CONSTIPATION

• Enquire about usual bowel habit
• If patient from nursing/residential home and unable to provide information, request the Home-to-Hospital form
• Enquire about laxatives from GP or bought over the counter
• Enquire about adverse effects from laxatives in the past

Risk factors

• Constipation likely in patients who are:
• immobile/less mobile than usual
• drinking less fluid than usual
• eating less cereal, fruit and vegetables than usual
• taking prescribed codeine and/or iron or post-operatively
• If taking opioids, prescribe laxatives routinely

Routine nursing care

• Complete bowels section on nursing sheets daily
• Encourage fluids (≥1 L/day)
• If patient usually takes prescribed laxatives, prescribe in hospital

Toileting

• Ensure toileting facilities provide safeguard privacy and dignity
• Transfer to toilet, if possible
• Avoid commode
• Prevent inhibition
• Ensure privacy
• Control noise (try to locate toilets in quieter part of ward)
• Ensure patient can easily summon help
• make bell or button accessible and respond promptly
• Control odours (use air freshener if necessary)

Cautions

• In patients with suspected intestinal obstruction, ask for senior advice
• take care when using laxatives of any kind
• If haemorrhoids or anal fissure, avoid rectal preparations
• In patients with inflammatory bowel disease, colitis or Crohn’s disease, avoid macrogols

Bowels not opened for >3 days

See Overall Flowchart - Bowels not open for 3 days

• Perform digital rectal examination
• document findings
• if rectum empty, follow No faecal impaction below
• if rectum full of faeces, follow Faecal impaction below

No faecal impaction

• Address correctable factors e.g.:
• diet and fluid intake
• fibre
• mobility
• toilet facilities
• medication

Symptoms persist (over next 24 hr)

• Repeat digital rectal examination
• document findings
• if rectum full of faeces, follow Faecal impaction below
• if rectum empty, follow Bowel transit disorder below

Faecal Impaction

Able to swallow

• Use oral route
• Macrogols 4 sachets on first day then
• increase in steps of 2 sachets daily
• maximum of 8 sachets daily
• Total daily dose to be drunk in a 6-hr period
• in patients with cardiovascular impairment, 2 sachets maximum in any 1 hr
• Dissolve each sachet in 125 mL water
• Use for 3 days maximum
• If faecal impaction is resolved, follow Bowel transit disorder below
• If faecal impaction is not resolved, discuss with consultant/SpR

Unable to swallow

• Follow decision algorithm below

Bowel transit disorder

• Patient constipated but rectum empty
• Follow decision algorithm below

Possible extra treatment for persistent symptoms

• Prescribe other laxatives singly or, if no response, in pairs e.g.:
• Fybogel^® 1 sachet 12-hrly, or
• Isogel^® 2 level 5 mL spoonfuls in water 12-hrly or once daily, or
• senna 2–4 tablets at night, or
• bisacodyl 5–10 mg at night, or
• lactulose 15 mL 12-hrly (this may take up to 24–48 hr to take effect), or
• docusate sodium 100 mg (up to 500 mg daily in divided doses)
• In terminally ill patients in a palliative care setting ONLY, consider dantron
• co-danthramer 25/200 1–2 caps at night OR
• co-danthramer strong 37.5/500 1–2 caps at night OR
• co-danthramer with docusate (faecal softener) as co-danthrusate 50/60 1–3 capsules at night
• For patients with severe opioid-induced constipation, consider naloxegol 25 mg daily orally
• only prescribe on advice from the palliative care team

Symptoms relieved

• If patient taking opioids or with Parkinson's disease or multiple sclerosis, continue maintenance dose of the effective treatment daily indefinitely
• If patient not taking opioids, neither has Parkinson's disease multiple sclerosis, further treatment is individual to each patient

Symptoms not relieved

• If patient does not respond to the above medications or 2 of them in combination, consider macrogols again