Sunday, September 10, 2006

The Bowels of the Hospital

In most hospitals in the US, poop is the nurses' purview.

Shit is our shingle.

Bowel movements are our raison d'etre.

It's an ugly fact of life, but it's true: if you have a patient who's undergone brain/cardiac/leg/facial surgery (anything, practically, short of surgery for an intestinal obstruction or ileus), it is your responsibility as a nurse to make sure that they're regularly moving their bowels. Pooping on schedule, as it were. Dumping a load like clockwork.

That sounds easier, to the lay person, than it actually is. See, we hand out narcotics like candy (what? They're not candy?), and narcotics slow the passage of feces (or "stuff", in the medical terminology) through the bowel. Stuff that takes a long time to pass through the lower intestine becomes dried out as more and more water is absorbed. Sometimes the lower intestine itself gets lazy, and then you have the dual problem of dry Stuff and Lazy Bowel.

In short, we deal with a lot of constipated patients a lot of the time.

Normally, protocols demand that a patient move (or "open", for our friends in the UK and Oz) their bowels no less than once every 48 hours. After certain surgeries, like an open aneurysm clipping, once every 24 is preferred, as to avoid straining and possible increase in thoracic and intracerebral pressure. I thought it might be nice and amusing and edifying to go over the ways in which we manage that. Note two things: that I'm on my second beer, or else I'd *never* be typing about poop, and that these hints and tips do not apply to spinal-cord-injury patients, who are a whole 'nother ball of wax. Or dung.

Stuff Softeners: The First Line of Defecation

Docusate sodium and docusate calcium fall into this category. They're over-the-counter medications that draw water into the bowel in small amounts, allowing Stuff to remain soft, pliable, and evacuate-able in the normal person. Note that overdosing a patient on Stuff Softeners is a bad idea, as the Stuff will become so soft that it either just sits there, or turns into diarrhea. Stuff Softeners won't work for a patient who has pre-existing problems with constipation or who's badly impacted. Don't waste your time.

Milk of Magnesia: The MOM of All Remedies

MOM is technically a saline laxative. Saline laxatives work by drawing water into the bowel, following the principle that heavily saline solutions on one side of a membrane will attract water to balance their concentration. (Am I reminding you of chemistry yet?) MOM works best, I've found, on an empty stomach, two hours before any medications, and when followed by sixteen ounces of water. It's good for the moderately-constipated patient with no huge health problems (the usual neurosurgery candidate, in other words).

Prune Juice: Grandma's Remedy or Old Wives' Tale?

I've never had a lot of success with prune juice, even warmed, unless it's with people who've been using it for years as a laxative. Apparently it contains some chemical that causes the bowel to move. The downside is that it won't work with most folks. The upside is that it's the Drink of A Warrior, according to Whorf (/geek).

Stimulants: Use At Your Peril

Bisacodyl and Bisacodyl Uniserts, also known as Dulcolax or Correctol (tablets and suppositories) are stimulant laxatives, as is senna (Sennakot). Both will send your patient into low-earth orbit if they're not terribly backed up, and will cause hemorrhoids if they are. I use the pills as a last resort and the suppositories as a next-to-last resort. The major drawback of stimulant laxatives is cramping; the secondary drawback is major, major pooping.

Magnesium Citrate: When Your Best Just Isn't Good Enough

Give a patient a glass full of ice-cold cherry flavored mag citrate and a straw, tell 'em to drink it fast, and then...stand back. You'll hear their bowel sounds from the doorway. Mag citrate is a saline laxative--the difference between it and milk of mag is volume. More volume equals more water equals more...well, you get the idea. I love mag citrate, though it should be used with extreme caution in people with electrolyte imbalances. It'll cure what ails you, for sure.

Back Door Remedies: When You Get Stuck

Enemas are often the nurse's best friend. You can have plain enemas (tap water or saline, warmed, with or without a little liquid soap added), weird enemas (SMOG or bubblegum or milk and molasses), or dreaded enemas (The Dreaded Triple-H).

