1. At the commencement of each shift and then prn.
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Perform Abdominal examination. |
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Expose and observe the abdomen, look for distension. |
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Auscultate for presence of bowel sounds. |
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Palpate for tenderness, tightness/rigidity. |
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Document passing flatus, bowels open and quantity/nature of faeces. |
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Notice for blood or mucous present in stool. |
2. Maintain patients’ dignity and privacy at all times.
3. Skin assessment and care is essential after bowel movement.
4. Consider for constipation if two days without stool (when orally or enterally fed), five days without stool (when receiving only parenteral nutrition or nil intake), or very dry hard stool at any time.
5. Manage constipation as follows
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Early mobilization. |
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Adequate fluid and fiber intake. |
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Electrolyte correction. |
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Minimize the use of opioids. |
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Obtain abdominal x-ray to rule out ileus. |
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Consider laxatives, lactulose 10 ml every 12 hourly. |
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Increase the dose of laxative and consider second agent such as ezivac. |
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Per rectal examination and manually disimpact if required. |
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Give 500 – 1000 ml soap suds enema. |
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Surgical consultation if required. |
6. Consider for Diarrhea if greater than 300ml or 3 liquid bowel motions in a 24-hour period.
7. Manage Diarrhea as follows:
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Ensure all laxatives have been withheld or stopped. |
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Review the need for prokinetics (Metoclopramide and Erythromycin). |
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Medications should be reviewed by the medical team- magnesium, sorbitol containing medications, antibiotic therapy all may have diarrhea as a side effect. |
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Discuss with dietician possible changes to feed regimen to increase the fiber content. |
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Exclude malabsorption conditions. |
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If clostridium difficile toxin is suspected, stool specimen should be sent. |
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Gut slowing medications (e.g., loperamide, codeine phosphate) may be considered if microbiological causes for diarrhea have been excluded. |
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In some cases, probiotic therapy or medications to stop diarrhea may need to be considered. |
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If the patient has large volume of liquid diarrhea, observe and manage fluid and electrolyte balance and assess the need to replace fluid losses. |
8. Avoid laxatives for the following patients:
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Patients who have had abdominal surgery and where feeding is yet to be established. |
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Patients with a bowel obstruction. |
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Patients with an ileus. |
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Patients who are on Total Parenteral Nutrition (TPN). |
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Patients with existing bowel pathology such as Crohn's disease and ulcerative colitis. |
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Patients who are unable to tolerate enteral feeding / oral diet. |
9. Aim for 2-3 bowel movement in Hepatic encephalopathy with the use of lactulose (30 ml Lactulose every 8 hourly and adjust dose as required).
10. Aim for one bowel motion per day in spinal cord injury.
Further Readings:
1. Mostafa, S. M., Bhandari, S., Ritchie, G., Gratton, N., & Wenstone, R. (2003). Constipation and its implications in the critically ill patient. British journal of anaesthesia, 91(6), 815-819.
2. McPeake, J., Gilmour, H., & MacIntosh, G. (2011). The implementation of a bowel management protocol in an adult intensive care unit. Nursing in critical care, 16(5), 235-242
