Transcript INTEGRATED CARE GUIDELINES FOR MANAGEMENT OF BOWEL DYSFUNCTION

Guidelines for Integrated Care
(Psychiatric & Medical)
In the Community
Module III:
Management of Bowel Dysfunction
Training Objectives
 Appreciate the need for integrated care in the mental
health community to prevent premature deaths and
increased disability from bowel dysfunction
 Understand the levels of risk and factors associated
with bowel dysfunction.
 Identify persons with mental illness in their caseload
who are at risk for or who have already experienced
bowel dysfunction.
 Identify actions that will aid the persons with bowel
dysfunction in communicating their needs and manage
their symptoms.
Physiology of Digestion
Realistic Diagram
Understanding the problem
 Bowel dysfunction: Problems with the frequency,
consistency and/or ability to control bowel movements
such as:
 Constipation
 Fecal impaction
 Obstruction
 Perforation
 Megacolon development
 Deaths in psychiatric settings are increasingly reported
as a result of bowel dysfunction.
Role of Guidelines
 Guidelines can serve as aids in development of protocols for
working with affected persons in community case loads.
 Guidelines begin with knowing who in community-based
case loads is at risk, who is already diagnosed, and who is
showing signs of consequences of bowel dysfunction.
 Implementation includes identifying and communicating
with both client and team members. It includes:
 The ability to identify symptoms, consult, advise, educate,
support and refer persons with bowel dysfunction.
 To recognize and get appropriate help for potentially
deadly symptoms of MEGACOLON—a true medical
emergency.
Bowel Dysfunction and Mental Illness
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Elimination of body waste is not a usual or particularly comfortable
topic and is not generally discussed.
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However, dysfunction in bowel evacuation is not a laughing matter
when outside of the normal experience.
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Extremes of bowel dysfunction disrupt a person’s entire life, and if not
recognized or not treated, may result in death.
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Persons with mental illnesses are particularly vulnerable to bowel
dysfunction.
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Rendering support and assistance are more likely to happen when
mental health community providers have knowledge the skills to
recognize, support and intervene/refer when appropriate.
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FIRST YOU HAVE TO ASK.
Case Managers and Integrated Care
 Knowledge needed by case managers when their clients
who have, or are at risk for developing bowel
dysfunction include:
 Understanding the potential for serious complication
 Understanding the necessity for supporting
preventative activities such as adherence to dietary
restrictions, exercise and selfmonitoring/management needs
 Case managers also need the support of their team
members and agencies in providing much needed
integrated care.
Role of Psychiatric Medication
 Risk for bowel dysfunction is, in part, related to
medications that block the nerves that control the
automatic functions of certain muscles in the body
(Anticholinergic effect).
 The affected muscles are particularly important to the
normal movement of the intestines in the elimination of
body waste products.
Warning Signs/Sx of Anticholinergic
Effects
 Memory loss and confusion
 Lightheadedness and mental fogginess/inability to
concentrate
 Wandering/inability to sustain a train of thought
 Incoherent speech
 Visual and auditory hallucinations/illusions
 Agitation
 Euphoria or Dysphoria
 Respiratory depression
Warning Signs/Sx of Anticholinergic
Effects
• Dry mouth
• Loss of coordination (ataxia)
• Dry, sore throat
• Increased body temperature
• Dilated pupils and loss of visual ability to
focus/accommodate/double vision
• Increased heart rate
• Tendency to be easily startled
• Urinary retention
• Shaking
Bowel Dysfunction:
Contributing Factors
 Genetic predisposition
 Narcotic pain-killers such as benzodiazepines (Valium,
Xanax, Ativan, etc.)
 Low fiber diet
 Limited fluid intake
 Disruption in routine
 Ignoring the urge
 Lack of privacy
 Sedentary life style
Bowel Dysfunction:
Contributing Factors
 Stress
 Hypothyroidism
 Neurological conditions such as Parkinson’s disease or
multiple sclerosis
 Overuse of antacid medicines containing calcium or
aluminum
 Depression
 Eating disorders
 Colon Cancer
Bowel Dysfunction:
Contributing Factors
 Medication
 Narcotics such as benzodiazapines
 (Valium, Ativan, Xanax, etc.)
 Antidepressants such as tricyclics , SSRIs, SNRIs
 Elavil, Desyrel, etc.
 Celexa, Prozac, Paxil, etc.
 Cynbalta, Effexor, etc.
 Second Generation/Atypical antipsychotics
 Ablify, Clozaril, Zyprexa, etc.