Plain enemas are used most often as cleansing treatments. They help the patient get rid of whatever's up there, plus, they leave the intestine relatively clean in the process. My personal favorite is 750 ml normal saline warmed in a graduated cylinder in the microwave, with the remaining room-temperature saline added until the temperature is comfortable. (Note: it should feel slightly warm on your wrist.) I'm not crazy about soap; it seems too turn-of-the-century to me, though there is plenty of evidence that the irritant nature of castille soap helps with evacuation. Personally, a liter of warm saline in yer poop chute seems like irritant enough to me.

SMOG, bubblegum, and...molasses? You're Kidding, Right?

No, children, I am not.

SMOG stands for saline, milk of mag, and glycerine. Bubblegum enemas are saline with some liquid docusate sodium added. Both are low-volume enemas that depend on the chemical ingredients for Stuff softening and stimulation. They're prescribed, in my experience, by well-meaning residents who have no clue what they're up against. The experienced nurse goes for...

Milk And Molasses: An Unlikely But Effective Combination

250 ml of whole milk (or thereabouts), mixed with an equal amount of ordinary molasses, warmed, works a treat. The molasses draws water into the bowel while the milk greases the works, as it were. Results are fast and gratifying (for the patient). We keep a gallon jug of molasses in the clean utility room and go through it in about three weeks. This, along with the half prune juice, half mag citrate cocktail, should be in every nurse's arsenal.

The Triple-H: High, Hot, and a Hell of a Lot

We're talking tap water or saline (my preference) in quantities of a liter. Or more. The outcome should be obvious. I only use these in extremely constipated patients with attitude problems.

Disimpaction: A Manual Manual

Disimpaction is unpleasant for both nurse and patient. Probably less pleasant for the patient, but it's close. We do manual (sticking fingers where fingers normally don't go) disimpaction when a patient has a rectum and lower bowel full of hard, dried feces that they can't excrete. It *hurts*. Using lots and lots of lubricant and a gentle touch will help, but you can't get around the fact that you're ouching somebody who's already ouched out.

It should be avoided at all costs, and not just because it lacks dignity. You can easily traumatize delicate tissue while doing a manual disimpaction. And, frankly, if a patient gets *that* impacted while in the hospital, somebody isn't doing their job. Even a mineral oil enema to loosen things up and grease them along is preferable to the trauma of disimpaction. You can always do a cleansing enema afterwards.

And there, children, you have it. Probably more than you wanted to know, but at least a bit helpful for the new nurse or student. Enjoy your day, eat your salad, and for heaven's sake, don't let your patient go more than 36 hours without a tour of the porcelain empire.

40 comments:

Kate said...

Dear *God.* I am *so* glad I'm a writer.

Kati said...

Yikes! It's one thing to do this stuff for my kids, but doing it for a total stranger--you are my hero!

Sid Schwab said...

Excellent! In my training, our grand rounds tended to be highly esoteric. Until a former chief resident came back after a year in practice to talk about the most common problem he saw: tiredness. Can't get far without the basics. And as a general surgeon, I can tell you (you already know) that nothing makes me happier than the sound of a fart or the smell of poop. In a paatient, that is.

shrimplate said...

The patient needs a colonoscopy tomorrow. They cannot tolerate the mag citrate prep orally so the doc has you sink an NG tube down their nose.

You pour in the prep, stand back, and wish that the patient didn't weigh 350 lbs.

It hits them and you assist them out of bed. They squirt liquid poop like a fire hose all over the floor. You both slip and fall.

Everybody gets cleaned up, hours later the shift ends and you laugh and go home, and when you get there the dogs sniff you over dismissively before they run to their corners.

The hot water tank runs out before you finish showering.

And you're lucky, because this is that day.

Cass said...

This is one of my favorite posts EVER. Yay for poop!

woolywoman said...

Prune juce- an amount to equal their hourly intake of tube feeding- is good stuff. And no one cares what goes down their ng. Not for the severley impacted, but a nice little prevantitive/ mild cure. I have never, ever gotten a patient to drink prune juice. If they're little kids, they throw it at you. Big kids purse their lips in the clench of no way, and large adult type kids just start swearing ( neuro stuff) Babies are the best- they take one swig, aresolize it right back at you, and then STARE at you, as though you've lost your mind. Which you have, because you believe that you can get juice from dried fruit.

NF said...

