Clinical Guidelines (Nursing)

Post-operative bowel management

  •  Note: This guideline is currently under review. 

    Introduction

    Constipation is one of the most frequent, adverse reactions that can occur post-operatively secondary to a reduction in fluid intake, immobility and medications such as opioids.

    Opioid analgesics are useful agents for managing acute or chronic pain however, faecal impaction may occur causing pain and discomfort for patients as well as increasing the length of hospital stay. Those prescribing the medications need to have an understanding of the risks and benefits associated with these medications. 

    Aim

    The aim of this guideline is to assist nurses’ who work within the paediatric field around the prevention and management of constipation in the post-operative patient. 

    Definition of terms


    Constipation – an alteration in the frequency, consistency or ease of passing stool. It can also be defined as passing less than three stools per week. Constipation can be an adverse drug effect due to the action upon opioid receptors in the gastrointestinal tract, which leads to a reduction in gastrointestinal propulsion and an increase in fluid absorption

    Functional Constipation - difficulty passing stool or idiopathic; caused by a symptom of disease.

    Laxatives – Oral or rectal medications which can be given to stimulate or facilitate in the evacuation of the bowels.

    Assessment


    All post-operative patients are at risk of developing constipation as a result of a variety of factors. If prophylactic laxatives weren’t commenced and the patient states difficulty in passing stools, the following assessments can be undertaken:

    Nursing CPG Post Op Bowel Mment Assessment

    1. Establish the child’s medical status – What is causing the child to be unwell? If the child is vomiting bile a review of the patient is required as soon as possible to prevent further deterioration.
    2. Undertake a physical assessment - This will assist in detecting for any bowel sounds, distension and abdominal pain. Clinically, patients receiving short or long term opioids after surgery can encounter the following – hard, dry stools, straining, incomplete evacuation, bloating, abdominal distension and increase in gastric reflux. Palpation of the abdomen will detect faecal masses in line of the colon. Rectal examination digitally can be performed if the bowels have not been open for >3 days or if the patient reports rectal discomfort or has diarrhoea suggestive of faecal impaction with overflow. Auscultate the abdomen for bowel sounds, if bowel sounds are present, clear fluids can commence and laxatives can be administered. Patients must not commence oral fluids if bowel sounds are not present as this finding indicates an ileus.
    3. Establish child’s level of hydration – A strict fluid balance chart should be maintained to ensure input and output is being documented. When did the patient last open their bowels? Diet should commence as soon as bowel sounds are present and patients are encouraged to drink fluids to maintain hydration. Offer water and juices between meals as oral fluids work as a natural stool softener which will assist in the prevention of constipation and promote opening of bowels.
    4. Establish child’s use of opioids in the post-operative period. Can opioid use decrease? If pain is well controlled, small reductions in the dose of opioids may help resolve the adverse effect of constipation while maintaining pain control.
    5. Administrations of medications – Laxatives have been identified as appropriate in the management and prevention of constipation in the post-operative population however literature states a specific bowel protocol has not yet been

    Investigations – biochemistry, procedures

    If the patient has a distended abdomen, a firm, large bloated appearance will be seen, this can indicate constipation and an abdominal x-ray can be performed to confirm. Ongoing physical assessments should be continued whilst the patient remains in hospital to ensure adequate gastrointestinal function. This can include auscultation of the abdomen to detect audible bowel sounds, maintaining a strict fluid balance chart to assess tolerability of diet and fluids and documentation of stool passages.

    Education needs (patient and parent/care-giver)

    Patients and their family/care-givers need to understand the importance of bowel actions in the post-operative period. Nursing staff can educate on encouraging fluid intake, mobilisation around ward and communicating with members of the health care team on usual bowel patterns and regimes on children with complex medical histories. The use of the Bristol Stool chart (see Links) may be helpful in detecting usual pattern of bowel motion.

    Management - acute & ongoing

    Administration of laxatives -

    ‘Lactulose’ is an osmotic medication that assists in the water production of the gut and can be administered with the use of ‘Coloxyl and Senna’, a bowel stimulant. These medications should be documented on the medication chart once the patient returns from theatre (if opioids prescribed) and commence once diet is tolerated on Post-Op Day 1 prophylactically to prevent constipation and encourage bowel motility. If required, ‘Movicol’ can be documented and administered to encourage bowel actions as this will also assist with softening of the stool. If no bowel action has occurred after 3-4 days, medical staff should be requested to chart an enema or suppository- ‘Microlax’ or ‘Fleet’ until bowels have opened. Once bowel actions have occurred, laxatives can be titrated to ensure bowel movements are every 48 hours for the post-surgical patient to ensure constipation has resolved secondary to opioids and decreased mobility. Please see below table to assist in types and mechanism of laxatives.

    Nursing CPG Post Op Bowel Mment Management table 1

    Fluid balance management:

    Ongoing fluid management is required to ensure patients are appropriately hydrated to maintain an adequate urine output and to ensure electrolyte imbalances do not occur. The management of post-operative constipation should extend beyond the use of laxatives for support thus increasing their dietary fibre intake as tolerated. It is recommended that the consumption of 2 servings of fruit per day, 3 servings of vegetables, avoiding processed cereals and encouraging the intake of wholemeal bread instead of white bread will assist in the prevention of constipation. Prevention of post-operative constipation can also include an increase in fluid intake (juice and water) however a reduction in the amount of cow’s milk (<500mls) in children over the age of 18 months, encouraging mobility and ambulation as soon as physically possible and encouraging daily bowel movements at the same time each day will assist in the prevention of post-operative constipation.

