Constipation Management: A Community Health Nursing Approach

Constipation Management

A Community Health Nursing Approach

Introduction to Constipation
Definition and Prevalence
Screening and Assessment
Diagnosis/Identification
Standing Orders
Primary Care Interventions
First Aid Management
Referral Protocols
Prevention Strategies
Special Populations
Global Best Practices
References

Introduction to Constipation

Constipation is a common gastrointestinal condition that significantly impacts patients’ quality of life. As community health nurses, understanding constipation management is essential for providing comprehensive care to individuals across all age groups and settings. This prevalent digestive issue affects approximately 16% of adults worldwide and about 33% of adults over 60 years old, making it one of the most common digestive complaints encountered in community health practice.

This guide provides community health nurses with evidence-based approaches to constipation management, including screening, diagnosis, standing orders, primary care interventions, and appropriate referral criteria. By implementing these constipation management strategies, community health nurses can significantly improve patient outcomes and quality of life.

Definition and Prevalence

Clinical Definition of Constipation

Constipation is defined as infrequent bowel movements (typically fewer than three per week) accompanied by difficult passage of stools that are often hard, dry, small in size, and difficult to eliminate. Constipation management requires a comprehensive assessment of both subjective symptoms and objective findings.

Rome IV Diagnostic Criteria

The Rome IV criteria define functional constipation as the presence of at least two of the following symptoms for at least 3 months, with symptom onset at least 6 months prior to diagnosis:

Straining during at least 25% of defecations
Lumpy or hard stools in at least 25% of defecations
Sensation of incomplete evacuation in at least 25% of defecations
Sensation of anorectal obstruction/blockage in at least 25% of defecations
Manual maneuvers to facilitate at least 25% of defecations
Fewer than three spontaneous bowel movements per week

Prevalence and Impact

Constipation affects people of all ages but is particularly common in:

Older adults (33% of adults over age 60)
Women (2-3 times more common than in men)
Pregnant women (approximately 40% experience constipation)
Children (prevalence of 1-30% depending on criteria used)
Individuals with limited mobility or neurological conditions

Effective constipation management is critical as chronic constipation significantly impacts quality of life, causing physical discomfort, anxiety, and social limitations. It also creates substantial healthcare costs due to medical visits, medications, and potential complications.

Screening and Assessment

Community health nurses play a pivotal role in screening for constipation. A systematic approach to constipation management screening helps identify at-risk individuals and those requiring intervention.

Screening Tools

Screening Tool	Description	Application in Community Setting
Bristol Stool Form Scale	Visual chart categorizing stool into 7 types based on form and consistency	Quick visual assessment; Types 1-2 indicate constipation
Constipation Assessment Scale (CAS)	8-item questionnaire measuring presence and severity of constipation	Comprehensive assessment for routine clinic visits
Patient Assessment of Constipation Symptoms (PAC-SYM)	12-item self-report measuring severity of constipation symptoms	Useful for monitoring symptom changes over time
Bowel Function Diary	Daily record of bowel movements, consistency, associated symptoms	Patient self-monitoring; valuable for home care settings

Key Assessment Components

History Taking

Bowel movement frequency and consistency
Duration of constipation symptoms
Dietary habits, especially fiber and fluid intake
Physical activity levels
Current medications (many are constipating)
Straining and painful defecation
Previous constipation management approaches

Physical Assessment

Abdominal examination (distention, tenderness)
Bowel sounds assessment
Rectal examination (if appropriate)
Assessment of mobility and functional status
Hydration status evaluation
Signs of complications (e.g., hemorrhoids)

CONSTIPATED Mnemonic for Assessment

Use this mnemonic during constipation management assessment:

C – Consistency and character of stool
O – Onset and duration of symptoms
N – Number of bowel movements per week
S – Straining and difficulty passing stool
T – Treatment history and attempts at relief
I – Intestinal habits and diet patterns
P – Pain or discomfort with defecation
A – Associated symptoms (bloating, cramping)
T – Toilet facilities and accessibility
E – Exercise and mobility status
D – Drugs and medications (current and past)

Diagnosis/Identification

Proper diagnosis is essential for effective constipation management. Community health nurses should be able to identify the type of constipation and potential underlying causes to guide treatment decisions.