Jeez, I wish I had known all this before my grandmother died this spring. She was constantly plugged up from her "candy" and did her own manual disimpaction. (We found that out after months of her denying she was constipated. I guess she thought that if any stuff came out, no matter how, all was well.) We never tried MOM or mag citrate. Bet she woulda loved it.

girl_in_greenwood said...

Oh, this is excellent. I am going to point all my nursing school classmates to this entry when we get to the elimination and enemas portion of our skills lab this quarter!

Anonymous said...

I figure about half of nurses are poop experts and the other half have foot fetishes - I'm in the first half. Ever recommended a Phillips Screwdriver-OJ and Milk of Mag, warmed for extra effect....or a black and white - MOM and cascara in equal parts....milk and molasses enemas work too, tho I have to say that giving one to a patient while I was pregnant put me off my dairy intake for a few weeks!
Seriously - if someone is constipated, getting relief matters to them more than anything else you can do. And prevention is WAY easier than treatment...so drink those fluids, eat those fruits and veggies, and move!

Kim said...

Nothing makes me madder than when a post op patient comes in who has not had a bowel movement in five days - in fact, was discharged without having had one!

As much as I gripe about ER enemas and ads that focus on the fecal aspects of life, being constipated post op is EXTREMELY uncomfortable.

Trust me on that. I was released after my first C-section and it was a WEEK.
I didn't have to go to the ER.

And while I don't feel enemas have a huge place in the ER world, the patients are usually mortified that they have to come in for "that" and I assure them that I see it in all ages and often.

Unless you work in a dermatology office, poop will be your companion at least occasionally in your career....

babe said...

am i the only one who was had to sqeeze metamucil down an ng tube???

Anonymous said...

I was a spinal cord injury patient and spent 4 1/2 months in a hospital. Every second day without fail we got a "bowel procedure" that involved manual stimulation and a small enema (Enemeez, it was called). I needed disimpaction only once or twice (wince!). Now I make do with six Metamucil ad ay and two Docusils. But from what I read from your blog, SCI patients are not all that different from constipated ones, except that the constipation is constant.

Jo said...

Babe, you're not. We switched to some sort of fiber supplement, the name of which I can't remember at the moment, that doesn't gel like Metamucil does. Ask your docs and pharmacists about it--you'll spend less time squeezing and meat-tenderizing.

Anonymous said...

As an RN I have used the good old M&M enema many times. The best result was having to put some down a colostomy. The stuff came flying out like a geyser---would have put Old Faithful to shame. It went straight into the air, hitting the ceiling, walls, curtains----you wouldn't have believed it. It was everywhere!!!!
All I could do was walk into the nurse's station and say, "It is all over the walls!" All of my fine co-workers were laughing so hard they couldn't pick themselves up off the floor to help me clean it up!! Thank goodness the housekeeper took pity on me and helped.

Anonymous said...

Manual disimpaction can be accomplished without inserting a finger in an anus! After much trial and error I have found the following to be the best way to perform this procedure. While sitting on the toilet, push forcefully and repetitively (1-3 times per second) with your fingers, from the left rear, 2-3 inches from but toward the anus. This procedure breaks the static friction of most impacted feces and in combination with gentle abdominal pressure, gets them moving easily out of the anus. So easily in fact, that within a week of first discovering this procedure my anal fissures, resulting from chronic constipation, were able to heal and have not since returned.

Anonymous said...

i'm a rehab nurse ... this is true and funny! thanks for the laughs!

Anonymous said...

I am a chronic pain patient and I have been taking opoids for over 12 years. Very strong opoids and 800mgs per day. I have constipation that can be very painful due to dry impacted feces which without help won't pass. I have tried all of your recomendations all have worked. However, there has been 3 times in my chronic life that none of the above have worked and have actually made me very sick.
The problem I have is that the material is void of water and has formed into a large rock just near my anus. A finger won't work. I have designed a stainless steel wire by bending it in half about 9" long strong but then and used it to insert to help break up the material so a finger may be able to work. The wire is bent double to form a long U shape and is as thick as a metal hanger. When used slowly carefully with Lubs and anti bactorial it does break up the material from small to large ball shapes and they pass. Still is painful but necessary the passing not the wire.
My problem is CPain along with broken tail bone that when I don't void as I should the matter us forced into this shape and presses outwards due to broken tail bone issue. As well as my bowel now seems to accomodate very large single movements. I may come to a point where I need medical assistance to remove impacted feces which I dread. And I could never request my spouse to do such a thing for me it would be too much to ask or bear.
Is there a medical instrument that would be of better or safer use since this is now my 4th experience of this happening to me. I would appreciate any quick help

Anonymous said...

