectal itching / engorgement of the rectal columns / painful tear in the anoderm / delayed healing of an anal fissure
Problem
Hemorrhoids
Pelvic floor damage
Rectal prolapse
Fecal impaction
Anal fissures
Drug dependency
Nursing Diagnosis
Risk for Deficient Fluid Volume
Assessment
Dry mucous membranes / weight loss / decreased urine output / hypotension / tachycardia / decreased skin turgor / nausea / vomiting / cool, clammy skin / weak pulses
Problem
Dehydration
Hypotonic laxative colon
Risk for circulatory collapse
References
- Basson, M. D., & Anand, B. (2020, March 30). Constipation: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved August 17, 2022, from https://emedicine.medscape.com/article/184704-overview#a1
- Borowitz, S. M., & Cuffari, C. (2022, June 17). Pediatric Constipation Treatment & Management: Approach Considerations, Colon Evacuation, Removal of Pain-Associated Defecation. Medscape Reference. Retrieved August 17, 2022, from https://emedicine.medscape.com/article/928185-treatment#d10
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- MEW, T. (2022, May 22). Constipation – StatPearls. NCBI. Retrieved August 17, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK513291/
- Olaru, C., Diaconescu, S., Trandafir, L., Gimiga, N., Stefanescu, G., Ciubotariu, G., & Burlea, M. (2016, October 26). Some Risk Factors of Chronic Functional Constipation Identified in a Pediatric Population Sample from Romania. NCBI. Retrieved August 17, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5141327/
