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Patient with constipation requiring a bowel management program
OPT ONS IN PRACTCE FEATURE EDITOR: Maureen Hanlon, RN, MN, CETN
Ptions in Practice presents different management approaches to the same clinical situation. You are invited to submit a brief case description, including the specialty nursing care provided, and several glossy, color photographs of the clinical situation. The case material will then be sent to another wound, ostomy, or continence care nurse, who will also address management concerns. Alternative solutions to difficult wound, ostomy, or incontinence clinical situations will be published.
O
PATIENT WITH CONSTIPATION REQUIRING A BOWEL MANAGEMENT PROGRAM A 60-year-old Hispanic woman presented to her local emergency department after experiencing no bowel movement for 8 days. Five years previously, breast carcinoma, initially staged as T3,N4,M0, was diagnosed. Her condition was managed with a modified radical mastectomy and systemic chemotherapy after surgery. One year later she presented with chest wall recurrence, and she was found to have metastases to the ribs and thoracic spine, which were treated with external beamradiationtherapy. Because of chronic pain, she was given 240 mg of MS-Contin per day, and morphine-sulfate immediate-release 10 mg every 4 hours as needed. The patient also has a history of diabetes mellitus, which she controls with glyburide and diet. She has frequent indigestion, controlled with antacids, and takes antihistamines for allergies to mold and dust. She is a widow who lives in the southern part of Texas with her daughter. Recent radiographs have detected additional metastases to the right ischium and lumbar spine. When examined for constipation in the emergency department, the patient stated that despite the absence of a bowel movement for 8 days, she drank 8 cups of tea per day, had a good appetite, and ate three meals daily. Annette Bisanz, RN, MPH: A comprehensive patient assessment and history is crucial. The patient's current blood glucose level and hemoglobin Alc should
be determined. Patients with uncontrolled diabetes tend to lose more fluid through the kidneys because they dilute the urine to excrete glucose in the urine. This process causes dehydration of the feces and subsequent constipation. The patient's use of over-the-counter antihistamines is important, because these medications may be constipating. Antacid use could be a factor, because some over-the-counter antacids have a calcium base that contributes to constipation, whereas others have a magnesium base that contributes to loose stools. Because of her chronic pain, the patient takes a significant dosage of opiates. Opioids have two major side effects that influence fecal elimination. They increase fluid resorption from the colon and decrease peristalsis. Individuals who use opioid analgesics commonly experience constipation, and the effect is typically dose related. Because of the risk of constipation associated with opioid use, the clinician should query whether the patient is counteracting the opiate effect on the gastrointestinal tract by taking a stimulant laxative and a stool softener, and whether the dosage of these agents is sufficient. Patients who experience severe constipation caused by narcotic analgesics may take u p t o eight senna and eight docusate sodium pills per day. The amount of fiber consumed on a daily basis (30 to 40 gm is required) and the fluid intake (a minimum of 2 quarts) should be assessed. The type of food and frequency of eating has an impact on the production and transit of stool, and a knowledge of these habits provides guidance to the clinician w h e n d e t e r m i n i n g a bowel management program. The presence or absence of air- conditioning in the patient's home in south Texas also provides a clue as to the magnitude of fluid loss through her skin. A rectal exam should be conducted to determine the presence of a low impaction. A negative digital exam in a patient after 8 days without defecation indicates the presence of a high impaction in the transverse or descending colon, and the need to initiate aggressive treatment.
Annefle Bisanz, RN, MPH, is the Clinical Practice Coordinator of the Gastrointestinal Center, the University of Texas, M. D. Anderson Cancer Center in Houston. Sandra Steigerwald, RN, BSN, CRRN, is a nurse liaison at TIRR Lifebridge Hospital, Houston. Ann Gutierrez, RN, MSN, CRRN, is Program Educator at the Institute for Rehabilitation and Research in Houston. Reprint requests: Anne#e Bisanz, RN, MPH, 26 Grants Lake Circle, Sugar Land, TX77479. J WOCN 1997;24:325-9. Copyright @ 1997by the Wound, Ostomy and Continence Nurses Society. 1071-5754/97/$5.00 + 0
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Milk and molasses e n e m a recipe 8 oz Warm w a t e r 3 oz P o w d e r e d milk 4.5 oz Molasses • Put w a t e r a n d p o w d e r e d milk into a jar, • Close the jar a n d shake until the w a t e r a n d milk a p p e a r t o b e fully mixed, • A d d molasses a n d shake t h e jar again until t h e mixture a p p e a r s to h a v e an even color throughout. • Pour t h e mixture into an e n e m a b a g , Administer e n e m a high by g e n t l y int r o d u c i n g t u b e a b o u t 12 inches. D o n o t push b e y o n d resistance. R e p e a t every 6 hours until no m o r e f o r m e d stool is e l i m i n a t e d - - t h e n stop. FIGURE 1. Treatment for impacted bowel. (Copyright © 1994. Annette Bisanz, RN, and the UniversityofTexas M.D.Anderson Cancer Center. With permission.)