 Iron pills
Bowel Dysfunction: Contributing
Factors
 Overuse of laxatives can weaken the bowel muscles:
 Metamucil
 FiberCon
 Citrucel
 Glycerin suppositories
 Docusate/Colace
 Polyethylene Glycol
 Milk of Magnesia
 Bisacodyl/Dulcolax/Correctol (these stimulant
laxative should only be used for a few days at most)
Symptoms of Constipation
 Infrequent bowel movements and/or difficulty having
bowel movements as evidenced by:
 Less than 3 bowel movements a week
 Straining or difficulty in evacuating bowel at least
25% of the time
More Serious Symptoms
That may Indicate Obstructed Bowel
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Swollen abdomen or abdominal pain
Pain
Vomiting
Cramping and belly pain that comes and goes
Pain occur around or below the belly button
Bloating
Constipation and a lack of gas indicate complete
blockage of the intestine
Diarrhea, if intestine is partly blocked
Chronic Constipation
Immediate Medical Attention
Required: Megacolon
What is Megacolon?
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Megacolon is an abnormal dilation of the colon (a part of the
large intestines)
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The dilatation is often accompanied by a paralysis of the
peristaltic movements of the bowel
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In more extreme cases, the feces consolidate into hard
masses inside the colon, called fecalomas (literally, fecal
tumor), which can require surgery to be removed
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THIS IS A MEDICAL EMERGENCY!
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All of the symptoms of obstruction may be present
–ABDOMINAL PAIN IS SEVERE AND CONSTANT
What is Megacolon?
 Rare event—a portion of the large intestine is paralyzed
and swells to many times its normal size
 Happens suddenly
 Worsening abdominal pain
 Visibly distended or bloated abdomen
 Abdominal tenderness
 Fever
 Vomiting
Megacolon: Signs/Sx
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Constipation of very long duration
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In toxic megacolon: fever, low blood potassium, tachycardia
and shock
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Stercoral ulcers (ulcer of the colon due to pressure and
irritation resulting from severe, prolonged constipation) are
sometimes observed in chronic megacolon - which may lead
to perforation of the intestinal wall in approximately 3% of
the cases, leading to sepsis and risk of death
Abdominal bloating
Abdominal tenderness and tympany, abdominal pain,
palpation of hard fecal masses
Megacolon
http://medlineplus.gov
Megacolon
66 y.o. man with schizophrenia – no BM for 1 month, presented with
constipation, shortness of breath, and severe abdominal pain
Risk classifications
 Please remember that the level of risk for megacolon is
determined by RN or MD
 If you notice the client is having difficulties—consult
with RN or MD
Low Risk
 No personal or family history of bowel problem
 No abnormal findings on medical record or alerts from
RN’s/Psychiatrist on team re medications/blood and
other medical tests
 No report from client regarding any difficulty with
bowel movement (when asked or spontaneously)
Low Risk
 Does not take medication with known anti-cholinergic
effects/nervous system depressants:
 pain medications
 muscle relaxants
 anti-anxiety medications (benzodiazepines)
 sleeping agents (Benadryl/diphenhydramine)
 EPS prophylactic agents (Cogentin/benztropine,
Artane)
 anti-psychotic medications
 anti-depressants
Moderate risk
• Meets some of the following criteria but no current problem
 refer to team RN/MD
• Personal past history of bowel problems
• Family history reported
• Takes one or more medications with some anti-cholinergic
activity e.g. Clozaril (antipsychotic) and Cogentin
(antiparkinsonian agent)—check over the counter
medication and from primary care practitioners
• History of occasional constipation
• RN/Psychiatrist report some abnormal findings indicative of
bowel dysfunction
High Risk
 Current problems
 Refer to team RN/MD—possible specialty referral
needed
 Personal and family history of bowel problems
 Takes more than one medication with high
anticholinergic activity/constipation effect
(polypharmacy)
 History of fecal impaction, and/or current constipation
 Current or recent (possibly chronic) use of laxatives
 Frequent complaints of constipation
Approaching the Question
of Bowel Dysfunction:
 How to approach this topic ---- which tends to be
uncomfortable for both the person asking the questions
and the person of whom they are being asked.
 One example:
 “The medications you are taking can make it difficult
for you to have a bowel movement. That can have very
serious consequences. It is important for you to keep
track of any issues you might be having.”
“When is my constipation a more
serious problem?”
