A night-shift nurse working on a busy medical unit is already caring for four patients when a new admission arrives from the ED. The 78-year-old male patient has not moved his bowels in three days. The physician has written the admission orders for the patient and has already left the hospital — but failed to include a bowel regimen. What does the nurse do? Does the nurse call the physician at 3 a.m. for an order for a bowel regimen or does he or she ask the patient’s day-shift nurse to obtain the order?
The geriatric specialists at Christiana Care Health System wanted to prevent the complications that can result from untreated constipation and improve this aspect of a patient’s care and comfort. An interdisciplinary team consisting of nurses, physicians, pharmacists, and dietitians was formed to develop a Constipation Care Management guideline and a nurse-driven constipation protocol/order set. The goals were to prevent or manage acute constipation in hospitalized patients, to increase the number of patients who have a bowel movement every two to three days, and to improve documentation of bowel movements. The team seems to have accomplished its goals.
“This has empowered us to really help our patients who take so many constipating medications,” says staff nurse Jean Marie Okoniewski, RN, BSN, BC. “This protocol is really useful and easy to start on patients.”Patricia Curtin, MD
How It Works
The protocol was approved by the medical/dental staff and appropriate nursing councils at Christiana Care for nurses to initiate a bowel regimen for acute constipation based on preapproved specific criteria. This information in included in a separate chart form that is part of the admission packet. The RN reviews a list of contraindications (i.e., diarrhea, NPO, ileus, active nausea/vomiting, abdominal surgery) and checks those which are applicable.
If there are no contraindications and the patient meets the criteria (no bowel movement in two to three days), the nurse will initiate the bowel regimen for acute constipation on admission and/or anytime during the hospital stay.
The protocol/order set includes oral medications (Senna and Docusate sodium). Suppositories (Bisacodyl) and enemas (mineral oil) are ordered for stool in the rectum, determined by rectal exam if no BM in three days. Emphasis also is placed on hydration and increased fiber in the diet, if appropriate. Patients are encouraged to drink 1500 mL of fluids daily unless medically contraindicated.
Fluid intake can include ice cream, sherbet, water ice, jello, soups, broth, coffee, tea, soda, or juice. The nurse also can order prune juice or consult a dietitian. Fiberfull pudding is available to patients with a dietitian order. A patient FYI sheet on constipation also is reviewed with the patient and family.
A one-day bowel movement monitor/chart review was completed on all patients by unit-based quality and safety councils at Christiana and Wilmington Hospitals in May 2006 (baseline), July 2007, and January 2008. The average patient census for the three reviews was 653.
Because the nurse-driven protocol was initiated, the percentage of patients documented with no bowel movement decreased by over 50% from baseline. There also was a 25% reduction in the percentage of patients who did not have a bowel movement in four days or more. Plus, there was a 15% improvement in the number of patients who had a bowel movement in one to three days.
Direct feedback from nurses regarding the constipation protocol has been positive.
“[The protocol] is wonderful,” says staff nurse Cynthia Noble, RN, BSN, BC. “It saves time from trying to obtain bowel orders from the physicians, and we see results much quicker. We have much more comfortable patients.”