Constipation: holistic assessment

Constipation is a common problem that can occur at any age. The incidence rate is 2-3 times higher in women than in men and prevalence increases with age. The true prevalence may be underestimated due to the high proportion of self-management and treatment (National Institute for Health and Care Excellence (NICE), 2023). Constipation is more common in pregnancy and can be exacerbated by medication. Effective treatment of constipation relies on a thorough holistic assessment to identify the cause.

Constipation is defined as unsatisfactory defecation due to the infrequent passing of stools (NICE, 2023). It is a subjective disorder and is measured in patients according to their dissatisfaction with the frequency of defecation and the relevance of the symptoms to the individual (Woodward, 2012; Basilisco and Coletta, 2013; Lister et al, 2020). Effective treatment of constipation relies on a thorough holistic assessment to identify the cause.

1. Assess the person's normal bowel habits (this may influence diagnosis)

2. Ask the patient how long they have they been constipated and whether this has occurred before. Also, what self-help methods have been previously tried and what the outcome was. Understanding a patient's bowel history is key to an accurate diagnosis. Withholding bowel movements following previous experiences of pain or discomfort is known to cause functional constipation, particularly in older people who are in hospitals or institutions (Basilisco and Coletta, 2013)

3. Record the volume, colour and consistency of stools, for example: hard, small. Use the Bristol stool chart to assess this (Figure 1). Constipation would be classified as types 1 or 2 (separate hard lumps or lumpy and sausage like) on the Bristol scale. Consider implementing a bowel diary to record the frequency of bowel evacuation, stool consistency, and to record any faecal incontinence (Royal College of Nursing (RCN), 2019). Ask

Digital rectal examination

A digital rectal examination should be performed only by nurses who have received suitable training and who have demonstrated a level of competence determined by the Nursing and Midwifery Council (NMC, 2018; Lister et al, 2020). All patients with chronic constipation should undergo a digital rectal examination to look for causes of anal pain that may precipice secondary constipation (Basilisco and Coletta, 2013). Before undertaking a digital rectal examination, nurses must observe the perineal areas for any abnormalities such as:

• Rectal prolapse (this should be graded)

• Anal fissure (can cause anal pain) or anal skin tags (Basilisco and Coletta, 2013)

• Thrombosed haemorrhoids (grade and note if they are internal or external, may be a cause of anal pain) (Basilisco and Coletta, 2013)

• Any wounds, areas of broken red or sore skin, lesions, fistulas or foreign bodies

• Pressure ulcers (this should be graded)

• If the anal tone is

Enemas should be used with caution and observing all the contraindications, for example, gastrointestinal obstructions or inflammatory bowel disease (NICE, 2023). Caution should be used in patients with ascites, congestive heart failure, older people or debilitated patients, patients with electrolyte disturbances or uncontrolled hypertension (a side effect of some enemas can be electrolyte disturbances) (NICE, 2023). Other side effects can include a local irritation. Nurses should advise patients and carers about adequate hydration particularly with osmotic enemas, and should ensure that the patients are warned about the potential for faecal overflow and diarrhoea during disimpaction (NICE, 2023).

Following treatment with an enema, regular laxatives should be considered to maintain bowel movements and the patient should be reviewed regularly to monitor their response to the treatment (Lister et al, 2020). If constipation fails to improve it is recommended that patients are referred to a specialist for further investigations (Basilisco and Coletta,

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages

Part 2: Procedures for the planning, provision and management of person-centred nursing care

6. Use evidence-based, best practice approaches for meeting needs for care and support with bladder and bowel health, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

6.1 observe and assess level of urinary and bowel continence to determine the need for support and intervention assisting with toileting, maintaining dignity and privacy and managing the use of appropriate aids

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