Steps to Effective Bowel Management

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There are 6 steps to good bowel management: assessment and diagnosis of bowel dysfunction, normalization of the bowel, establishment of expectations for bowel-movement frequency, development of a bowel management program, assessment of outcomes, and adjustment of the bowel management program through problem-solving.

Assessment and Diagnosis of Bowel Dysfunction

Thoroughly assessing bowel function and obtaining a bowel history together constitute the most important step in bowel management. Unless the cause of the dysfunction or problem is diagnosed, the wrong treatment may be prescribed, leading to an unfavorable outcome. The assessment should include the following: vital signs; hydration status; abdominal status; perianal or peristomal skin integrity; frequency of bowel movements in the previous 2 weeks; consistency of stool (liquid, soft formed, or hard and hard to eliminate); number of impactions since cancer diagnosis; appetite (ranging from 3 big meals per day to only sips of liquid); daily fluid intake; daily fiber intake; medications currently being taken, particularly those that affect bowel elimination; presence of abdominal pain or cramping; concomitant diseases that affect bowel function (e.g., diabetes, Crohn's disease, and irritable bowel syndrome); presence of abdominal distention; frequency of bowel movements before cancer diagnosis; usual time of day that bowel movements occur; effective corrective measures previously used for bowel problems; extent of cancer; current treatments for cancer; laboratory results; and diagnostic imaging results. This information provides a comprehensive picture, allowing the problem to be correctly diagnosed and its causes to be identified.

Comorbid conditions unrelated to cancer need to be assessed, along with consumption of over-the-counter drugs; changes in the patient's physiologic make-up secondary to surgery, disease process, or treatment; and dietary habits. All of these factors must to be weighed when advising patients about a bowel management program.

Normalization of the Bowel

Normalization means bringing the bowel back to a normal state without constipation or impaction and with no more than 3 bowel movements per day. When a patient is constipated or has a fecal impaction, the buildup of stool or the impaction must be removed. If a patient has diarrhea, the motility of the GI tract must be slowed to decrease the frequency of bowel movements to 3 or fewer per day. A bowel management program will be ineffective if it is begun before the bowel is returned to a normal state.

Establishment of Expectations for Bowel-Movement Frequency

The amount of stool output is directly related to the amount of food consumed; this idea is central to expectations about the frequency of bowel movements. Such expectations help patients with cancer intervene at the first sign of bowel irregularity. At M. D. Anderson Cancer Center, patient-education materials clearly outline normal expectations. For instance, patients who eat 3 full meals per day can expect to have a bowel movement daily; patients who eat half of their normal amount can expect to have a bowel movement every other day; and patients who eat one third of their normal amount can expect to have a bowel movement every third day. Under the guidelines, the failure to have a bowel movement at the expected time signals the patient to induce a bowel movement. Patients with no expectations to have bowel movements at set intervals tend to ignore irregularity, which leads to complications, such as impaction from constipation or dehydration from diarrhea. Patient education is crucial in helping patients prevent bowel problems.

Development of a Bowel Management Program

A bowel management program for long-term use should not be initiated until therapy that has side effects on the GI tract is completed. During treatment, however, bowels can be managed using a symptom management approach. After the patient finishes all chemotherapy, radiation therapy, and biotherapy, the patient's present pattern of elimination is assessed, and a long-term bowel management program can be initiated.

All bowel programs must consider the titration of food, fluids, fiber, and medication. This is the fundamental, founding principle of bowel management.

All patients need to be on a bowel management program; few need to be placed in a bowel training program, which will be addressed later in this chapter.

Assessment of Outcomes

Patients must understand the importance of informing the health care team if defecation does not occur as expected. The bowel management program can then be altered.

Adjustment of Bowel Management Program to Achieve the Desired Outcome

The bowel management program may need to be altered multiple times to obtain the optimal outcome for an individual patient. Patients should adhere to each change in the regimen for 3 days to allow the bowel to adjust and to permit determination of the consistent response to that change.

Patients need to be taught how to problem-solve, adjusting the regimen regularly every 3 days until the desired response is obtained. They should be encouraged to understand their own bodies so that once they learn the principles of a bowel management program, they can alter the regimen of food, fluid, fiber, and bowel medication independently of the health care team. Again, prevention is the key, and patient education is a requirement.

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Constipation Prescription

Constipation Prescription

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