Self-Care for Constipation

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Questions and Answers

Which patients should avoid saline laxatives due to potential safety concerns?

Individuals with mild dehydration

Active athletes

Healthy adults with occasional constipation

Patients on a sodium-restricted diet (correct)

What is the recommended method for administering saline laxatives to achieve optimal effectiveness?

With high-fat meals to aid intestinal movement

At bedtime for overnight relief

With food to enhance absorption

On an empty stomach with a full 8 oz. of water (correct)

In which of the following scenarios should a saline laxative be prescribed cautiously?

A patient aiming for occasional constipation relief

A patient with mild renal impairment (correct)

An adult planning to undergo a colonoscopy

A healthy child over 6 years old

What age restriction is recommended for saline laxative usage?

Children under 6 years old should not use saline laxatives unless prescribed Signup and view all the answers

Which of the following adverse effects is commonly associated with the use of saline laxatives?

Hyperphosphatemia Signup and view all the answers

What is a common contraindication for the use of saline laxatives?

Patients with congestive heart failure Signup and view all the answers

What is the primary mechanism of action for saline laxatives?

They draw water into the intestines or colon through osmosis Signup and view all the answers

Why should magnesium-based saline laxatives be avoided in certain populations?

They can lead to hypermagnesia in patients with renal impairment Signup and view all the answers

What is the minimum frequency of bowel movements that classifies an adult as experiencing constipation?

Less than 3 per week Signup and view all the answers

Which of the following is NOT a common cause of constipation?

Increased physical activity Signup and view all the answers

Which of the following medications is known to cause constipation?

Antidepressants Signup and view all the answers

What is a common exclusion for self-care treatment of constipation?

Marked abdominal pain Signup and view all the answers

Which demographic is at a higher risk for developing constipation?

Older adults Signup and view all the answers

At what age is self-care for constipation generally not recommended?

Under 2 years old Signup and view all the answers

What dietary change can help alleviate constipation?

Increase fiber intake Signup and view all the answers

Which of the following statements about bowel habits is true when considering exclusions for self-care?

Changes in stool character can indicate the need for professional evaluation. Signup and view all the answers

Which of the following is a recommended non-pharmacological measure for preventing constipation?

Gradually increase dietary fiber Signup and view all the answers

What feeling might a patient experiencing constipation commonly report?

Feeling of incomplete bowel elimination Signup and view all the answers

What is a significant counseling point regarding the use of laxatives in patients?

Lifestyle modifications should be considered before recommending laxatives. Signup and view all the answers

Which laxative is recommended as the first choice for simple constipation management?

PEG-3350 Signup and view all the answers

Which of the following should be avoided in older adults when selecting laxatives?

Mineral oil Signup and view all the answers

Which age group should dietary and behavior modification be prioritized before considering laxative use?

Ages 2-6 Signup and view all the answers

How long should a patient avoid taking laxatives without healthcare provider monitoring?

1 week Signup and view all the answers

What common drug interaction advice applies to bisacodyl?

Avoid antacids or milk 1 hour before taking. Signup and view all the answers

Which of these laxative types should be prioritized in pediatric patients first?

Bulk-forming laxatives Signup and view all the answers

Which laxative class is recommended to treat or prevent opioid-induced constipation?

Stimulant laxatives Signup and view all the answers

What potential adverse effect is associated with stimulant laxatives?

Severe cramping Signup and view all the answers

Which laxative is generally NOT appropriate for older adults?

Saline laxatives Signup and view all the answers

What is the primary concern of laxative overuse in patients?

Dehydration and electrolyte imbalances Signup and view all the answers

Which age group is unlikely to have docusate as the first option for constipation management?

Under 2 years old Signup and view all the answers

Which laxative should be avoided in high-risk patients for renal disease?

Oral sodium phosphate products Signup and view all the answers

What additional counseling should be provided when suggesting laxatives for patients?

Monitor bowel habits for changes and report unusual symptoms. Signup and view all the answers

Which condition might limit the choice to use certain laxatives in older adults?

