Constipation & Intestinal Gas Gina Ryan Learning Objectives 1. Define constipation 2. Describe the signs and symptoms of constipation and which ones require further work up (i.e. alarm symptoms). (Collect) 3. Describe the epidemiology of constipation. (Collect) 4. Describe common causes of constipation.(Collect) 5. Collect the necessary subjective and objective information about a patient with constipation in order to understand the relevant medical/medication history and clinical status of the patient using SCHOLARMAC. (Collect) 6. List the goals of therapy for the treatment of constipation 7. Describe why the onset of action is important when considering agents for the treatment of constipation. 8. List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Learning Objectives 9. Assess the information collected and analyze the clinical effects of the patient’s therapy for constipation in the context of the patient’s overall health goals in order to identify and prioritize problems and achieve optimal care. (Assess) 10. Develop an individualized patient-centered care plan for constipation that is evidencebased and cost effective for adults, children, geriatrics, and pregnant women. (Plan) 11. List patient counseling points for treatment of constipation. (Implement) 12. List monitoring parameters for potential adverse drug reactions associated with laxatives and stool softeners. (Monitor) Learning Objectives 12. Define intestinal gas and common symptoms (Collect) 13. Describe the common causes of intestinal gas (Collect 14. List the nonpharmacological therapy for the treatment of intestinal gas. (Assess) 15. List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for intestinal gas. (Assess) 16. Develop an individualized patient-centered care plan for intestinal gas that is evidence-based and cost effective for adults, children, geriatrics, and pregnant women. (Plan) 17. List patient counseling points for treatment of intestinal gas. (Implement) 18. List monitoring parameters for potential adverse drug reactions associated with medications used to treat gas. (Monitor) Sally • 56 year old female with a long-term history of being constipation prone. Sometimes Colace or Senokot helps, but the results have been mixed lately. She frequently strains at the stool and often feels like she can’t completely empty her bowels. Additionally, she frequently has a lot of gas and abdominal pain. She has tried taking Metamucil, but that does not work at all. She has also tried eating high fiber cereal – Fiber One and Raisin Bran. She is not sure but thinks these make things worse. She took 2 tablets of senna two days ago, but still hasn’t really worked. A friend of hers is into health foods and recommends peppermint oil. She takes HCTZ, lisinopril, Zyrtec, and Flonase and doesn’t have any drug allergies. She occasionally takes Benadryl for sleep. She has reported this to her doctor, but has not had a colonoscopy or endoscopy. She is very uncomfortable now. Constipation • Definition: difficult or infrequent passage of stool • Often described as: • • • • • Decreased bowel movement frequency Changes in stool size or consistency Straining for multiple minutes Sensation of incomplete evacuation Inability to defecate at will • Considered chronic constipation if symptoms present for at least 3 months Define constipation Alarm Symptoms • Positive history of colorectal cancer • Rectal bleeding w/o hemorrhoids or anal fissures • Unintentional weight loss • Anemia • Signs of obstruction- severe pain, N/V after long-term constipation Describe the signs and symptoms of constipation and which ones require further work up (i.e. alarm symptoms). (Collect) Bristol Stool Chart Define constipation Etiology Constipation Acute Intestinal obstruction Dehydration Surgery or inflammation Chronic Diet Colon cancer Medications Diet Dehydration Pregnancy Diabetic gastroparesis Hypothyroidism IBD/IBS Describe common causes of constipation.(Collect) Secondary Constipation Medical Disorders Conditions Possible Causes GI Disorders Irritable bowel syndrome Diverticulitis Hemorrhoids Tumors Hernia Ulcerative proctitis Metabolic and endocrine disorders Diabetes with neuropathy Hypothyroidism Hypercalcemia Neurogenic disorders Trauma to the brain Spinal cord injury CNS tumors Stroke Parkinson’s disease Multiple sclerosis Cardiac disorders Heart failure Pregnancy Decreased gut motility Increased fluid absorption from colon Iron supplementation Describe common causes of constipation.