The impacted bowel is treated by removal of all formed stool by administering a milk and molasses enema every 6 hours at home or every 4 hours under medical supervision (Figure 1). At the same time, an oral, nonstimulating laxative (e.g., lactulose) should be given every 6 hours until all formed stool has been evacuated. The laxative is indicated because it stimulates the bowel to push fecal material from the u p p e r to lower gastrointestinal tract, while the enemas eliminate stool from the lower tract. It m a y take 1 to 3 days of enemas and oral laxatives to e m p t y the large bowel of its impaction. It is important not to stop treatment after the passage of one large stool, because this will n o t completely eliminate the impacted stool from the gastrointestinal system. Once the large bowel is completely relieved of formed stool the patient should receive an appropriate bowel management program. For this patient, the constipating effect of the opiate analgesics should be counteracted by administering stool softeners. I recommend 100 mg of docusate sodium, beginning with two tablets per day, and titrating the dosage up to eight per day as indicated. If the patients is found
to live in a non-air- conditioned environment, I would recommended starting with four capsules of docusate sodium per day, and rapidly titrating up to eight tablets per day if her stool remains hardened. A peristaltic stimulant, senna (Senokot), should be administered. The dosage can be titrated to a level that ensures adequate peristalsis for a bowel movement. Given the dosage of opiates she must use for pain control, I recommend starting with two tablets every morning and two tablets in the evening. In addition to adding a peristaltic stimulant and stool softener, insoluble fiber (psyllium in medicinal form) should be introduced to help the patient achieve a formed, soft stool. The fiber must be gradually introduced to avoid severe cramping or diarrhea. However, psyllium should be avoided if the patient is unable to drink the volume of fluids needed to achieve a soft, formed stool. Each dosage of the psyllium is given in 8 ounces of fluid, and should be followed by another 8 ounces of fluid. She should be advised to drink at least 2 quarts of fluid daily; nonetheless, more than this quantity may be needed during the summer if her house is not air-conditioned. The patient should be advised to change any calcium-based antacids to magnesium-based antacids. In addition, her serum and urine glucose levels should be monitored, and the importance of controlling her diabetes emphasized to minimize the dehydrating effect of glucosuria on her stool. Defecation m a y be stimulated by administering prune juice before a meal, followed by a hot liquid after the meal. If this m a n e u v e r - - i n combination with the bowel m a n a g e m e n t p r o g r a m outlined--is not successful, the patient m a y benefit from a bowel training p r o g r a m (Figure 2). If the doctor identifies a poor prognosis and limited life expectancy, the bowel management program should be changed to realistically meet the defecation needs only, and bowel training is not advised. If the patient consumes three large meals per day, the patient should have one bowel m o v e m e n t per day. If the patient is eating half the normal intake, expect a bowel movement every other day. If the patient's intake is one third the normal intake, a bowel m o v e m e n t every third day is sufficient. If no bowel movement has occurred on the day a bowel movement is expected,
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Bowel Training Program for patients with constipation Goal: The patient will empty the large bowel of soft, formed stool one time per day at the same time e a c h day following the bowel training program. Basic concepts regarding bowel training: (1) Bowel training should staff 3 days after emptying the bowel of stool through taking oral laxatives or enemas. (25 Once bowel training staffs, oral laxatives are not allowed. (3) Bowel training must be centered around a large meal since that is when everything moves down normally in the gastrointestinal tract. (4) Bowel training must occur at the same time every day. (5) This is a program for life. Once bowel training is completed, the same process occurs with the exception of inserting a bisacodyl suppository. (6) Any problems with the program should be referred to a resource that can recommend an appropriate alteration in the program that will meet your individual need. This program is successful if you consistently follow it. Procedure for bowel training: (1) Before the big meal of your choice, drink four (4) ounces of prune juice. (2) Eat a big meal. (3) Drink a warm liquid. (4) Insert a bisacodyl suppository and make sure it is pushed against the mucous membrane of the intestine. Do this for 14 days and on day 15 substitute a glycerin suppository. (5) Record results. (6) Make sure you take a minimum of two (2) quaffs of fluid a day, e a t fiber in the diet, and take no oral laxatives o n c e the bowel training is staffed. You may take stool softeners for hard stools. Alterations in the program: (1) If you have a problem responding to the glycerin suppository, insert the bisacodyl suppository for one (1) more week and try the glycerin again. (2) If the rectal sphincter muscle is too tight, massage around the rectal opening to relax the muscle for easy passage of stool. (3) If the outcome of the program is not w h a t is desired, you may alter the program by making one c h a n g e at a time and persisting for three (3) days on that plan to determine the results. For example: a. If you have diarrhea or extra stools during the day: 1. Decrease the amount of prune juice to two (2) ounces. 