Constipation

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Constipation

  1. 1. Al-Sadeel Society Palliative Care for Cancer Patients Constipation Copyrights © 2009 by Al-Sadeel Society All Rights Reserved, No part of this publication may be reproduced, transmitted, or used without the prior permission by AL-Sadeel Society Emai l: sadeelsoc@yahoo.com. Website : www.sadeel.co.cc, Tel : +972 2 2767337
  2. 2. Constipation Amal Dweib Khleif RN, BSN, ON, Palliative care Specialist
  3. 3. Constipation <ul><li>Straining </li></ul><ul><li>Hard stool </li></ul><ul><li>Sensation of </li></ul><ul><ul><li>Incomplete evacuation </li></ul></ul><ul><ul><li>Anorectal obstruction </li></ul></ul><ul><li>Fewer than 3 BM / week </li></ul><ul><li>12 weeks duration > 2 symptoms </li></ul>
  4. 4. . . . Constipation <ul><li>Epidemiology </li></ul><ul><li>Impact: abdominal discomfort / pain, nausea and vomiting </li></ul><ul><li>Prevalence: up to 90% among cancer patients treated with opioids </li></ul><ul><li>Prognosis: can limit prognosis if untreated </li></ul><ul><ul><li>Management always possible </li></ul></ul>
  5. 5. Pathophysiology <ul><li>Medications </li></ul><ul><ul><li>Opioids </li></ul></ul><ul><ul><li>Calcium-channel blockers </li></ul></ul><ul><ul><li>Anticholinergic </li></ul></ul><ul><li>Decreased motility </li></ul><ul><li>Ileus </li></ul><ul><li>Mechanical obstruction </li></ul><ul><li>Metabolic abnormalities </li></ul><ul><li>Spinal cord compression </li></ul><ul><li>Dehydration </li></ul><ul><li>Autonomic dysfunction </li></ul><ul><li>Malignancy </li></ul>
  6. 6. Chemotherapeutic agents associated with constipation <ul><li>Cyclophosphamide </li></ul><ul><li>Mechlorethamine </li></ul><ul><li>Chlorambucil </li></ul><ul><li>Melphalan </li></ul><ul><li>Carmustine (BCNU) </li></ul><ul><li>Lomustine (CCNU) </li></ul><ul><li>Semustine (Methyl-CCNU) </li></ul><ul><li>Thiotepa </li></ul><ul><li>Triethylenemelamine </li></ul><ul><li>Busulfan </li></ul><ul><li>Procarbazine </li></ul><ul><li>Dacarbazine </li></ul><ul><li>Hexamethylmelamine </li></ul><ul><li>Cisplatin </li></ul><ul><li>Vinblastine </li></ul><ul><li>Vincristine </li></ul><ul><li>Vinorelbine </li></ul>
  7. 7. Assessment <ul><li>History and examination </li></ul><ul><li>full clinical assessment of constipation includes the following: </li></ul>◗ the pattern of recent bowel movements; ◗ the pattern of pre-illness bowel movements; ◗ past history of use of laxatives;
  8. 8. full clinical assessment of constipation includes the following: <ul><li>◗ the use of potentially constipating drugs; </li></ul><ul><li>◗ food intake (especially fibre content); </li></ul><ul><li>◗ fluid intake; </li></ul><ul><li>◗ presence or absence of faeces in the rectum; </li></ul><ul><li>◗ consistency of faeces—soft or hard; </li></ul><ul><li>◗ presence of anal tone and reflex; </li></ul><ul><li>◗ evidence of normal or abnormal sacral nerve root sensation; </li></ul><ul><li>◗ presence of predisposing factors for constipation; </li></ul><ul><li>◗ overall disease status and prognosis. </li></ul>
  9. 9. <ul><li>◗ assessment of the mouth for </li></ul><ul><li>possible causes of reduced intake of food and fluids (such as ulceration or ill-fitting dentures); </li></ul><ul><li>◗ inspection of the abdomen for distension; </li></ul><ul><li>◗ abdominal palpation, which might reveal a palpable colon and faecal mass; </li></ul><ul><li>◗ assessment of bowel sounds, which might be diminished, slow, or absent; </li></ul><ul><li>◗ inspection of the anus for haemorrhoids, fissure, or faecal fluid leakage </li></ul><ul><li>◗ rectal examination, </li></ul>
  10. 10. Summary of assessment <ul><li>An effective bowel care plan is based on a thorough assessment which includes: </li></ul><ul><li>◗ obtaining a comprehensive history including the person’s preferences for </li></ul><ul><li>bowel management; </li></ul><ul><li>◗ assessment of the impact of constipation on quality of life; </li></ul><ul><li>◗ physical assessment; </li></ul><ul><li>◗ identification of risk factors; </li></ul><ul><li>◗ accurate documentation; </li></ul>
  11. 11. INTERVENTION <ul><li>General measures </li></ul><ul><ul><li>Regular toileting </li></ul></ul><ul><ul><li>Gastrocolic reflex </li></ul></ul><ul><ul><li>Activity </li></ul></ul><ul><li>Specific measures </li></ul><ul><ul><li>Softeners </li></ul></ul><ul><ul><li>Osmotics </li></ul></ul><ul><ul><li>Stimulants </li></ul></ul><ul><ul><li>Lubricants </li></ul></ul><ul><ul><li>Large volume enemas </li></ul></ul>
  12. 12. Stool softeners ( detergent laxatives) <ul><li>Sodium docusate </li></ul><ul><li>Calcium docusate </li></ul><ul><li>Phospho-soda enema PRN </li></ul>
  13. 13. Stimulant laxatives <ul><li>Prune juice </li></ul><ul><li>Senna </li></ul><ul><li>Casanthranol </li></ul><ul><li>Bisacodyl </li></ul>
  14. 14. Osmotic laxatives <ul><li>Lactulose or sorbitol </li></ul><ul><li>Milk of magnesia (other Mg salts) </li></ul><ul><li>Magnesium citrate </li></ul><ul><li>Polyethylene glycol </li></ul>
  15. 15. Lubricants / enemas <ul><li>Glycerin suppositories </li></ul><ul><li>Phosphate enema </li></ul><ul><li>Oil retention enema </li></ul><ul><li>Tap water, 500 – 1,000 ml </li></ul>
  16. 16. Constipation from opioids . . . <ul><li>Occurs with all opioids </li></ul><ul><li>Pharmacological tolerance develops slowly, or not at all </li></ul><ul><li>Dietary interventions alone usually not sufficient </li></ul><ul><li>Avoid bulk-forming agents in debilitated patients </li></ul>
  17. 17. . . . Constipation from opioids <ul><li>Combination stimulant / softeners are useful first-line medications </li></ul><ul><ul><li>Casanthranol + docusate sodium </li></ul></ul><ul><ul><li>Senna + docusate sodium </li></ul></ul><ul><li>Prokinetic agents </li></ul><ul><li>Opioid antagonists </li></ul>
  18. 18. Prophylaxis of constipation <ul><li>Maintain good general symptom control </li></ul><ul><li>Encourage activity </li></ul><ul><li>Maintain adequate oral fluid intake </li></ul><ul><li>Maximize the fibre content of the diet </li></ul><ul><li>Anticipate constipating effects of drugs </li></ul><ul><li>altering treatment or starting a laxative prophylactically </li></ul><ul><li>Create a favourable environment </li></ul>
  19. 19. Summary <ul><li>Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience </li></ul>

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