(Collect) Lifestyle Causes Dietary changes Inadequate fluid intake Low dietary fiber intake Decrease physical activity/Increased comorbidities Institutionalization Stress Describe common causes of constipation.(Collect) Medications that frequently cause constipation • Opioids • Anticholinergics • Antihistamine • Tricylic antidepressants • Calcium carbonate and aluminum hydroxide • Iron (prenatal vitamins) Describe common causes of constipation.(Collect) Epidemiology • Approximately 20% in US • Women more frequently than men 3.77:1 • Increased incidence in elderly • 4th ranked GI cause for seeking care • Billions of $ spent on nonprescription laxatives • 1.4 billion in 2019 Describe the epidemiology of constipation. (Collect) Sanchez MI, Bercik P. Epidemiology and burden of chronic constipation. Can J Gastroenterol. 2011;25 Suppl B(Suppl B):11B-15B. doi:10.1155/2011/974573 1 Goals of Therapy Major goals of therapy include: 1. Relieve symptoms 2. Remove underlying cause 3. Re-establish normal bowel habits 4. Improve quality of life by minimizing adverse effects of therapy List the goads of therapy for the treatment of constipation General Treatment Approach • Treat specific cause • No underlying diagnosis, then choose symptomatic therapy: • Dietary modifications • Lifestyle modifications • Increase fluid intake • Discontinue potential medications associated with symptoms if possible • Bulk-forming agents or Polyethylene glycol-electrolyte preparations (PEG) Non-Pharmacological Therapy Diet modifications Increase fluid intake Increase physical activity Toilet Training Pelvic floor relaxation Surgery List the nonpharmacological therapy for the treatment of constipation. (Assess) 35 gms of fiber 2 cups 2 cups 2 cups 1 cup Pharmacological Therapy Agents that cause softening of stool (typically work in 1-3 days) • Bulk-forming agents • Emollients • Osmotic laxatives • Lactulose • Sorbitol • Polyethylene glycol-electrolyte preparations (PEG) Agents that cause soft or semifluid stool (typically work in 6 – 12 hours) • Bisacodyl • Senna Agents that cause watery evacuation (typically work in 1 – 6 hours) • • • • Magnesium citrate Magnesium hydroxide Sodium phosphates Suppositories List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Fiber- Bulk-Forming Agents • Mechanism of action: increase water content in the stool to increase stool bulk and weight • Adverse effects: • Gas (especially psyllium) • Abdominal bloating/Distention • Diarrhea • Constipation (especially if not taken with lots of fluid • Patient Education • MUST drink lots of fluid • 24-72 hour onset • See MD if symptoms more than 14 days or alarm symptoms present • Titrate slowly for chronic use Drug Dosing Calcium polycarbophil (Fibercon®) Two caplets PO daily to QID with 8 ounces of water Psyllium hydrophilic mucilloid (Metamucil®): capsule and powder 3.4 g PO daily to TID dissolved in 8 ounces of water Methylcellulose (Citrucel®): caplet and powder Two caplets PO daily with 8 ounces of water (maximum of 12 caps/ day) List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Bulk Forming agents List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Emollients (Stool Softeners) • Mechanism of action: • Surfactants reduce surface tension of the oilwater interface of the stool allowing more water and fat to mix with stool • Adverse effects: >10% • Abdominal pain • Bitter taste • Patient Education • Typically ineffective at treating constipation but used for prevention use when stool is hard and dry • Takes 24-72 hours • Mostly for prevention than treatment Drug Docusate sodium (Colace®, Dulcolax®, Fleet Sof-Lax®, Phillips Stool Softener®) Docusate calcium (Surfak Stool Softener®) Dosing Oral: 100 mg PO daily to BID Enema: 283 g/5 mL PR daily - TID 240 mg PO daily • Clinical Pearls • Use after surgery or MI to prevent straining at stool List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Stool Softener List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Example of Branding Osmotic Laxatives • Mechanism of action: • Draw excess water into colon through hyperosmotic effects colon distention increase peristalsis • Contain large ions or molecules that are poorly absorbed • Adverse effects: >10% • Gas • Abdominal discomfort • Diarrhea • Dehydration • Electrolyte disturbances (especially Mg products or sodium phosphate – caution with renal impairment) • Patient Education • Most likely agents to cause diarrhea • Only PEG should be used for chronic constipation - mix with any beverage and drink lots of water List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Osmotic Laxatives Drug Dose Onset of Action Magnesium