INTEGRATED CARE GUIDELINES FOR MANAGEMENT OF ...

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14 Δεκ 2013 (πριν από 3 χρόνια και 5 μήνες)

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Guidelines for Integrated Care

(Psychiatric & Medical)

In the Community


Module III:


Management of Bowel Dysfunction

Training Objectives


Appreciate the need for integrated care in the mental
health community to prevent premature deaths and
increased disability from bowel dysfunction


Understand the levels of risk and factors associated
with bowel dysfunction.


Identify persons with mental illness in their caseload
who are at risk for or who have already experienced
bowel dysfunction.


Identify actions that will aid the persons with bowel
dysfunction in communicating their needs and manage
their symptoms.




Physiology of Digestion

Realistic Diagram

Understanding the problem


Bowel dysfunction: Problems with the frequency,
consistency and/or ability to control bowel movements
such as:


Constipation


Fecal impaction


Obstruction


Perforation


Megacolon development




Deaths in psychiatric settings are increasingly reported
as a result of bowel dysfunction.


Role of Guidelines


Guidelines can serve as aids in development of protocols for
working with affected persons in community case loads.



Guidelines begin with knowing who in community
-
based
case loads is at risk, who is already diagnosed, and who is
showing signs of consequences of bowel dysfunction.



Implementation includes identifying and communicating
with both client and team members. It includes:


The ability to identify symptoms, consult, advise, educate,
support and refer persons with bowel dysfunction.


To recognize and get appropriate help for potentially
deadly symptoms of MEGACOLON

a true medical
emergency.


Bowel Dysfunction and Mental Illness


Elimination of body waste is not a usual or particularly comfortable
topic and is not generally discussed.



However, dysfunction in bowel evacuation is not a laughing matter
when outside of the normal experience.



Extremes of bowel dysfunction disrupt a person’s entire life, and if not
recognized or not treated, may result in death.



Persons with mental illnesses are particularly vulnerable to bowel
dysfunction.



Rendering support and assistance are more likely to happen when
mental health community providers have knowledge the skills to
recognize, support and intervene/refer when appropriate.



FIRST YOU HAVE TO ASK
.



Case Managers and Integrated Care


Knowledge needed by case managers when their clients
who have, or are at risk for developing bowel
dysfunction include:



Understanding the potential for serious complication



Understanding the necessity for supporting
preventative activities such as adherence to dietary
restrictions, exercise and self
-
monitoring/management needs



Case managers also need the support of their team
members and agencies in providing much needed
integrated care.


Role of Psychiatric Medication


Risk for bowel dysfunction is, in part, related to
medications that block the nerves that control the
automatic functions of certain muscles in the body
(Anticholinergic effect).



The affected muscles are particularly important to the
normal movement of the intestines in the elimination of
body waste products.


Warning Signs/Sx of Anticholinergic
Effects


Memory loss and confusion



Lightheadedness and mental fogginess/inability to
concentrate



Wandering/inability to sustain a train of thought



Incoherent speech



Visual and auditory hallucinations/illusions



Agitation



Euphoria or Dysphoria



Respiratory depression


Warning Signs/Sx of Anticholinergic
Effects


Dry mouth



Loss of coordination (ataxia)



Dry, sore throat



Increased body temperature



Dilated pupils and loss of visual ability to
focus/accommodate/double vision



Increased heart rate



Tendency to be easily startled



Urinary retention



Shaking


Bowel Dysfunction:

Contributing Factors


Genetic predisposition



Narcotic pain
-
killers such as benzodiazepines (Valium,
Xanax
,
Ativan
, etc.)



Low fiber diet



Limited fluid intake



Disruption in routine



Ignoring the urge



Lack of privacy



Sedentary life style



Bowel Dysfunction:

Contributing Factors


Stress



Hypothyroidism



Neurological conditions such as Parkinson’s disease or
multiple sclerosis



Overuse of antacid medicines containing calcium or
aluminum



Depression



Eating disorders



Colon Cancer




Bowel Dysfunction:

Contributing Factors


Medication



Narcotics such as benzodiazapines


(Valium, Ativan, Xanax, etc.)



