Managing Constipation Resulting from Opioid Use
How to Manage Constipation from Pain Medication
The best way to manage constipation is to prevent it
Make sure you drink enough fluids
Make sure you get some form of exercise each day (i.e. walking). Even a little bit helps
Eat foods high in fiber
Use a bowel regimen (stool softeners and laxatives) as instructed by your healthcare providers.
Bowel Regimen
Start with Senokot S*, two tablets at bedtime. If no BM on day 1
Senokot S, two tablets twice a day. If no BM on day 2
Senokot S 3-4 tablets twice a day or three times a day. If no BM on day 3
Dulcolax 2-3 tablets three times a day and/or at bedtime.
If there have been no BMs for 4+ days contact MD or pharmacist.You may be asked to use:
Fleet Enema
Lactulose (45-60 ml by mouth)
Magnesium citrate (8oz. by mouth)
* Senokot S is to be taken on a regular basis unless you are having loose stools.Adapted from National Cancer Institute (NCI)
Managing Diarrhea
Do NOT
Eat foods that may stimulate/irritate the digestive tract
Whole grain breads/cereal or bran
Fried or greasy food
Nuts
Raw fruits or vegetables
Rich pastries/candy, or jellies
Strong spices/herbs
Caffeinated, alcoholic, or carbonated drinks
Milk/milk products
Very hot/very cold foods
When to Call the Doctor
6 or more loose bowel movements per day, for > 2 days
Blood in /around anal area or in stool
Weight loss of 5 lbs or more after diarrhea starts
New abdominal cramps/pain lasting 2 or more days
Inability to urinate for 12 or more hours
Fever
Sudden puffy or bloated abdomen
Constipation for several days accompanied by a small amount of diarrhea or oozing of fecal material
What Caregivers Can Do
See that the patient drinks about 3 quarts of fluids per day
Keep a record of bowel movements to help decide when to call the doctor
Check with the doctor before using any over the counter medicine. Many of these contain compounds that are like aspirin, which can worsen bleeding problems.
Check anal area for red, scaly, broken skin
http://www.cancer.orgFrom the American Cancer Society
Managing Fatigue
What is Fatigue?
An overwhelming sense of exhaustion physically, mentally, emotionally
Can occur with cancer, cancer treatment or other chronic illnesses
Can persist over time and interfere with usual activities
Differs from the tiredness of everyday life, which is usually temporary and relieved by rest
More distressing and not always relieved by rest
Can vary in it unpleasantness and severity
Can make being with friends/family difficult
Can make it difficult to follow medical treatment plan
Common Causes of Cancer-Related Fatigue
Anemia (low red blood cell count)
Pain
Emotional distress
Sleep problems
Poor nutrition
Lack of Exercise
Other illnesses such as infection, hypertension, diabetes
Common Words Used to Describe Cancer-Related Fatigue
Feeling tired, weak exhausted, weary, worn out
Having no energy, not being able to concentrate
Feelings of heaviness in arms and legs, feeling little to no motivation, sadness and/or irritability, and unable to sleep or sleeping too much
What to Tell Your Doctor
When did the fatigue start?
Has it progressed over the course of your treatment?
What makes your fatigue better?
What makes your fatigue worse?
How has the fatigue affected your daily activities?
Energy Conservation Principles
Prioritize your activities in order of importance
Ask for help and delegate tasks when you can
Establish a structured routine
Balance rest and activities, performing activities during times of higher energy
Establish a regular bedtime
Whenever possible, sit instead of stand when performing tasks
Listen to your body. If you need to rest or nap do so
Principles of Exercise
Your heart, lungs, and muscles require a daily workout. When you are less active, especially while in bed, your heart, lungs and muscles have very little work to do. Over time, your heart pumps less forcefully, your lungs expand less fully, and your muscles will become weak and tight. This causes a drop in your energy level, which affects your ability to carry out your daily routine.
The following tips should be considered:
Check with your doctor before exercising
Do exercises slowly and completely
If too tired to finish exercises, do what you can
Always work at your own target heart rate (see your doctor for details)
Remember to breathe while you exercise
Walk!
Adapted from National Cancer Institute (NCI)
Nausea & Vomiting
Nausea and Vomiting
Can often occur together
Nausea is an unpleasant feeling in the back of the throat and stomach that may result in vomiting. Symptoms that may occur during nausea include: increased saliva, dizziness, light-headedness, difficulty swallowing, skin temperature changes, and fast heart rate.
Vomiting (emesis) is a forceful contraction of the stomach muscles that causes the contents of the stomach to come up through the mouth. Nausea may or may not be present.
Retching is the attempt to vomit without bringing anything up from the stomach (gagging or dry heaves)
Causes of Nausea and Vomiting
Chemotherapy
Radiation Therapy
The cancer itself
Certain medications
Constipation
Other: anxiety, infections, other diseases or illnesses
Types of Nausea and Vomiting
Acute nausea and vomiting usually occurs a few minutes to several hours after chemotherapy and goes away within 24 hours.
Delayed nausea and vomiting occurs around 24-72 hours after chemotherapy and can last 6-7 days.
How is Nausea and Vomiting Treated?