2. Cut the bisacodyl suppository in half and insert only 1/2a suppository. b. If you are still exhibiting constipation: 1. Add stool softeners. 2. You may a d d five (5) prunes the night before. 3. Increase the fluid intake. 4. Increase the fiber content of the diet. 5. Increase activity. Remember: Only one c h a n g e listed a b o v e at a time. Persist for three (3) days before making any further changes. These are the basic guidelines for bowel training. Each person, however, responds differently based on individual b o d y reaction to the program. People are bowel trained for different reasons: some with constipation and others with loose stools. An initial assessment by an experienced nurse is the first step toward individualizing the program for you. Following that, your Bowel Training Program is altered based on your individual response.
CONSULTATION FROM A NURSE AT THE BEGINNING IS ESSENTIAL TO A SUCCESSFUL PROGRAM.
FIGURE 2. Bowel training program. (Copyright © 1994. Annette Bisanz, RN, and the Universityof Texas M.D. Anderson Cancer Center. With permission.) a laxative of choice should be administered. I have found that Sorbitol (lactulose) is very mild in its effect and produces good results. Sandy Steigerwald, RN, BSN, CRRN, and Ann Gutierrez, RN, MSN, CRRN: As rehabilitation nurses, we find that problems with bowel elimination occur in almost all of our patients. A major factor
in this problem is the alteration in mobility that is so often seen in patients being rehabilitated. External factors such as diet, water intake, and medications help to relieve constipation, but are often not sufficient to resolve constipation in the patient with significantly impaired mobility. In this patient, cancer-related pain may severely limit her physical activity.
328
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Table. Common sources of dietary fiber Grains Whole grain cereals Breads Bran Oats Wheat Rye Granola
Fruits Raisins Oranges Tangerines Plums Apples
Vegetables Lettuce Spinach Broccoli Squash Cauliflower
In addition, because high doses of narcotic analgesics are required for pain management, she is at increased risk for falling as a result of poor balance, altered perception, diminished safety awareness, and impaired judgment. Thus her needs for mobility must be accomplished in a manner that also prevents falls or secondary injuries. In the rehabilitation setting, this patient would be assessed by an interdisciplinary team. The rehabilitation nurse is the primary team member responsible for planning and implementing a successful bowel program with patients and their families. As previously stated, planning starts with a t h o r o u g h evaluation. In addition to obtaining the information outlined by Annette Bisanz, I would recommend evaluation of the physical layout of the patient's home, including the number of levels, steps to get into the house, and whether there are potential or actual barriers to accessing toileting facilities. The evaluation should include activities of daily living, mobility level, and any history of falls, confusion, and numbness or tingling of the extremities. This information helps the multidisciplinary team identify the best management plan for this patient's severe constipation. For this client, the physician may order magnetic resonance imaging of the thoracic and lumbar spine to assess for spinal lesions or lesions causing a neurogenic bowel. The dietitian assists the team by identifying the nutritional requirements of the patient, as well as fiber and water needs. The pharmacist helps in identifying drug interactions that may further constipation. The physical therapist can assist the patient to develop an appropriate exercise program and safe techniques for mobility. In this patient's case,
safety would become a major concern if the spine has been compromised secondary to metastases. The occupational therapist can help to identify adaptive devices to help the individual in managing the act of defecation (e.g., raised toilet seat, bedside commode, safety bars). The assessments of the interdisciplinary team are then combined to develop an individualized treatment plan for the patient. Physical activity or exercise is essential to stimulate defecation. This can be accomplished easily in a rehabilitation setting during therapy settings. Ambulating short distances in the home care setting m a y be sufficient to stimulate defecation. If the patient needs an assistive device for ambulating in a safe manner, or i s a t risk for falling due to altered perception, the nurse should reinforce the importance of those safety issues with the patient and family. If walking is painful for the patient, then exercise m u s t be altered to incorporate the patient's physical