This case study outlines the clinical management of a client with a problem Opoid induced constipation. Throughout the analysis the anonymity and confidentiality of this patient will be protected as outlined by the Nursing and Midwifery Council (2008) therefore the patient will be referred to as Mark Scott. Additionally consent was gained by Mark to allow the author to use his case for my assessment.
History of present illness
Mark Scott is a 64 year old gentleman who is 2 days post op following a Right Total Hip Replacement (RTHR). Total hip replacement involves removal of a diseased hip joint and replacement with a prosthetic joint.
Whilst doing the medications Mark confided in the nurse that he may have a problem with his bowels and that he may be constipated. He asked if there was anything she could give him. Mark has presented with a new problem with the possibility of him needing medicaion. Before considering this the nurse would first need to undertake a holistic assessment of Mark. The purpose of assessment is to allow the nurse to examine all relevant factors of the problem and allow her to make the decision of whether prescribing a patient group directive (PGD) is an appropriate intervention (Humphries 2002).
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Consider the patient
When Mark stated he thought he was constipated it was important to ascertain his own interpretation of what this meant. For example, Wondergerm (2005) states that for some, constipation may mean opening their bowels less than three times a day. On the other hand constipation may mean opening of the bowels less than three times a week. There appears to be a general consensus that the range for normal bowel activity lies somewhere between three bowel motions daily to one bowel motion every three days. However, it is important to remember that a change from three bowel motions a day to one every three days may represent a significant change for the patient, despite remaining within the normal limits (Peate 2003).
Mark felt he was constipated because he hadn’t had a bowel movement in the last five days. On further questioning it emerged that these symptoms had been going on approximately 4 days before his surgery and when he did have a bowel movement he had difficulty passing the stools and often had to strain. Additionally he stated that the stools were very hard, Constipation can be diagnosed by using the Rome 11 criteria whereby two or more of the following symptoms are present for at least three months and for at least a quarter of the time, However, it is important to note that in order to be diagnosed with chronic constipation using the Rome II criteria, patients specifically must not fulfill the criteria for irritable bowel syndrome (IBS). The primary differentiating factor between these 2 diagnoses is the presence and prominence of abdominal pain or discomfort that is relieved with defecation in patients with IBS. Straining at defecation, lumpy and/or hard stools, a sensation of incomplete evacuation and two or fewer bowel movements a week (Thompson et al 1999). The symptoms that Mark presented with were consistent with the above and would indicate that Mark was indeed constipated. However the cause of constipation is multifactoriol with many influencing factors that need to be investigated and eliminated wherever possible (Banks 1998).
During Mark’s assessment, enquiries were made as to whether he was experiencing other symptoms with his constipation, such as blood in the stools, rectal bleeding and/or mucus discharge, recent weight loss, abdominal pain or alternating constipation/diarrhoea. Edwards and Bentley (2001) state that this is important during history taking as all of these symptoms are common of colon and rectal cancer and the possibility of this disease should be in the mind of the nurse prescriber. Mark assured the nurse that he hadn’t experienced any of the symptoms mentioned although he did have a little discomfort in the area of his abdomen but no pain. If Mark had any of these symptoms the nurse would have to discuss with the patients consultant. No medication would have been given by the nurse at this stage. This is because as a nurse she is accountable for her actions and omissions (NMC 2008) For example, if Mark was to have a bowel obstruction such as a tumour which is contra-indicated for most laxatives, if she had prescribed such medication then Mark may believe he has been harmed by my careless prescribing. Additionally failure to refer a patient for more senior opinion is considered to fall below an acceptable standard of care (Griffith and Tengnah 2004).
It is important to ascertain how much dietary fibre and fluids are being taken by the patient as high fibre content is effective in increasing stool weight and bowel movement frequency, ultimately preventing constipation. Additionally, low fluid intake has been associated with constipation, slowing colonic transit time or reducing stool output (Walker 1997).
Current medication regimes whether prescribed or purchased over the counter is essential information and can assist in identifying any drugs that may be responsible for causing constipation (Annells and Koch 2002). Additionally, a history of medicine taking should include noting whether a patient has any allergies. For example, arachis oil enemas have a nut basis and may cause allergic reactions (Edwards and Bentley 2001). Pre and post operatively Mark had been prescribed analgesics in the form of Paracetamol, codiene and ibupfen for his pain. He had been taking these regularly daily. Mark wasn’t taking any other medication, wasn’t allergic to anything he knew of and hadn’t purchased anything over the counter for his constipation. Opioids are a common cause of constipation and act by increasing intestinal smooth muscle tone, by suppressing forward peristalsis and reducing sensitivity to rectal distension. This results in delayed passage of faeces through the gut (Fallon and O’Neil 1998).
Through assessment together with eliminating possible causes and sinister abnormalities the nurse diagnosed Mark with constipation secondary to opioid use.
Which Strategy/Product
Where the patient complains of feeling constipated and is experiencing discomfort, a rectal examination is indicated in order to detect a loaded rectum and to determine choice of product which will depend on the consistency of the stool found on examination (Edwards and Bentley 2001). The Royal College of nursing guidelines (2003) recommend that nurses undertaking digital examination are appropriately trained. Furthermore consent to this procedure needs to be gained as outlined by the Nursing and Midwifery Council (NMC) (2008) Further to examination, it emerged that no stools could be felt within the rectum. However, Edwards and Bently (2001) suggest that it is anatomically impossible to conclude that the rectum is empty through simple digital examination as the length of the rectum is approximately 15cm and is therefore beyond the reach of the longest index finger. Therefore Mark’s history, the preferred medical route will therefore guide the need to administer a laxative. Amongst the stimulant laxatives are senna and bisacodyl. These laxatives stimulate the intestinal mucosa, promoting the secretion of water and electrolytes, enourging peristalsis (Duncan 2004. Timby et al (1999) recommend that stimulant laxatives be used only for short periods of time to allow normal bowel function to return as soon as possible as long term use may result in diarrhoea and hypokalaemia. However Mark’s constipation may remain for as long as he is using opioids or could re-occur. Therefore this type of laxative may not be sufficient.