Smog enema is saline, MINERAL OIL (not MoM) and glycerine.

I've made it plenty of times in our hospital pharmacy.

We had a nurse call down and ask if it was to be administered orally! (not kidding) I told it might have the same effect, but no. She must have misssed class the day they defined enema.

Anonymous said...

Oh, for the anonymous poster w/ opiod induced constipation, there is a product called Relister (methylnaltrexone) for this. It's an opiod antagonist, but doesn't cross the BBB so it doesn't offset the analgesic effect, but manages some side effects.

Satyavati devi dasi said...

OMG! LMAO! I haven't given a black and white in 15 years!! And just yesterday I was explaining what a 3H was to a new nurse who could not believe that nurses would use such a term.

Ah the joys of the fecally obsessed...

I remember in nursing school my clinical instructor saying: 'It's very simple: shit or die.'

Truer words never spoken.

Satyavati devi dasi said...

And actually, I've done smogs with both MOM and mineral oil.. and without the MOM as well. Depends on who's ordering it.

And my preferred prep for colonoscopy:

1. clear liquid diet beginning 10 AM the day before the procedure

2. at 3pm, 2 dulcolax tabs (10mg) and 1 bottle mag citrate.

3. if not clear by 7pm, repeat mag citrate (obviously this is for people with no chemistry disturbances)

4. by 10pm you will be pooping stuff you haven't even eaten yet and your insides will be so squeaky clean they'll look like they've never been used.

5. Procedure report will say: PREP: EXCELLENT.

:)

Anonymous said...

is the milk and molasses an enema? or to take orally?
oh the joy of pregnancy.

Anonymous said...

Been manually disimpacting myself for years! At least once a week. I keep gloves on the standby! Oh God its terrible! Amazing the things we can adjust to and accept as "normal"!

Nick said...

I just concluded a six day hell of constipation that included an enema, hundreds of milliliters of Milk of Magnesia, Colace (suppository), Ducolax, Metamucil, tons of fibrous foods and a glycerin suppository. None of which helped in the least. I then had TWO manual disimpactions in as many days. I'm finally clear, and very grateful to the doctor and nurse who did it, both for their care, giving me Xanax, and putting up with my S#@T.

Just a coupla' notes: for any nurses and/or doctors reading this:
1. Aside from the thin sterile sheet (that paper thing) that they put over me, I was also given a blanket which was both comforting and warming, which was great because you would be surprised how cold and uncomfortable you get with your pants off and someones finger up your butt.
2. Wet wipes would have been really good to clean up afterwards, especially in my case where the stool softeners and saline laxatives caused very wet excrement.

Anonymous said...

I'm glad to learn that I'm not the only one who relies on manual disimpaction, on a daily basis, to remove hard feces. I eat lots of fiber, drink lots of water and am very active, but still, and for many years, "manufacture" but don't "export" solid waste. I'm so full of sh** my eyes are brown! But seriously, it's not a pleasant situation and I worry about it becoming worse as I age. Is it okay to use Milk of Magnesia or mag citrate on a regular basis?

Anonymous said...

I'm pregnant and at risk of preterm labor, instructed not to "push." I've been constipated for 8 days, taking colace, high fiber cereal, prune juice, and finally a suppository, but none helped. Terrified about what to do, what a stupid terrible predicament :(

Rag Doll Design said...

Two days post cholecystectomy and I'm FREAKING OUT
I am the kind of person you could set a clock to when it comes to being regular. I have to go so bad it hurts but I can't and cannot push..been doubling up on the Miralax with no luck. My question is what should I try next?

Anonymous said...

Not me! Any questions pertaining to my bowel habits and frequency is always, always followed by a None of your business throughout my hospital stay no matter how long!

Rodger said...

Informative but your writing style is very immature. if you were aiming for funny you missed big time

Ricini said...