limitations. Simple bed exercises not only stimulate the bowel, they also increase endurance. Heel slides, bridges, and hip abductions or adductions are exercises that can be done in a bed. Twenty-two to 30 repetitions daily will help with endurance and bowel stimulation. A sitting program is an important daily activity that will further enhance bowel evacuation. The ability to sit up safely and long enough (15 to 20 minutes) allows gravity to assist in peristalsis and stool expulsion. The immediate goat for this patient is to relieve a probable high impaction. Auscultation of the abdominal quadrants is essential, because a hypoactive bowel m a y indicate a megacolon and a high impaction. Abdominal distention and a hard abdomen are also possible signs of constipation. A plain abdominal film (KUB) would be requested for clinical correlation. Once constipation is confirmed, the patient would be administered a SMOG enema. This enema, p r e p a r e d b y the pharmacist, includes equal parts (300 ml each) saline solution, mineral oil, and glycerin (SMOG). We have found this to be very effective in cleansing the bowel over a 24- hour period. If the s y m p t o m s of constipation persist, another SMOG enema w o u l d be administered, and a follow-up KUB would be performed to ensure that the bowel was clean. Once the bowel is clean, a daily bowel p r o g r a m is instituted to prevent future
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problems. This patient might be given Peri-Colace 100 m g twice a day and a Dulcolax suppository daily. Timing of the suppository would be determined by the patient and her schedule at home. Milk of Magnesia could be taken if there were no results for the ongoing bowel p r o g r a m for 2 days, or if other s y m p toms of recurrent constipation such as abdominal distention or discomfort occur. The following m n e m o n i c - - " S E L F ' - can remind the patient and caregiver of the elements of a successful bowel control program.
"S" [] S c h e d u l e All factors involved, including medications, evacuations, and exercise should follow a schedule so that they w o r k together. The bowel medications taken by m o u t h m u s t be t i m e d to w o r k w h e n a suppository is due. S-elect a time to carry out the bowel p r o g r a m that is most conv e n i e n t for the p a t i e n t ' s schedule at home.
"E" = Exercise Exercise includes all normal activity as well as following the exercise program designed for the patient. Any increase or decrease in the patient's activity prog r a m might cause changes in the movement of bowel contents. Long periods of time in bed can result in constipation and require adjustments in the usual daily routine. Our therapists suggest ambulating a minimum of 150 feet several times each day (5 to 6 times if possible)--as the patient can tolerate. As noted earlier, if ambulation is not an option because of other factors such as pain, general debility, or safety issues, then bed exercises will meet the patient's needs to help stimulate the bowel and improve endurance.
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"L" = Liquids H o w m u c h liquid is as important as what type of liquid the patient drinks. Caffeinated beverages such as coffee will generally increase bowel activity, and p r u n e or apricot nectar help p r o m o t e bowel regularity. Whenever possible, the patient should be encouraged to drink at least 2400 ml (4 to 5 pints) of liquid daily to keep stools soft. A hot drink stimulates peristalsis, so we would not discourage all the cups of tea the patient drinks. We would, however, encourage her to time her tea-drinking to coincide with her first meal of the day. Bowel results are usually best after the first meal of the day.
"F" : Fiber Tracking the patient's diet over 3 days will aid in determining which foods are constipating or stimulating. It is important to understand the cultural indications of diet. The traditional foods found in the Hispanic culture are high in starches and fats and low in fiber. Foods high in fat are slower to digest and slowdown transit. It also is crucial to help the patient identify those foods that are affecting the consistency of the stool, and restore balance by adding or subtracting certain foods. The r e c o m m e n d e d daily fiber needed is 35 gm. Examples of foods high in fiber are found in the Table. Other factors that can affect a bowel routine include emotional stress, positioning, psychologic factors, privacy, and timing. Each patient requires an individualized p r o g r a m that takes into account all the contributing factors resulting in constipation. The patient often wonders whether a normal routine can ever be established, but it is usually possible when a reasonable, reliable bowel p r o g r a m is developed.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the Journal of WOCN are available to subscribers (only) for the 1997 issues from the Publisher, at a cost of $38.00 for domestic, $48.15 for Canadian, and $45.00 for international subscribers for Vol. 24 (January-November). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after the publication of the last issue of the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA; phone 800-453-4351 or 314-4534351.
Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.
Ptions in Practice presents different management approaches to the same clinical situation. You are invited to submit a brief case description, including the specialty nursing care provided, and several glossy, color photographs of the clinical situation. The case material will then be sent to another wound, ostomy, or continence care nurse, who will also address management concerns. Alternative solutions to difficult wound, ostomy, or incontinence clinical situations will be published.
O
PATIENT WITH CONSTIPATION REQUIRING A BOWEL MANAGEMENT PROGRAM A 60-year-old Hispanic woman presented to her local emergency department after experiencing no bowel movement for 8 days. Five years previously, breast carcinoma, initially staged as T3,N4,M0, was diagnosed. Her condition was managed with a modified radical mastectomy and systemic chemotherapy after surgery. One year later she presented with chest wall recurrence, and she was found to have metastases to the ribs and thoracic spine, which were treated with external beamradiationtherapy. Because of chronic pain, she was given 240 mg of MS-Contin per day, and morphine-sulfate immediate-release 10 mg every 4 hours as needed. The patient also has a history of diabetes mellitus, which she controls with glyburide and diet. She has frequent indigestion, controlled with antacids, and takes antihistamines for allergies to mold and dust. She is a widow who lives in the southern part of Texas with her daughter. Recent radiographs have detected additional metastases to the right ischium and lumbar spine. When examined for constipation in the emergency department, the patient stated that despite the absence of a bowel movement for 8 days, she drank 8 cups of tea per day, had a good appetite, and ate three meals daily. Annette Bisanz, RN, MPH: A comprehensive patient assessment and history is crucial. The patient's current blood glucose level and hemoglobin Alc should
be determined. Patients with uncontrolled diabetes tend to lose more fluid through the kidneys because they dilute the urine to excrete glucose in the urine. This process causes dehydration of the feces and subsequent constipation. The patient's use of over-the-counter antihistamines is important, because these medications may be constipating. Antacid use could be a factor, because some over-the-counter antacids have a calcium base that contributes to constipation, whereas others have a magnesium base that contributes to loose stools. Because of her chronic pain, the patient takes a significant dosage of opiates. Opioids have two major side effects that influence fecal elimination. They increase fluid resorption from the colon and decrease peristalsis. Individuals who use opioid analgesics commonly experience constipation, and the effect is typically dose related. Because of the risk of constipation associated with opioid use, the clinician should query whether the patient is counteracting the opiate effect on the gastrointestinal tract by taking a stimulant laxative and a stool softener, and whether the dosage of these agents is sufficient. Patients who experience severe constipation caused by narcotic analgesics may take u p t o eight senna and eight docusate sodium pills per day. The amount of fiber consumed on a daily basis (30 to 40 gm is required) and the fluid intake (a minimum of 2 quarts) should be assessed. The type of food and frequency of eating has an impact on the production and transit of stool, and a knowledge of these habits provides guidance to the clinician w h e n d e t e r m i n i n g a bowel management program. The presence or absence of air- conditioning in the patient's home in south Texas also provides a clue as to the magnitude of fluid loss through her skin. A rectal exam should be conducted to determine the presence of a low impaction. A negative digital exam in a patient after 8 days without defecation indicates the presence of a high impaction in the transverse or descending colon, and the need to initiate aggressive treatment.
Annefle Bisanz, RN, MPH, is the Clinical Practice Coordinator of the Gastrointestinal Center, the University of Texas, M. D. Anderson Cancer Center in Houston. Sandra Steigerwald, RN, BSN, CRRN, is a nurse liaison at TIRR Lifebridge Hospital, Houston. Ann Gutierrez, RN, MSN, CRRN, is Program Educator at the Institute for Rehabilitation and Research in Houston. Reprint requests: Anne#e Bisanz, RN, MPH, 26 Grants Lake Circle, Sugar Land, TX77479. J WOCN 1997;24:325-9. Copyright @ 1997by the Wound, Ostomy and Continence Nurses Society. 1071-5754/97/$5.00 + 0
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Milk and molasses e n e m a recipe 8 oz Warm w a t e r 3 oz P o w d e r e d milk 4.5 oz Molasses • Put w a t e r a n d p o w d e r e d milk into a jar, • Close the jar a n d shake until the w a t e r a n d milk a p p e a r t o b e fully mixed, • A d d molasses a n d shake t h e jar again until t h e mixture a p p e a r s to h a v e an even color throughout. • Pour t h e mixture into an e n e m a b a g , Administer e n e m a high by g e n t l y int r o d u c i n g t u b e a b o u t 12 inches. D o n o t push b e y o n d resistance. R e p e a t every 6 hours until no m o r e f o r m e d stool is e l i m i n a t e d - - t h e n stop. FIGURE 1. Treatment for impacted bowel. (Copyright © 1994. Annette Bisanz, RN, and the UniversityofTexas M.D.Anderson Cancer Center. With permission.)