hydroxide (Phillips Milk of Magnesia®) 30-60 mL PO QD PRN 1-6 hours Magnesium sulfate (Epsom salt®) 1-2 teaspoons with one glass of water PO twice daily PRN 1-6 hours Magnesium citrate 1 bottle with 8 oz water PO daily PRN 1-6 hours Polyethylene glycol 17 g (1 heaping tablespoon) in 8 oz water 12-24 hours Sodium phosphate (Fleet Enema®) 1 bottle rectally PRN 15-30 minutes Lactulose 15-30 mL PO PRN oral 2-3 days of use; enema 15-30 minutes Sorbitol 120-240 mL PO PRN oral 2-3 days of use; enema 15-30 minutes Glycerin Suppositories • Mechanism of action: Draw excess water into colon through hyperosmotic effects colon distention increase peristalsis • Relieves symptoms of constipation within 15 minutes – 30 minutes of use • Adverse effects: • Rectal irritation • Abdominal pain • Cramping • Dosing: 1 suppository once • Patient Education • 15-30 minute onset • If needed more than occasionally, consult MD • Lay child down on side and bend one knee up • Used commonly in children and the elderly List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Suppository Administration • Store in refrigerator • Administration: http://www.safemedication.com/safemed/MedicationTipsTools/Howt oAdminister/HowtoUseRectalSuppositoriesProperly Polyethylene Glycol (PEG) Used for treatment of constipation List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Used for bowel prep. Stimulant Laxatives • Mechanism of action: • Stimulate the mucosal nerve plexus of the colon peristalsis • Relieves symptoms of constipation within 6 – 12 hours of oral use and 15-30 minutes of rectal use • Adverse effects: • Abdominal cramping • Urine discoloration (senna) • Patient Education • Take in PM for an AM BM • Bisacodyl – don’t crush EC tablets List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Drug Dose Pearl Senna 17.2 PO daily – BID Can be used daily Bisacodyl Oral Dose: 5 – 15 mg PO daily Reserved for intermittent use Rectal Dose: 10 mg suppository once daily (works within 15-30 minutes) Stimulant Laxatives Other Medications Top 300 agent Lubiprostone (Amitiza®) • Mechanism of action: • Class called secretagogues • Activates chloride channels in the gut to stimulate chloride-rich fluid secretion into the intestinal lumen softens the stool and causes peristalsis • Approved for chronic idiopathic constipation, irritable bowel syndrome (IBS), and opioidinduced constipation • Relieves symptoms of constipation within 24-48 hours of use List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) • Dosing for chronic constipation and opioidinduced constipation: 24 mcg PO twice daily with food • Adverse effects: •Nausea •Headache •Diarrhea •Hypokalemia •Patient Education •Take w/ food to reduce nausea •Dyspnea possible with first dose – self-limiting • Used for patients who have failed conventional therapy Guanylate Cyclase C Agonists • Mechanism of action: • Activates guanylate cyclase C receptor on the intestinal epithelium to increase chloride and sodium bicarbonate secretion into the intestinal lumen increases GI transit • Approved for chronic idiopathic constipation and IBS • Relieves symptoms of constipation within 24-48 hours of use List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) • Adverse effects: • Diarrhea • Flatulence • Abdominal distention • Headache • Used for patients who have failed conventional therapy Drug Dosing Linaclotide (Linzess®) 145 mcg PO daily Plecanatide (Trulance®) 3 mg PO daily Peripheral-Acting Mu-Opioid Antagonists • Mechanism of action: • Block mu-opioid receptors in the GI tract decreasing constipation • Does not cross the blood brain barrier • Approved for opioid-induced constipation (OIC) • Relieves symptoms of constipation within 24 hours of use • Adverse effects: •Abdominal pain •Flatulence •Nausea Drug Dose Methylnaltrexone (Relistor) 12 mcg subcutaneously daily or 450 mg PO daily Naloxegol (Movantik®) 25 mg PO daily Naldemedine (Symproic®) 0.2 mg PO daily List the mechanism of action, role in therapy, adverse effects, onset of action and dosing (for top 200) of the various pharmacologic treatments for constipation. (Assess) Typical Management of Constipation Patient presents with constipation SCHOlARMAC to collect Rule out alarm s/sx Chronic management Behavior change (Fiber, fluid, scheduled toileting) Rapid relief requested? Poor response Use OTC agent with rapid onset Stimulant suppository Mag citrate Enema These should not be used chronically Stool softener or PEG Poor response or >14 dyas Add Stimulant laxatives Pt should see PCP for chronic use Pt should see gastroenterologist Poor