Fluid restrictions due to health conditions Signup and view all the answers

Study Notes

Self-Care Constipation

Defined as a frequency of fecal elimination less than 3 bowel movements per week in adults.
Characterized by difficult passage of hard, dry stools.
Patients may report straining, hard/dry stool passage, small stools, feelings of incomplete bowel elimination, and decreased stool frequency.

Constipation Statistics

Very common gastrointestinal (GI) complaint (2-28% of the general population).
Older adults are 5 times more likely to develop constipation, and women are 3 times more likely than men.
Common reason for self-treatment; 2.5 million physician visits per year.

Etiology of Constipation

Lifestyle/Extrinsic factors: Low fiber diet, low fluid intake, sedentary lifestyle, or suppressing the urge to defecate.
Structural factors: Colorectal or anorectal injury, inflammation, pelvic floor disorders, or structural abnormalities.
Systemic factors: Thyroid disorders, diabetes mellitus, irritable bowel syndrome (IBS), neurological disorders, autonomic neuropathy, cerebrovascular accidents, multiple sclerosis, dementia, Parkinsonism, or post-surgical causes.
Psychological factors: Depression, eating disorders, and situational stress.
Medications: Calcium or aluminum antacids, narcotic analgesics, and anticholinergics.

Medications Causing Constipation

Analgesics
Antacids
Anticholinergics
Anticonvulsants
Antidepressants
Antihistamines
Antimotility
Antimuscarinics
Benzodiazepines
Calcium Channel Blockers
Calcium supplements
Diuretics
Hematinics
Hyperlipidemia agents
Hypotensives
Muscle relaxers
Opiates
Parkinsonism agents
Polystyrene sodium sulfonate
Psychotherapeutic drugs
Sedative hypnotics
Serotonin agonists
Sucralfate

Treatment Goals

Relieve constipation and reestablish normal bowel function.
Establish dietary and exercise habits to prevent future constipation.
Promote safe and effective use of laxative products.

Exclusions to Self-Care

Marked abdominal pain, significant distention, or cramping.
Unexplained flatulence or fever.
Nausea, vomiting
Daily laxative use.
Excluded fiber-based therapies.
Unexplained change in bowel habits, especially with weight loss.
Blood in stool or dark, tarry stools.
Presence of chronic medical conditions (IBS, paraplegia/quadriplegia, colostomy).
Marked change in stool character (e.g., pencil thin).
A sudden change in bowel habits lasting 2 weeks or recurring over 3 months.
Inflammatory bowel disease.
Anorexia.
Age less than 2 years old.

Non-Pharmacological Measures

Increased fruit, vegetables, and whole grains (14 g/1000 kcal fiber per day; 25 g/day for women and 38 g/day for men).
Gradual increase in fiber (1-2 weeks).
Limit foods lacking fiber (e.g., cheese, meat, processed foods).
Supplement with fiber if diet is insufficient.
Bulk-forming laxatives (methylcellulose, polycarbophil, psyllium).
Dietary supplements (inulin, powdered cellulose, wheat dextrin, partially hydrolyzed guar gum).
2 liters of water per day, or increased fluids for pregnant or lactating women.
Establish regular bowel habits, ideally after eating or upon rising.
Encourage physical activity.

Goals of Pharmacologic Therapy

Nonirritating and nontoxic action.
Act only on the descending and sigmoid colon.
Produce a normally formed stool within a few hours.
FDA mandates labeling for short-term use (<1 week) without healthcare provider oversight.

Types of Laxative Agents

Bulk-forming
Emollient
Lubricant
Saline
Hyperosmotic
Stimulants

Bulk-Forming Laxatives

Methylcellulose, polycarbophil, and psyllium (e.g., Citrucel®, FiberCon®, or Metamucil®).
Most recommended for constipation.
Mechanism involves dissolving or swelling in the intestinal fluid, facilitating passage of intestinal contents.
Not absorbed systemically.
Take with 8 ounces of water, 12-24 hours onset, up to 72 hours.

