Practice Recommendations

Recommendation

Level of Evidence

 1.0 Assess constipation by obtaining a client history.

IV

2.0 Obtain information regarding:

• Usual amount and type of daily fluid intake with particular attention to the amount of caffeine and alcohol.
• Usual dietary fibre and amount of food ingested.
• Any relevant medical or surgical history which may be related to constipation such as neurological disorders, diabetes, hypothyroidism, chronic renal failure, hemorrhoids, fissures, diverticular disease, irritable bowel syndrome, previous bowel surgery, depression, dementia or acute confusion.

IV

3.0 Review the client’s medications to identify those associated with an increased risk for developing constipation, including chronic laxative use and history of laxative use.

III

3.1 Screen for risks of polypharmacy, including duplication of both prescription and over-the-counter drugs and their adverse effects.

III

4.0 Identify the client’s functional abilities related to mobility, eating and drinking, and cognitive status related to abilities to communicate needs, and follow simple instructions

III

5.0 Conduct a physical assessment of the abdomen and rectum. Assess for abdominal muscle strength, bowel sounds, abdominal mass, constipation/fecal impaction, hemorrhoids and intact anal reflex.

IV

6.0 Prior to initiating the constipation protocol, identify bowel pattern (frequency and character of stool, usual time of bowel movement), episodes of constipation and/or fecal incontinence/soiling, usual fluid and food intake (type of fluids and amounts), and toileting method through use of a 7-day bowel record/diary

IV

7.0 Fluid intake should be between 1500-2000 milliliters (ml) per day. Encourage client to take sips of fluid throughout the day and whenever possible minimize caffeinated and alcoholic beverages

III

8.0 Dietary fibre intake should be from 21 – 25 grams of dietary fibre per day. Dietary intake of fibre should be gradually increased once the client has a consistent fluid intake of 1500 ml per 24 hours.

III

9.0 Promote regular consistent toileting each day based on the client’s triggering meal. Safeguard the client’s visual and auditory privacy when toileting.

III

9.1 A squat position should be used to facilitate the defecation process. For clients III who are unable to use the toilet (e.g., bed-bound) simulate the squat position by placing the client in left-side lying position while bending the knees and moving the legs toward the abdomen.

III

10.0 Physical activity should be tailored to the individual’s physical abilities, health condition, personal preference, and feasibility to ensure adherence. Frequency, intensity and duration of exercise should be based on client’s tolerance.

IV

10.1 Walking is recommended for individuals who are fully mobile or who have limited mobility (15-20 minutes once or twice a day; or 30-60 minutes daily or 3 to 5 times per week). Ambulating at least 50 feet twice a day is recommended for individuals with limited mobility.

IV

10.2 For persons unable to walk or who are restricted to bed, exercises such as pelvic tilt, low trunk rotation and single leg lifts are recommended.

IV

11.0 Evaluate client response and the need for ongoing interventions, through the use of a bowel record that shows frequency, character and amount of bowel movement pattern, episodes of constipation/fecal soiling and use of laxative interventions (oral and rectal). Evaluate client satisfaction with bowel patterns, and client perception of goal achievement related to bowel patterns.

IV