Types of Constipation

Type	Description	Clinical Features	Nursing Implications
Primary/Functional Constipation	No underlying medical cause; related to lifestyle factors	Meets Rome IV criteria; normal physiological function	Focus on lifestyle modifications and education
Secondary Constipation	Due to medications, medical conditions, or structural issues	Symptoms associated with specific cause; may have other symptoms	Address underlying cause; referral may be needed
Slow Transit Constipation	Delayed movement of stool through the colon	Infrequent urge to defecate; abdominal bloating	May require specialized testing; pharmacological interventions
Outlet Dysfunction	Difficulty with expulsion of stool from rectum	Feeling of rectal blockage; excessive straining	Pelvic floor assessment; possible biofeedback referral

Common Causes of Constipation

Lifestyle Factors

Low-fiber diet
Inadequate fluid intake
Physical inactivity
Ignoring urge to defecate
Stress and anxiety
Changes in routine or travel

Medications

Opioid analgesics
Anticholinergics
Calcium channel blockers
Iron supplements
Antacids containing aluminum or calcium
Anticonvulsants
Antidepressants

Medical Conditions

Irritable bowel syndrome
Hypothyroidism
Diabetes mellitus
Parkinson’s disease
Multiple sclerosis
Spinal cord injuries
Depression
Cognitive impairment

Structural Causes

Colorectal cancer
Anal fissures
Rectocele
Strictures
Pelvic floor dysfunction
Hirschsprung’s disease

Red Flags Requiring Immediate Referral

These warning signs may indicate serious underlying conditions requiring prompt medical attention:

New onset constipation in older adults
Unexplained weight loss
Rectal bleeding
Family history of colorectal cancer or inflammatory bowel disease
Severe, persistent abdominal pain
Iron deficiency anemia
Alternating constipation and diarrhea
Failure to respond to constipation management interventions

Standing Orders

Definition of Standing Orders

Standing orders are written protocols that authorize nurses and other healthcare providers to deliver specific health services without a physician’s direct examination when certain predetermined conditions are met. For constipation management, standing orders provide community health nurses with a standardized approach to assessment, intervention, and referral.

Uses of Standing Orders in Constipation Management

Standardize evidence-based care across community health settings
Expedite assessment and treatment without requiring physician consultation for routine cases
Clarify criteria for escalation and referral to higher levels of care
Empower community health nurses to implement appropriate interventions
Improve efficiency and timeliness of constipation management
Ensure consistent documentation and follow-up protocols

Sample Standing Order Protocol for Constipation Management

Component	Protocol
Assessment	Complete constipation assessment using CONSTIPATED mnemonic Document bowel movement frequency, consistency (Bristol Stool Scale), and associated symptoms Perform focused physical assessment including vital signs and abdominal examination Screen for red flags requiring physician referral
Diagnostic Testing	Obtain stool sample for occult blood testing if indicated (age >50 or concerning symptoms) Monitor and document response to interventions using Bristol Stool Scale
Interventions	Provide education on lifestyle modifications: Increase dietary fiber to 25-30g daily Ensure adequate hydration (minimum 1.5-2L daily) Encourage physical activity Establish regular toileting schedule For mild constipation (no BM for 3 days): Recommend bulk-forming laxatives (psyllium, methylcellulose) For moderate constipation (no BM for 4-5 days): May initiate osmotic laxatives (milk of magnesia, polyethylene glycol)
Documentation	Record assessment findings, interventions implemented, and patient response Document patient education provided and understanding Note follow-up plan and timeframe
Referral Criteria	Severe constipation (no BM for >5 days) Presence of any red flag symptoms Failure to respond to initial interventions after 1 week Chronic constipation requiring ongoing management Suspected medication-induced constipation requiring regimen adjustment
Follow-up	Schedule follow-up within 3-5 days for telephone assessment In-person reassessment within 1-2 weeks if symptoms persist Provide contact information for worsening symptoms

Implementation Tips for Standing Orders

Ensure all community health nurses are trained in the standing order protocol
Review and update standing orders regularly based on emerging evidence
Maintain clear documentation of standing order implementation
Establish quality improvement mechanisms to monitor outcomes
Develop a system for regular communication with supervising physicians

Primary Care Interventions

Community health nurses play a critical role in implementing primary care interventions for constipation management. These interventions include non-pharmacological approaches, pharmacological management, and patient education.

