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Bowel Management
25/06/2015
• Focus should not be on managing episodes of incontinence or constipation
• Focus should be on promoting normal bowel motions
as well as management• Needs to be realistic and maintainable• Needs to involve the person as appropriate
Bowel Management
• If not possible to prevent problems, identify and treat issue
• Complete bowel chart & assessment • Individualized and based on assessment
Where to start
• Needs to be a multi-disciplinary approach:• Nurses & care staff• Medical staff• Dieticians• Food services• Physiotherapists• Occupational therapists• Pharmacists
Management
• Offer general advice to the person • Explain what is normal
• Bristol stool form scale• Don’t deny the urge to pass a bowel movement• Avoid excessive straining• Don’t worry if you don’t go every day• Explain the correct toileting position
Bowel ManagementStep 1
• Squatting is best position• When sitting on a toilet:
• Feet supported, so knees higher than hips• Lean forward• Legs apart• Elbows on knees• Bulge out abdomen and widen waist• Do not hold breath
Bowel ManagementCorrect positon for opening bowels
• Ensure the environment assists toileting• Privacy• Noise• Heating • Lighting• Confusing bathroom• Mirror
Bowel ManagementStep 1
• Adequate hydration • 6-9 drinks per day• Water is best• Check skin turgor
• Must have extra fluids if increasing fibre
• Encourage exercise• Encourages peristalsis• Assists regular bowel habits
Bowel ManagementStep 1
• Well balanced diet• Fruit snacks to assist with soft bowel motions
• Plums, prunes, apricots, raisins, kiwi fruit, papaya, cantelope and peaches
• Pear juice/prune juice• Homogenized diets – impact on fibre
• Must have breakfast
Bowel ManagementStep 1
• A dedicated time for toileting• When is the best time?
• How often?
Bowel ManagementStep 1
• Establish a bowel routine• 20 minutes after a meal/s• Sit for 5 minutes • Correct sitting position
• Raised toilet seats – foot stools – hand rails• Avoid straining
Bowel ManagementStep 1
• If person has chronic laxative use and there is no signs of constipation
• Not confirmed diagnostically• Discontinue by withdrawing slowly• Offer reassurance and a regular sitting routine
Bowel ManagementStep 1
Treatment of Constipation• Dietary fibre
• Takes up water and makes stools bulkier• Bulky stools increase bowel movement• 2 types:
• Soluble: binds and firms• Oats, lentils, beans, peeled fruit and vegetables• Assists with diarrhoea/ IBS
• Insoluble: speeds up bowel movement & softer• Multi/whole grain, wheat corn and rice cereals• Assists with firm stools
Bowel ManagementStep 2
Treatment of Constipation- fibre supplements• Many different types and can have different actions
• Psyllium (e.g. Metamucil)• Ispaghula (e.g. Fybogel)• Inulin (e.g. Benefibre)
• Increase fibre slowly • May cause bloating and flatulence/ diarrhoea/ no effect• Must have an adequate fluid intake (1.5 – 2litres)• Not appropriate if immobile• Increased fibre can make constipation worse
Bowel ManagementStep 2
Treatment of Constipation• Review medications and seek an alternative if
possible• Pain medication – opioids /codeine• Anticholinergics
Bowel ManagementStep 2
Treatment of Constipation• Stool softeners
• If stool is hard & hasn’t improved with fibre and fluid intake
• Coloxyl causes water to move from body to bowel• Coloxyl & Senna should be given separately• Prolonged use or overdose may result in
• Diarrhoea• Water and salt imbalance esp. potassium loss
• Onset 12-24 hours
Bowel ManagementStep 2
Treatment of Constipation• Macrogol (Movicol, Osmolax)
• Passes through the gut without being absorbed into the body
• It relieves constipation by combining with the water it is mixed with and retains it in the bowel makes stool softer and easier to pass
• Relief of constipation• Maintenance 1-2 per day (Movicol)• Disimpaction 8 per day (Movicol)
• Onset 1- 2 days could be longer
Bowel ManagementStep 2
Treatment of Constipation• Osmotic laxatives (Lactulose, Sorbitol)
• Draws fluid into the lower bowel from the body• Can cause increased flatulence and bloating/explosive
stools• Onset up to 3 days • 10-20mls per day
Bowel ManagementStep 3
Treatment of Constipation• Stimulant laxatives
• Increases peristalsis and stimulates a mass movement• e.g. Sennakot, Durolax
• Can cause:• Cramping and diarrhoea
• 2 tablets nocte• Suitable for short term use
Bowel ManagementStep 4
Suppositories
• Can be useful if problem is rectal evacuation• Poor result due to:
• Inadequate administration• Type of suppository• Position of person• Timing of insertion
• Need to take advantage of gastro-colic reflex • Allow time to let it work
• Insert against the rectal wall, not into the stool
Bowel ManagementLast resort
• Cause need to be identified• Rule out diarrhoea is due to overflow• Review medications
• Correct diagnosis before using anti-diarrhoea medications
• Change of diet• Soluble fibre
Bowel ManagementDiarrhoea
A sitting routine is the most important for bowel evacuation and management
Bowel Management
Thank you.