In this section
Note: This guideline is currently under review.
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.
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.
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.
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:
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.
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.
‘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.
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.
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.
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.
Kids Health Info – Constipation
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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.