• Constipation likely in patients who are:
  
  • immobile/less mobile than usual
  • drinking less fluid than usual 
  • eating less cereal, fruit and vegetables than usual 
  • taking prescribed opioid type medication, e.g. codeine and/or iron or post-operatively
• If taking opioids, prescribe laxatives routinely

• Enquire about usual bowel habit
• If patient from nursing/residential home and unable to provide information, request the Home-to-Hospital form 
• Enquire about laxatives from GP or bought over the counter
• Enquire about adverse effects from laxatives in the past

Routine nursing care

• Complete bowels section on nursing sheets daily
• Encourage fluids (≥1 L/day)
  
  • if patient is on restricted fluids for heart failure, may have to avoid giving >1 L/ day
• If patient usually takes laxatives at home, prescribe in hospital unless there are now contraindications

Toileting

• Ensure toileting facilities safeguard privacy and dignity 
• Transfer to toilet, if possible
• Avoid commode
• Prevent inhibition 
• Ensure privacy 
• Control noise (try to locate toilets in quieter part of ward)
• Ensure patient can easily summon help
  
  • make bell or button accessible and respond promptly
• Control odours (use air freshener if necessary)

Cautions

• In patients with suspected intestinal obstruction, ask for senior advice
  
  • take care when using laxatives of any kind 
• If haemorrhoids or anal fissure, avoid rectal preparations
• In patients with inflammatory bowel disease, colitis or Crohn’s disease, avoid macrogols

Perform digital rectal examination

• Document findings
• If rectum full of faeces, follow Faecal impaction below 
• If rectum empty, follow Bowel transit disorder below

Faecal impaction

Able to swallow

• Use oral route
• Macrogols 4 sachets on first day, then 
  
  • increase in steps of 2 sachets daily
  • maximum of 8 sachets daily
  • total daily dose to be drunk in a 6-hr period 
  • in patients with moderate to severe heart failure 2 sachets maximum in any 1 hr
  • dissolve each sachet in 125 mL water
  • use for 3 days maximum
• If faecal impaction is resolved, follow Bowel transit disorder below
• If faecal impaction is not resolved, consider Extra treatment section below 

Unable to swallow

• Follow decision algorithm below

Flowchart 1

Bowel transit disorder

• Patient constipated but rectum empty
• Address correctable factors e.g.:
  
  • diet and fluid intake
  • fibre
  • mobility
  • toilet facilities
  • medication

Unable to swallow

• If unable to swallow, discuss with consultant
  
  • if patient is very distressed by constipation, consider trial of sodium citrate enema or macrogol given via nasogastric tube

Able to swallow

• Follow Flowchart 2: Bowel transit disorder below

Flowchart 2 – Bowel transit disorder

Extra treatment

• Prescribe other laxatives singly or, if no response, in pairs e.g.:
  
  • ispaghula husk sachet, 1 twice daily, preferably at 0600 hr and 1800 hr or
  • senna 2 tablets at night (maximum dose 4 daily), or 
  • bisacodyl 5-10 mg at night, or 
  • lactulose 15 mL 12-hrly (this may take up to 24-48 hr to take effect) avoid using 2 osmotic laxatives, macrogol and lactulose at same time; also avoid using senna and bisacodyl at the same time, or 
  • docusate sodium 100 mg (up to 500 mg daily in divided doses)
• For patients with severe opioid-induced constipation, consider naloxegol 25 mg daily orally 
  
  • only prescribe on advice from the palliative care team 

Symptoms relieved

• If patient taking opioids, or with Parkinson's disease or multiple sclerosis, continue maintenance dose of the effective treatment daily indefinitely
• If patient not taking opioids, neither has Parkinson’s disease nor multiple sclerosis, further treatment is individual to each patient

Symptoms not relieved

• If patient does not respond to the above medications or 2 of them in combination, consider macrogols again