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Tag Archives: constipation

Risk of phosphate neuropathy from phosphate based enema use

17 Sunday Apr 2016

Posted by Annette Horton in Aged Care, Nurse Convo

≈ Comments Off on Risk of phosphate neuropathy from phosphate based enema use

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bowel, constipation, enema, fleet, hypersulphaemia, medication, neuropathy, perforation, toilet

Use of hypertonic sodium phosphate enemas (ie Fleet) in the elderly may cause severe phosphate neuropathy and  hyperphosphatemia.

Deposits of phosphate crystals form within the kidneys causing kidney dysfunction. Sodium phosphate is absorbed into the blood stream due to the significant absorption properties found in the bowel.

Cleansing enemas are used in hospitals for pre operative bowel preparation and when bowel activity has not occurred for many days and the risk of bowel obstruction is real. First line treatment should always be non pharmacological. In addition to strategies below patients should be provided with opportunities to sit on a toilet/commode regularly (at least daily particularly postprandially).

  • patient education                             image
  • hydration
  • diet
  • activity

Enemas distend the bowel stimulating colon contractibility causing stool expulsion. Phosphate enemas additionally stimulate the bowel muscles to contract facilitating stool expulsion. Adverse effects for all enemas irrespective of the active ingredient includes electrolyte imbalance (metabolic derangement) and bowel perforation.

Bowel perforation can generally be related to muscle weakness of the bowel wall, an obstruction or incorrect positioning of the patient during enema administration. Bowel perforation, hyperphosphatemia and phosphate neuropathy may occur, causing death in up to 4% of cases post enema administration.

Symptoms of acute phosphate nephropathy are:

  • lethagy
  • drowsiness
  • decreased urination
  • swelling of ankles, feet and legs.

Symptoms of hyperphosphatemia potentially are:

  • muscle cramps                                               image
  • joint pain
  • tingling and numbness

and in prolonged states:

  • itchy skin
  • pain
  • skin rashes

Patient groups at risk for phosphate neuropathy and hyperphosphatemia are:

  • aged > 65 years

and patients with

  • CKD
  • dehydrated
  • bowel obstruction, delayed bowel emptying or active colitis and
  • on medications (diuretics, angiotensin converting enzyme [ACE] inhibitors, angiotensin, receptor blockers [ARBs], non inflammatories ( NSAIDs) and analgesics (opiates)

Preventing constipation particularly post operatively is vitally important. Being aware of your patients usual bowel habits and routines provides a baseline for the development of their bowel management plan.

“A stitch in times saves nine”

Negating the need to consider the use of enemas is a primary role of the nurse. Asking your patient “have your bowels moved today” is not a rhetorical question. Enquiring about the bowel activities of your patients is only the first step in preventing constipation. Doing something about lack of bowel movements is necessary.

Caution in use of phosphate based enemas for bowel cleansing pre procedure or for treatment of constipation is highly recommended. If administration is prescribed then nurses must be aware of patients at risk for hyperphosphatemia and phosphate neuropathy. Initiating a conversation with the prescriber regards the risks and clinical reasoning for your particular patient is necessary for their safety and wellbeing.

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Have Your Bowels Moved – Postoperative Constipation

30 Tuesday Jun 2015

Posted by Annette Horton in Nurse Convo

≈ Comments Off on Have Your Bowels Moved – Postoperative Constipation

Tags

bowel, constipation, movement, postoperative

Constipation postoperatively is common. So too is the “have you moved your bowels today” catch cry from nurses everywhere. Many factors increase the risk for constipation in patients who have undergone a general anaesthetic.

Change in routine and diet, reduced fluid intake perioperatively, nausea and vomiting postoperatively, reduced mobility, pain, opioid medications and use and type of anaesthetic agents all have an effect on reducing gut motility increasing the risk for constipation.

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Constipation is defined on the basis of stool frequency, stool consistency and difficulty passing stools. It is the accumulation of old hardened faces that is so tightly packed together that the bowel movements are infrequent and incomplete, causing much difficulty and strain, producing dry, hardened feces. The hardened feces will then stick to the walls of the colon and inhibit proper nutrient absorption.

Screening the patient prior to or on admission for chronic constipation is an important aspect to consider for minimising the risk for constipation. Ideally patients with a history of constipation should be flagged as high risk for developing constipation postoperatively.

Gathering information from the patient preoperatively is most likely to include their usual patterns of bowel movements, including the frequency, consistency, size or amount, and also amount or degree of straining when passing bowel motions.

A management plan could be implemented immediately paying very close attention to hydration perioperatively. Including the patient preoperatively in the development of their bowel management plan ensures that the patient has a voice in what works well for them. As part of developing the plan is patient education on risk factors which can exacerbate constipation.

Patients need to understand the importance of bowel movements in general and particularly postoperatively. Nursing staff can play a significant role in educating patients on appropriate level of fluid intake and the importance of moving and mobilising as much as possible. The use of the Bristol Stool chart is helpful in educating patients of appropriate stool consistency.

Postoperative nausea and vomiting (PONV) if not adequately treated can result in dehydration which impacts on fluid absorption and consistency of the bowel motion. Prolonged periods of fasting preoperatively has a similar effect if not adequately managed. The elderly are particularly vulnerable to perioperative dehydration.

Mobility restriction postoperatively due to type of surgical procedure performed and or pain adds an additional aspect impacting on constipation. Studies on the effects of physical activity in healthy subjects on colonic transit suggests accelerated transit time after physical activity . All patients should be encouraged to physically move as much as possible within the restrictions in place medically.

Optimising pain relief for mobility is a balancing act that is at times complex. Opioids reduce gastrointestinal propulsion and increases fluid absorption. Decreased mobility reduces gut motility. Ensuring the patient has the right amount of pain medication to maximise physical mobility is the goal here.

Medications may be used to assist in the prevention and treatment of constipation. Emollient stool softeners are easy to use and are best used prophylacticly in the short-term particularly for the patient receiving a postoperative opioid medication.

Many health professionals do not give bowel management the focus and the respect it requires. Constipation is uncomfortable and distressing for patients. Constipation postoperatively can lead to faecal impaction and gut obstruction which are possible serious consequences of untreated constipation.

Patient and staff education regards risks associated with constipation and how to prevent it postoperatively are the key to ensuring patients respond more often and with confidence “Yes my bowels have moved today thank you nurse”.

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