Non-pharmacological Interventions

Dietary Modifications

Fiber intake: Gradually increase to 25-30g daily
High-fiber foods: Whole grains, fruits, vegetables, legumes
Hydration: 1.5-2L of fluid daily (unless contraindicated)
Probiotic foods: Yogurt, kefir, fermented vegetables
Limit constipating foods: Processed foods, cheese, white bread

Lifestyle Modifications

Physical activity: 30 minutes of exercise most days
Toileting routine: Scheduled time after meals
Proper positioning: Use footstool for squatting position
Stress reduction: Relaxation techniques, adequate sleep
Time allocation: Allow sufficient time for defecation

Pharmacological Management

When non-pharmacological approaches are insufficient, pharmacological interventions may be necessary. Community health nurses should understand the various laxative options for constipation management:

Laxative Type	Examples	Mechanism	Nursing Considerations
Bulk-Forming	Psyllium (Metamucil), Methylcellulose (Citrucel)	Absorb water to increase stool bulk and stimulate peristalsis	Take with adequate fluid (240mL) Start with low dose and increase gradually May cause bloating initially First-line therapy for mild constipation
Osmotic	Polyethylene glycol (Miralax), Magnesium hydroxide (Milk of Magnesia)	Draw water into intestines to soften stool	Monitor electrolytes in elderly or renal impairment Onset typically 24-48 hours Good for moderate constipation May cause cramping or flatulence
Stimulant	Bisacodyl (Dulcolax), Senna (Senokot)	Stimulate intestinal motility; increase water secretion	More rapid onset (6-12 hours) Short-term use only (5-7 days maximum) May cause cramping or discomfort Avoid in suspected obstruction
Stool Softeners	Docusate sodium (Colace)	Increase water penetration into stool	Gentle action; minimal side effects Often used preventatively Limited effectiveness alone for existing constipation Good for patients who should avoid straining
Lubricants	Mineral oil	Coat stool and intestinal mucosa to ease passage	Risk of aspiration; take upright May reduce absorption of fat-soluble vitamins Limited duration of use Not recommended for elderly or debilitated patients
Enemas/Suppositories	Glycerin suppositories, Sodium phosphate enemas	Local stimulation and softening of stool	Rapid action (15-60 minutes) For lower bowel evacuation Use cautiously in elderly (electrolyte concerns) Teaching proper administration technique is essential

Patient Education for Constipation Management

Key Educational Points

Community health nurses should provide comprehensive education on:

Normal bowel function: Variations in normal patterns and consistency
Warning signs: When to seek medical attention
Dietary fiber: Sources, gradual increase, and fluid requirements
Medication effects: Identifying constipating medications
Exercise benefits: How physical activity promotes bowel function
Toileting habits: Responding to urges and proper positioning
Proper use of laxatives: Indications, administration, potential side effects
Self-monitoring: Using bowel diaries and the Bristol Stool Scale

FIBER Mnemonic for Patient Education

Use this mnemonic to structure patient education for constipation management:

F – Fluids (adequate daily intake)
I – Increase fiber gradually
B – Bowel routine establishment
E – Exercise regularly
R – Respond promptly to urges

First Aid Management

First aid management for constipation focuses on providing immediate relief for acute constipation while assessing for complications. Community health nurses should be prepared to offer these interventions as part of comprehensive constipation management.

