Blog Viewer

https://www.infirmiere-canadienne.com/blogs/ic-contenu/2026/03/16/protocole-intestinal-a-lechelle-de-lhopital

Significant reduction in constipation rates 3 days after admission to hospital

By Heather Ead
March 16, 2026

In the fast-paced hospital environment, there can be challenges that lead to negative patient outcomes, extended length of stay, and increased care costs. While it may be common knowledge that bowel health and constipation prevention is an important part of a holistic and comprehensive care plan, impaired gut motility is not an uncommon issue. Current literature indicates that there is a high prevalence of constipation and related issues, such as patient discomfort, extended length of stay, and increased workload for nursing staff in hospitals (Okusaga, Mowat, & Cook, 2022).

The following article outlines the gaps, opportunities, strategies and benefits of securing improvements in bowel health for the inpatient population in hospital settings.

The issue

While the topic of bowel health may be less appealing for patients (and health-care providers) to analyze and discuss, it has a significant role in overall wellness, recovery, and patient satisfaction. There are varying definitions of constipation, which may add to its prevalence. Constipation can include bowel movements that are “infrequent,” “unsatisfactory,” “incomplete,” “difficult” or a combination of these terms (Al Nou’mani et al., 2023). Other sources define constipation as having fewer than three bowel movements per week accompanied by uncomfortable, hard stools (Ali et al., 2025).

Across community settings, constipation is estimated to be as high as 39% (Rao & Brenner, 2021). This leads to patients being admitted to hospital settings with established constipation as a challenge, in addition to their admitting diagnosis. Further, the prevalence of constipation by day 3 of hospital admission is reported to be 43% (Al Nou’mani et al., 2023). Other studies support that there are high rates of constipation for inpatient settings, ranging from 45% to 65% (Byard, Langlois, & Tiemensam, 2025; Noumani et al., 2023). However, because the onset of constipation is frequently unrecognized, actual rates are anticipated to be upwards of 74% (Byard, Langlois, & Tiemensam, 2025). Although symptoms of constipation are documented within the patient chart, recognition of the issue and subsequent treatment can be delayed (Ali et al., 2025).

Awareness of which patient populations are at increased risk, and symptoms of impaired gastrointestinal (GI) motility (beyond the date of the last bowel movement), can help address issues earlier. For example, diarrhea can also be a symptom of overflow constipation (Ali et al., 2025). A comprehensive GI assessment should be considered as integral to the nursing care plan as vital signs, pain level, and other basic assessments. Signs and symptoms go beyond identification of the last day for a bowel movement; they also include abdominal distention, reduced bowel sounds, oozing liquid stool, rectal pressure, smaller stool size, hard stools that are difficult to pass, or the urge but inability to pass stool (Bedawy et al., 2023). The list of medications that can increase risk of constipation should also be considered when completing patient assessments (see list below).

Medications that contribute to constipation

• Antacids
• Anticholinergics
• Antidepressants
• Anticonvulsants
• Antipsychotics
• Antidiarrheals
• Antiemetics
• Antihistamines
• Antispasmodics
• Calcium channel blockers
• Calcium supplements
• Chemotherapy
• Diuretics
• General anesthesia
• Iron preparations
• Opioid analgesics
• Antiparkinsonians
• Non-steroidal anti-inflammatory drugs

Sources: Byard, Langlois, & Tiemensma (2025); Noumani et al. (2023); Registered Nurses’ Association of Ontario [RNAO] (2020).

Overall, the prevalence of constipation highlights the need for an effective, user-friendly bowel management strategy within hospital settings.

Complications

The complications resulting from the undermanagement of bowel health go well beyond patient inconvenience and discomfort. Constipation is a broadly recognized GI disorder that can impact quality of life, recovery and morbidity (Gan, 2017). The list of potential complications is lengthy and includes nausea and vomiting, abdominal distention and pain, difficulty with mobility and activities of daily living, urinary retention, bowel obstruction, ileus, straining (which may cause cardiac instability and elevated intracranial pressure), respiratory distress, exacerbation of chronic obstructive pulmonary disease (COPD), delirium, hypokalemia, and dehydration. Further, impaired bowel motility that goes unresolved can lead to the need for more costly and time-consuming rescue medications, such as sodium phosphate or Fleet Enema (Noumani et al, 2023). As noted in the following list, impaired bowel health can create a cycle that perpetuates impaired bowel motility.

