Clarify the person's understanding of the problem, and confirm the diagnosis of constipation:

• What does the person believe to be normal bowel movements?
• What is their normal pattern of defecation?
• When did constipation first become a problem?
• If constipation pre-dates the illness requiring palliative care, further enquiry may be indicated.
• What is the frequency and character of stools, and how have they changed?
• What is the frequency of defecation now, and what was it before constipation became a problem?
• Are stools sometimes loose, or are they soft and formed?
• Loose stools are not always due to diarrhoea; they may be the result of an excessively high dose of laxatives, or they may be from colonic contents soft enough to bypass hard impacted faeces.
• Ribbon-like stools suggest haemorrhoids or anal stenosis or irritable bowel syndrome.
• Are they always hard?
• Are they large (e.g. do they sometimes block the toilet)? Or, are they small, like pebbles?
• Is there discomfort with defecation?
• Is there blood or mucus with the stool?
• Suggests haemorrhoids, tumour, or colitis.
• Is straining necessary?
• Stool emerging partway through a bulging anal outlet after significant straining suggests haemorrhoids.
• Ineffective straining suggests faecal loading/impaction.

Assess the presence and degree of faecal loading/impaction and faecal incontinence:

• Can faecal masses be felt when palpating the lower left abdomen or when examining the rectum?
• Is there faecal incontinence, or loose stools?
• Have manual measures been necessary to relieve faecal loading/impaction?
• A finger having to be inserted into the vagina suggests a rectocele.
• A finger in the rectum to push away a flap suggests a rectal ulcer.
• Pressure behind the anus assists defecation if the levator muscles are weak.
• Digital rectal evacuation of faeces confirms severe faecal loading/impaction.

Assess the severity and impact of the constipation and, if present, faecal incontinence:

• Is there nausea, vomiting, loss of appetite, or loss of body weight?
• Is there abdominal pain or abdominal distension?
• Is there pain or bleeding with passing stools?
• Is underwear regularly and involuntarily soiled? If yes, what are the social consequences of this?

Assess the role (and potential for modification) of predisposing factors and drugs:

• Is the diet adequate, especially in terms of fibre. Is the person dehydrated?
• Is access to the toilet difficult? Is there a lack of privacy (auditory and visual)?
• Is mobility significantly restricted?
• Is the person using opiates or other constipating drugs?

Identify any direct effects of malignant tumour or other concurrent disease that could cause constipation:

• Does the person have a history or features of:
• Obstructive colonic mass lesions (e.g. colorectal cancer)?
• Careful examination can usually distinguish a faecal mass from a tumour or cyst: firm pressure exerted by a finger will leave a palpable indentation in hard faeces.
• Damage to the spinal cord or nerve supply of the gut.
• An endocrine or metabolic disease, a myopathic condition, a neurological disease?
• Irritable bowel syndrome?
• Anal fissure, haemorrhoids, rectal prolapse, or rectocele?
• Colonic strictures (following diverticulitis, ischaemia, surgery)?
• Inflammatory bowel disease?
• Pelvic floor dyssynergia?
• Having to strain, feeling of incomplete evacuation.

Assess effectiveness of management to date:

• What measures (self-care and prescribed, non-drug and drug) have been tried?
• What has been the response?

[Sykes, 2004]