Immediate Relief Measures

Assessment: Confirm constipation and rule out complications requiring emergency care
Hydration: Encourage drinking 2-3 glasses of warm water
Movement: Gentle walking or light exercise to stimulate peristalsis
Abdominal massage: Gentle clockwise massage following the colon’s path
Warm bath: To relax abdominal muscles and reduce discomfort
Over-the-counter relief: Based on severity and standing orders

Urgent Situations

When to Seek Emergency Care

Advise patients to seek immediate medical attention if constipation is accompanied by:

Severe, unrelenting abdominal pain
Vomiting with abdominal distension
Inability to pass gas
High fever with constipation
Rectal bleeding with severe pain
Signs of impaction with mental status changes
Significant abdominal distention

First Aid Interventions by Severity

Severity	Presentation	First Aid Interventions
Mild	No bowel movement for 3 days Some discomfort Hard stool	Increase fluid intake (warm liquids) Add fiber-rich foods Physical activity Consider bulk-forming laxative
Moderate	No bowel movement for 4-5 days Abdominal discomfort Bloating and distention	Osmotic laxative (e.g., polyethylene glycol) Stool softener if straining Warm compress to abdomen Abdominal massage Follow up within 24 hours
Severe	No bowel movement for >5 days Significant pain Marked distention Nausea	Refer for medical evaluation Consider stimulant laxative if appropriate per protocol Glycerin or bisacodyl suppository if authorized Monitor for complications Documentation and follow-up plan
Fecal Impaction	Hard mass in rectum Liquid stool leakage around impaction Inability to pass stool despite urge	Immediate medical referral Do not administer oral laxatives Monitor vital signs Position for comfort Digital removal may be needed by trained provider

First Aid Kit for Constipation Management

Community health nurses should recommend a home first aid kit for constipation that includes:

Basic Supplies

Bulk-forming laxative
Stool softener
Glycerin suppositories
Measuring cup for fluid intake
Bristol Stool Chart

Comfort Items

Heating pad for abdominal comfort
Toilet footstool
Soothing tea (e.g., peppermint)
Comfortable clothing

Documentation Tools

Bowel movement diary
Medication log
Symptom tracker
Contact information for healthcare provider

Referral Protocols

Community health nurses must know when and how to refer patients for additional care as part of effective constipation management. Timely referrals can prevent complications and ensure appropriate treatment.

Referral Indications

Referral Type	Indications	Timeframe	Recommended Actions
Urgent Medical Referral	Severe abdominal pain Vomiting with constipation Signs of bowel obstruction Significant rectal bleeding Fever with abdominal pain	Same day	Direct to emergency department or urgent care Call ahead to alert facility Provide detailed documentation Arrange transport if needed
Primary Care Provider	Failed community interventions after 1 week Chronic, recurring constipation Recent change in bowel habits in adults >50 Need for medication adjustment Moderate symptoms not improving	Within 1-2 weeks	Schedule appointment Provide summary of interventions attempted Continue appropriate management Follow up after appointment
Gastroenterologist	Suspected structural abnormality Family history of colorectal cancer Alarm symptoms with normal initial evaluation Persistent symptoms despite primary care management	Within 2-4 weeks	Obtain referral from primary provider Compile complete medical history Document all treatments attempted Prepare patient for possible procedures
Dietitian	Difficulty implementing dietary changes Complex dietary needs (e.g., multiple conditions) Fiber intolerance Need for specialized diet plan	Within 4 weeks	Refer with specific nutrition concerns Document current dietary patterns Coordinate care with other providers Follow up on adherence to recommendations
Pelvic Floor Therapist	Symptoms of outlet dysfunction Difficulty with evacuation despite soft stool Pelvic floor dyssynergia Post-childbirth constipation	Within 4 weeks	Obtain appropriate referral Educate on pelvic floor function Prepare for biofeedback therapy Continue supportive management

Referral Documentation

Proper documentation is essential for effective constipation management referrals. Include:

Essential Documentation Elements

Duration and pattern of constipation
Complete symptom history
Bristol Stool Scale findings
Red flag assessment results
Physical assessment findings
Interventions attempted and outcomes
Current medications and relevant medical history
Specific reason for referral

Sample Referral Statement

“Referring 68-year-old female with 3-month history of progressively worsening constipation (Bristol Type 1-2). Patient reports straining, incomplete evacuation, and abdominal discomfort. Has implemented dietary changes, increased fluid intake, and tried OTC Miralax without significant improvement. Recent unintentional weight loss of 5kg in 2 months. No rectal bleeding. Requesting gastroenterology evaluation for persistent symptoms and concerning weight loss. Constipation management interventions have been ineffective.”

