Effects on the Neurological System

Effects on the Neurologic System: Constipation

Authors: Ayda G. Nambayan, DSN, RN, St. Jude Children’s Research Hospital Erin Gafford, Pediatric Oncology Student, St. Jude Children's Research Hospital;Nursing Student, School of Nursing, Union University Content Reviewed by: Nancy E. Kline, PhD, RN, CPNP, FAAN, Director, Evidence Based Practice and Research, Memorial Sloan-Kettering Cancer Center, New York, NY Cure4Kids Release Date: 6 June 2006

Constipation (A – 1) is the infrequent passing of hard and dry stools, often accompanied by straining, abdominal cramping, bleeding and rectal discomfort. In patients with cancer, constipation is often related to decreased gastrointestinal motility associated with altered or diminished autonomic function secondary to the effects of the following. - chemotherapy (especially treatment in which plant alkaloids such as vincristine, vinblastine, paclitaxel are administered) - procedures such as abdominal or pelvic surgery - radiation therapy - spinal cord compression by primary or metastatic lesions - use of drugs such as anticholinergic agents and opioids that are common in supportive therapy.

Other factors that may contribute to the development of constipation are dehydration due to nausea and vomiting, a lack of fluid intake due to mucositis and anorexia, hypercalcemia and immobility due to weakness, surgery, etc. Disease progression causing bowel obstruction and spinal cord compression may have constipation as its presenting symptom.

Assessment

The patient with constipation may complain of nausea, decreased appetite and abdominal fullness. The patient and family may also report a decreased frequency of normal stools and the occurrence of formed, hard and possibly blood-streaked stools. Straining during bowel movements may also be reported. For infants, the assessment should determine the number of diaper changes for both stool and urine elimination. It is important to remember that patients who have prolonged or severe constipation may present with watery stools and their condition may be misdiagnosed as diarrhea.

When the patient’s history is obtained, the patient should be asked about his/her cancer treatments; his/her use of pain medications, especially opioids; his/her eating patterns and the presence of gastrointestinal side effects such as mucositis and anorexia. Because constipation is often associated with spinal cord compression, patients with constipation should be further

Module 7 - Document 20 Page 1 of 8 Effects on the Neurological System evaluated for other signs and symptoms of the compression and/or other types of disease progression.

Patients at risk for constipation should undergo assessment to evaluate their bowel sounds (which may be decreased or absent), the presence for abdominal tenderness, generalized abdominal tenderness or distension; decreased appetite; nausea and vomiting.

Other factors that may cause constipation in children and adolescents include emotions, dietary changes, febrile illnesses and environmental changes such as new home, new school and new friends. In patients who have prolonged constipation, a constipation scale (A – 2) may be useful to further evaluate the severity of the problem.

Planning

The plan of care is expected to result in the following.  the recognition by the patient and family of factors that cause constipation  the implementation of measures by the patient and family to prevent and manage constipation  the identification by the patient and family of a regular pattern of bowel movement  the recognition by the patient and family of signs and symptoms of constipation that require medical attention

Implementation

The goals of care for patients experiencing constipation is prevention, recognition of early occurrence and prompt management. Patients at risk should be given prophylactic laxatives and stool softeners (A – 3) to prevent constipation. Patients should be encouraged to maintain activity levels, have adequate fluid intake (especially in warm climates) and have a sufficient quantity of dietary fiber (A – 4). However, in patients whose constipation is due to autonomic deficits (slowed peristalsis), care should be taken regarding the use of increased fiber and bulk laxatives (A – 5), as the fiber may cause intestinal obstruction. Stimulant (contact) laxatives (A – 6) may be prescribed for these patients.

For patients who are experiencing severe constipation, potent oral laxatives such as hyperosmotic agents (A - 7) may be prescribed. The use of rectal suppositories and enemas to relieve constipation may be contraindicated for patients who are neutropenic and thrombocytopenic. The reason for this contraindication is the use of these dosage forms could injure the rectal area, and such injury increases the risk of infection and bleeding.

If not contraindicated because of other treatment or disease-related factors, play that requires increased physical activity should be encouraged in children who are at risk of constipation or who are constipated. Older children may be encouraged to do simple exercises or walk; games such as hide and seek may encourage younger children to move around.

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Patient and Family Education

Patients and their families should be taught to report any deviation from the normal patterns of bowel elimination patterns. Caregivers of patients who are at risk for constipation should be taught preventive measures such as the use of stool softeners, a high-fiber diet, increased activity and sufficient fluid intake.

Evaluation

Nursing care outcomes for patients who have cancer and are experiencing constipation include prevention of constipation through proactive approaches and prevention of possible complications such as infection and bowel obstruction.