Indications for Bulk-Forming Laxatives

Short-term relief.
Low-residue (low-fiber) diets.
Women during postpartum.
Advanced age.
Patients with colostomies, IBS, or diverticular disease.
Prevention of straining.
Potential benefit in lowering cholesterol.

Safety Considerations for Bulk-Forming Laxatives

Common adverse effects: abdominal cramping and flatulence.
Choking is a risk without adequate fluid intake.
May bind or hinder drug absorption (separate by 2 hours).
Not appropriate for fluid-restricted diets (e.g., renal failure, congestive heart failure).
May cause esophageal or intestinal obstruction.
Children <6 years and patients on opioids at increased risk.
Calcium polycarbophil limited to 150 mg in patients susceptible to hypercalcemia (renal disease).
Avoid in patients with hypersensitivity.

Fluids and Bulk-Forming Laxatives

Choking may occur with insufficient fluids.
FDA labeling emphasizes the need for adequate fluid intake to avoid product swelling and blockage of the esophagus.

Hyperosmotic Laxatives

Glycerin or polyethylene glycol (PEG) 3350 (e.g., Fleet, Babylax, MiraLAX).
Large ions/molecules draw water into the rectum to facilitate movement.
Not systemically absorbed.
Useful for occasional simple constipation.
PEG 3350 became an OTC option in 2006.
Glycerin onset: 15-30 minutes rectally.
PEG 3350 onset: 12-72 hours orally, up to 96 hours.

Safety Considerations for Hyperosmotics

Poorly absorbed, little drug interactions.
Bloating, discomfort, cramping, and flatulence may occur in some individuals.
Dosing:
- Glycerin: 1-2.8 grams in children younger than 6 years old and 2-5.6 grams in children and adults age 6 years or older.
- PEG-3350: 1 capsule/packet mixed in water
Avoid in patients with rectal irritation.

Emollient Laxatives

Docusate sodium and calcium (e.g., Colace, Correctol).
Anionic surfactant that acts as a wetting agent to soften stool.
Helps prevents straining.
Onset: 12-72 hours.
May take up to 3-5 days.

Indications for Emollients

Occasional constipation.
Straining/painful defecation.
Anorectal disorders or conditions where straining is undesired.
Post-abdominal/rectal surgery or postpartum.
Opioid-induced constipation (in conjunction with stimulants).
Avoid co-administration with mineral oil.

Lubricant Laxatives

Mineral oil (liquid petrolatum) (e.g., Fleet Mineral Oil Enema, Kondremul Emulsion).
Coats the intestines decreasing fecal H2O absorption.
Onset: 6-8 hours by mouth, 5-15 minutes rectally.
Judicious use to maintain soft stool to prevent straining/painfu defecation.
Routine use not preferred, docusate is a better option.

Safety Considerations for Lubricants

Drug interactions (ADEK vitamins, avoid co-administration with docusate)
Do not take within 2 hours of eating
Lipid pneumonia (esp. in dysphagia patients)
Pruritis ani, cryptitis, or perianal conditions (DC use)
Contraindicated in bedridden patients, or in situations with limited mobility.
Avoid in young children, pregnant women, older, or immobile patients.
Don't use in children younger than 6 unless prescribed

Saline Laxatives

Magnesium Citrate, Magnesium Hydroxide, Dibasic sodium phosphate and monobasic sodium phosphate, Magnesium Sulfate (e.g., Fleet Ready-to-Use, Phillips, Epsom).
Ions draw water into intestines/colon via osmosis increasing intraluminal pressure & motility.
Take on an empty stomach.
Onset: 30 minutes - 6 hours rectally, 0.5-3 hours orally.

Indications for Saline Laxatives

Occasional constipation relief
Bowel preparation for colonoscopy.
Not for long-term constipation management.

Safety Considerations for Saline Laxatives

Abdominal cramping, nausea/vomiting, or dehydration.
Electrolyte imbalance (fluid loss).
Label warnings to avoid in patients on restricted diets (Mg, PO4, Na).
Up to 20% of magnesium salts may be absorbed leading to hypermagnesemia.
Not recommended in patients with renal impairment, newborns, or older adults.
Most do not use in children younger than 6 years old.