Anti-nausea/vomiting medications
Based on your condition, ability, preference
By mouth is most common
For severe vomiting or for those unable to swallow, medications can be given into a vein or subcutaneously
Nondrug treatments such as relaxation, distraction, imagery, and medication
Managing Side Effects
Try to eat small frequent meals instead of 3 larger meals
Eat foods high in calories and protein
Try eating when you are best able to eat. Some people are more hungry at breakfast time
Let your doctor or nurse know when eating is a problem for you
Let your doctor or nurse know if you would like a referral to see the dietician
Let your doctor or nurse know when your nausea and vomiting are not relieved
To Help Manage or Reduce Nausea and Vomiting
Key is to try to prevent nausea. Take medications for nausea on a regular schedule
Eat foods and drink beverages that are easy on the stomach or made you feel better when you had the flu, such as ginger ale, bland foods, sour candy, dry crackers or toast
Do NOT force yourself to eat when you feel nauseated
Restrict fluids with meals
Eat food cold or at room temperature
Ask someone else to make the meals if you are nauseated
Please ask your physician to refer you to a dietician if you:
Have had minimal intake for 5 days or more
Have difficulties with chewing or swallowing
Are receiving tube feedings or IV nutrition (TPN)
Have a pressure ulcer or skin breakdown
Are not able to maintain weight
Wish to see a dietician about your nutrition concerns
Preventing and Managing Constipation
What To Do:
Drinking adequate fluid is very important. If permissible by your doctor, drinking eight to ten cups of liquid each day may be required.
Try to eat at the same times each day.
Eat foods high in fiber (e.g. uncooked fruits [with the skin on], vegetables, whole grain breads and cereals, fresh raw fruits with skins and seeds).
Add one or two tablespoons of unprocessed bran to your food. This adds bulk and stimulates bowel movements. Sprinkle on food at mealtimes.
Avoid foods and beverages that cause gas, such as cabbage, broccoli, cauliflower, cucumbers, dried beans, peas, onions, and carbonated drinks if these items cause you distress.
Get as much exercise as you can, even if that means only walking a very short distance.
Try to have a bowel movement whenever you have the urge.
Use stool softeners and laxatives only as instructed by your doctor or nurse. (Will need to take routinely if on opioids)
Use a rectal suppository only after checking with your doctor or nurse.
If you are confined to bed, try to use the toilet or bedside commode when you have a bowel movement, even if that is the only time you get out of bed.
Use an enema to provide immediate relief from constipation, but first check with the doctor or nurse. Enemas should be the last step for relieving constipation. They evacuate the lower bowel and help the upper bowel move as well.
Do Not:
Strain or use extreme force when trying to move your bowels
Use over-the-counter laxatives or enemas unless first discussed with your doctor
Use laxatives and enemas if you have a low white blood count or low platelet count
Recommendations for Treating ConstipationDay 0
Senokot S two tablets at bedtime if no BM on day 1
Senokot S two tablets twice a day if no BM on day 2
Senokot S three or four tablets twice a day or three times a day if no BM on day 3
Dulcolax two or three tablets three times a day and/or at bedtime
If no BM, rule out impaction
If impacted:
Lubricated rectum with oil-retention enema
Medicate with opioid and/or benzodiazepine
Disimpact
Give enemas until clear
Increase daily laxative therapy per above
If NOT impacted:
Give additional laxatives
Lactulosse (45-60 mL by mouth)
Magnesium Citrate (8oz.)
Dulcolax suppository (one per rectum)
Fleet enema (one per rectum)
At any step, if medication is effective, continue at that dose. If less than one BM per day, increase laxative therapy per steps. If less than two BM per day, decrease laxative therapy by 24% to 50%Source: Adapted from Levy (1991), Constipation and diarrhea in cancer patients. Cancer Bull 1991; 43:412-422.Adapted from National Cancer Institute (NCI)
Dyspnea
Assessment/General Principles
Dyspnea is a term used to describe difficulty breathing, a sense of breathlessness, or a feeling of shortness of breath.
It is important to describe your dyspnea to your physician. Does your shortness of breath come on suddenly? With activity? What makes it better or worse?
Dyspnea is very different for each person.
One way to communicate your difficulty breathing is on a scale
Feeling short of breath can be very upsetting and can greatly impact your life. It is common to be anxious or distressed if you have difficulty breathing.
It is very important to communicate with your physician about your difficulty breathing. Your doctor may want to prescribe medications to help your breathing or anxiety.
Treatment
There are many things that may help your sense of breathlessness. This includes:
Sitting upright supported by pillows or leaning over a bedside table.
Using a fan or open window to circulate air
Use of oxygen if recommended by your physician
Use of medications such as morphine, inhalers, or other agents that may be helpful as determined by your physician.
Because dyspnea is associated with anxiety, methods to decrease your anxiety such as relaxation, meditation, and breathing exercises may be helpful.
Because dyspnea is often made worse by activity, efforts to conserve energy or use medications before activity may be helpful.
It is important to let your physician know if your respiratory symptoms change, you are coughing more, you have a fever, or you have any blood in your sputum.Pursed Lip Breathing is a simple way to help control shortness of breath by slowing your pace of breathing, making each breath more effective.How It Works
Improves ventilation by releasing air trapped in the lungs
Keeps your airway open longer thus reducing the work of breathing
Extends exhalation resulting in slower breathing
Moves old air out of your lungs allowing new air to enter
Slowing the breathing also helps general relaxation
When to Use Purse Lip Breathing
During activity such as bending, lifting, climbing stairs, or any activity that requires extra effort
Practice 4-5 times a day to be sure you have the correct breathing pattern
Techniques of Pursed Lip Breathing
Relax your neck and shoulder muscles
Breathe in slowly through your nose with you mouth closed, taking in a normal breath
Purse your lips together like you are blowing out a candle or whistling
Breathe slowly through you pursed lips while counting to four
Breathing out must be 3-4 times longer than breathing in, so do not force air out
Repeat steps 2 through 5 until shortness of breath is relieved
Activity/Energy
Plan important or fun activities first. Limit unnecessary activity.
Take rest periods during activities
Perform grooming activities while sitting
Keep frequently used items easily accessible
Use a wheelchair as needed
Wear flat shoes
Wear loose, easy to put on clothes
Avoid warm temperatures, unpleasant odors or fumes
Establish a regular routing
Ask for help and delegate tasks when you can
