Rehab, feeding tubes, & constipation

[CrunchRN, ADN, RN]

Patient situation:

On rehab unit with PT twice a day and otherwise mostly in bed. Taking narcotic pain meds for need pain relief, receiving usual standard daily laxative per routine.

The patient experienced extremely severe constipation and had to be manually (partially) disimpacted. Pt. says they don't want to live if they ever have to experience that agony again. Cannot wean off the narcotics yet. Swallow not effective enough yet for oral intake

Rehab/feeding tubes are not my area of experience. Does anybody have suggestions I can give the physician about how to prevent and treat in this situation?

Like many they do not seem to have a good handle on preventing this type of thing.

Thank you for any information or references that might be helpful.

I am not seeking medical advice, but I am seeking colleague advice that I can then suggest to the covering physician.

Thank you.

[Pepper The Cat, BSN, RN]

Increase laxatives.

High fibre feed

Increase water

Increase mobility.

[Scottishtape]

Maybe consider adding in some prune juice and/or lactulose. We used to mix those at a rehab I worked at. They called them butt bombs. Worked well.

[brillohead, ADN, RN]

Colace, Miralax, etc., administered on a scheduled basis (rather than PRN, at which point it's too late) will keep things moving along.

[brownbook]

Agree with all. However it is never too soon to start the discussion between patient and doctors about weaning off opioid pain medications. There are new, improved, and even as good as or better ways to deal with pain besides opioids.

I have nothing against patients needing and using narcotics, but to the point of rather die than experience digital disimpaction again, the alternatives need to be started sooner rather than later.

[KatieMI, BSN, MSN, RN]

Among other things....

1). Make D*** sure that laxatives are in fact given. Cleaning of patients is a heavy task and in some facilities staff quietly witholds laxatives. Sorry to say that, but I've seen it done.

The way to do it is to see MAR (Meds Administration Record), figure out the time they are supposed to be given, and then visit approximately 1 hour before to watch them being given and do so randomly over couple of weeks.

2). Ask doctor to order the following labs: serum calcium, albumine, ionized calcium, phosphorus, vit D3, free PTH (if available), T3, TSH. "Low mobility hyperparathyroidism" happens way more often than it is diagnosed in population which is basically bed ridden and it causes severe constipation among other, even more unpleasant, things. T3 and TSH will catch hypothyroid, another common cause of severe constipation.

[Pepper The Cat, BSN, RN]

Also, get pt up on commode/toilet daily to evacuate the bowels better. Give a supp/fleet is new and the get them up!

[KelRN215, BSN, RN]

What is the "usual standard daily laxative" that the patient is receiving? With narcotics, I would think they should be on colace, senna and miralax. Mix miralax with water prior to adding to feeding bags otherwise it will clump with the formula. Formula could be changed to the "with Fiber" variety.

[Qing]

The pt is not ready for swallowing yet as they don't have the strength or have not passed the test yet. Is that what you are saying?

Is the pain medication working for them and can they go on a lower dose or something else that works just as well or better? Cold or Hot packs works wonders and rubs/creams help too. Voltairen gel is an option. Aromatherapy helps some and mental training also helps some to better manage pain as well.

The tube feeding- changing the type could help with the constipation, but the nutritionist will have to assess if the switch meets the caloric requirements (increased fiber).

The constipation can be addressed with using a combination of medications - Senokot with Colace, plus treatments that may or may not be at the facility. An enema is another option to help the bowels to clear out. There is a heavy duty one called the SMOG ( Saline, Mineral oil and Glycerin). It works very well and the clean up is very messy.

Blood work as someone else mentioned can identify if there are underlying conditions that can make the constipation worse.

Improving mobility will help with the bowels too. Miralax needs to be mixed with water, or else it clumps when mixed with the formula.

Increasing water intake and adjusting the amount of the tube feeding is something I have seen too.

[CrunchRN, ADN, RN]

Thank you all for this great input.

The 1st thing I said was need to wean off the pain meds. They have vertebral fractures though and were not very receptive. I will continue to work on that issue as well as giving your suggestions about prevention to the physician.

As far as the swallowing..... last scope there was still cord swelling and the speech therapist is working with him, but apparently his swallow is still too weak to allow anything by mouth except ice chips. He speaks fine ( with trach they put in last month), but he was ventilated for several weeks off and on so tube in tube out before they eventually placed the trach. Also, he had an SAH from TPA. The TPA was because mentation changes made them think he was having a stroke which ultimately he was not. So, not sure if the swallow issues are due to cord trauma or the bleeding. This man is 65 and was surfing the day prior to his fall that resulted in all this subsequent trauma.

Really appreciate the time you took to share this advice. I am trying to help from afar and readily admit being in Alzheimer's research in no way imparts a single shred of expertise when it comes to this type of situation.

[MunoRN, RN]

Keep in mind that fiber is more likely to cause constipation than prevent it. We often reflexively add fiber to tube feeding to avoid diarrhea, but then forget to d/c it when there is constipation.

[kbrn2002, ADN, RN]

The amount of bowel meds required can be a lot higher that you might think to combat chronic constipation. Not unusual for me to give miralax, metamucil and senna plus twice a day. Plus a prn dose when required. There's also prune juice, lactulose and colace to consider. All these come in liquid form or can be crushed or mixed in liquid for feeding tube administration. Coordinate with the provider to start adding additional bowel meds until the constipation resolves. Also consider a bisacodyl suppository or fleets enema before trying manual disimpaction, most facilities have these as part of their standing orders.