 Only a small number of patients with constipation have
a more serious medical problem
 If constipation persists for more than two weeks, a
physician or nurse practitioner should be seen to
determine the source of the problem and treat it
 If constipation is caused by colon cancer, early detection
and treatment is very important
Healthy Assumption
 Assume that all vomiting clients (especially those in
high risk categories) to have a bowel obstruction
 A person with schizophrenia may have altered pain
perception and therefore may not notice bowel issues
Self-management strategies
 Monitoring Questions:
 Are you having less that 3 bowel movements a week?
 Do you strain a lot when you are trying to have a
bowel movement?
 Do you have lumpy hard stools or a sensation of not
getting it all out more than 25% of time?
 Use of a monthly “calendar” might be helpful to keep
track
Suggestions on
Approaching the Subject
 Treat this issue like any sensitive and confidential
clinical issue. Find a private place and suitable time to
talk
 Tell the client that you want to discuss the client’s bowel
management issue
 Explain that it is part of the client’s overall health and it
is oftentimes a difficult and private subject to discuss
 Explain that because clients sometimes are too
embarrassed to discuss bowel management issues,
some encounter problems which could have been
prevented if dealt with sooner
Clinically Precise and Sensitive Wording
 Words and how they are used are very important to how
your conversation will move forward
 Use words like: “bowel movement”, “stool”, “constipation”,
and “diarrhea”
 What are some other words that you can use to discuss
this topic in a kind and sensitive way?
All Risk Groups Need
 Education:
 High fiber diet
 Exercise
 Drinking fluids (6-8 ounces water or other non-
carbonated fluids--not to excess)
 Keep track of bowel movements
Reminder
 Mental health is essential to overall health and other
physical health
 Physical health is essential to mental health and
recovery
Reminder
 Develop primary/specialty care resources available
 Develop relationships in community
 Develop protocols for consistent collaboration and
prevention/wellness services
 For example, finance/billing: Review use of
Behavioral Health (Community) Medicaid and
inclusion of collaborating in indirect service costs
Reminder
 Encouraging services that include identification and
monitoring of other physical health issues:
 Amended job descriptions
 Updated policies and forms
 Staff performance indicators and evaluation
 Amended mission and vision
CASE STUDIES
See Handout
Case Study 1
 Joseph is an African-American male in his mid 50s. He
has a long history of Schizoaffective disorder with
multiple hospitalizations. Joseph lives in a group home.
He smokes heavily and has a diagnosis of COPD. He
often complains of indigestion, bloating and
constipation and he was treated for fecal impaction
about 8 months ago.
 He is currently prescribed Seroquel, Haldol, and
Cogentin. He has been also taking medication for
constipation and heartburn. Joseph has not had a bowel
movement for the past 14 days.
Case Study 1
 You are a CPST worker
 Create a set of specific talking points on how to
approach Harry
 Role play this interaction with a partner next to you.
Take turns playing the CPST worker and Joseph
 Have fun role playing. Be imaginative but realistic
Case Study 2
 Harry is a Caucasian male in his late 20s. He was diagnosed
with paranoid schizophrenia four years ago with history of
multiple involuntary hospitalizations. During the past 12
months, Harry was prescribed Prolixin, Risperdal Consta,
Zyprexa, Cogentin and anti-anxiety medication.
 Harry has been complaining of GI symptoms such as
heartburn, indigestion and constipation for the past several
months and was prescribed Mylanta and Milk of Magnesia for
GI related problems.
 Yesterday, a CPST worker observed Harry to have diarrhea
during transport to a housing appointment and just this
morning the same CPST worker observed Harry vomited in
his apartment.
Case Study 2
 You are that CPST worker
 Create a set of specific talking points on what you would
say to Harry
 Role play this interaction with a partner next to you.
Take turns playing the CPST worker and Harry
 Have fun role playing. Be imaginative but realistic
Case Study 3
 Sarah was a 14 year old teenager hospitalized at a state
mental facility. She was diagnosed with Autism and
Schizophrenia. Sarah passed away on February 13,
2006.
 The medical examiner said the 14-year-old died of
severe intestinal blockage that medical records showed
went unnoticed by doctors and nurses.
 Sarah vomited several times the night before she died.
The next morning, staffers found her body with an
enlarged abdomen and brown substance oozing from
her mouth. Sarah had no pulse and was lying in vomit.
Case Study 3
 You are a member of the Critical Incident Committee,
the committee that examines critical incidences at the
hospital and to recommend quality improvement
measures to the Medical Director of that state
psychiatric facility.
 What are some early warning signs and symptoms that this
patient may have exhibited or reported?
 How would you as a line staff at the hospital approach the
patient when you see her not eat for the past day or so?
 Recommend some specific and sensitive talking points in
broaching the subject of bowel management with the patient.