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WEBINAR Preventing Constipation & Bowel Obstruction

KAREN GREEN McGOWAN

RN, CDDN

Presented by

EARN 3 CEUs

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About the PresenterKaren Green McGowan, RN, CDDN

1. Clinical Nurse Consultant2. Specializes in assistance to agencies serving persons with complex health needs

3. Nurse in the ID/DD field for 50 years4. Advisory Board for Disability Rights International5. President of Developmental Disabilities Nurses Association (DDNA)

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Preventing Constipation & Bowel Obstruction

Learning Objectives:1. Participants will correctly identify the

structure and function of the GI Tract.2. Participant will describe the primary

measures to facilitate healthy bowel elimination. Ø Physical activity and immobilityØ Enteric friendly bacteriaØ FiberØ Fluid

Learning Objectives(contd.):

3. Participants will identify and define the most common causes with signs/ symptoms of:

Ø ConstipationØ Paralytic IleusØ Large bowel obstructionØ Small bowel obstruction

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24’ of chambers, locks & glands

Mouth

Esophagus

Upper digestive tract

Lower digestive tract

LiverStomach

Gall BladderPancreas

Large Intestine

The Digestive System

Atlas of the GI Tract

Peristalsis • Primary peristaltic wave: Esophagus• Stomach stores food, mixes it up with

digestive juices and empties contents slowly into the small intestine

• Finally, all digested nutrients absorbed through intestinal walls

• Undigested products propelled into colon, and remain for a day or two, until expelled as a bowel movement.

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The Digestive System

A. Oral-­Motor:• Lips• Tongue• Jaw• Cheeks

B. Flow– From mouth to anus assisted by:• Gravity• Pressure of fill and empty• Peristalsis• Backflow Valves

Normal Alignment and Function:

The Digestive System • Large hollow organs contain muscle that enables

walls to move• Movement of organ walls propels food and liquid and

mixes contents within each organ• Movement is called peristalsis• Peristalsis looks like an ocean wave moving through

the muscle• Waves of narrowing are

propelled down the length ofthe organ

• Pushes food and fluid in front of them through succeeding organs

Our Internal EcosystemFoodsNutrients, Minerals, Vitamins, Fibers

GUT Secretions-­Electrolytes, Enzymes, Protein, water, fat

MicrofloraBacteriaVirusesFungi

Parasites

DigestionImmune FunctionDetoxification

Hormone Production

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Leaky Gut Syndrome• Inflammation in gut allowing pores to

remain open too long• Toxic substances absorbed and sent to

liver• May affect other systems by causing joint

pain, skin disorders, food sensitivities, etc. • Far more common than we

know

Five Protective Barriers of the GI System

• Intelligence Don’t take your diet for granted.• Stomach Acid Sterilizes food, begins protein

digestion, and processes minerals.

• Digestion Our food furnace-­ kills germs, grinds food, digests proteins, and processes minerals

• The Liver Grand Central Station• Friendly Flora Immune defenses, provides Vitamin K

and fatty acids.

The Small Intestine

• 25 feet of tubing covered on the inside with tiny folds• If unrolled flat, the surface would be 25’ x 60’-­area of a tennis court

Duodenum Jujunem

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Transverse Colon

Descending Colon

Ascending Colon

The Large Intestine• Large intestine is 5’-­

surface smaller than a desktop

• Water absorbed from spent food in large intestine, preparing it for discard

• Host to a huge population of bacteria, including friendly flora.

The Healthy, Moist Colon Lining

• Protects nerve endings and regularity

• Helps healthy bacteria flourish

• Protects the colon from infection

• Movement of fluids in/out of colon wall is more efficient

• Uptake of vitamins/electrolytes more efficient

• Stool passage is made easier

GI Transit-­How Long Does it Take?• 50% of stomach empty-­ 2.5 to 3 hours• Total emptying of stomach-­ 4 to 5 hours• 50% of small intestine empty-­ 2.5 to 3 hrs.

