Presentation on theme: "Module III: Management of Bowel Dysfunction"— Presentation transcript:
1 Module III: Management of Bowel Dysfunction Guidelines for Integrated Care (Psychiatric & Medical) In the CommunityModule III:Management of Bowel Dysfunction1
2 Training ObjectivesAppreciate the need for integrated care in the mental health community to prevent premature deaths and increased disability from bowel dysfunctionUnderstand 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.
5 Understanding the problem Bowel dysfunction: Problems with the frequency, consistency and/or ability to control bowel movements such as:ConstipationFecal impactionObstructionPerforationMegacolon developmentDeaths in psychiatric settings are increasingly reported as a result of bowel dysfunction.
6 Role of GuidelinesGuidelines 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.
7 Bowel Dysfunction and Mental Illness Elimination of body waste is not a usual or particularly comfortable topic and is not generally discussed.However, dysfunction in bowel evacuation is not a laughing matter when outside of the normal experience.Extremes of bowel dysfunction disrupt a person’s entire life, and if not recognized or not treated, may result in death.Persons with mental illnesses are particularly vulnerable to bowel dysfunction.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.FIRST YOU HAVE TO ASK.
8 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 complicationUnderstanding the necessity for supporting preventative activities such as adherence to dietary restrictions, exercise and self- monitoring/management needsCase managers also need the support of their team members and agencies in providing much needed integrated care.
9 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.
10 Warning Signs/Sx of Anticholinergic Effects Memory loss and confusionLightheadedness and mental fogginess/inability to concentrateWandering/inability to sustain a train of thoughtIncoherent speechVisual and auditory hallucinations/illusionsAgitationEuphoria or DysphoriaRespiratory depression
11 Warning Signs/Sx of Anticholinergic Effects Dry mouthLoss of coordination (ataxia)Dry, sore throatIncreased body temperatureDilated pupils and loss of visual ability to focus/accommodate/double visionIncreased heart rateTendency to be easily startledUrinary retentionShaking
12 Bowel Dysfunction: Contributing Factors Genetic predispositionNarcotic pain-killers such as benzodiazepines (Valium, Xanax, Ativan, etc.)Low fiber dietLimited fluid intakeDisruption in routineIgnoring the urgeLack of privacySedentary life style
13 Bowel Dysfunction: Contributing Factors StressHypothyroidismNeurological conditions such as Parkinson’s disease or multiple sclerosisOveruse of antacid medicines containing calcium or aluminumDepressionEating disordersColon Cancer
14 Bowel Dysfunction: Contributing Factors MedicationNarcotics such as benzodiazapines(Valium, Ativan, Xanax, etc.)Antidepressants such as tricyclics , SSRIs, SNRIsElavil, Desyrel, etc.Celexa, Prozac, Paxil, etc.Cynbalta, Effexor, etc.Second Generation/Atypical antipsychoticsAblify, Clozaril, Zyprexa, etc.Iron pills
15 Bowel Dysfunction: Contributing Factors Overuse of laxatives can weaken the bowel muscles:MetamucilFiberConCitrucelGlycerin suppositoriesDocusate/ColacePolyethylene GlycolMilk of MagnesiaBisacodyl/Dulcolax/Correctol (these stimulant laxative should only be used for a few days at most)
16 Symptoms of Constipation Infrequent bowel movements and/or difficulty having bowel movements as evidenced by:Less than 3 bowel movements a weekStraining or difficulty in evacuating bowel at least 25% of the time
17 More Serious Symptoms That may Indicate Obstructed Bowel Swollen abdomen or abdominal painPainVomitingCramping and belly pain that comes and goesPain occur around or below the belly buttonBloatingConstipation and a lack of gas indicate complete blockage of the intestineDiarrhea, if intestine is partly blocked
19 Immediate Medical Attention Required: Megacolon
20 What is Megacolon?Megacolon is an abnormal dilation of the colon (a part of the large intestines) The dilatation is often accompanied by a paralysis of the peristaltic movements of the bowelIn more extreme cases, the feces consolidate into hard masses inside the colon, called fecalomas (literally, fecal tumor), which can require surgery to be removedTHIS IS A MEDICAL EMERGENCY!All of the symptoms of obstruction may be presentABDOMINAL PAIN IS SEVERE AND CONSTANT
21 What is Megacolon?Rare event—a portion of the large intestine is paralyzed and swells to many times its normal sizeHappens suddenlyWorsening abdominal painVisibly distended or bloated abdomenAbdominal tendernessFeverVomiting
