No Bowel Movement in Three Weeks

[RN1981]

I have a 60-something year old male patient whos primary diagnosis is Prostate CA. He is very weak and basically lies in bed all day and eats a couple bites of peaches or applesauce daily. He is also on Oxycodone 5mg every 4 hours for pain and Roxanol 1mg as needed every two hours (which he takes maybe a few times daily) His wife works and the only person there with him is his son during the day but luckily the wife works close by so she can run back and forth when needed.

My problem is this patient was admitted almost about four weeks ago. He had just had surgery (stent placement) and hadnt had a BM in a few days. I figured no big deal at that point since he was already on Senna to soften his stool and he probably hadn't eaten for a few days. The next week he still didn't have one so I checked him for impaction. I got an extremely tiny amount of soft stool out. I gave a Fleet enema with no return. I started him on suppostories daily until BM. The next week still nothing and I find out his wife was giving suppostories but no Senna anymore (even though I had written the instructions down). I checked him for impaction (only got a tiny bit of stool out) and I gave a mineral oil/fleet enema with no return. He is not able to bare down at all. Stomach was slightly distended but still soft but bowel sounds hypoactive. So I started him on mineral oil 1tbsp two times daily until he has a BM (I figured once he had a bowel movement we could take him off since there's an aspiration risk). So I called today and still no bowel movement! He said the mineral oil made him sick and I have no idea if hes been getting the Senna since his wife was not there. I visit him again tomorrow and I'm at a loss. What do I do? I am starting to think he may have a bowel obstruction and one of the docs needs to visit him...

[tewdles, RN]

what a crappy situation...

I typically use a combo of senna and colace routinely for patients with opioids in the POC. In the event that this plan is ineffective I add another agent...usually MOM or Mag Citrate or similar. With no stool palp in the rectal vault it is unlikely that a fleets enema will be adequate and a standard (H, H, and H) enema may be more effective.

Given that this guy continues to take po food and is not complaining of nausea, I would question if it is possible that he has had a BM which has not been reported to you.

Good luck!

[abbnurse]

Hi, this question is for tewdles,

What is a standard (H,H, and H) enema?

Thanks so much !

[lesrn2005]

I think H-H-H- means "High, hot, and a helluva lot".

[abbnurse]

Thanks, lesrn2005! And good luck to you and your pt., RN1981.

[VivaLasViejas, ASN, RN]

Have you listened to his bowel tones and palpated his abdomen? If he's obstructed, his abdomen is probably big and firm, and bowel tones would naturally be altered. Is he nauseated? Vomiting? Any watery anal seepage?

Sounds to me like he needs to be 'busted loose' from above, not below. If he truly does not have an obstruction, here's a 'cocktail' you can try that has rarely failed me; it's called the Hot Slider:

Take six ounces of prune juice, 30 mL of either MOM or Lactulose (Karo dark corn syrup is also a good substitute) and 2 pats of butter, zap the mixture in the microwave for 45 seconds, stir, and give to the patient. Then........apres moi, le deluge! I've cleaned out so many constipated folks with this recipe that I think somebody ought to patent it. It's not terribly tasty unless you're using the corn syrup, but boy does it get the job done.

Good luck!

[RN1981]

Thanks guys for your tips, especially that cocktail. We're having IDT today so I'll discuss it with the team before moving forward.

[leslie :-D]

i'd be requesting a kub before implementing all those nasty, uncomfortable interventions.

leslie

[heron, ASN, RN]

Hi, this question is for tewdles,

What is a standard (H,H, and H) enema?

Thanks so much !

High, hot and he11uvalot

A last resort along with milk and molasses enema.

[annacnatorn]

8 to 10 oz of warm prune juice will usually do the trick. But a call to the MD should be done...remember...CYA?

[mschelee, MSN, RN]

A last resort along with milk and molasses enema.

Milk and Molasses enemas work every time Ive had to use them on patients..

[ErinS, BSN, RN]

Our MD used to also be a family practice doc, and he had samples of a medication called amitiza. It was very effective for this kind of thing without the terrible cramping and diarrhea you can sometimes get. I agree with a previous poster- if pt is not uncomfortable after three weeks, then there is probably some bowel movements happening. Good luck!