One really effective treatment in order to cleanse the bowels totally is not listed in this article: Early in the morning, not having breakfasted, swallow 2 oz Castor Oil together with fridged orange juice and you will astonished upon the effects that will occur 2 to 4 hours later.

Anonymous said...

Well when I had a baby two yrs ago the nurse said I had to poop before I could leave I never did & they never said anything about it but ever since then I have the worst time pooping sometimes I go 3 -4 days without pooing this past time I went 8 days & started havein MAJOR cramps so I tried the mag citrate Omg I can't stay off the toliet but my cramps are gone :)

Anonymous said...

Ok its been two weeks since I've had a bowel movement.. I'm now horribly backed up. Went to er & they said literally I'm full of shit, but said to do suppositories & enema. Did the suppositories & nothing, but more pain, I was able to break very little piece, but then came blood & alot of pain! Want to do enema, but don't know if mineral oil, or saline would be better? Especially worried cuz of blood. Help!

Anonymous said...

90'p
Thank you for this blog. A week ago i had nuerosurergy. I am so stopped up now but cannot push. I am about at a point to visit my gp but am going to try a few of your hints first. Thank you again.

Anonymous said...

Oh, I forgot, have you heard of "brown cows" enemas? brown cow = m+m = milk and molasses enema

warm 8oz milk in pan on stove or microwave 1 min. mix in 8 oz molasses. allow mixture to cool to room temp (test on inside of forearm).
once cooled, add to enema bag and your ready to go. (Credit: My old mom 1st told me about it but online found recipe: http://allnurses.com/general-nursing-discussion/milk-molasses-enema-119574.html

Anonymous said...

I transcribed a report yesterday on an obese man who suffers from alcoholism and pain medication addiction secondary to a work-related injury to his spine. He came in via EMS highly intoxicated and said he hadn't had a BM in over 10 days. They tried everything but they finally worked their magic with good ol' MOM; dictator/doctor said, with an impressed smile in his voice, "the patient then had 2 MASSIVE BMs!" He sounded so proud of himself, or the patient, I am not sure. But we all know it was you nurses who did it. :) xoxo

Anonymous said...

I am 4 days out from a cystocele repair and rectocele repair. The urogyn. also removed my cervix. I have stitches from my behind all the way up to where my cervix used to be. Going #2 is a major event for me and something that is (to me) worse than childbirth, as the pressure and pain on the stitches is too intense to bear.. think near passing out here.. My doc says nothing but to use enemas (which are not too happy either, but they have helped a tad bit). My question is this.. when you have soooo many stitches down there, how can I NOT be in pain even with really soft stool? :(

Anonymous said...

I have always had a great deal of respect for two professions. The first one being teachers, and the second being NURSES!!! You guys should be making TWICE the amount that doctors make!!! Seriously, I bow to you. I really am so thankful to you, and REALLY thankful that you had a beer or two;) lol Although I am not a nurse, I am an expert at constipation, and "impacted" stuff...as I have been suffering from both forEVER.
My favorite remedy, and most effective, is definitely the Magnesium Citrate Solution. Actually, my SO just brought me some home. It's been a miserable day, and I have been googling, trying to find something that might work better for the "impact" problem. Although the M.S. almost always works, there was a time that it did not work and I ended up in the ER. NOT. PLEASANT. I'm afraid that this time might be similar, so I was hoping to find a magic solution. After reading your blog, I suppose I'd better just stick to my bottle of MS. Bottoms up, and Cheers! :S Wish me luck.
Thanks again for all you and the rest of your profession deals with day in and day out!!!! :)

Anonymous said...

You were up past 1am reading about poop, buddy.

Jazzed-ica said...

wow, found this old post randomly - loving the way that you write and I am also a nurse so I can relate.

Keep i tup i see you have some current posts as well.

C Fangerow said...

I was looking for a solution to my post surgery constipation and this old post is a God send! I had been stopped up for about 10 days and was really starting to worry. After reading your post and the comments I went to Walmart and armed myself with Milk of Magnesia, Magnesium Citrate, Glycerin suppositories, and as a final weapon should it be needed, the extra large size Fleet enema. Thankfully, after about 10 hours the MOM kicked in sufficiently to give me relief, so I didn't have to resort to any of the rest of my arsenal, but I'm well ready for any future attacks should they occur. Thanks!