Clinical Setting
The patient with breast cancer at the centre of this assignment (Mrs Andrews) was admitted as an inpatient to a hospice in London where the author was on placement. The hospice has an inpatient unit, community Palliative care team and a day care unit. The inpatient unit has 29 beds and provides care for 350-420 patients in a year. It has three wards that are made up of bays and side rooms. Each bay is maintained as a single sex and there is no particular designation of beds across the three wards. The wards employ team nursing and the named nurse approach to care. The multi-professional team includes nurses, social workers, ward clerks, physiotherapists, pharmacist, research practitioner, complementary therapies coordinator, art therapist, psychiatrist and the medical team.
Patient Profile
Mrs Andrews is an 80 year old widow with metastise breast cancer for 15 months. Her husband died of prostate cancer 2 months ago. She lives alone in a single bedroom council flat. She receives weekly visits from a social worker and a district nurse and she receives fortnightly visits from Macmillan nurses. She does her own cooking and shopping and is on state benefits. She is mostly indoors watching television. She initially kept silent about her constipation choosing to buy over the counter laxatives instead. She then started having diarrhoea. She complained to the district nurse about her loose stool. She stated that she was having leakages with no warning. Over time she was put on several laxatives including Senna, Lactulose and Novical after admitting being constipated. Mrs Andrews stated that after she told the district nurse about her constipation it took a month before she was started on laxatives.
Recently Mrs Andrews started vomiting and experiencing severe pain when defecating and was referred by the district nurse to the hospice. During the admission assessment it was determined that Mrs Andrews was not eating and drinking enough. Her mobility was also considerably reduced. After a pain assessment Mrs Andrews was put on 10 mg oramorph as the cocodamol she was on was proving ineffective. After a rectal examination by the medical team, glycerine suppositories were administered. Mrs Andrews’ named nurse, Emma referred her to the ward dietician, physiotherapist, social worker, the community palliative care team and the occupational therapist. Emma also invited the district nurse to a multidisciplinary meeting about Mrs Andrews at the hospice. The district nurse was unable to attend. The physiotherapist initiated exercises, the dietician place Mrs Andrews on a high fibre diet, the social worker increased her care package to include help with cooking and there was to be follow up visits by the community Palliative care team after discharge. After 3 weeks Mrs Andrews improved and was discharged home. The district nurse and Mrs Andrews’s general practitioner were informed about her pending discharge two days earlier. Just before discharge the occupational therapist visited Mrs Andrews home and recommended a raised toilet seat, handrails and a commode.
Analysis
Maybe Mrs Andrews Should have had an abdominal X-ray in the hospice to exclude obstruction or to identify the level of faecal impaction and faecal loading (Groenwald 1996). The primary goal of the management of constipation should be prevention (Groenwald 1996). According to Groenwald (1996) the aim of laxative treatment is to ease defecation not necessarily to achieve a daily bowel action. In addition Groenwald (1996) identify the need for a bowel diary at home.
Mrs Andrews Complained of being bloated with abdominal pain and feelings of incomplete evacuation, which are all associated symptoms of constipation (Fallon and O’Neil 1997). Symptoms of complications of constipation include overflow diarrhoea, nausea and vomiting. According to Fallon and O’Neil (1997) constipation is more common in patients with advanced cancer than in those with other terminal diseases, and many of the associated symptoms may mimic features of the underlying disease (Fallon and O’Neil 1997). About half of patients admitted to specialist palliative care units report constipation and about 80% will require laxatives (Fallon and O’Neil 1997). Ms Andrews Complained of leakages, bacterial degradation of hard tools can result in leakages of which the patient has no warning (Fallon and O’Neil 1997). During the admission assessment the named nurse took an accurate background history of Mrs Andrews. Gabriel (2001) suggests that an accurate history is essential for effective management of constipation. Constipation could be cause by cancer (depression); poor nutrition, poor fluid intake and opioids (Gabriel 2001). Mrs Andrews could be depressed as a result of her husband’s death and her cancer (Fallon and O’Neil 1997). It is debatable why Mrs Andrews was started on oramorph in the hospice as the use of opioids is the commonest cause of constipation (Corner and Bailey 2001).
According to Annels and Koch (2002) the advice of attention to dietary fibre, adequate fluid intake and regular exercise is not always successful in the management of constipation. This may firstly be because constraints not uncommon to older people exist which makes it unlikely that they will use one or more of the options (Annels and Koch 2002). For example the cost of fruit and vegetables, a tendency of urinary incontinence, not feeling safe to take walks alone when widowed (Annels and Koch 2002).Mrs Andrews may have started buying laxatives over the counter as a holiday preparation this is recommended by some practice nurses (Goldman 1999). An increase in fluid intake helps keep stool soft (Gates and Fink 2001). Raised toilet seats, footstools and bedside commodes are considered helpful for constipated patients (Gates and Fink 2001). It could have been better if Emma had informed the district nurses earlier about Mrs Andrews’ pending discharge instead of just two days earlier. Research evidence suggests that district nurses are particularly concerned that patients with actual or potential palliative care needs are not always referred to them early enough (Pateman et al 2003). Mrs Andrews’s activity levels were identified as a risk associated with the development of constipation. Furthermore, constipation has been identified as being the most frequent complication of immobility (Taylor 1990). Mrs Andrews mentioned that she was drinking 2-3 cups of tea a day and two glasses of water. This is about 600ml a day and optimal fluid intake is 2-3L per day, and minimum fluid intake for the maintenance of regular bowel habits is 1-2 L per day (Cameron 1992; McFarland and McFarlane 1989). Research evidence suggests a team approach that includes dietician, social workers, psychologists, dentists, medical and nursing staff in the management of constipation (Whitney 1998). As mentioned earlier Mrs Andrews was started on opioids at the hospice for her acute pain. Opioids are known to cause constipation (Gates and Finch 2001). On the other hand the recognition of the under treatment of pain and efforts to improve pain control has led to increased use of opioids (Bates et al 2004).
Implications and recommendations for practice
- In patients with a history of diarrhoea, care should be taken to separate true diarrhoea from overflow due to faecal impaction (Fallon and O’Neil 1997).
- A constipated patient may have malodorous breath or the smell of faecal leakage could be obvious (Fallon and O’Neil 1997).
- The management of constipation should extend well beyond the use of laxatives; attention should be given to other symptoms especially pain and advice on diet, fluid intake, mobility and toileting contributes to an effective outcome (Corner and Bailey 2001).
- Older people have a different understanding of the term constipation, therefore, health care professionals should explore what the term ‘constipation’ means to an older person presenting with that self diagnosis (Annels and Merilyn 2002).
- Patient management of constipation must be individualised (Vikery 1997). According to Vikery (1997) a patient’s willingness to change must be established before treatment of constipation is commenced; the patient’s wishes must be considered in attempting to make changes. Changing lifestyle and establishing an elimination routine are slow and time-consuming and patients will need much support and encouragement, nurses should make sure that individual patients and family understand this (Vikery 1997).
Conclusion
The author has highlighted the importance of constipation and its management in palliative care. A rationale for the choice of topic has been presented. The clinical setting has been explained and a patient profile presented. A comprehensive analysis of research evidence is included and implications and recommendations for practice provided. The need for holistic care and the relevance of the multidisciplinary team in the management of constipation has been emphasised.
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