BOWEL MANAGEMENT 
(CONSTIPATION AND DIARRHEA) IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION
  • Change in stool frequency or consistency
  • Fecal incontinence, oozing stool, or fecal impaction
  • Fecal retention in colon on abdominal x-ray
  • New urinary incontinence
  • New or worsening hemorrhoidal pain
  • Mental status changes accompanied by infrequent bowel movements

 

CONTEXT / / COMMUNICATION

All residents should be evaluated for these changes with treatment given to resolve condition and prevent worsening. If the resident is moribund treatment is intended to enhance comfort. The facility nurse should communicate with the responsible party with MD or NP contact as needed. 

 

ASSOCIATED RISKS

 

Constipation

Diarrhea

Medications

antidepressants, anticholinergics, iron, bismuth, narcotics, aluminum hydroxide, calcium channel blockers, Clonidine, Oxybutynin

iron, antibiotics, laxatives, antineoplastic drugs, antidiabetics

Conditions

PD, DM, dementia, DM, hypothyroid, hemorrhoids, dehydration, scleroderma, hypercalcemia, hyperkalemia, diverticular disease, uremia, CVA, history of bowel surgery, SBO, ileus

DM, hyperthyroid, diverticular disease, IBS, Crohn's Disease

Nutrition

decreased fluids, decreased fiber, altered texture diets

enteral feedings

Environment

Toileting schedules, delays in answering call bells, failure to monitor bowel record

Functional

Immobility, cognition, change in anal sphincter control or stimulation, urinary retention, lax abdominal musculature

 

PHYSICAL EXAMINATION
  • Pertinent to assess overall status with specific attention to abdominal and rectal examination

 

DIAGNOSTIC WORK-UP
  • BMP (evaluate hydration), CBC with diff (infectious diarrhea, diverticulosis), TSH
  • Abdominal flat plate (R/O bowel obstruction, high impaction, ileus, tumor, volvulus)
  • Stool for clostridium difficile, ova and parasites, C&S (where appropriate)

 

TREATMENT OPTIONS

Constipation

Diarrhea
  • Review medications and eliminate offending drugs where possible
  • Review medications and eliminate offending drugs where possible
  • Dietary evaluation to recommend change to increased fluids and fiber
  • Dietary evaluation to recommend changes to decreased fiber and fruit juices
  • Review bowel pattern and when drugs are necessary order to treat specific problem ** and at time of day to enhance "normal" physiological movement for this resident
  • Start antisecretory Pepto Bismal 30 cc per hour until diarrhea stops (maximum 8 doses) to maintenance dose 60 cc QID
  • Increase current bowel medication (if minimally effective) to therapeutic doses or start another medication**
  • If C-diff + treat with Flagyl 250 mg QID 10 – 14 days+ Lactinex Granules 1pkt/QDX7
  • If C-diff - and Pepto Bismal not effective (as ordered) start Imodium 2 mg after each loose stool (MDD=8)
  • If C-diff + after 1st treatment treat with Vancomycin 125 mg Q 6 hours 10-14 days .
  • Testing for cure with repeat stools is not necessary in asymptomatic patient.

 

  • For severe, chronic diarrhea, any etiology, consider oral rehydration solution therapy with Elder Lyte or Rehydralyte and Questran

 

MEDICATIONS FOR CONSTIPATION **

Problem

Classification

Medication

BM < 3 X week, normal size & consistency

Bulk or stimulant laxative

Metamucil 1 TSP or 3 capsules with 8 oz liquid (if  resident has adequate liquid intake) otherwise Senna 1 QD- both can be increased to effectiveness

Stools hard to pass

Softener/stimulant

Colace or Senna-S 1 QD - increase as needed

Stools unformed, frequent but not diarrhea

Bulk

Metamucil 1 TSP or 3 capsules in 4 oz of liquid QD and discontinue other laxatives or stool softeners

Normal to hard stool requiring straining to pass

Stimulant

Senna and Dulcolax or Glycerin suppositories 3 x week

Fecal impaction (considered Sentinel Event by DOH)

Stimulant/hyperosmolar laxative/manual evacuation

Manual disempaction followed by oil retention enema or tap water enemas until complete evacuation. Also start Lactulose 30 cc QD and Senna QD and increase dose as needed



References for Bowel Management

  1. Bennett, RG, Greenough, WB: Diarrhea in Principles of Geriatric Medicine and Gerontology, 3rd Edition, 1994, 1275-1284.
  2. Bentley, DW: Clostridium difficile - Associated Disease in Long-Term Care Facilities in Topics in Long-Term Care, Infection Control Hospital Epidemiology, 1990; 11: 434-438.
  3. Clostridium Difficile Information for Healthcare Providers in CDC Bulletin, 9/23/04.
  4. Cheskin, LJ, Schuster, MM: Constipation in Principles of Geriatric Medicine and Gerontology, 3rd Edition, 1994, 1267-1274.
  5. Chico, GF & Chico MA: Clostridium difficile Colitis in Emergency Medicine, January 2005, 27-32.
  6. Donowitz, M. Kokke, FT et al: Evaluation of Patients with Chronic Diarrhea in NEJM, Vol. 332, No. 11, March 16,1995, 725-729.
  7. Constipation in the Elderly, in Medical Sciences Bulletin, January 1994, published by Pharmaceutical Information Associates, Ltd.
  8. Mardini, HE & deVilliers, WJ: Preventing Outbreaks of Clostridium difficile – Associated Diarrhea in LTC Facilities in Long-Term Care Interface, March 2005, 48-54.
  9. Minaker, CK, Harari, D: Constipation in the Elderly in Hospital Practice, May 15, 1995, 67- 76.
  10. Robson, K., Lembo, T.: Management of Constipation in Geriatric Patients in Long-Term Care Interface October 2001, 54-58.
  11. Thomas, DR et al: Clinical Consensus: The Constipation Crisis in Long-Term Care in Supplement to Annals of Long-Term Care, October 2003.

 


MS/10.99
©EMS
Revised 7/05

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