The cycle of impaired bowel motility

• Surgical/medical treatment requiring hospital admission
• Medications that are associated with constipation
• Change in diet, reduced intake, NPO status, and associated reduced bowel hydration
• Nausea from surgery and/or medications leading to reduced oral intake and bowel hydration
• Reduced mobility associated with hospital admission and increased risk of constipation
• Reduced privacy with or without non-adherence/refusal of laxatives prescribed
• Perpetuation/worsening of impaired bowel motility and related complications (e.g., urinary retention, straining resulting in vasovagal event)

Sources: Bedawy et al. (2023); Byard, Langlois, & Tiemensma (2025); RNAO (2020); Roa & Brenner (2021).

Who is at increased risk?

Consideration of which patient populations are at increased risk can be helpful in guiding staff to provide individualized care. Some of the many risk factors for constipation include age (older than 65 years), frailty, diabetes mellitus, hypothyroidism, chronic renal disease, scleroderma, Parkinson’s disease, colorectal cancer, irritable bowel syndrome, major surgery (orthopaedic surgery in particular), schizophrenia, anorexia nervosa, and use of medications such as opioid analgesics and those listed under the heading “medications that contribute to constipation” above (Byard, Langlois, & Tiemensma, 2025; Noumani et al., 2023). Inflammatory states and critical illness can also add to GI dysmotility (Pachisia, Pal, & Govil, 2025).

Related article

Low-dose ketamine: overcoming stigmas to optimize pain management

With consideration to the epidemiology of constipation, it is also recognized as a diversity–equity issue. Constipation is more often found in older adults, females, Black people, and individuals with lower socioeconomic status (Byard, Langlois, & Tiemensma, 2025). Nurses have an important role in promoting awareness and access to interventions that promote bowel health, such as dietary choices, mobility (as able), and adherence to laxatives as indicated (Okusaga, Mowat, & Cook, 2020).

Considerations for seniors

Canada’s aging population means that an increasing proportion of patients arrive at hospital with short-term memory loss, dementia, and other cognitive impairments. This makes completing a bowel screening assessment more difficult. In these situations, it is even more important that the assessment and documentation is comprehensive and accurate to help identify constipation as early as possible. When needed, family and caregivers can facilitate the assessment, particularly to help with any language barriers. Providing patients and families education on bowel health in various formats can also reinforce good bowel care practices.

Treatment options and other solutions

Although there is a paucity in the literature of which laxatives are superior for the treatment of constipation, there is agreement that a structured, user-friendly and stepped approach is an important part of bowel health management within the hospital setting (Ali et al., 2025; Rao & Brenner, 2021). There are a variety of constipation assessment tools and scoring aids in use today in inpatient and outpatient settings. The following list outlines important parameters to consider when completing a constipation assessment.

Constipation assessment

• Abdominal distention/bloating
• Change in bowel sounds/flatus
• Rectal fullness or pressure
• Rectal pain with bowel movement
• Oozing liquid stool
• Small stool size (incomplete bowel movement)
• Urge but inability to pass stool

Sources: Ali et al. (2025); Wickman (2016).

Documentation of the GI assessment is commonly completed on an e-chart, which can facilitate consistency and communication to all providers. This may include drop-down options that allow the health-care provider to use descriptors, such as those found in the Bristol Stool Chart. This will facilitate early recognition of signs and symptoms of constipation (e.g., incomplete bowel movement, abdominal distention) versus solely focusing on the date of the last bowel movement (Rao & Brenner, 2021).

The Murdoch Bowel Protocol is one example of a validated tool to guide day-specific interventions, based on the GI assessment (Bedawy et al., 2023). While some of the products on various international protocols are not available in Canada, the principles of these protocols, in addition to literature reviews, were helpful in developing a bowel protocol at Trillium Health Partners. See Table 1 below.

Table 1: Adult bowel care protocol

Abbreviations: BID – twice a day; HS – before bedtime; QHS – once daily at bedtime; PEG – polyethylene glycol; PR – per rectum.

Source: Trillium Health Partners (2025), reproduced with permission.

With a standardized bowel protocol for the inpatient population, there has been a reduction in constipation rates and related discomfort at Trillium Health Partners. The medications within the bowel protocol are based on the most robust clinical evidence with respect to their efficacy and patient tolerance (Roa & Brenner, 2021). The protocol also aligns to the best practice of administering multimodal agents in a pre-emptive and proactive manner.

Benefits of a proactive approach

Following the implementation of the bowel protocol, chart audits indicate that constipation rates 72 hours after admission were reduced significantly. Before the protocol, prevalence of constipation was 75%; after, it was 20%.