Post-Referral Follow-Up

Community health nurses should maintain continuity of care after referral:

Confirm patient attended referral appointment
Document specialist recommendations
Adjust community-based constipation management plan based on specialist input
Provide ongoing monitoring and support
Ensure communication between all providers involved in care
Update standing order implementation as appropriate

Prevention Strategies

Prevention is a key component of constipation management in community health nursing. Proactive strategies can reduce the incidence and recurrence of constipation.

Primary Prevention

Strategies to prevent initial occurrence:

Regular health education on bowel health
Promotion of balanced diet with adequate fiber
Hydration awareness campaigns
Physical activity promotion
Early identification of at-risk individuals
Medication review for potential constipating effects

Secondary Prevention

Early detection and management:

Routine screening in high-risk populations
Prompt intervention for early symptoms
Regular assessment of medication side effects
Bowel monitoring protocols in institutional settings
Health literacy assessment and education

Tertiary Prevention

Preventing complications and recurrence:

Comprehensive management plans for chronic cases
Regular reassessment of chronic constipation
Monitoring for complications
Adjustment of interventions based on effectiveness
Support groups for chronic constipation

Population-Based Prevention Strategies

Prevention in Children

Age-appropriate fiber intake education for parents
Toilet training techniques that don’t promote stool withholding
Regular toileting schedule, especially after meals
Education on recognizing early signs of constipation
Promotion of physical activity and play
Limiting constipating foods (excessive dairy, processed foods)
School-based education on bathroom access and privacy

Prevention in Adults

Workplace health promotion focusing on hydration and activity
Stress management techniques for gut-brain axis health
Education on dietary fiber sources and gradually increasing intake
Medication review during routine healthcare visits
Exercise prescriptions as part of routine healthcare
Travel constipation prevention strategies
Addressing cultural barriers to discussing bowel habits

Prevention in Elderly

Medication regimen review and adjustment
Mobility preservation strategies
Modified fiber recommendations based on individual needs
Dehydration prevention protocols
Bathroom accessibility assessment
Regular toileting schedule implementation
Nutritional assessment and intervention
Caregiver education on constipation recognition

Prevention in Institutional Settings

Standardized bowel monitoring protocols
Staff education on constipation prevention
Environmental modifications for proper toileting
Regular medication reviews by clinical pharmacists
Menu planning for adequate fiber and hydration
Scheduled physical activity programs
Quality improvement initiatives targeting constipation rates
Privacy provisions for toileting

PREVENT Mnemonic for Constipation Prevention

Community health nurses can use this mnemonic for constipation management prevention:

P – Physical activity daily
R – Regular toileting schedule
E – Eat fiber-rich foods
V – Volume of fluids (adequate hydration)
E – Education about bowel health
N – Note medication effects
T – Timely response to bowel urges

Special Populations

Effective constipation management requires tailored approaches for special populations with unique considerations.

Population	Special Considerations	Nursing Interventions
Pregnant Women	Hormonal changes (progesterone) relax smooth muscles Pressure from growing uterus Iron supplementation Limited medication options	Early prevention strategies Safe exercise recommendations Pregnancy-safe fiber sources Consider alternative iron preparations Avoid stimulant laxatives
Children	Toilet training issues School bathroom avoidance Dietary preferences limiting fiber Potential for withholding behaviors Different diagnostic criteria	Age-appropriate education Parent education on proper toileting Behavioral approaches Child-friendly fiber sources School nurse coordination
Older Adults	Decreased mobility Multiple medications Decreased fluid intake Cognitive impairment Higher risk of serious pathology Physiological changes in GI tract	Regular medication reviews Fall-safe mobility encouragement Toileting schedule implementation Environmental modifications Lower threshold for medical referral
Bedridden Patients	Immobility Difficulty using toilet facilities Inadequate fluid intake Higher risk of impaction Complications from constipation	Prophylactic constipation management Regular bowel program Positioning to facilitate defecation Adequate privacy provisions Passive range of motion exercises
Neurological Conditions	Impaired neurological control Autonomic dysfunction Medication effects Mobility limitations Neurogenic bowel	Specialized bowel programs Digital stimulation techniques Timed bowel regimens Assistive devices for toileting Coordinated multidisciplinary care
Palliative Care	Opioid use Decreased mobility Reduced intake Multiple medications Quality of life focus	Prophylactic laxative with opioids Balance comfort with effectiveness Gentle interventions Regular assessment Adjust goals to palliative context

