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Constipation

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    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.
    1. 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).
    2. Ensure adequate fluids, dietary fiber, and exercise, if feasible.
    3. Prune juice followed by warm beverage may be considered.
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