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What Contributes to Breakdown

• Certain medications• Infection• Disease

Benefits of Good Flora• Crowds out harmful microbes• Slows the growth of pathogens• Improves digestion• Reduces harmful effects of

cholesterol• Regulates the immune system• 70% of the immune system is located in

the gut• Protects against

cancer

Digesting: The Basics• 35-­50% of Probiotics live in the large

intestine. • Probiotics lining the intestinal wall break

down food that can’t be elsewhere.• Nutrients necessary to healthy colon

come from probiotics which produce substances that help wipe out pathogens:

a. Acidophilus-­kills dangerous bacteriab. Lactic acid-­forms acidic and

inhospitable environmentc. Hydrogen peroxide-­free radical to combat pathogens

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Good Bacteria Gone Bad• Poor diet• Overuse and Misuse of Antibiotics• Excessive use of antacids and acid

lowering drugs• Excessive use of laxatives• Use of synthetic estrogens and steroids

When the Lining Breaks Down• Irregularity and/or constipation• Increased risk of impaction• Diminished capacity to secrete

moisture or extract fluids• Potential damage to nerve endings• Decrease in healthy bacteria• Increase in infectious bacteria• Poorly formed stools w/o lubrication• Slowed stool transit time

Bowel Health-­The Role of Fiber• Dietary fiber is the portion of the diet not

digested by the secretions in the human digestive tract.

• Fiber = Plant cellulose• Fiber binds water.

• Fiber increases fecal bulk.• Fiber decreases the transit time

of the colon.

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Sources of Fiber• Legumes• Fruits (with skins, please)

• Vegetables• Seeds• Nuts• Whole Grains

Sources of Fiber• Beans: garbanzo, kidney, lima, black-­ 6 or more• All-­bran, All-­bran with extra fiber, Fiber One-­ 14

• Bran flakes or Raisin Bran-­ 4 to 5• Berries-­ 4 to 5• Broccoli one cup-­ 4 to 5 grams• Pear with skin-­ 4 to 5 grams, applewith skin 2-­3

• Brown rice, wild rice, barley-­ 2 to 3 • Celery, popcorn, nuts-­ 5 to 8 grams• Miller’s Bran, Flax seed, fruit butter-­ 7 or 8

How Much Fiber?• Americans consume an average of 10-­12 grams of fiber daily.

• They need 25-­35 grams per day.• Adolescents 6-­7 grams (four basic food groups are hamburgers, French fries, soda and pizza.

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Fiber’s Effect on Bowel Function• Fiber traps water

• Fecal output increases proportionately with intake of fiber

• Fermentability is dependent on the fiber type and bacteria that colonize colon

• Fiber reduces cholesterol

• Fiber lowers the glycemic response to carbohydrates

• Fiber reduces body weight in obesity

All About Fluid• Stool is 70-­80% water

• 64-­80 ounces per day of non-­caffeinated fluids for adequate hydration

• Higher end with:

1. Fiber supplementation

2. 85 degrees or higher with high humidity

3. Medical condition with atypical fluid loss (fever, vomiting, diarrhea, increased metabolism)

Types of Fluids• Water

• Juices

• Iced Tea

• Hot tea, cocoa, coffee (decaf)

• Soda (preferable no sugar or caffeine)

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When Fluid Intake Should Go Up

• When fiber is supplemented in the diet

• When ambient temps are high (<85)• In any medical condition with atypical fluid loss, i.e., fever, vomiting, diarrhea or increased metabolism

• When fluids are restricted, as in chronic renal disease, intake and output along with careful assessment of stool consistency and fluid balance.

Do You Drink Enough Water?

• Amount of Fluid Needed from beverages daily:

• 1-­3 years 4 cups

• 9-­13 7-­8 cups

• 14-­18 8-­11 cups

• 19-­50 9-­13 cups• 51+ 9-­13 cups

Lower amount female, higher male

Figure your fluid needs!• 25-­55 years 16 ml/lb

• 56-­65 14 “ “• >65 12 “ “

• multiply the number for your age range and divide the result by 240 (ml/8 oz.)

• 30 year old weighing 200 = 3200 ml or 13.33 8 oz. glasses of water

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You Snooze, You Lose!• Lactulose needs adequate fluid to work

• For laxatives requiring fluid to work, do not give the dose at night.