response Patient taking opioids Describe why the onset of action is important when considering agents for the treatment of constipation. Mu opioid antagonists Naloxegol Methylnaltrexone Naldemedine Poor response Setcretagogues – lubiprostone linaclotide plecanatide Mounsey A, et al. Am Fam Physician 2015; 92(6)500-504. Monitoring for Constipation • Diet and hydration • Exercise regimen • Monitor alarm symptoms – (blood in stools, increase abdominal pain, weight loss, s/sx of obstruction – severe pain and N/V) • Monitor adverse effects of medication List monitoring parameters for potential adverse drug reactions associated with laxatives and stool softeners. (Monitor) Patient Education • Stress importance of diet, fluids, and exercise • Try going every morning for 10 minutes to toilet train • Report any alarm symptoms to PCP • Per CDC – patient over 50 years old should be screened for colon cancer. Especially patients with chronic constipation • Nondrug remedies • Prunes • Strong coffee List patient counseling points for treatment of constipation. (Implement) Intestinal Gas • Some amount of intestinal gas is normal • Symptoms • Belching – results from accumulation of swallowed air in the stomach that is expelled via the mouth • Bloating – sense of fullness in the upper abdomen because of food or gas in the stomach • Flatulence – passage of gas via the rectum; this gas is generally from swallowed air or action of colon bacteria of undigested carbohydrates • Abdominal pain – pressure from the gas can cause pain Define intestinal gas and common symptoms (Collect) https://gi.org/topics/belching-bloating-and-flatulence/ Intestinal Gas • Causes • • • • • Excess swallowing Lactose intolerance Eating - bran, cabbage, cauliflower, broccoli, and beans Overgrowth of bacteria Constipation Describe the common causes of intestinal gas (Collect) Intestinal Gas – Nonpharmacological Therapy • Eliminate carbonated beverages • Avoid - cauliflower, broccoli, cabbage, beans, and bran (classic foods that cause gas) • Confirm lactOse tolerance • Avoid products containing mannitol or sorbitol (artificial sweeteners) List the nonpharmacological therapy for the treatment of intestinal gas. (Assess) Intestinal Gas- Treatment • Simethicone – breaks up bubbles (surfactant) • Alpha-d-galactosidase – enzyme for nondigestable CHOs (can be taken prior to eating certain foods) • LactAse- enzyme to breakdown lactOse List the mechanism of action, role in therapy, adverse effects, and clinical pearls of the various pharmacologic treatments for intestinal gas. (Assess) Simethicone • Mechanism • Antifoaming activity – alters surface tension of gas and mucus bubbles enabling gas to disperse and be absorbed into the bloodstream or pass through the intestines faster • Dose (GasX, Mylicon, etc) • 40-360 mg po qid after meals and hs prn • Adverse Effects >10% • Diarrhea, heartburn and flatulence • Patient Education • Avoid – carbonated beverages, bran, cabbage, cauliflower, broccoli, and beans • Take after meals • Consult MD for chronic problems Simethicone Products Alpha-d-galactosidase • Mechanism • Food enzyme from Aspergillus niger mold that breaks down nonabsorable complex carbohydrates in foods before they can be metabolized by colonic bacteria – which causes gas. • Dose (Beano) • 150 -300 galactosidases units • Adverse Effects >10% - none • Patient Education • Take with first bite of meal • Do not cook or heat product • Can swallow or chew tablets LactAse • MOA – enzyme the breaks down lactOse • Common Brand Names: • Lactaid, Lac-Dose, Lactaid Fast Act, Surelac • Dose • 3,000 units or 9,000 units • Tablets and Chewable • Adverse Drug Reaction - Well tolerated – allergic reactions rare • Patient Education • Take 1-3 tablet before first bite of dairy • No dose adjustment for renal or hepatic impairment There is a lactOse-free milk product line Sally • 56 year old female with a long-term history of being constipation prone. Sometimes Colace or Senokot helps, but the results have been mixed lately. She frequently strains at the stool and often feels like she can’t completely empty her bowels. Additionally, she frequently has a lot of gas and abdominal pain. She has tried taking Metamucil, but that does not work at all. She has also tried eating high fiber cereal – Fiber One and Raisin Bran. She is not sure but thinks these make things worse. She took 2 tablets of senna two days ago, but still hasn’t really worked. A friend of hers is into health foods and recommends peppermint oil. She takes HCTZ, lisinopril, Zyrtec, and Flonase and doesn’t have