    Potential complications:

    Laxative therapy has recognized side effects, the most frequent of which is diarrhoea. The use of intravenous antibiotics which are often administered during the post-operative period can also cause diarrhoea therefore a strict fluid balance should be maintained and effective communication regarding stool appearance (see Bristol Stool Chart) should be discussed with the family/care giver to determine type and frequency of stool. A more serious post-operative complication that can occur is an ileus. An ileus is characterized by the loss of forward flow of intestinal contents, often accompanied by abdominal cramps, increasing abdominal distension, constipation or vomiting, electrolyte disturbances and dehydration. An ileus is common in abdominal surgery and contributing factors can include anaesthesia, post-operative opioids, previous abdominal surgery and early post-operative feeding, thus the importance of audible bowel sounds before commencing oral diet and fluids is strongly recommended.

    Discharge planning:

    Constipation is known to increase hospital stays unnecessarily which adds to health-care costs. The added length of hospital stay can add to the already discomfort of a constipated patient and in many cases, exacerbate pain and increase morbidity. This supports the need to have laxatives already prescribed on the medication chart and to begin once the patient is tolerating diet to ensure bowel actions occur in the first 48 hours after surgery. Once stool has passed and if patients are discharged home on opioids, laxatives should also be distributed home to ensure constipation isn’t an ongoing issue with the use of the opioid. The health-care team (nursing, pharmacy and medical team) should advise family members on titrating the laxative and opioid to ensure regular bowel movements and adequate pain management once home.

    Special considerations

     

    • Rectal suppositories and enemas should not be used in the Neutropenia/thrombocytopenia population due to the risk of bowel perforation, infection or uncontrolled rectal bleeding.
    • Pre-operative bowel care is important and families should be encouraged to monitor bowel movements prior to hospitalization. Families can consider talking with a pharmacist pre-operatively to discuss best management prior to surgery to prevent constipation.
    • Children with Cerebral Palsy and other complex histories will already have bowel management issues as they have decreased gastric motility and inadequate fibre intake therefore a thorough bowel regime should be initiated early with the treating team and family to assist in preventing constipation.
    • General surgical patients undergoing abdominal surgery will have different bowel patterns in the post-operative period, thus discretion regarding the use of laxatives needs to be taken by treating team.

     

    Companion documents

    Kids Health Info – Constipation

    Appendix 1

    Nursing CPG Post Op Bowel mment Bristol Stool

    References

     

    Becker, G., Galandi, D. & Blum, E. (2007). Peripherally acting opioid antagonists in the
    treatment of opiate-related constipation: A systemic review. Journal of Pain and
    Symptom Management, 34 (5), 547-565

    Castiglia, P.T. (2001). Constipation in children. Journal of Paediatric Health Care, 15 (4),
    200-202

    Hockenberry, M.J. & Wilson, D. (2009). Wong’s Essential of Paediatric Nursing (8th ed.). St
    Louis: Mosby

    Howarth, L.J. & Sullivan, P.B. (2012). Management of chronic constipation in children.
    Paediatrics and Child Health, 22 (10), 401-408

    Levitt, M.A., Mathis, K.L. & Pemberton, J.H. (2011). Surgical treatment for constipation in
    children and adults. Best practice & Research Clinical Gastroenterology, 25, 167-
    179

    Librach, S.L., Bouvette, M., De Angelis, C., Farley, J., Oneschuk, D., Pereira, J. & Syme, A.
    (2010). Consensus recommendations for the management of constipation in
    patients with advanced, progressive illness. Journal of Pain and Symptom
    Management, 40 (5), 761-773

    Mugie, S.M., Benninga, M.A. & Di Lorenzo, C. (2011). Epidemiology of constipation in
    children and adults: A systemic review. Best Practice & Research Clinical
    Gastroenterology, 25, 3-18

    Online Oxford Dictionary. (2013). Retrieved from www.oxforddictionnaries.com

    RCH Clinical Practice Guidelines, (2013). Constipation.
    www.rch.org.au/clinicalguidline/constipation

    Sorensen, E. (2007). Enema use prohibited in the neutropenic and thrombocytopenic
    patient: What is the evidence? Oncology Nursing Forum, 34 (2), 544-545

    Swegle, J.M. & Logemann, C. (2006). Management of common opioid-induced adverse
    effects. American Academy of Family Physicians, 74 (8), 1347-1354

    Quitadamo, P., Coccorullo, P., Gianetti, E., Romano, C., Chiaro, A., Campanozzi, A., Poli,
    E., Cucchiara, S., Di Nardo, G. & Staiano, A. (n.d.). A Randomized, Prospective,

    Comparison Study of a Mixture of Acacia Fibre, and Fructose vs. Polyethylene Glycol
    3350 with Electrolytes for the Treatment of Chronic Functional Constipation in
    Childhood, 161 (4), 710-715

    Wilson-Jones, M., Morgan, E. & Shelton, J.E. (2007). Primary care of the child with
    cerebral palsy: a review of systems (Part II). Journal of Paediatric Health Care, 21
    (4), 226-237

    Evidence table

    Click here to view the evidence table.

     

    Please remeber to read the disclaimer.

     
    The development of this nursing guideline was coordinated by Elise Dixon, RN, Playtapus Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2014.