- Establish the patient's normal bowel pattern and habits (time of day for normal bowel movement, consistency, color, and amount).
- Explore the patient's level of understanding and compliance relating to exercise level, mobility, and diet (fluid, fruit, and fiber intake).
- Determine normal or usual use of laxatives, stimulants, or enemas.
- Determine laboratory values, specifically looking at platelet count.
- Conduct a physical assessment of the rectum (or stoma) to rule out impaction.
Commonly used interventions:
- Record bowel movements daily.
- Encourage patient to increase fluid intake, with a goal of drinking eight 8-oz (240-mL) glasses of fluid daily unless contraindicated.
- Encourage regular exercise, including abdominal exercises in bed or moving from bed to chair if the patient is not ambulatory.
- Encourage adequate fiber intake. Experts recommend that:
- Healthy adults consume 20 g to 35 g of fiber per day (average consumption is 11 g).
- Children and adolescents consume the number of grams of fiber equal to their age plus 5-for example, a 10-year-old should consume 15 g of fiber per day (10 + 5). This guideline applies until age 18 years; at that time, the adult recommendations should be followed.
While there are no specific fiber recommendations for cancer patients, they should also be encouraged to eat more high-fiber foods such as fruits (e.g., raisins, prunes, peaches, and apples), vegetables (e.g., squash, broccoli, carrots, and celery), and 100% whole-grain cereals, breads, and bran. Increased fiber intake must be accompanied by increased fluid intake, or constipation may result. High fiber intake is contraindicated in patients at increased risk for bowel obstruction, such as those with a history of bowel obstruction or status postcolostomy.
- Provide a warm or hot drink approximately one-half hour before time of patient's usual defecation.
- Provide privacy and quiet time at the patient's usual or planned time for defecation.
- Provide toilet or bedside commode and appropriate assistive devices; avoid bedpan use whenever possible.
Another approach, shown below in two parts, is adapted from the MD Anderson Cancer Center practice consensus algorithm for the prevention and management of opioid-induced constipation. Copyright 2008 The University of Texas MD Anderson Cancer Center
MD Anderson Cancer Center Algorithm for the Prevention of Opioid-induced Constipation
|Unless there are existing alterations in bowel patterns (e.g., bowel obstruction or diarrhea), all patients receiving opioids should be started on a laxative bowel regimen and receive education for bowel management.|
- Stimulant laxative plus stool softener (e.g., Senokot-S [senna 8.6 mg plus docusate 50 mg]), two tablets per day and titrate up (maximum nine tablets per day).
- Ensure adequate fluids, dietary fiber, and exercise, if feasible.
- Prune juice followed by warm beverage may be considered.
MD Anderson Cancer Center Algorithm for the Management of Opioid-induced Constipation
- Assess potential cause of constipation (e.g., recent opioid dose increase, use of other constipating medications, or new bowel obstruction).
- Increase Senokot-S (or senna and docusate tablets, if using separately), and add one or both of the following:
- Milk of magnesia oral concentrate (1170/5 mL), 10 mL by mouth 2 to 4 times per day.
- Polyethylene glycol (MiraLAX), 17 g in 8-oz beverage daily.
- If no response to above, perform digital rectal examination to rule out low impaction. Continue above steps AND:
- If impacted, disimpact manually if stool is soft. If not, soften with mineral oil fleets enema before disimpaction. Follow up with milk of molasses enemas until clear with no formed stools.
- Consider use of rescue analgesics before disimpaction.
- If not impacted on rectal examination, patient may still have higher level impaction; if history is appropriate, consider abdominal imaging and/or administer milk of molasses enema with magnesium citrate 8 oz by mouth. Consider bowel management consult.
- If patient is neutropenic or thrombocytopenic, arrange for bowel management consult.
- Start one of the following regimens if the patient has not had a stool in 3 days or on the first day that any patient starts taking drugs associated with constipation:
- Stool softeners (e.g., docusate sodium, one to two capsules per day). For opioid-related constipation, stool softeners should be used in combination with a stimulant laxative. Bulk-producing agents are not recommended in a regimen used to counteract the bowel effects of opioids.
- Two tablets of a senna preparation twice daily.
- One bisacodyl tablet at bedtime.
- Milk of magnesia, 30 to 45 mL, if a bowel movement is not achieved in 24 hours after other methods are instituted.
- If the amount of stool is still inadequate, increase stool softeners up to six capsules per day or a senna preparation (e.g., Senokot) gradually to a maximum of eight tablets (four tablets twice a day); bisacodyl may be increased gradually to three tablets.
- If the amount of stool is still inadequate, a glycerin or bisacodyl suppository or enema (phosphate/biphosphate, oil retention, or tap water) should be used with caution, especially in patients with neutropenia or thrombocytopenia.