any drug allergies. She occasionally takes Benadryl for sleep. She has reported this to her doctor, but has not had a colonoscopy or endoscopy. She is very uncomfortable now. Sally - Assessment • Patient uncomfortable now, but not experience alarm symptoms. Needs rapid relief and • Long history of constipation needs maintenance therapy • Patient also need screening colonoscopy Full case answers in Canvas Sally – Plan and Implement • See MD for colonoscopy • STAT treatment options • Bisacodyl PR x1 or • Fleets enema PR x1 bottle per instructions or • MOM 15 ml PO • Chronic treatment (after colonoscopy is negative) • PEG 17 g po daily • Fiber- calcium polycarbophil or methylcellulose (avoid psyllium) • Hydrate well daily Full case answers in Canvas Constipation and Gas in Special Populations Gas – special population • No difference in treatment (other than pediatric dosing) for gas in peds, geriatrics or pregnancy. Pediatric Case - Kevin • A frustrated mother brings her 5-year-old son, Kevin, to the pediatrician's office. She says he had been having normal bowel movements until about 2 years of age, when, after passing a very hard stool, he became "afraid of going." He took to crossing and stiffening his legs when he felt the urge to have a bowel movement. • At first, Kevin's mother thought he was trying to push the stool out, but later realized that he was actually trying to hold it in. He then started to go to "special" places to withhold (corners of the room, behind the sofa) and, since then, has been having fewer movements. He now moves his bowels once a week. The mother can tell from his facial expression that it hurts to hold it in and, when he does have a movement, the stool is large and hard. He is soiling a lot, and children make fun of him. The mother has also noticed some blood in his stool, which she assumes is coming from a rectal tear. Constipation in Pediatrics • 3% of visits to pediatrician are for constipation • Many times due to withholding because of painful bowel movements • Children may not be able to self diagnosis constipation • Treatment • Disimpaction – use of enema, suppository, and rapid acting oral agent for severe • Diet and fluids • Pharmacologic Develop an individualized patient-centered care plan for constipation that is evidence-based and cost effective for adults, children, geriatrics, and pregnant women. (Plan) Pediatrics– Diet and Fluid • Adequate fiber • Adequate fluid – can use fruit juices • Avoid excessive amounts of dairy Develop an individualized patient-centered care plan for constipation that is evidence-based and cost effective for adults, children, geriatrics, and pregnant women. (Plan) Pediatrics - Treatment Acute Chronic • Rapid response <1 hr • PEG • Fiber • Glycerin suppository • Enema • Within a day • Senna/bisacodyl • Milk of magnesia Develop an individualized patient-centered care plan for constipation that is evidence-based and cost effective for adults, children, geriatrics, and pregnant women. (Plan) Treating Constipation in Children Pharmacists Letter Resource #330403 Pediatric Case - Kevin • A frustrated mother brings her 5-year-old son, Kevin, to the pediatrician's office. She says he had been having normal bowel movements until about 2 years of age, when, after passing a very hard stool, he became "afraid of going." He took to crossing and stiffening his legs when he felt the urge to have a bowel movement. • At first, Kevin's mother thought he was trying to push the stool out, but later realized that he was actually trying to hold it in. He then started to go to "special" places to withhold (corners of the room, behind the sofa) and, since then, has been having fewer movements. He now moves his bowels once a week. The mother can tell from his facial expression that it hurts to hold it in and, when he does have a movement, the stool is large and hard. He is soiling a lot, and children make fun of him. The mother has also noticed some blood in his stool, which she assumes is coming from a rectal tear. Options for Fecal Disimpaction Oral Rectal • High dosage of mineral oil • Magnesium hydroxide together with a stimulant laxative • Polyethylene glycol (PEG)electrolyte solution • Phosphate soda enema • Saline enema • Mineral oil enema followed by phosphate soda enema • Bisacodyl suppository • Glycerine suppository Sometimes both are needed Develop an individualized patient-centered care plan for constipation that is evidence-based and cost effective for adults, children, geriatrics, and pregnant women. (Plan) Kevin is given a diagnosis of fecal