Project Coversheet

Date of Award


Degree Type

DNP Project

Degree Name

Doctor of Nursing (ND)




Diane Monsivais, PhD, RN, CNE, ANEF


Franchesca Nuñez, PhD, RN


This quality improvement (QI) project was an evidence-based screening and treatment algorithm for chronic constipation at a skilled nursing facility. The project aimed to decrease the occurrence of constipation using an evidence-based screening tool, Rome IV criteria for chronic constipation, and a modified algorithm for managing chronic constipation in a skilled nursing facility population setting. The project will provide skilled nursing facilities with a practical and straightforward management algorithm for patients with chronic constipation as described by Rome IV criteria.

Background During a review of bowel movement records from a 129-bed capacity nursing home with post-acute care subspecialty hospital, the data revealed no standard of care for identifying and managing chronic constipation, requiring frequent diagnostic testing and rescue laxative medications. The PICOT question was "Will the Implementation of an Evidence-Based Screening and Treatment Algorithm for Chronic Constipation in a Skilled Nursing Facility decrease the occurrence of chronic constipation"?

Methods The design methodology was an evidence-based, Plan-Do-Study-Act paradigm. The project manager performed a comprehensive literature review to identify the most appropriate guideline for chronic constipation applicable to the skilled nursing home population. The project manager used a PRISMA Flowchart (Garrard, 2017) to track the number of studies or records selected for inclusion and deemed eligible for this QI project (n = 56). The nursing staff and the project manager completed a needs gap assessment. The team reviewed 32 patient charts to check medication lists, frequency of bowel movements, and documentation of subjective evaluation of constipation complaints using the electronic health record (EHR). The project manager reviewed 32 charts and selected five patients meeting Rome IV criteria for chronic constipation as the sampling population.

Intervention The QI project made use of the Rome IV criteria for constipation. The QI initiative used a modified algorithm for chronic constipation from a peer-reviewed article by Bharucha and Lacy (2020). The project manager modified the algorithm to use interventions for the population group appropriately. The Plan-Do-Study-Act methodology was designed to analyze the outcomes of the QI project appropriately. The project manager collected data through EHR review and interviews with staff and patients. Using the modified algorithm for chronic constipation with the sampling population was provided with an increase in daily fiber and oral fluids if clinically appropriate. In determining patients' clinical response to the intervention for bowel management, clinical rounding was completed three times a week for assessment and correlating this assessment to existing documentation in the EHR.

Results An unintended positive result came from this project. Upon reviewing the EHR, a 100% improvement in the documentation was noted by nursing staff, and nursing staff verbalized their satisfaction and feeling of ownership of the project. After four weeks of following the study and using Rome IV criteria for chronic constipation and daily use of fiber and fluid intake, the project manager collected data using the same elements in Rome IV criteria for chronic constipation. The details are a combination of subjective symptoms to define constipation: the sensation of incomplete evacuation, straining, abdominal bloating, prolonged or failed attempts to move bowels, and the presence of hard stools during evacuation. We have excluded the "episode of manual disimpaction" in the Rome IV criteria due to the facility's protocol prohibiting manual stool disimpaction. The results were: 0% result documented regarding straining, abdominal bloating, or failed attempts to move bowels.

Conclusion Identification and implementation of the modified algorithm for constipation decreased episodes of symptoms of constipation from the participants of this QI project. There was also the unintended result of improvement in the documentation of bowel movements by nursing staff at the skilled nursing facility. The project guided proper assessment documentation on daily bowel movements, and staff verbalized a sense of ownership and satisfaction. Initially, the project manager identified an opportunity for improvement with documentation of some symptoms associated with constipation complaints. However, with further one-on-one training, nursing staff gained additional knowledge of screening using Rome IV criteria and the application of daily fiber and increased fluid intake for patients with chronic constipation.

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