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Bowel Function—Constipation and Diarrhea
Phone calls regarding your patients’ bowel functions will be frequent; fortunately, many of these problems can be managed over the phone. Patients may have changes in bowel function while hospitalized because of dietary changes, less mobility, narcotic analgesics, and other medications, and abdominal surgery with functional ileus. You should be familiar with the major causes of these changes and feel comfortable with the range of options for treating these problems. Many patients become distressed with bowel function changes and appreciate being made to feel more comfortable.
Constipation
Phone Call 
Questions
- 1.
Has this patient had surgery? If so, what was the procedure and when was it performed?
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Patients undergoing abdominal surgery develop a functional ileus that lasts 4 to 5 days or more. These patients should not be given a laxative. They must wait for their gastrointestinal (GI) function to return. Ambulation and chewing gum can help stimulate return of GI function postoperatively. Also, postoperative appendectomy patients should not receive rectal suppositories. Some surgeons believe that this may cause contractions in the colon and increase the risk for appendix stump leaks.
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- 2.
Why does the patient want a laxative? When was the last bowel movement (BM)? What is the normal bowel routine for this patient?
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Some people have up to three BMs per day, whereas others have a BM as infrequently as once a week. These ranges are normal. You should know a patient’s normal routine before prescribing a laxative. That being said, all patients taking narcotics orally need to be on some sort of bowel regimen, unless contraindicated.
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- 3.
Is the patient nauseated or has he or she been vomiting?
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Be hesitant to prescribe a laxative to a patient who has signs of upper GI dysfunction. The patient could have another problem, such as intestinal obstruction or appendicitis. Constipation alone does not lead to upper GI symptoms unless the patient is impacted and has a significant ileus.
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- 4.
Does the patient have abdominal pain?
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A patient with abdominal pain and who requests a laxative should be examined. An ileus, and hence constipation, results from many serious surgical problems of the abdomen. For example, a perforated viscus often presents with abdominal pain and ileus.
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- 5.
Has a rectal examination been performed on the patient?
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Fecal impaction is diagnosed by rectal examination. Laxatives do not usually help patients who are impacted. Manual disimpaction may be necessary.
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- 6.
Does the patient routinely use laxatives?
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Some patients may abuse laxatives; these patients develop GI dysfunction.
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Orders
Once you have determined that it is safe and appropriate to prescribe a laxative or an enema, you must think about what type of agent to use ( Table 6.1 ). Laxatives can be delivered by mouth or rectum; enemas are delivered by rectum. Contraindications for laxatives or a bowel regimen include GI obstruction/perforation, severe inflammatory bowel disease, an active infectious GI process, reduced consciousness level, inability to swallow without aspirating, or hypersensitivity to any of the medications ingredients.
Table 6.1
Common Laxatives and Enemas for Use in Surgical Patients
| Type of Agent | Name of Agent | Dose | Cautions |
|---|---|---|---|
| Bulk-forming laxative | Psyllium seed (Metamucil; Konsyl) | 1 tsp in liquid PO each day; up to 3 times per day | Some drugs may be bound by the cellulose |
| Surface-active laxative | Docusate (Colace) | 50–360 mg PO daily, or in divided doses | |
| Lubricant laxative | Mineral oil | 10–45 mL in 24 hours, may divide doses mL PO bid | Decreases fat-soluble vitamin absorption |
| Osmotic laxatives | Magnesium citrate | 100 mL of a 15 g/300 mL solution PO | Do not use in patients with renal dysfunction |
| Glycerin | 1 preformed suppository PR | ||
| Polyethylene glycol (Miralax) | 17g PO daily | ||
| Stimulant laxatives | Dulcolax | 5–15 mg PO or 10 mg PR | |
| Senna | 17.2 mg PO at bedtime | ||
| Hypertonic enema | Fleet enema | 60–120 mL PR from a disposable container | Do not use in patients with nausea, vomiting, or abdominal pain |
| Mineral oil enema | Fleet mineral oil | 60–120 mL PR from a disposable container | Good for fecal impaction |
PO, by mouth; PR, rectally. Please refer to drug reference for most current dosage recommendations.
Table 6.2
Antidiarrheal Therapies
Notes: Diphenoxylate HCl and difenoxin HCl are related to meperidine HCl; they are considered Schedule V medications and are habit forming. Opium powder is a Schedule II medication and is habit forming. Do not exceed recommended dosage. Please consult drug reference to confirm most current dosage recommendations.
| Generic | Brand Name | Dose |
|---|---|---|
| Diphenoxylate HCl (2.5 mg) | Lomotil | 2 tablets PO qid (may take up 48 h to work) |
| Loperamide HCl | Imodium | 4 mg PO initial dose followed by 2 mg PO with each unformed stool (not to exceed 16 mg/d) |
| Difenoxin HCl (1 mg) with atropine sulfate (0.025 mg) | Motofen | 2 tablets PO initial dose followed by 1 tablet PO tid or qid PRN, or 1 tablet with each unformed stool (not to exceed 8 tablets/d |
| Belladonna (16.2) with opium powder (30–60 mg) | B&O Supprette | 1 suppository PR qd or bid as needed (not to exceed 4 doses/d) |
| Bismuth subsalicylate | Pepto-Bismol | 2 tbsp or tablets PO q0.5–1h as needed (not to exceed 8 doses/d) (may take up to 24 h to work) |
| Morphine (2 mg/5 mL) | Paregoric a | 5–10 mL PO 4 qid PRN with anise oil (0.02 mL), benzoic acid (20 mg), camphor (0.2 mL), and alcohol (45%) |
| Kaolin (975 mg/5 mL) and pectin (22 mg) | Kaopectate | 60–120 mL PO after each loose stool (not to exceed 240 mL/d) |
PO, by mouth; PR, rectally; PRN, as needed.
Oral Laxatives
Laxatives can be divided according to their mechanism of action:
- 1.
Stool softeners include surface-active agents (docusate sodium [Colace]) and bulk-forming agents (psyllium [Metamucil, Konsyl]). These agents tend to soften the stool for the foodstuffs eaten at about the same time that the agent is taken. For example, a patient with constipation who begins taking Metamucil is unlikely to benefit until the older hard stool has been cleared and the bulk-forming agent can soften the newly formed stool. In a similar fashion, surface-active laxatives such as Colace take a day or more to show significant stool-softening action.
- 2.
Osmotic laxatives include magnesium citrate. This is a pleasant tasting, carbonated liquid. Most patients have a BM within several hours of taking this agent. You can repeat the dose if no results are obtained with the first dose. The osmotic agent GoLYTELY is commonly used in bowel preparation before surgery. This agent contains polyethylene glycol, circumvents fluid absorption, and rapidly cleanses the bowel. It is not used routinely as a laxative, but it is a good bowel preparation agent.
- 3.
Motility agents include senna. Onset of action is usually 8 hours (given at bedtime). These work by antagonizing the constipating effect of opiates by blocking the mu opioid receptor in the GI tract. This can be routinely given to patients who are taking oral narcotic agents, but be cautious in those not taking narcotics as it can cause cramps and abdominal pain.
Rectal Laxatives
Glycerin is an osmotic laxative given rectally as a suppository. Onset of action is usually 30 to 60 minutes. Diphenylmethane (bisacodyl [Dulcolax]) is a stimulant of defecation given as a suppository and is popular in hospitals. If the first bisacodyl suppository is ineffective, the dose can be repeated.
Enemas
Enemas deliver agents directly to the rectum. This is useful to help the patient evacuate hard stool. Options include the hypertonic enemas (Fleet enemas), oil-retention enemas, and soapsuds enemas.
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