The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.
Practice Recommendations
Recommendation 1.0
Assess constipation by obtaining a client history.
(Level of Evidence = IV)
Recommendation 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 neurologic disorders, diabetes, hypothyroidism, chronic renal failure, hemorrhoids, fissures, diverticular disease, irritable bowel syndrome, previous bowel surgery, depression, dementia or acute confusion
(Level of Evidence = IV)
Recommendation 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.
(Level of Evidence = III)
Recommendation 3.1
Screen for risks of polypharmacy, including duplication of both prescription and over-the-counter drugs and their adverse effects.
(Level of Evidence = III)
Recommendation 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.
(Level of Evidence = III)
Recommendation 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.
(Level of Evidence = IV)
Recommendation 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.
(Level of Evidence = IV)
Recommendation 7.0
Fluid intake should be between 1,500 and 2,000 milliliters (ml) per day. Encourage client to take sips of fluid throughout the day and whenever possible minimize caffeinated and alcoholic beverages.
(Level of Evidence = III)
Recommendation 8.0
Dietary fibre intake should be from 25 to 30 grams of dietary fibre per day. Dietary intake of fibre should be gradually increased once the client has a consistent fluid intake of 1,500 ml per 24 hours. Consultation with a dietitian is highly recommended.
(Level of Evidence = III)
Recommendation 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.
(Level of Evidence = III)
Recommendation 9.1
A squat position should be used to facilitate the defecation process. For clients 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.
(Level of Evidence = III)
Recommendation 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.
(Level of Evidence = IV)
Recommendation 10.1
Walking is recommended for individuals who are fully mobile or who have limited mobility (15 to 20 minutes once or twice a day; 30 to 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.
(Level of Evidence = IV)
Recommendation 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.
(Level of Evidence = IV)
Recommendation 11.0
Evaluate client response and the need for on-going 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.
(Level of Evidence = IV)
Education Recommendations
Recommendation 12.0
Comprehensive education programs aimed at reducing constipation and promoting bowel health should be organized and delivered by a nurse with an interest in or advanced preparation in continence promotion (e.g., Nurse Continence Advisor, Clinical Nurse Specialist, Nurse Clinician). These programs should be aimed at all levels of health care provider, clients, and family/caregivers. To evaluate the effectiveness of the constipation program, built in evaluation mechanisms such as quality assurance and audits should be included in the planning process.
(Level of Evidence = IV)
Organization and Policy Recommendations
Recommendation 13.0
Organizations are encouraged to establish an interdisciplinary team approach to prevent and manage constipation.
(Level of Evidence = IV)
Recommendation 14.0
Nursing best practice guidelines can be effectively implemented only where there are adequate planning, resources, organizational and administrative support, as well as the appropriate facilitation of the change process by skilled facilitators. The implementation of the guideline must take into account local circumstances and should be disseminated through an active educational and training program. In this regard, Registered Nurses Association of Ontario (RNAO) (through a panel of nurses, researchers, and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines, based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of the Registered Nurses Association of Ontario Nursing Best Practice Guideline Prevention of Constipation in the Older Adult Population.
(Level of Evidence = IV)
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials
Ib Evidence obtained from at least one randomized controlled trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