• Fluid intake is at it’s lowest and the laxative will not work

• Metamucil needs 16 oz. of fluid to be effective-­need time in the day to push the fluids

• Almost all laxatives best given on an empty stomach

Physical Activity• Constipation is related to activity level

• Bedridden, hospitalized persons have fewer bowel movements than healthy active persons

Physical Activity (contd.)• Lack of exercise leads to constipation-­

particularly abdominal and lower extremity• For people who cannot move on their own,

prone positioning will assist with movements

• Abdominal exercises, such as sit-­ups• Knee-­chest position. Spending 10-­15 minutes

in this position may activate the bowel.

• Kegel exercises for those who can understand how to do them

• Walking 30 minutes briskly each day

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Whenever I feel the urge to move, I lay down until it passes!

Exercise Examples

• Walking

Exercise Examples

• Sit-­ups

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Exercise Examples

•Prone-­on-­forearms

Exercise Examples

•Knees on Chest

Exercise Examples•Quadruped-­on-­Forearms

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Constipation

CONSTIPATION IS NOT A DISEASE, IT IS A SYMPTOM

Constipation Criteria

• Infrequent defecation

• Smallness of stool• Hardness of stool

• Need to strain during defecation

• Feeling of incomplete emptying

Constipation

Most of its ill-­effects are caused by its treatment!

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Most Common Causes

• Diet low in fiber

• Less than 2 quarts of water a day• Misuse of laxatives

• Lack of physical activity

Constipation not responding to RX

Medical evaluation to rule out the following:

1. Rule out mechanical obstruction

2. Weakness of intestinal motility (colonic inertia)

3. Pelvic floor issues

Medication:A very common cause of constipation

• Antacids

• Antidepressants, antipsychotics• Diuretics

• Iron supplements

• Opiates

• Anticholinergics of any type

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Paralytic Ileus

Paralytic ileus is a partial or complete non-­mechanical lockage of the small and/or large intestine.

• Often due to infection of the peritoneum

• Disruption of blood flow to the abdomen• In kidney disease, with low potassium

• Drugs such as narcotic pain relievers, or blood pressure medication

Symptoms of Ileus•Abdominal cramping

•Abdominal distension

•Nausea and vomiting

•Failure to pass gas or stool

•Hiccups

Small Bowel Obstruction•The small bowel may become blocked by scar tissue (adhesions) which grow between sections and trap loops of bowel.

•A hernia is a weakness in the wall through which bowels protrude and become trapped.

•Inflammatory bowel disease-­ Crohn’s, diverticulitis

•Intussusception, twisted or knotted bowel

•Cancer

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Symptoms-­Small Bowel Obstruction

•In small bowel obstruction, pain tends to be colicky (cramping and intermittent) with spasms lasting a few minutes.

•Pain tends to be central and mid-­abdominal

•Vomiting-­green upper;; brown lower•Hyperactive bowel sounds early.

•Hypoactive bowel sounds late.

•Fever and tachycardia-­late with strangulation

Large Bowel Obstruction

An emergency condition requiring early intervention resulting from:1. Neoplasms

2. Hernias

3. Inflammatory bowel disease

Symptoms-­ Large Bowel Obstruction

1.Abdominal pain

2.Bloating3.Diarrhea or constipation

4.Vomiting

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Signs and Symptoms1.Pain Abdominal with muscle guarding, or rebound tenderness-­the higher the

obstruction, the more intense the pain

2.Abdominal Distension Becomes more pronounced the further down the GI tract the obstruction occurs. Small bowel distends upper quadrants, large bowel lower abdomen. Bowel can rupture if pressure becomes too great.

3.Bowel Sounds Hyperactive in small-­bowel obstruction proximal to obstruction, and hypoactive distal to the obstruction if it is complete.

4.Vomiting The higher the obstruction, the sooner vomiting begins and character is important to describe:a) Lots of clear , gastr ic fluid-­pylor ic obstructionb) Bile and mucus-­high small-­bowel obstructionc) Gastr ic contents and bile-­paralytic ileusd) Bile-­stained fluid with mild distention-­proximal small intestinee) Orange-­brown feculent drainage-­low ileal obstruction.