Osmotic laxatives act by retaining fluid within the bowel that they are administered with or by drawing fluid from the body. They include lactulose, macragols, magnesium salts, rectal phosphates and rectal sodium citrate (Peate 2003). A phosphate enema would not be used in this case because this is usually used prior to radiology, endoscope and surgery for rapid bowel clearance. Additionally Mark stated he didn’t want to go through having an enema, and would prefer something he could take orally. Lactulose is non-absorbable and acts by softening and increasing water absorption. This laxative may take up to 72 hours to act and bloating, flatulence, cramping and an unpleasant taste have all been reported side effects, (Banks 1998). Additionally lactulose may not be suitable in constipation where gut motility is impaired such as opioid use in Mark’s case, unless accompanied by a stimulant such as Senna. However, choosing a senna/lactulose combination, means that taken together they will act at different times (Edwards and Bently 2001).
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However, evidence comparing different types of laxative is very limited. Nonetheless, a study was found comparing a low dose macragol with lactulose for the treatment of constipation. The treatment was 1-3 sachets of compound oral powder (movicol) versus 10-30g of lactulose daily. After 4 weeks patients in the movicol group had a mean number of stools and a lower median daily score for straining than the lactulose group (Attar et al 1999).This concluded that movicol was more effective and better tolerated than lactulose in the treatment of constipation. This would then justify prescribing movicol for Mark in increasing the frequency of bowel movements and reducing straining. However the Nurse had to get Marks doctor to prescribe Movicol as it is not listed in Patient group directive, so the nurse gave Mark 10mls of lactulose and 2 senna until this was prescribed.
Negotiate contract
In implementing the strategy the consent and agreement of the patient is paramount, and may be viewed as a shared contract between patient and nurse. This is known as concordance. It is important for nurses to adopt this approach to administering medication, as this directly involves patients in decision making about their treatment
Nurses owe a duty of care to their patients. Duty of care is a legal requirement owed by one person to another to take reasonable care not to cause harm. The courts have held that the nurse-patient relationship gives rise to such a duty (Kent v Griffiths 2001). Additionally, common law decided from cases requires that nurses take care when prescribing, otherwise, a patient harmed by careless medicine administration can sue for damages by claiming negligence (Griffith and Tengnah 2004). It is essential therefore that duty of care extends to quality of prescribing, including, assessment, advice and information giving, record keeping, decision making along with medication selection and calculation, as well as communication with the patient and other professionals. The patient needs to know what is expected of them in carrying out the treatment plan and when the nurse needs to reassess the situation. Additionally the patient needs to know what the medication is for, how long it takes to work and how to take the product (Edwards and Bentley 2001). In Mark’s case it was explained to him that he would be prescribed a product by the name of movicol for his constipation and evidence found on its appropriateness along with possible side effects for his condition was explained. He would receive 20 sachets with a view to taking 1-3 sachets a day. It was explained he would have to mix 1 sachet with 125ml of water (British National Formulary, BNF 2009) and the importance of drinking 2lts of fluid was explained along with the effects that movicol will have within his bowel. Mark was alerted to any know side effects of movicol as these could be alarming to the patient if that information is not given, for example, abdominal distension, pain and nausea. However this does not mean that Mark will experience any of these. Nonetheless, this information is essential and Mark was told to report any adverse effects to either myself or his GP.
Record keeping
The NMC (2005) guidelines for records and record keeping, state that good record keeping is integral to our role as records are sometimes called in evidence in order to investigate a complaint. In light of this all details, including full assessment details, along with care plans which were both planned and executed, plans for review, and medications and prescriptions given, were all entered into Mark’s patient held records immediately. Additionally this was also recorded within notes in Nursing Notes. Mark’s own GP was also informed of this information by a duplicate prescription in order to assist with prescribing and also to avoid polypharmacy and adverse events from drug interactions.
Complementary Therapies
Abdominal massage has been shown to be effective as a marginally effective laxative regimen in one trial. However, massage is extremely demanding on staff time, and consequently is unlikely to be of widespread utility. Acupuncture, One small within subject trial of sham versus true acupuncture showed some benefit in chronically constipated children, but acupuncture has never been tested for opioid-induced constipation. Herbal preparations such as Senna, a laxative, may be used as pods or a tea. Rhubarb stems (not the leaf, which contains poisonous oxalic acid), chrysanthemum stems, and peach leaves have laxative properties. Many preparations promoted as herbal or natural laxatives are in fact bulk forming preparations which should be avoided in opioid-induced constipation.
However, if possible medication can be avoided as bowel movements may be facilitated if done at the same time every day, by mobility and physical activity, and increased dietary fibre and fluid intake. However, these approaches alone may not benefit all patients, especially those with severe constipation. Nevertheless, deficiencies in physical activity, and fluid and fibre intake should be addressed. Physical constraints and barriers should also be rectified, and commonsense toilet practices should be reinforced, such as not suppressing the urge to defecate, and using public washrooms if out of the house rather than waiting to return home.
Summary
The above account highlights that in the clinical management of medicine administration, it is vital that this is undertaken in an informed and systematic manner. This can be achieved through the selection and application of an assessment tool and by having clarity about the decision-making framework used to underpin Evidence Based Practice. The NMC guidelines of professional conduct (2008) require that nurses must maintain knowledge and competence. This can partly be achieved by the use of reflection on prescribing and administrating decisions.
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