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.