16.7 Constipation

Constipation refers to difficult bowel movements or fewer than three bowel movements in the span of a week. Although there are a variety of constipation subtypes, the most common type in children is functional constipation. Functional constipation is constipation that is not caused by an underlying disease process. Functional constipation is common in pediatric clients, especially those who are undergoing toilet training and can be triggered by a single pain inducing or frightening bowel movement. Other risk factors are dietary changes, excessive pressure from caregivers during toilet training, sexual abuse, undesirable bathroom facilities, or trauma to the perineum. Some pediatric clients will also voluntarily withhold bowel movements to not interrupt playing, which can lead to functional constipation.^[1],[2]

Pathophysiology

When bowel movements are delayed, stool starts to build up in the colon. While in the colon, more and more water is removed from the stool. Additionally, as stool builds up, the smooth muscles in the colon are overstretched and start to lose their effectiveness. This results in stools that are hard, large, and painful to expel. This can lead to further withholding of bowel movements. In chronic functional constipation, the sensation of needing to have a bowel movement is lost. This can lead to soft or liquid stool leaking around the harder stool, resulting in fecal incontinence.^[3]

Assessment (Recognizing Cues)

Physical Exam

Common signs and symptoms of functional constipation include the following^[4]:

• Infrequent bowel movements or fewer bowel movements than normal
• Pain with bowel movements
• Hardened bowel movements or bowel movements may be small and pebble-like or abnormally large
• Incomplete emptying of stool from the colon
• Abdominal pain
• Vomiting

In clients with severe functional constipation, a fecal impaction may occur, resulting in the inability to pass any stool. This could lead to a palpable mass being felt in the abdomen. A rectal exam may be performed to assess for the presence of hardened stool in the rectum. Other complications of functional constipation are the presence of rectal fissures, which can lead to bright red blood in the stool. Prolapse of the rectum, hemorrhoids, or fecal and urinary incontinence can also occur.^[5]

Common Laboratory and Diagnostic Tests

A diagnosis of functional constipation is a diagnosis of exclusion, meaning other disease processes have been ruled out as a cause. To help diagnose functional constipation, providers can use Rome IV criteria, but different criteria are used for children under and over four years of age. Based on the Rome IV criteria, pediatric clients up to four years of age can be diagnosed with functional constipation if they have fewer than two bowel movements per week or at least two of the following criteria over the past month^[6]:

• History of retaining stool
• Bowel movements are painful or hard
• History of excessively large bowel movements that may be large enough to block the toilet
• Large mass of feces is present in the rectum
• For those who are toilet trained, fecal incontinence occurs at least once a week

For those clients who are over four years of age, the Rome IV criteria state that over the past month, they must have at least two of the following symptoms^[7]:

• Fewer than two bowel movements per week
• Fecal incontinence occurs at least once a week
• History of voluntarily retaining stool
• Bowel movements are painful or hard
• Large mass of feces is present in the rectum
• Bowel movements are excessively large and may be large enough to block the toilet

Imaging studies may be ordered by a health care provider if a fecal impaction is suspected, but they are not routinely used to diagnose functional constipation.^[8]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with constipation include symptom management and the prevention of complications.

Nursing diagnoses for clients with constipation are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment. Possible nursing diagnoses for pediatric clients with constipation include the following^[9]:

• Constipation r/t voluntary retention of stool
• Acute pain r/t dry, hard or large bowel movements

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) within a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes for clients with constipation include the following^[10]:

• The client will refrain from voluntary stool retention and experience soft bowel movements that occur more than three times a week within two weeks.
• The client will verbalize the absence of pain during bowel movements within 48 hours.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Medical treatment of functional constipation consists of disimpaction, as well as maintenance therapy. Disimpaction is the removal of hard/dry stool from the colon. This can be done manually and/or by the administration of laxative suppositories or enemas. Another common option for pediatric clients is the administration of polyethylene glycol to clean out the bowels. Maintenance therapy with oral stool softeners and/or laxatives are then prescribed to keep stool soft and prevent recurring buildup of stool. After functional constipation is well-managed, the dosage of oral medications can be reduced and eventually stopped.^[11]

Lifestyle modifications can also be employed to help manage functional constipation. Children should be encouraged to consume adequate fluids and fiber and to also engage in age-appropriate physical activities. Children who have undergone toilet training should also be encouraged to establish good bowel habits by sitting on the toilet for five to ten minutes at the same time each day.^[12]

Nursing Interventions

Registered nurses develop interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client. When caring for pediatric clients with constipation, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching, as described in the following subsections.^[13],[14]

Nursing Assessments

• Assess the bowel habits of the client, including the frequency and the amount of stool passed as baseline data and throughout the course of treatment.
• Monitor for the development of complications, such as fecal impaction, anal fissures, or hemorrhoids.
• Assess for factors that may contribute to the client’s constipation such as dietary intake, perineal trauma, or stress.
• Assess stool characteristics using the Bristol Stool Scale, as this allows for consistency among caregivers. See Figure 16.12^[15] for a depiction of the Bristol Stool Scale.
• Assess the client’s abdomen for the presence of bowel sounds and distention. Bowel sounds are often decreased in those with constipation. Distension often occurs in those with chronic constipation.

Nursing Actions

• Encourage adequate fluid and fiber intake to help ensure regular bowel movements.
• Administer stool softeners, laxatives, and/or enemas per provider order.
• Perform manual disimpaction per provider order.
• Encourage the development of a bowel routine to help prevent the accumulation of stool.
• Encourage age-appropriate physical activity to encourage bowel movements.
• Ensure privacy for bowel movements when age appropriate as this can encourage relaxation.

Client Teaching

• Teach the client and their caregivers about the need for lifestyle changes, along with medications to help treat and prevent constipation.
• Teach the client and their caregivers about foods that are high in fiber such as fruits, vegetables, and whole wheat foods. Prune juice is also high in fiber and works as a natural laxative.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.