The impacted bowel is treated by removal of all formed stool by administering a milk and molasses enema every 6 hours at home or every 4 hours under medical supervision (Figure 1). At the same time, an oral, nonstimulating laxative (e.g., lactulose) should be given every 6 hours until all formed stool has been evacuated. The laxative is indicated because it stimulates the bowel to push fecal material from the u p p e r to lower gastrointestinal tract, while the enemas eliminate stool from the lower tract. It m a y take 1 to 3 days of enemas and oral laxatives to e m p t y the large bowel of its impaction. It is important not to stop treatment after the passage of one large stool, because this will n o t completely eliminate the impacted stool from the gastrointestinal system. Once the large bowel is completely relieved of formed stool the patient should receive an appropriate bowel management program. For this patient, the constipating effect of the opiate analgesics should be counteracted by administering stool softeners. I recommend 100 mg of docusate sodium, beginning with two tablets per day, and titrating the dosage up to eight per day as indicated. If the patients is found
to live in a non-air- conditioned environment, I would recommended starting with four capsules of docusate sodium per day, and rapidly titrating up to eight tablets per day if her stool remains hardened. A peristaltic stimulant, senna (Senokot), should be administered. The dosage can be titrated to a level that ensures adequate peristalsis for a bowel movement. Given the dosage of opiates she must use for pain control, I recommend starting with two tablets every morning and two tablets in the evening. In addition to adding a peristaltic stimulant and stool softener, insoluble fiber (psyllium in medicinal form) should be introduced to help the patient achieve a formed, soft stool. The fiber must be gradually introduced to avoid severe cramping or diarrhea. However, psyllium should be avoided if the patient is unable to drink the volume of fluids needed to achieve a soft, formed stool. Each dosage of the psyllium is given in 8 ounces of fluid, and should be followed by another 8 ounces of fluid. She should be advised to drink at least 2 quarts of fluid daily; nonetheless, more than this quantity may be needed during the summer if her house is not air-conditioned. The patient should be advised to change any calcium-based antacids to magnesium-based antacids. In addition, her serum and urine glucose levels should be monitored, and the importance of controlling her diabetes emphasized to minimize the dehydrating effect of glucosuria on her stool. Defecation m a y be stimulated by administering prune juice before a meal, followed by a hot liquid after the meal. If this m a n e u v e r - - i n combination with the bowel m a n a g e m e n t p r o g r a m outlined--is not successful, the patient m a y benefit from a bowel training p r o g r a m (Figure 2). If the doctor identifies a poor prognosis and limited life expectancy, the bowel management program should be changed to realistically meet the defecation needs only, and bowel training is not advised. If the patient consumes three large meals per day, the patient should have one bowel m o v e m e n t per day. If the patient is eating half the normal intake, expect a bowel movement every other day. If the patient's intake is one third the normal intake, a bowel m o v e m e n t every third day is sufficient. If no bowel movement has occurred on the day a bowel movement is expected,
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Bowel Training Program for patients with constipation Goal: The patient will empty the large bowel of soft, formed stool one time per day at the same time e a c h day following the bowel training program. Basic concepts regarding bowel training: (1) Bowel training should staff 3 days after emptying the bowel of stool through taking oral laxatives or enemas. (25 Once bowel training staffs, oral laxatives are not allowed. (3) Bowel training must be centered around a large meal since that is when everything moves down normally in the gastrointestinal tract. (4) Bowel training must occur at the same time every day. (5) This is a program for life. Once bowel training is completed, the same process occurs with the exception of inserting a bisacodyl suppository. (6) Any problems with the program should be referred to a resource that can recommend an appropriate alteration in the program that will meet your individual need. This program is successful if you consistently follow it. Procedure for bowel training: (1) Before the big meal of your choice, drink four (4) ounces of prune juice. (2) Eat a big meal. (3) Drink a warm liquid. (4) Insert a bisacodyl suppository and make sure it is pushed against the mucous membrane of the intestine. Do this for 14 days and on day 15 substitute a glycerin suppository. (5) Record results. (6) Make sure you take a minimum of two (2) quaffs of fluid a day, e a t fiber in the diet, and take no oral laxatives o n c e the bowel training is staffed. You may take stool softeners for hard stools. Alterations in the program: (1) If you have a problem responding to the glycerin suppository, insert the bisacodyl suppository for one (1) more week and try the glycerin again. (2) If the rectal sphincter muscle is too tight, massage around the rectal opening to relax the muscle for easy passage of stool. (3) If the outcome of the program is not w h a t is desired, you may alter the program by making one c h a n g e at a time and persisting for three (3) days on that plan to determine the results. For example: a. If you have diarrhea or extra stools during the day: 1. Decrease the amount of prune juice to two (2) ounces. 