Bowel Regimen

Those patients at high risk for acute constipation should be started on a bowel regimen. If a patient is receiving tube feeds and has less than one Bowel Movement (BM) every two days, they should be started on the bowel care protocol. A bowel care protocol also may be started empirically with initiation of enteral nutrition in patients know to be at risk for constipation.

Acute Constipation

Inclusion criteria for patients at high risk for acute constipation:

- Opioids
- Immobility
- Altered diet and fluid intake
- Stress
- History of constipation

Relative Contraindications

- Rectal surgery
- Abdominal pain
- Allergy to bowel regimen medications
- Neutropenia (ANC < 1000/mm3)
- Thrombocytopenia (platelets < 30,000)

Absolute Contraindications

Suspected or confirmed bowel obstruction

NOTE: If patient has had one BM every two days, patient is at Stage One or under observation only.

Stage One

(If no bowel movement for 48 hours)

Patient assessment and rectal exam

1. Impacted: Manually dis-impact; give soap suds enema once OR Bisacodyl 10 mg suppository once daily
2. Not impacted: Docusate 100 mg PO or NJFT q 8 hours and Senna 1 tab PO or 5ml via NJFT every am
3. If no BM or very small amounts in 24 hours following initiation of Stage One, proceed to Stage Two.

Stage Two

1. Add Bisacodyl 10 mg supp once daily, hold if stooling and continue with Stage One regimen.
2. If no BM or very small amounts within 24 hours, proceed to Stage Three.
3. If patient develops loose stools or diarrhea, return to Stage One.

Stage Three

1. Add Milk of Magnesia 30 ml PO every 6 hours or Miralax 17 grams PO/NJFT twice daily until BM, then stop (avoid Milk of Magnesia if renal insufficiency is present). Return to Stage Two.
2. If no BM in 24 hours or very small amounts, proceed to Stage Four.
3. If patient develops loose stools or diarrhea, return to Stage One.

Stage Four

1. Call and notify MD.
2. Obtain an abdominal x-ray.
3. Clarify continued therapy for bowel care.