Cultural Considerations in Constipation Management

Community health nurses should incorporate cultural sensitivity into constipation management:

Respect cultural beliefs around bowel habits and privacy
Adapt dietary recommendations to culturally appropriate foods
Consider cultural attitudes toward medication use
Acknowledge traditional remedies that may be effective
Use culturally appropriate language when discussing bowel function
Address potential language barriers in educational materials
Consider gender-specific concerns about discussing bowel habits

Global Best Practices in Constipation Management

Different regions have developed effective approaches to constipation management in community settings. These global practices can inform and enhance nursing care.

Nordic Countries

Approach focuses on lifestyle and prevention:

Integration of physical activity into daily routines
High-fiber traditional diets promotion
National dietary guidelines emphasizing whole grains
Public health campaigns for digestive health
School-based education on digestive health
Community health nurses leading preventive programs

Japan

Combines traditional and modern approaches:

Promotion of traditional high-fiber Japanese diet
Integration of fermented foods (probiotics)
Public toilet accessibility and design excellence
Kampo medicine (traditional herbal medicine) integration
Abdominal massage techniques (Ampuku)
Technologically advanced toilet systems supporting assessment

Australia

Emphasizes nurse-led community interventions:

Advanced practice nursing roles in gastroenterology
Nurse-led constipation clinics in community settings
Telehealth services for rural and remote areas
Standardized protocols across healthcare settings
Aboriginal health worker involvement for cultural appropriateness
Integration with aged care assessment teams

United Kingdom

Focuses on systematic community care pathways:

NICE guidelines for standardized approach
Specialist constipation nurses in community services
Bowel care pathways across healthcare settings
School nurse programs focusing on childhood constipation
Integration with pharmacist consultation services
Quality improvement initiatives measuring outcomes

“The integration of traditional wisdom with evidence-based practice creates the most effective approach to constipation management in community settings.”

Lessons for Implementation

Community health nurses can incorporate these global best practices for constipation management:

Develop culturally appropriate educational materials based on global approaches
Advocate for specialized constipation management roles within community health
Implement standardized protocols adapted from successful global models
Explore integration of traditional approaches with evidence-based practices
Develop community partnerships to address environmental and social factors
Advocate for improved public toilet accessibility and design
Create multidisciplinary approaches involving dietitians, pharmacists, and physicians
Establish quality metrics to evaluate constipation management outcomes

References

World Gastroenterology Organisation Global Guidelines. (2018). Constipation: A global perspective.
National Institute for Health and Care Excellence. (2021). Constipation in children and young people: Diagnosis and management. NICE Guideline NG99.
American Gastroenterological Association. (2013). American Gastroenterological Association medical position statement on constipation. Gastroenterology, 144(1), 211-217.
European Society for Paediatric Gastroenterology, Hepatology and Nutrition/North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. (2018). Evaluation and treatment of functional constipation in infants and children.
Bharucha, A. E., Pemberton, J. H., & Locke, G. R. (2013). American Gastroenterological Association technical review on constipation. Gastroenterology, 144(1), 218-238.
Camilleri, M., Ford, A. C., Mawe, G. M., et al. (2017). Chronic constipation. Nature Reviews Disease Primers, 3, 17095.
Joanna Briggs Institute. (2020). Best practice information sheet: Management of constipation in older adults. JBI, 24(2), 1-4.
World Health Organization. (2018). Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity.
Registered Nurses’ Association of Ontario. (2019). Assessment and management of constipation. Clinical Best Practice Guidelines.
International Continence Society. (2019). Management of chronic constipation in adults. ICS Educational Module.

Table of Contents