22 Megacolon: Signs/Sx Constipation of very long duration Abdominal bloatingAbdominal tenderness and tympany, abdominal pain, palpation of hard fecal massesIn toxic megacolon: fever, low blood potassium, tachycardia and shockStercoral 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
24 Megacolon 66 y.o. man with schizophrenia – no BM for 1 month, presented with constipation, shortness of breath, and severe abdominal pain
25 Risk classificationsPlease remember that the level of risk for megacolon is determined by RN or MDIf you notice the client is having difficulties—consult with RN or MD
26 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 testsNo report from client regarding any difficulty with bowel movement (when asked or spontaneously)
27 Low RiskDoes not take medication with known anti-cholinergic effects/nervous system depressants:pain medicationsmuscle relaxantsanti-anxiety medications (benzodiazepines)sleeping agents (Benadryl/diphenhydramine)EPS prophylactic agents (Cogentin/benztropine, Artane)anti-psychotic medicationsanti-depressants
28 Moderate riskMeets some of the following criteria but no current problem refer to team RN/MDPersonal past history of bowel problemsFamily history reportedTakes 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 practitionersHistory of occasional constipationRN/Psychiatrist report some abnormal findings indicative of bowel dysfunction
29 High Risk Current problems Refer to team RN/MD—possible specialty referral neededPersonal and family history of bowel problemsTakes more than one medication with high anticholinergic activity/constipation effect (polypharmacy)History of fecal impaction, and/or current constipationCurrent or recent (possibly chronic) use of laxativesFrequent complaints of constipation
30 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.”
31 “When is my constipation a more serious problem?” Only a small number of patients with constipation have a more serious medical problemIf constipation persists for more than two weeks, a physician or nurse practitioner should be seen to determine the source of the problem and treat itIf constipation is caused by colon cancer, early detection and treatment is very important
32 Healthy AssumptionAssume that all vomiting clients (especially those in high risk categories) to have a bowel obstructionA person with schizophrenia may have altered pain perception and therefore may not notice bowel issues
33 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
34 Suggestions on Approaching the Subject Treat this issue like any sensitive and confidential clinical issue. Find a private place and suitable time to talkTell the client that you want to discuss the client’s bowel management issueExplain that it is part of the client’s overall health and it is oftentimes a difficult and private subject to discussExplain that because clients sometimes are too embarrassed to discuss bowel management issues, some encounter problems which could have been prevented if dealt with sooner
35 Clinically Precise and Sensitive Wording Words and how they are used are very important to how your conversation will move forwardUse 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?
36 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
37 ReminderMental health is essential to overall health and other physical healthPhysical health is essential to mental health and recovery
38 Reminder Develop primary/specialty care resources available Develop relationships in communityDevelop protocols for consistent collaboration and prevention/wellness servicesFor example, finance/billing: Review use of Behavioral Health (Community) Medicaid and inclusion of collaborating in indirect service costs
39 ReminderEncouraging services that include identification and monitoring of other physical health issues:Amended job descriptionsUpdated policies and formsStaff performance indicators and evaluationAmended mission and vision
41 Case Study 1Joseph 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.
42 Case Study 1 You are a CPST worker Create a set of specific talking points on how to approach HarryRole play this interaction with a partner next to you. Take turns playing the CPST worker and JosephHave fun role playing. Be imaginative but realistic
43 Case Study 2Harry 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.
44 Case Study 2 You are that CPST worker Create a set of specific talking points on what you would say to HarryRole play this interaction with a partner next to you. Take turns playing the CPST worker and HarryHave fun role playing. Be imaginative but realistic
45 Case Study 3Sarah 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,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.
46 Case Study 3You 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.