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Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
Constipation
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  • 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. Constipation Amal Dweib Khleif RN, BSN, ON, Palliative care Specialist
  • 3. Constipation
    • Straining
    • Hard stool
    • Sensation of
      • Incomplete evacuation
      • Anorectal obstruction
    • Fewer than 3 BM / week
    • 12 weeks duration > 2 symptoms
  • 4. . . . Constipation
    • Epidemiology
    • Impact: abdominal discomfort / pain, nausea and vomiting
    • Prevalence: up to 90% among cancer patients treated with opioids
    • Prognosis: can limit prognosis if untreated
      • Management always possible
  • 5. Pathophysiology
    • Medications
      • Opioids
      • Calcium-channel blockers
      • Anticholinergic
    • Decreased motility
    • Ileus
    • Mechanical obstruction
    • Metabolic abnormalities
    • Spinal cord compression
    • Dehydration
    • Autonomic dysfunction
    • Malignancy
  • 6. Chemotherapeutic agents associated with constipation
    • Cyclophosphamide
    • Mechlorethamine
    • Chlorambucil
    • Melphalan
    • Carmustine (BCNU)
    • Lomustine (CCNU)
    • Semustine (Methyl-CCNU)
    • Thiotepa
    • Triethylenemelamine
    • Busulfan
    • Procarbazine
    • Dacarbazine
    • Hexamethylmelamine
    • Cisplatin
    • Vinblastine
    • Vincristine
    • Vinorelbine
  • 7. Assessment
    • History and examination
    • full clinical assessment of constipation includes the following:
    ◗ the pattern of recent bowel movements; ◗ the pattern of pre-illness bowel movements; ◗ past history of use of laxatives;
  • 8. full clinical assessment of constipation includes the following:
    • ◗ the use of potentially constipating drugs;
    • ◗ food intake (especially fibre content);
    • ◗ fluid intake;
    • ◗ presence or absence of faeces in the rectum;
    • ◗ consistency of faeces—soft or hard;
    • ◗ presence of anal tone and reflex;
    • ◗ evidence of normal or abnormal sacral nerve root sensation;
    • ◗ presence of predisposing factors for constipation;
    • ◗ overall disease status and prognosis.
  • 9.
    • ◗ assessment of the mouth for
    • possible causes of reduced intake of food and fluids (such as ulceration or ill-fitting dentures);
    • ◗ inspection of the abdomen for distension;
    • ◗ abdominal palpation, which might reveal a palpable colon and faecal mass;
    • ◗ assessment of bowel sounds, which might be diminished, slow, or absent;
    • ◗ inspection of the anus for haemorrhoids, fissure, or faecal fluid leakage
    • ◗ rectal examination,
  • 10. Summary of assessment
    • An effective bowel care plan is based on a thorough assessment which includes:
    • ◗ obtaining a comprehensive history including the person’s preferences for
    • bowel management;
    • ◗ assessment of the impact of constipation on quality of life;
    • ◗ physical assessment;
    • ◗ identification of risk factors;
    • ◗ accurate documentation;
  • 11. INTERVENTION
    • General measures
      • Regular toileting
      • Gastrocolic reflex
      • Activity
    • Specific measures
      • Softeners
      • Osmotics
      • Stimulants
      • Lubricants
      • Large volume enemas
  • 12. Stool softeners ( detergent laxatives)
    • Sodium docusate
    • Calcium docusate
    • Phospho-soda enema PRN
  • 13. Stimulant laxatives
    • Prune juice
    • Senna
    • Casanthranol
    • Bisacodyl
  • 14. Osmotic laxatives
    • Lactulose or sorbitol
    • Milk of magnesia (other Mg salts)
    • Magnesium citrate
    • Polyethylene glycol
  • 15. Lubricants / enemas
    • Glycerin suppositories
    • Phosphate enema
    • Oil retention enema
    • Tap water, 500 – 1,000 ml
  • 16. Constipation from opioids . . .
    • Occurs with all opioids
    • Pharmacological tolerance develops slowly, or not at all
    • Dietary interventions alone usually not sufficient
    • Avoid bulk-forming agents in debilitated patients
  • 17. . . . Constipation from opioids
    • Combination stimulant / softeners are useful first-line medications
      • Casanthranol + docusate sodium
      • Senna + docusate sodium
    • Prokinetic agents
    • Opioid antagonists
  • 18. Prophylaxis of constipation
    • Maintain good general symptom control
    • Encourage activity
    • Maintain adequate oral fluid intake
    • Maximize the fibre content of the diet
    • Anticipate constipating effects of drugs
    • altering treatment or starting a laxative prophylactically
    • Create a favourable environment
  • 19. Summary
    • Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience

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