“The Blessed Event Occurred This Morning”: Counseling Patients on Good Bowel Management

I laughed out loud when I listened to the voice mail from Harry. Then I listened again, and laughed some more. Harry is an older, jovial gentleman, always quick with a joke or witty retort. His brand of humor bordered on being over the top, yet he managed to walk the line so that his comments were funny and insightful rather than shallow and merely a byproduct of anxiety.

CASE

The message he left me was, literally, the end result of a long conversation we’d had about opioid induced constipation (OIC).  The day before we’d gone over what a good bowel movement (BM) regimen would look like for someone requiring opioids to manage their pain.

“So,” I instructed, “the goal is for you to have a soft formed BM every 1 to 2 days,”

He stared at me like I had 2 heads. “Oh. The last BM I had was 5 days ago.”

“Okay,” I took in a deep breath, “let’s go over our strategy for managing this. We’ve got to throw the kitchen sink at it.”

His celebratory call meant that after no BM for 5 to 6 days, he had followed my directions and had a large BM. This was his “blessed event” since he said he thought it felt like what he imagined giving birth to a large baby would be like.

Constipation can be a huge problem, pun intended. What can we do as oncology nurses to adequately educate our patients to avoid constipation? While many patients experience constipation as a result of medications, many do not know the best way to manage it.

Discussion

Oncology patients are likely to experience pain at some point during their treatment. Statistics vary slightly, but of those undergoing cancer treatment, 55% will experience pain. That number rises to 70% to 75% in those with advanced cancer.¹ Opioids are a big part of cancer pain management, and when opioids are used, there will be issues with bowel management and constipation.  One interesting statistic is the average cost for an emergency department (ED) visit for constipation, as noted in a study from 2011, was $3060.^2-3 Of course, the dollar amount does not include the suffering incurred in the days leading up to a decision to go to the ED, and the experience of the ED visit itself. Those are incalculable in the monetary projection, and yet we know for oncology patients, many of whom have limited energy or perhaps even remaining time, the idea of spending hours in the ED is a tragedy that should be avoided.  I don’t know anyone who wants to be constipated or wants to end up needing to be dis impacted.  A good bowel regimen is an essential bit of patient education that is often overlooked — after all there is an unspoken assumption that everyone knows how to manage their bowels, right?

How do we as nurses address the potential for constipation? By starting a bowel regimen on day 1 of opioid therapy, knowing and communicating to our patients that even 1 dose of an opioid will slow down bowel stimulation.

For our patients on opioid therapy or even those who have taken occasional opioids there are some common misunderstandings that can lead to constipation or other complications.