2. Cut the bisacodyl suppository in half and insert only 1/2a suppository. b. If you are still exhibiting constipation: 1. Add stool softeners. 2. You may a d d five (5) prunes the night before. 3. Increase the fluid intake. 4. Increase the fiber content of the diet. 5. Increase activity. Remember: Only one c h a n g e listed a b o v e at a time. Persist for three (3) days before making any further changes. These are the basic guidelines for bowel training. Each person, however, responds differently based on individual b o d y reaction to the program. People are bowel trained for different reasons: some with constipation and others with loose stools. An initial assessment by an experienced nurse is the first step toward individualizing the program for you. Following that, your Bowel Training Program is altered based on your individual response.
CONSULTATION FROM A NURSE AT THE BEGINNING IS ESSENTIAL TO A SUCCESSFUL PROGRAM.
FIGURE 2. Bowel training program. (Copyright © 1994. Annette Bisanz, RN, and the Universityof Texas M.D. Anderson Cancer Center. With permission.) a laxative of choice should be administered. I have found that Sorbitol (lactulose) is very mild in its effect and produces good results. Sandy Steigerwald, RN, BSN, CRRN, and Ann Gutierrez, RN, MSN, CRRN: As rehabilitation nurses, we find that problems with bowel elimination occur in almost all of our patients. A major factor
in this problem is the alteration in mobility that is so often seen in patients being rehabilitated. External factors such as diet, water intake, and medications help to relieve constipation, but are often not sufficient to resolve constipation in the patient with significantly impaired mobility. In this patient, cancer-related pain may severely limit her physical activity.
328
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Table. Common sources of dietary fiber Grains Whole grain cereals Breads Bran Oats Wheat Rye Granola
Fruits Raisins Oranges Tangerines Plums Apples
Vegetables Lettuce Spinach Broccoli Squash Cauliflower
In addition, because high doses of narcotic analgesics are required for pain management, she is at increased risk for falling as a result of poor balance, altered perception, diminished safety awareness, and impaired judgment. Thus her needs for mobility must be accomplished in a manner that also prevents falls or secondary injuries. In the rehabilitation setting, this patient would be assessed by an interdisciplinary team. The rehabilitation nurse is the primary team member responsible for planning and implementing a successful bowel program with patients and their families. As previously stated, planning starts with a t h o r o u g h evaluation. In addition to obtaining the information outlined by Annette Bisanz, I would recommend evaluation of the physical layout of the patient's home, including the number of levels, steps to get into the house, and whether there are potential or actual barriers to accessing toileting facilities. The evaluation should include activities of daily living, mobility level, and any history of falls, confusion, and numbness or tingling of the extremities. This information helps the multidisciplinary team identify the best management plan for this patient's severe constipation. For this client, the physician may order magnetic resonance imaging of the thoracic and lumbar spine to assess for spinal lesions or lesions causing a neurogenic bowel. The dietitian assists the team by identifying the nutritional requirements of the patient, as well as fiber and water needs. The pharmacist helps in identifying drug interactions that may further constipation. The physical therapist can assist the patient to develop an appropriate exercise program and safe techniques for mobility. In this patient's case,