STAGE I-­ Prevention1. Avoid use of irritant laxatives

2. Provide Adequate Fluid3. Increase dietary fiber gradually

4. Give time and attention to periods of high gut motility

5. Increase physical activity

6. Supplement gut flora with yogurt, or probiotics with 6-­7 billion per capsule

7. Uncooked high fiber fruit/vegetable at each meal

STAGE II

In addition to steps at Stage I:

8. Supplement dietary fiber intake.a. no more than 7 first 2 weeks, 14 second 2 weeks, and 21 thereafter

9. Administer stool softeners, lubricants, and antispasmotics as needed.

10. Stool frequency, amount and quality should be evaluated.

11. Evaluate medication regime

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Offending Drugs

•Narcotic pain medications

•Anti-­depressants and anti-­psychotics

•Anticonvulsants

•Calcium channel blockers

•Aluminum antacids

STAGE III-­ Obstipation

• Hyperosmotic agents i.e. lactulose or sorbitol

• Local agents i.e. suppositories, enemas,

particularly in the presence of pelvic floor

dysfunction, or colonic inertia.

Four Laxative Types

• Bulk Forming (bran, psyllium, cellulose, ca polycarbophil)

• Surfactant Laxatives (castor oil, docusates, poloxamers

• Stimulants (bisacodyl, phenophthalein

• Osmotics (sodium phosphates, MOM, mag citrate, Sorbitol, glycerine,

lactulose)

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Medical EvaluationA Definitive Diagnosis

When to evaluate the cause for the chronic constipation?

When there is no response to Stage 1 measures

…then what?

Things to Consider•Medications

•Habit

•Diet

•Laxatives

•Hormonal Disorders

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Things to Consider

•Diseases that affect the colon

•Central nervous system diseases

Roadmap to a Definitive Diagnosis

Definitive Diagnosis = Optimal Bowel Function

Physical Exam

Blood tests

Abdominal x-­ ray

Barium enema

colonic transit (marker) studies

Definitive diagnosis

Optimal Bowel function

Bowel Management PRN Suppository Usage/Monthly Janaury 1998 -­ September 2006

0

200

400

600

800

1000

1200

Jan-­98

May

Sep

Jan-­99

May

Sep

Jan-­00

May

Sep

Jan-­01

May

Sep

Jan-­02

May

Sep

Jan-­03

May

Sep

Jan-­04

May

Sep

Jan-­05

May

Sep

Jan-­06

May

Sep

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RecipesFruit Butter•2 c ups ra is ins•3 ¼ c up prunes wi th ju ice•¼ c up honey• 1 ts p. v ani l la•½ c up apple ju ice•Soak ov er n ight, then dra in , p lac e in food proces sor for 3 mins . •Serv ing s iz e-­ 2 ½ ounc es dai ly in am•Serv ings per batc h-­ 16 @ 8 grams of fiber per serv ing

Trail Mix•1 lb . raw a lmonds•1 lb . raw walnuts or pec ans•2 c . ra is ins•2 c . dried c ranberries•2 c . unsweetened c oc onut flak es•1 box Fiber One c ereal•1 box Fiber One Honey Clusters cereal•1 bag b i ttersweet c hoc olate ch ips• Two ounc es = 6-­7 grams of fiber and about 200 c a lories.

Be sure to encourage extra fluids and do not increase daily fiber intake by more than 6-­7 grams/day for each two week period. For example, if baseline is 8 -­10 grams per day, go to 14-­16 day for two weeks and then bounce up to 20-­22 for the next two weeks and then to 26-­28 for another two weeks. For each 6-­7 grams of fiber increase, add another 8 ounces of non-­dehydrating fluid.

Appendix A: Bristol Stool Chart

Appendix B: Group Exercise

Get a set of these “substances”. Identify the type of stool that each of these types of chocolate represent:1. Chocolate chips in chocolate milk2. A tootsie roll bar 3. Smear of chocolate pudding4. Large, medium, small tootsie roll5. Baby Ruth bar

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Appendix C: Handout

Match the following “samples” 1-­5 with its mate a-­e1. Baby Ruth Bar a. impaction2. Pudding on diaper b. normal bm3. Chips in milk c. smear4. 3, 2 and 1 segments d. small, soft

e. large, softf. medium, soft

Available for Pre-­Order!

Reference Poster“Bowel Obstruction”

Great for bothResidential and Day Program Sites

For more information, email:webinars@hrstonline.com

Thank you for attending!

KAREN GREEN McGOWAN, RN,CDDN

Founder & President, Health Risk Screening, Inc.President, Developmental Disabilities Nurses Association

www.hrstonline.com www.ddna.org