impaction secondary to functional constipation. He is treated with one pediatric Fleet enema followed by milk of magnesia, 2 mL/kg/d, and one teaspoon of Senokot (extract of senna concentrate) syrup daily for three days. During the visit, the pediatrician makes the effort to explain the cause of the problem and discusses behavioral interventions (use of a calendar and reward stickers to encourage regular sitting on the toilet). The impaction is removed, and maintenance therapy is begun. Maintenance Therapy for Kevin • Diet • Fluid • PEG daily (preferred) • Other options – MOM and mineral oil Develop an individualized patient-centered care plan for constipation that is evidence-based and cost effective for adults, children, geriatrics, and pregnant women. (Plan) Middle Schooler Signs and Symptoms • c/o ab pain and straining at stool • Regularly clogging the toilet • Child has h/o constipation when she was younger. • Other signs of dehydration – dry skin, chapped lips, etc. Develop an individualized patient-centered care plan for constipation that is evidence-based and cost effective for adults, children, geriatrics, and pregnant women. (Plan) Constipation during Pregnancy/Lactation • Increased incidence of constipation during pregnancy • Increase fluid and fiber • Treatment • • • • • • Fiber Colace – commonly used Small doses of PEG or lactulose Senna – low risk for short term Bisacodyl – low risk with short term use Milk of magnesium – not absorbed probably okay for short-term use • Avoid – sodium phosphate (induce contractions) Develop an individualized patient-centered care plan for constipation that is evidence-based and cost effective for adults, children, geriatrics, and pregnant women. (Plan) GI Med Use in Pregnancy and Lactation. Pharmacist Letter Resource #331232 Constipation Geriatrics • Increased risk of developing constipation • Increased polypharmacy • Treatment • • • • • Chronic - Increase fiber and fluid - Colace/PEG- stimulant laxatives Impacted – may need both PR and oral therapy Rule out underlying causes and medications Caution with osmotic laxatives because of electrolyte disorders Must consider mobility when recommending a treatment Develop an individualized patient-centered care plan for constipation that is evidence-based and cost effective for adults, children, geriatrics, and pregnant women. (Plan) Cases Sally • 56 year old female with a long-term history of being constipation prone. Sometimes Colace or Senokot helps, but the results have been mixed lately. She frequently strains at the stool and often feels like she can’t completely empty her bowels. Additionally, she frequently has a lot of gas and abdominal pain. She has tried taking Metamucil, but that does not work at all. She has also tried eating high fiber cereal – Fiber One and Raisin Bran. She is not sure but thinks these make things worse. She took 2 tablets of senna two days ago, but still hasn’t really worked. A friend of hers is into health foods and recommends peppermint oil. She takes HCTZ, lisinopril, Zyrtec, and Flonase and doesn’t have any drug allergies. She occasionally takes Benadryl for sleep. She has reported this to her doctor, but has not had a colonoscopy or endoscopy. She is very uncomfortable now. Sally Obtain from Patient What patient said Symptom (What are the main symptoms) I am constipated Characteristics (What is the situation like? Is it changing?) Frequently strains at the stool, incomplete evacuation of bowels, gas and abdominal pain History (What has been done so far? Has this ever happened before. If Long-term history yes, what was done and did it work? Onset (When did this start?) She took 2 tablets of senna two days ago, but still hasn’t really worked. She is very uncomfortable now. Location (Where is the problem?) Abdominal and rectum Aggravating factors (What makes it worse? What are the common Fiber seems to make it worse – should clarify causes?) Remitting factors (What makes it better?) Need to ask Medications, Allergies, Conditions HCTZ, lisinopril, Zyrtec, Flonase, and diphenydramine I don’t have any allergic reactions to medications. I have high blood pressure Sally - Assessment • Patient uncomfortable now, but not experience alarm symptoms. Needs rapid relief and • Long history of constipation needs maintenance therapy • Patient also need screening colonoscopy Sally – Plan and Implement • See MD for colonoscopy • STAT treatment options • Bisacodyl PR x1 or • Fleets enema PR x1 bottle per instructions or • MOM 15 ml PO • Chronic treatment (after colonoscopy is negative) • PEG 17 g