safety would become a major concern if the spine has been compromised secondary to metastases. The occupational therapist can help to identify adaptive devices to help the individual in managing the act of defecation (e.g., raised toilet seat, bedside commode, safety bars). The assessments of the interdisciplinary team are then combined to develop an individualized treatment plan for the patient. Physical activity or exercise is essential to stimulate defecation. This can be accomplished easily in a rehabilitation setting during therapy settings. Ambulating short distances in the home care setting m a y be sufficient to stimulate defecation. If the patient needs an assistive device for ambulating in a safe manner, or i s a t risk for falling due to altered perception, the nurse should reinforce the importance of those safety issues with the patient and family. If walking is painful for the patient, then exercise m u s t be altered to incorporate the patient's physical limitations. Simple bed exercises not only stimulate the bowel, they also increase endurance. Heel slides, bridges, and hip abductions or adductions are exercises that can be done in a bed. Twenty-two to 30 repetitions daily will help with endurance and bowel stimulation. A sitting program is an important daily activity that will further enhance bowel evacuation. The ability to sit up safely and long enough (15 to 20 minutes) allows gravity to assist in peristalsis and stool expulsion. The immediate goat for this patient is to relieve a probable high impaction. Auscultation of the abdominal quadrants is essential, because a hypoactive bowel m a y indicate a megacolon and a high impaction. Abdominal distention and a hard abdomen are also possible signs of constipation. A plain abdominal film (KUB) would be requested for clinical correlation. Once constipation is confirmed, the patient would be administered a SMOG enema. This enema, p r e p a r e d b y the pharmacist, includes equal parts (300 ml each) saline solution, mineral oil, and glycerin (SMOG). We have found this to be very effective in cleansing the bowel over a 24- hour period. If the s y m p t o m s of constipation persist, another SMOG enema w o u l d be administered, and a follow-up KUB would be performed to ensure that the bowel was clean. Once the bowel is clean, a daily bowel p r o g r a m is instituted to prevent future
JWOCN Volume 24, Number 6
Bisanz, Steigerwald, and Gutierrez
problems. This patient might be given Peri-Colace 100 m g twice a day and a Dulcolax suppository daily. Timing of the suppository would be determined by the patient and her schedule at home. Milk of Magnesia could be taken if there were no results for the ongoing bowel p r o g r a m for 2 days, or if other s y m p toms of recurrent constipation such as abdominal distention or discomfort occur. The following m n e m o n i c - - " S E L F ' - can remind the patient and caregiver of the elements of a successful bowel control program.
"S" [] S c h e d u l e All factors involved, including medications, evacuations, and exercise should follow a schedule so that they w o r k together. The bowel medications taken by m o u t h m u s t be t i m e d to w o r k w h e n a suppository is due. S-elect a time to carry out the bowel p r o g r a m that is most conv e n i e n t for the p a t i e n t ' s schedule at home.
"E" = Exercise Exercise includes all normal activity as well as following the exercise program designed for the patient. Any increase or decrease in the patient's activity prog r a m might cause changes in the movement of bowel contents. Long periods of time in bed can result in constipation and require adjustments in the usual daily routine. Our therapists suggest ambulating a minimum of 150 feet several times each day (5 to 6 times if possible)--as the patient can tolerate. As noted earlier, if ambulation is not an option because of other factors such as pain, general debility, or safety issues, then bed exercises will meet the patient's needs to help stimulate the bowel and improve endurance.
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"L" = Liquids H o w m u c h liquid is as important as what type of liquid the patient drinks. Caffeinated beverages such as coffee will generally increase bowel activity, and p r u n e or apricot nectar help p r o m o t e bowel regularity. Whenever possible, the patient should be encouraged to drink at least 2400 ml (4 to 5 pints) of liquid daily to keep stools soft. A hot drink stimulates peristalsis, so we would not discourage all the cups of tea the patient drinks. We would, however, encourage her to time her tea-drinking to coincide with her first meal of the day. Bowel results are usually best after the first meal of the day.
"F" : Fiber Tracking the patient's diet over 3 days will aid in determining which foods are constipating or stimulating. It is important to understand the cultural indications of diet. The traditional foods found in the Hispanic culture are high in starches and fats and low in fiber. Foods high in fat are slower to digest and slowdown transit. It also is crucial to help the patient identify those foods that are affecting the consistency of the stool, and restore balance by adding or subtracting certain foods. The r e c o m m e n d e d daily fiber needed is 35 gm. Examples of foods high in fiber are found in the Table. Other factors that can affect a bowel routine include emotional stress, positioning, psychologic factors, privacy, and timing. Each patient requires an individualized p r o g r a m that takes into account all the contributing factors resulting in constipation. The patient often wonders whether a normal routine can ever be established, but it is usually possible when a reasonable, reliable bowel p r o g r a m is developed.
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