Clinical Guidelines (Nursing)

Post-operative bowel management

  • Introduction

    Aim

    Definition of Terms

    Assessment

    Management

    Special Considerations

    Education 

    Companion Documents

    Evidence Table

    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. Faecal impaction may occur causing pain and discomfort for patients as well as increasing the length of hospital stay.

    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 consistency or ease of passing stool or the failure of the bowels to open for 3 consecutive days.
    • Opioids - Analgesics that are useful agents for managing acute or chronic pain. These can be given both orally or intravenously. 
    • Aperients – Oral or rectal medications which can be given to stimulate or facilitate the evacuation of the bowels.  
    • Ileus - A post-operative complication that is characterized by the loss of forward flow of intestinal contents. It is often accompanied by abdominal cramps, increasing abdominal distension, constipation or vomiting, electrolyte disturbances and dehydration.

    Assessment

    All post-operative patients are at risk of developing constipation as a result of a variety of factors. Constipation can be an adverse drug effect from opioid use due to the action upon opioid receptors in the gastrointestinal tract. This leads to a reduction in gastrointestinal propulsion and an increase in fluid absorption.
     
     If the patient reports difficulty in passing stools, have not had their bowels opened post op or are currently on opioids the following must be considered:

    • What is causing the child to be unwell/ what is their reason for admission?
    • Does the patient have a history of constipation/ are they on regular aperients at home? 
    • Ensure these have been prescribed in their MAR. 
    • Are they currently on opioid medications?
    • What is their mobility like? Is their mobility decreased/ are they likely to be resting in bed for a period of time?

    Physical Assessment

    • Auscultate the abdomen for bowel sounds, if bowel sounds are present, or the patient reports they are passing flatus, clear fluids can commence and aperients can be administered. Patients must not commence oral fluids if bowel sounds are not present as this finding indicates an ileus.
    • Assess their oral intake by monitoring their fluid balance on a fluid balance chart to identify the patients input and output. Is the patient tolerating oral intake? How much are they drinking/ are they staying hydrated?
    • What is their usual diet/ are they eating/ how much are they eating and is it a healthy balanced diet?
    • A physical assessment of the child can be performed by observing if their abdomen is bloated or distended. 
    • Palpation of the abdomen may detect faecal masses in line of the colon.
    • Abdominal xrays can be ordered if concerned.

    Management 

    • Consider reducing opioid intake. Is the patient still requiring the same amount of analgesia or can they switch to a medication that is not an opioid?
    • Encourage mobilisation. Physiotherapy can be utilised to assist patients to mobilise. Continue to encourage patients to get out of bed and walk around.
    • Encourage a healthy/ balanced diet.
    • Consider commencing aperients for patients on opioid infusions.
    • Has the child previously used aperients that have been successful or are they on regular aperients at home?
    • Do they have aperients charted in their MAR?
    • Movicol™ (Macrogol 3350 plus electrolytes) is a common aperient that can be given orally as a prophylactic when patients are tolerating oral intake
    • If Movicol™ is unsuccessful Lactulose™ can be given in conjunction with Movicol™ or Movicol™ can be escalated to Osmolax™.  
    • For older patients that prefer to take tablets Coloxyl and Senna™ can be given
    • If they have been given oral aperients (see table) and BNO 3/7 continue to escalate treatment. Consider the use of an enema such as a Glycerol Suppository, a Microlax™ or a FLEET™.

    Special considerations

    • The use of aperients has recognized side effects, the most frequent of which is diarrhoea.
    • Intravenous antibiotics can also cause diarrhoea so a fluid balance chart should be maintained.
    • An ileus is a more serious post op complication that can occur. An ileus is more 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.  
    • General surgical or gastrointestinal patients undergoing abdominal or bowel surgery will have different bowel patterns in the post-operative period, thus discretion regarding the use of aperients needs to be taken by the treating team. In most cases, the treating team will not prescribe aperients for this patient group.
    • 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.
    • Children with cerebral palsy and other complex histories may already have bowel management issues as they have decreased gastric motility and inadequate fibre intake therefore are often on regular aperients at home. A thorough bowel regime should be initiated early with the treating team and family to assist in preventing constipation.

    Education 

    • Provide information for parents on appropriate diets and healthy bowel actions. This can be accessed via Kids Health Info.
    • Educate patients and their families on the use of aperients if required on discharge.

    Companion documents

    Kids Health Info – Constipation

    Table 1  

    Class Agent Onset of Action Side Effects    

    Practice

    Points

     

    Osmotic

    Stool

    Softener

    Lactulose™ 1-3 days

    Abdominal discomfort

    and

    flatulence

    Mix with H20 or juice to improve taste

    Osmotic

    Stool

    Softener

    Movicol™ 1-4 days     Nausea
    Vomiting
    Abdominal cramps &
    distention
      Dissolve sachet in 125mls of cold H2O or cordial

    Gut

    Stimulant

    Senokot™
    Coloxyl &
    Senna™
    6-12 hours Abdominal cramps     Can be eaten or mixed with water, milk or food
    Enema     Fleet™
    Microlax™
    Glycerol Suppository™
    Within 30 minutes

    Renal

    patients = dehydration

    Do not use in oncology patients

     Note: please refer to RCH policies and procedures for medications that can be nurse initiated https://www.rch.org.au/policy/policies/Medication_Management/

    Evidence table

    Click here to view the evidence table.

     

    Please remember to read the disclaimer.

     
    The development of this nursing guideline was coordinated by Mica Schneider, RN, Platypus Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2019.