Safety Considerations for Saline Laxatives (continued)

Sodium phosphate can cause hyperphosphatemia, hypocalcemia, and hypernatremia.
Use cautiously in renal impairment, or with other medications that affect electrolytes (e.g., diuretics) and/or cardiac conditions.
Contraindicated in congestive heart failure.
Avoid rectal administration in cases of megacolon, gastrointestinal obstruction, imperforate anus or colostomy.
Take on an empty stomach with full 8 oz glass of water.
Avoid dehydration
Drug interactions vary depending on the specific medication, and require counseling.

FDA Actions for Oral Sodium Phosphate Products

Acute phosphate nephropathy linked to oral sodium phosphate products used for bowel cleansing.
In 2008, the FDA issued a boxed warning regarding the use of sodium phosphate-containing laxatives, along with additional recommendations for product labeling and usage instructions.
Oral non-prescription products are not intended for bowel cleansing.
Use is restricted in high risk patients (e.g., renal disease or those >55 years of age).
Should not exceed one dose per 24-hr period.

Stimulant Laxatives

Bisacodyl and senna (e.g., Correctol®, Dulcolax®, Ex-Lax®, Senokot®).
Increase peristaltic activity.
Local irritation of intestinal mucosa.
Increase water & electrolyte secretions.
Onset: 6-10 hours orally, 15-60 minutes rectally.

Indications for Stimulant Laxatives

Components for endoscopic examinations
Prevent/treat opioid-induced constipation.
Second-line agent, after bulk-forming and hyperosmotics, in occasional constipation cases.

Safety Considerations for Stimulant Laxatives

Adverse effects: cramping, electrolyte/fluid deficiencies.
Enteric loss of protein or hypermobility.
Laxative abuse consequences.
Use cautiously due to mucous/fluid loss
Take 1 hour before antacids or milk to avoid reduced enteric coating.
Do not crush or break enteric-coated pills.
Senna may discolor urine.

Laxative Overuse

Misconceptions about bowel movements (fear of constipation, co-morbid conditions).
Clinical features: diarrhea, vomiting, fluid & electrolyte imbalance, and dehydration.
Wean off laxatives gradually, increasing fiber and fluid intake, and encouraging physical activity.

Opioid-Induced Constipation

Stimulant laxatives with or without docusate are commonly recommended.
PEG-3350 can prevent and/or treat opioid-induced constipation, whereas bulk-forming solutions/agents are not appropriate for these individuals
Saline laxatives can be useful for acute cases when necessary.

Selecting Laxatives

Review Figure 2.
Lifestyle management, especially in cases of simple constipation.
Bulk forming or PEG-3350 recommended as initial choice in simple cases.
Consider co-existing conditions.
Avoid mineral oil if possible

Pediatric Approach to Constipation

Dietary and behavioral modification first for children.
Consult healthcare provider for children under 2; for children aged two to six, docusate or magnesium hydroxide are viable options.
Senna, or other rectal glycerin agents are viable choices for children ages 6 to 12 years.
Methylcellulose, calcium polycarbophil, psyllium powder, magnesium hydroxide, or docusate sodium are viable options for children ages 6-12.

Older Adult Approach to Constipation

Dietary and behavior modification first for older adults.
Educate on normal bowel habits.
Medication adjustments may be necessary.
Bulk-forming laxatives are a good starting point, but account for any fluid restrictions and co-morbid conditions.
PEG-3350 is another good initial option.
Docusate useful in cases of hemorrhoids.
Avoid mineral oil and watch for concerns about saline laxatives.

Counseling Issues for Laxative Use

Lifestyle modifications always needed
Do not use laxatives for more than one week without a healthcare provider's supervision.
Be aware of potential co-morbid conditions and drug interactions.
Onset varies based on the laxative type.
Consider prevention strategies versus treatment solutions for long term care.

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Description

This quiz will explore the common issue of constipation, its definitions, statistics, and various causes. Understand the lifestyle, structural, and systemic factors that contribute to this gastrointestinal complaint. Learn how self-care can help alleviate symptoms and improve bowel health.