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.