po daily • Fiber- calcium polycarbophil or methylcellulose (avoid psyllium) • Hydrate well daily Sally- Monitor and Follow Up • Monitor • Alarm symptoms- s/sx obstruction – severe pain and N/V, blood in stool • Disease progression – see MD immediately if MOM and suppositories don’t work • Adverse effects – cramps, abdominal pain and discomfort • Patient education • • • • • Should have BM within 1-6 hours – if not seek additional care May have cramping and abdominal pain – for severe pain see MD Must see MD and need colonoscopy Peppermint oil- might help gas Increase fluid, fiber and exercise Robert – Geriatric Case Robert Mercer Harris DOB – 8/17/1931 85 y/o male in a nursing home patient with fall history. Fell a few hours ago and sustained laceration on right forearm. Doctor was notified and new orders have been issued. Patient requires sterile dressing change now. Robert also has severe constipation with decreased bowel sounds and some abdominal pain. States has not had a BM in a week. Will require oral Milk of Mag and enema for relief from constipation. Requires PO pain med for right arm pain. Administration of daily meds has not been completed and should be done at this time. Medications: Metoprolol, meloxicam, acetaminophen, galantaminde, New RX: APAP 500 mg/hydrocodone bitatrate 5 mg oral tablet (Vicodin) 1 tablet PRN Q4H Robert • What will he need now? • MOM 15 mL now and Fleets enema • Will need to be closely monitored on the way to bathroom or use bed pan • Will need to closely monitor because using narcotic • Start Colace 100 mg po bid Clara a 32 year old pregnant (24 weeks) woman presents to the pharmacy and asks what she should take for constipation Obtain from Patient What patient said Symptom (What are the main symptoms) I am constipated Characteristics (What is the situation like? Is it changing?) I have not had a good bowel movement in over a week. History (What has been done so far? Has this ever happened before. If I tried drinking more water and some fiber. But now I am very gassy yes, what was done and did it work? Onset (When did this start?) I’ve had this on and off for years. I get constipated easily Location (Where is the problem?) My stomach hurts and I feel like I haven’t fully emptied my bowels. I’m really miserable and will be traveling on a long trip tomorrow. Aggravating factors (What makes it worse? What are the common I’m not really sure causes?) Remitting factors (What makes it better?) Drinking strong coffee Medications, Allergies, Conditions I take Zyrtec for spring allergies, I don’t have any allergic reactions to medications. I have high blood pressure Clara- Assessment • Pregnant female constipated for >1 week and wants rapid relief Clara – Plan and Implement • Milk of magnesia 10 mL PO now, and take second dose if no BM in 2-3 hours. • Chronic management – docusate 100 mg PO bid • Rationale: Want safe in pregnancy, rapid acting and something that can be titrated Clara Monitor and Follow Up • Monitor • Alarm symptoms- s/sx obstruction – severe pain and N/V, blood in stool • Disease progression – see MD immediately if MOM • Adverse effects – cramps, abdominal pain and discomfort • Patient education • • • • Should have BM within 1-6 hours – if not seek additional care May have cramping and abdominal pain – for severe pain see MD Drink plenty of water daily Eat soluble fiber PPCP Test Questions 1. 2. 3. 4. 5. List this patient subjective symptoms of constipation. Spelling should be recognizable; points will be deducted for incorrect answers. List this patient’s objective symptoms of constipation. Spelling should be recognizable; points will be deducted for incorrect answers. What is your assessment of this patient’s constipation? (Assessment must be complete, Spelling should be recognizable; points will be deducted for incorrect answers.) (– assessment must be complete) A. Please describe your plan for this patient’s constipation. (Must include name dose route and frequency) – B. What is your rationale for your choice? (Because the treatment guidelines recommend this is not an acceptable answer)C. What three monitoring parameters would follow? (Must be specific and pertinent, only the first three will be graded,). List three important patient education points. (Must be specific and pertinent, only the first three will be graded,) Assess the information collected and analyze the clinical effects of the patient’s therapy for constipation in the context of the patient’s overall health goals in order to identify and prioritize problems and achieve optimal care. (Assess)