Helpful Web Links

Dr. Spock.com Anticonstipation Diet http://www.drspock.com/article/0,1510,5879,00.html

Bawarch Health and Nutrition Sify Limited, Chennai, India Constipation www.bawarchi.com/ health/constipation.html

National Digestive Disease Information Clearinghouse (NDDIC), Bethesda, MD National Institutes of Health http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/

Family Practice Notebook.com Constipation in Cancer http://www.fpnotebook.com/GI56.htm

National Cancer Institute Gastrointestinal Complications/Constipation http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications/Patient/page3

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APPENDIX

A – 1 Cycle of Constipation

Constipation

Reduced bowel Fecal accumulation in efficiency the large bowels

Increased time between Fecal accumulation bowel movements decreases bowel diameter

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A – 2 Bristol Constipation Scale

Medscape, LLC, New York, NY http://www.medscape.com/pages/sites/infosite/zelnorm/article-diagnosis

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A – 3 Emollients and Lubricant Laxatives Emollients are fecal-moistening agents and include stool softeners and surfactants. Examples are the following.  Docusate sodium (Colace)  Docusate calcium  Docusate sodium and casanthranol (PeriColace)

One type of lubricant laxative is mineral Oil, which penetrates and coats the fecal mass and prevents excessive absorption of water; thus, mineral oil keeps the stool soft. In children who have cancer and are immunocompromised, this softening is desirable because it can prevent rectal tears and infection. Softening of the stool by mineral oil can also prevent straining after abdominal surgery. The dose of mineral oil for children older than 6 years is 5 to 15 ml.

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A - 4 High-Fiber, High-Residue Diet

The following are components of a high-fiber, high-residue diet: Juice with pulp Fresh fruits (care should be used if the patient is immunocompromised) Prunes Bananas Dates Figs Mangoes Oranges Bran or whole-grain cereals Leafy vegetables

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A – 5 Bulk-Forming Laxatives

Two common bulk-forming laxatives are polycarbophil calcium and psyllium.

Polycarbophil calcium is used to treat diarrhea and constipation. The compound restores the normal level of moisture in the stool and provides bulk in the intestinal tract. Polycarbophil calcium absorbs water to form the gel bulk and should not be taken if the patient has hypercalcemia or is at risk of hypercalcemia.

Psyllium (Metamucil) is a mixture of dextrose and the mucilaginous portion of the psyllium seed. This mixture promotes the formation of soft, water-retaining residue in the lower bowel.

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A – 6 Stimulant (Contact) Laxatives

Stimulant (contact) laxatives usually act within 6 to 8 hours of administration; their primary effect is on the small and large intestines. Side effects include abdominal cramping, nausea, diarrhea and flatulence.

The following are types of stimulant laxatives. Bisacodyl (Dulcolax) is an enteric coated form and should not be crushed, chewed or taken with milk or antacids ( taking this drug with milk or antacids will increase abdominal cramping).

Castor oil causes the formation of semiliquid stools by promoting the rapid passage of fecal matter. The typical dose for children older than 2 years is 5 to 15 ml.

Cascara sagrada is the mildest of all the stimulant laxatives. This laxative can discolor the urine (color ranges from pink to brown). To make it more palatable, cascara sagrada may be chilled or mixed with fruit juice or carbonated drinks before it is administered.

Senna (Senokot) is similar to cascara but is more potent. Senna can cause abdominal cramping. For children older than 6 years, the dose is usually 1 tablet given twice a day.

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A – 7 Osmotic (Saline) Laxatives

As the name suggests, osmotic laxatives cause an osmotic effect that draws water into the small intestine; the result is ncreased peristalsis and eventual bowel movement.

Magnesium sulfate has a bitter saline taste. The dose for children older than 6 years is 5 to 10 g in 4 ounces of water.

Magnesium hydroxide (milk of magnesia, MOM) interacts with HCl in the stomach to form magnesium chloride, which causes the laxative effect. The dose for children 1 to 12 years old is 7.5 to 30 ml.

Magnesium citrate is carbonated and usually flavored. It should be chilled or given over ice. The normal dose for children 6 to 12 years of age is 50 to 100 ml.

Effervescent sodium phosphate (Fleet’s Phosphosoda) should always be diluted in water (usually 4 ounces) when it is administered orally. The dose is 5 ml for children 6 to 9 years old and 10 ml for children 10 years and older.

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Acknowledgments:

Authors: Ayda G. Nambayan, DSN, RN, St. Jude Children’s Research Hospital Erin Gafford, Pediatric Oncology Student, St. Jude Children's Research Hospital; Nursing Student, School of Nursing, Union University Content Reviewed by: Nancy E. Kline, PhD, RN, CPNP, FAAN, Director, Evidence Based Practice and Research, Memorial Sloan-Kettering Cancer Center, New York, NY Edited by: Julia Cay Jones, PhD, ELS, Freelance Biomedical Editor, Memphis, TN Cure4Kids Release Date: 6 June 2006

Cure4Kids.org International Outreach Program St. Jude Children's Research Hospital 332 N. Lauderdale St. Memphis, TN 38105-2794

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