NSICU Bowel Management Protocol
This protocol is a set of guidelines to help patients to avoid constipation and diarrhea in a surgical ICU. We should follow it for all patientsespecially those who have narcotics ordered whether that is scheduled or PRN. It also serves as guidelines for Spinal Cord Injuries and head injured patients.
Admitted to NSICU < 48 hours or 65 and older
(Pt not on narcotics):
1)Docusate 100mg every 12hr
PRN: Senna 1 Tablet PO at bedtime
Psyillium 5.85g packet three times a day
MOM concentrates 10ml
Bisacodyl 1 suppository every 12hr or daily
Admitted to NSICU > 48 hours:
1)Docusate 100mg every 12hr
2)Senna 1 tab every night
PRN: Bisacodyl 1 suppository daily (up to double dose if needed)
Psyillium5.85g packet three times a day
MOM concentrates 10 ml every 12 hours
Bisacodyl 1 Suppository every 12hr or daily
Daily Assessment should include but not limited too:
Bowel sounds
Amount of NG aspirate
Visible peristalsis
LBM (if diarrhea state color, consistency & quantity)
ConstipationHaving less that 3 BM’s per week.
Assess patient for:
Assess LBM and patient normal BM pattern
Assess for Feedings, Tube feeds or PO
Assess GI system for Bowel Sounds,
tenderness, high residuals, distended
abdomen
Assess for excessive use of pain medication
Possible causes:
Iron, Antidepressants, anti-seizure meds.
Endocrine, electrolytes.
If all are within normal limits and last BM was >2 days:
Then start constipation relief: ( do not do all at once)
Mobilization of patient.
2 Biscodyl suppositories
Disimpaction
MOM concentrate 10ml
Docusate
Senna
Fleets enema/ soap suds enema
Magnesium citrate
Electrolyte replacement.
Mobilization of patient.
Prevention:
Make sure patient is getting at least 1.5 liters of fluid each day.
S/S: vomiting, restlessness
Complications: Perforation, prolonged ventilation, delay in nutrition, hemorrhoids, illeus, and rectal tear. / Diarrhea
Any loose stool or watery stools at least 3X per day or in daily volumes of at least ½ liter (about 2 cups) for 2 consecutive days or more.
Assess patient for:
Urinary retention/ Distended bladder
Use of antibiotics
Medications- Reglan, etc
Sorbitol based medication
Some cardiac meds
Acute infections
Phosphate level/ refeeding syndrome
C-Diff
Lactose Intolerance (use lactaid if pt taking PO Calcium) (our Tube feeds do not contain lactose)
Hypoalbuminanemia
Cardiac meds such as digoxin
Fecal incontinence
Impaction
Magnesium replacement
K+ and Phos replaced( make sure properly diluted)
Sepsis
If these are normal then start anti- diarrhea medications such as:
1) Psyillium 5.85g packet three times a day
2) Lactobacillus ( consider use with patient on antibiotics)
3) Assess for potential need for re: hydration
4) Hold caffeinated products
Hold BM meds if patient is having diarrhea.
Protect skin w/ Barrier cream.
Assess need for fecal incontinence device:
If flexi seal is needed use only with patients with frequent liquid stools. If there is no stool within 12hrs D/C device. Please mark on bag where last stool was measured
and change bag as needed.
If C-diff is positive from lab, pt should be treated with Flagyl or Vancomycin.
Complications:
Dehydration
Malnourished
Skin breakdown
Documentation:
Nursing to document stools frequency, color and consistency. Also as a part of your assessment note LBM. When a patient is admitted and family is available assess and document patient normal bowel movement and daily amount. Document this on admission assessment. Also document any GI Hx such as IBS or surgeries as well as OTC drugs or aids used at home on home med sheet.
Make sure patient has privacy and proper toileting facility.