Palliative Care

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

1. Relax your neck and shoulder muscles

2. Breathe in slowly through your nose with you mouth closed, taking in a normal breath

3. Purse your lips together like you are blowing out a candle or whistling

4. Breathe slowly through you pursed lips while counting to four

5. Breathing out must be 3-4 times longer than breathing in, so do not force air out

6. 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