| A Multidisciplinary Team Approach to Chronic Constipation
3/8/2010 |
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Due to the clinical complexity and patient variability in chronic constipation, the condition is ideally managed by a multidisciplinary team in the long-term care setting. The team should include a physician, nurse, nurse's aide, and consultant pharmacist. The team must collaborate, and each team member should have a clearly defined role to assess the patient and ensure successful treatment. The physician should conduct a physical examination and obtain a detailed history. The physical exam should include a rectal examination to rule out an obstruction. The presence of blood in the stool should be evaluated further. In addition, the physician may consider ordering laboratory tests such as a complete blood count, thyroid-stimulating hormone, serum glucose, creatinine, and electrolytes to determine the constipation's underlying cause(s).
A thorough patient history is critical for a diagnosis of chronic constipation. The physician should determine the patient's perception of a "normal" bowel movement by asking the patient about bowel movement frequency, level of straining, and stool consistency. The Bristol Stool Scale can be utilized with the patient to prompt discussion about stool consistency. This discussion should lead to the establishment of patient-specific goals. The nurse and aides will use these goals to establish a care plan for the patient. It is essential that the nurse or aides assist the patient with toileting by providing adequate privacy and time for the patient to have a bowel movement. The patient should not feel rushed or pressured by staff standing outside the bathroom door waiting for them to finish. The nurse or aide will also act as a communications conduit from the patient to the rest of the team by providing feedback on how prescribed therapies are working, any adverse effects, and overall patient satisfaction. Ideally, this information would be documented in a standard fashion to improve the staff's ability to observe trends and quickly scan for the effectiveness of the prescribed regimen. Standardized bowel protocols are often helpful in long-term care facilities, but they must be tailored to each patient. Giving the nurse the autonomy to make appropriate modifications and communicate them back to the team would streamline the process. Finally, the nurse's aide can monitor the food and fluid intake of the patient.
The consultant pharmacist should take the approach that the constipation symptoms are drug induced until proven otherwise. He/she should assess the patient's medication profile to look for highly constipating medications such as verapamil, diltiazem, and ferrous sulfate, and recommend either a dose reduction or alternative therapies. The pharmacist should also look for strong anticholinergic medications that are associated with chronic constipation and recommend alternatives. It is important to note that the concept of anticholinergic burden--anticholinergic side effects that are the result of the cumulative effect of using many drugs with only minimal anticholinergic properties--has been associated with chronic constipation. These patients will often benefit from a reduction in the number of medications they take per day. Finally, the consultant pharmacist can recommend appropriate therapies for chronic constipation, aid in the design of treatment protocols, and monitor for safety and efficacy of medications used.
There is an opportunity for each member of the team to contribute to the care of a patient with chronic constipation. Ideally, the multidisciplinary team will prevent chronic constipation before it is a problem by collaborating on a care plan that is patient specific. The approach described in this article requires no special equipment or training, just a group of dedicated individuals that share the goal of improving the lives of their patients.
Editorial by:
Michael R. Brodeur, PharmD, CGP, FASCP
Associate Professor
Department of Pharmacy Practice
Albany College of Pharmacy
Albany, NY |
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A Multidisciplinary Team Approach to Chronic Constipation
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