A Quick Guide to Constipation

Constipation Definition

Constipation is defined as stools that are usually hard, dry, small in size, and difficult to eliminate. It may be painful to have a bowel movement and can include straining, bloating, and the sensation of a full bowel. Understanding its causes, prevention, and treatment will help most people find relief.

Causes

• Medication
• Dietary
• Inadequate fluid intake
• Lack of physical activity
• Disease process (especially abdomen cancers)
• Psychological

Assessment

• History of constipation
• Precipitating/relieving factors
• Last bowel movement (LBM) and usual bowel pattern
• Fluid and dietary intake
• Disease process (abdominal disease, abdominal radiation treatment, decreased fluid and dietary intake, decreased activity)
• Medications (esp. Opioids, Anticholinergics, Tricyclic antidepressants, Scopolamine, Oxybutinin, Promethazine, Diphenhydramine), Lithium, Verapamil, Bismuth, Iron, Aluminum, Calcium salts.)
• Associated symptoms (weakness, nausea, restlessness, CNS changes,
• pain/cramping)
• Anxiety
• Social concerns
• Spiritual concerns
• Impact on functionality, quality of life

Physical Exam

• Appearance of patient
• Auscultation of bowel sounds
• Palpate abdomen for tenderness
• Digital rectal exam
• Appearance of stool: lumpy, hard, amount, blood, straining during evacuation

Utilize team collaboration in assessment, intervention and education with the patient and family.

Non-Pharmacological Interventions

• Increase Fluids especially water
• Increase activity as able (assisting patient up to BSC)
• Massage Therapy
• Provide privacy
• Routine pattern each day for toileting
• Increased fiber must go together with increased fluid or gas/pain/constipation may worsen (contraindicated in patients with risk for bowel obstruction)

Pharmacological Interventions

Pharmacological treatment should be based on relieving cause of constipation

whenever possible. Resolution of underlying factor(s) should be primary goal

whenever possible.

Avoid pharmacologic treatment in patients with undiagnosed abdominal pain

or vomiting, abdominal malignancy or other signs of intestinal obstruction.

Stimulants cause rhythmic muscle contractions in the intestines and are most often combined with stool softeners or lubricants to grease and soften the stool,

enabling it to move through the intestine more easily.

Senna with docusate sodium (Senekot S®)

• First choice for opioid induced constipation
• Available in tablets, liquid

Adult Dosing

• 1-3 tabs po q hs to TID

Bisacodyl (Dulcolax®) suppository

• Use for patients unable to take po medications

Adult Dosing

• 1 pr prn, may repeat 1 x in 6 hours if no results

Osmotics cause fluids to flow in a special way through the colon, resulting in bowel distention.

Sorbitol 70%

• Less expensive than Lactulose
• Sweet taste

Adult Dosing

• 15-60 ml PO daily

If no BM in 3 days after other bowel regimin

• 15-30 ml PO q 3 hours X 3 or until results

Saline laxatives act like a sponge to draw water into the colon for easier passage of stool.

Magnesium salt laxative

Milk of Magnesia (Magnesium Hydroxide)

• Rapid onset (within 3 hours)
• May cause abdominal cramping at higher doses

Adult Dosing

• 15 – 60 ml PO qd prn

Evaluate and Document symptom at each visit until resolved. Evaluate discontinuing medications as symptoms resolve.

References

Clinical Practice Guidelines: The Hospice of the Florida Suncoast (2008).

Grauer P, Shuster J & McCrate-Protus B. (2008). Palliative Care Consultant: A reference guide for palliative care 3RDed.

Kendall/Hunt Publishing Co.

Kuebler KK, Davis MP & Moore CD. (2005). Palliative Practices: An Interdisciplinary

Approach. Elsevier/Mosby: Missouri.

McEvoy, GK, Editor, AHFS Drug Information-2003. American Society of Health-System Pharmacists, Bethesda, MD, pp.2740-41

Mercadante, S in Principles and Practice of Palliative Care and Supportive

Oncology. 2nd Edition, Lippincott, pp 233-237

Oxford Textbook Palliative Medicine. 2nd ed. 1998. Oxford. U. Press, NY, pp. 521-Fallon M. O’Neill B. ABC of palliative care. Constipation and diarrhea BMJ.

1997; 315:1293-6.

Saunders DC. Principles of symptom control in terminal care. Med Clin North Amer

(66): 1175, 1982.

http://digestive.niddk.nih.gov/ddiseases/pubs/constipation

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