Constipation onset is multifactorial and is not resolved with medications alone. Although bowel protocols may not be able to prevent all cases of constipation, they are a valuable part of a comprehensive strategy to promote bowel health. Other key steps include promotion of mobility, adequate hydration, balanced nutrition with high-fibre choices and, ideally, titrating down opioids as soon as possible (Noumani et al., 2023; Okusaga, Mowat, & Cook, 2020; Rao & Brenner, 2021).

By enacting a bowel protocol for our inpatient population, Trillium Health Partners has created a strategic and stepped approach to managing each individual’s progress in their recovery and bowel health. Consistent application of an evidence-based approach supports safety and quality care. By being proactive, we can either prevent constipation or reduce its severity. Of note, the use of preventive agents, such as polyethylene glycol (PEG) and senna, are much less costly and time consuming than more aggressive agents — such as Fleet Enema and lactulose — that may be required when interventions are delayed (Okusaga, Mowat, & Cook, 2020).

Summary

This article highlights the importance of enacting improvements in bowel health in hospital settings. By increasing awareness of the benefits of employing a bowel protocol as part of the strategy to optimize outcomes, we can proactively address this issue and secure improvements in patient care.

Constipation is a concerning issue that can lead to many complications, which can hinder recovery, reduce patient satisfaction, extend hospital length of stay, and increase related costs (Pachisia, Pal, & Govil, 2025).

References

Ali, R., Ali, J., Elwany, S. M., Abdelbaky, M. M., & Nesnawy, S. (2025). Murdoch bowel protocol and its effect on the occurrence of constipation among open heart surgery patients. Minia Scientific Nursing Journal, 17(1), 101-113. https://doi.org/10.21608/msnj.2025.352969.1155

Bedawy, F. M., Elmeligy, O. A., Mahmoud, A. A., & Abdalla, A. K. (2023). Efficacy of Murdoch bowel protocol on constipation among patients with hip and pelvic surgery. Tanta Scientific Nursing Journal, 29(3), 103-124. https://doi.org/10.21608/tsnj.2023.306356

Byard, R. W., Langlois, N. E. I., & Tiemensma, M. (2025). Forensic considerations in cases of fatal constipation. Forensic Science, Medicine and Pathology. https://doi.org/10.1007/s12024-025-00950-8

Gan, T. J. (2017). Poorly controlled postoperative pain: Prevalence, consequences, and prevention. Journal of Pain Research, 10, 2287-2298. https://doi.org/10.2147/JPR.S144066

Noumani, J., Alawi, A. M., Al-Maqbali, J. S., Abri, N., & Sabbri, M. (2023). Prevalence, recognition, and risk factors of constipation among medically hospitalized patients: A cohort prospective study. Medicina, 57(7), 1-10. https://doi.org/10.3390/medicina59071347

Okusaga, O., Mowat, R., & Cook, C. (2022). Effectiveness of early mobilization versus laxative use in reducing opioid-induced constipation in post-operative orthopaedic patients: An integrative review. Australian Journal of Advanced Nursing, 37(2), 23-35. https://doi.org/10.37464/2020.392.410

Pachisia, A. V., Pal, D., & Govil, D. (2025). Gastrointestinal dysmotility in the ICU. Current Opinion in Critical Care, 31(2), 179-188. https://doi.org/10.1097/MCC.0000000000001252

Rao, S. S. C., & Brenner, D. M. (2021). Efficacy and safety of over-the-counter therapies for chronic constipation: An updated systematic review. The American Journal of Gastroenterology, 116(6), 1156-1181. https://doi.org/10.14309/ajg.0000000000001222

Registered Nurses’ Association of Ontario. (2020). A proactive approach to bladder and bowel management in adults (4th ed.). RNAO. https://rnao.ca/sites/rnao-ca/files/bpg/Bladder_and_Bowel_Management_FINAL_WEB.pdf

Trillium Health Partners. (2025). Adult bowel care protocol. Trillium Health Partners, Mississauga, Ontario.

Wickman, R. J. (2016). Assessment of constipation in patients with cancer. Journal of the Advanced Practitioner in Oncology, 7(5), 457-462. https://www.jadpro.com/media/nqcfnknl/457.pdf

Heather Ead, RN, BScN, MHS, is a clinical educator at Trillium Health Partners in Mississauga, Ont. She can be reached by email at Heather.Ead@thp.ca.

#analysis
#clinical-practice
#nursing-practice
#pharmacare
#opioids
#quality-improvement