Antidepressants such as tricyclics , SSRIs, SNRIs


Elavil, Desyrel, etc.


Celexa, Prozac, Paxil, etc.


Cynbalta, Effexor, etc.



Second Generation/Atypical antipsychotics


Ablify, Clozaril, Zyprexa, etc.



Iron pills



Bowel Dysfunction: Contributing
Factors


Overuse of laxatives can weaken the bowel muscles:



Metamucil



FiberCon



Citrucel



Glycerin suppositories



Docusate/Colace



Polyethylene Glycol



Milk of Magnesia



Bisacodyl/Dulcolax/Correctol (these stimulant
laxative should only be used for a few days at most)



Symptoms of Constipation


Infrequent bowel movements and/or difficulty having
bowel movements as evidenced by:


Less than 3 bowel movements a week


Straining or difficulty in evacuating bowel at least
25% of the time


More Serious Symptoms

That may Indicate Obstructed Bowel


Swollen abdomen or abdominal pain


Pain


Vomiting


Cramping and belly pain that comes and goes


Pain occur around or below the belly button


Bloating


Constipation and a lack of gas indicate complete
blockage of the intestine


Diarrhea, if intestine is partly blocked


Chronic Constipation

Immediate Medical Attention

Required: Megacolon

What is Megacolon?


Megacolon

is an abnormal dilation of the colon (a part of the
large intestines)




The dilatation is often accompanied by a paralysis

of the
peristaltic movements of the bowel



In more extreme cases, the feces consolidate into hard
masses inside the colon, called
fecalomas

(literally,

fecal
tumor
), which can require surgery

to be removed



THIS IS A MEDICAL EMERGENCY!



All of the symptoms of obstruction may be present


ABDOMINAL PAIN IS SEVERE AND CONSTANT


What is Megacolon?


Rare event

a portion of the large intestine is paralyzed
and swells to many times its normal size



Happens suddenly



Worsening abdominal pain



Visibly distended or bloated abdomen



Abdominal tenderness



Fever



Vomiting

Megacolon: Signs/Sx


Constipation of very long duration



Abdominal bloating



Abdominal tenderness and
tympany
, abdominal pain,
palpation of hard fecal masses



In toxic
megacolon
: fever, low blood potassium, tachycardia
and shock



Stercoral

ulcers (ulcer of the colon due to pressure and
irritation resulting from severe, prolonged constipation) are
sometimes observed in chronic
megacolon

-

which may lead
to perforation of the intestinal wall in approximately 3% of
the cases, leading to sepsis and risk of death

Megacolon

http://medlineplus.gov

Megacolon


66 y.o. man with schizophrenia


no BM for 1 month, presented with
constipation, shortness of breath, and severe abdominal pain

Risk classifications


Please remember that the level of risk for megacolon is
determined by RN or MD



If you notice the client is having difficulties

consult
with RN or MD



Low Risk


No personal or family history of bowel problem



No abnormal findings on medical record or alerts from
RN’s/Psychiatrist on team re medications/blood and
other medical tests



No report from client regarding any difficulty with
bowel movement (when asked or spontaneously)




Low Risk



Does

not
take medication with known anti
-
cholinergic
effects/nervous system depressants:



pain medications



muscle relaxants



anti
-
anxiety medications (benzodiazepines)



sleeping agents (Benadryl/diphenhydramine)



EPS prophylactic agents (Cogentin/benztropine,
Artane)



anti
-
psychotic medications



anti
-
depressants



Moderate risk


Meets some of the following criteria but no current problem


refer to team RN/MD



Personal past history of bowel problems



Family history reported



Takes one or more medications with some anti
-
cholinergic
activity e.g.
Clozaril

(antipsychotic) and
Cogentin

(
antiparkinsonian

agent)

check over the counter
medication and from primary care practitioners



History of occasional constipation



RN/Psychiatrist report some abnormal findings indicative of
bowel dysfunction




High Risk


Current problems



Refer to team RN/MD

possible specialty referral
needed



Personal and family history of bowel problems



Takes more than one medication with high
anticholinergic activity/constipation effect
(polypharmacy)



History of fecal impaction, and/or current constipation



Current or recent (possibly chronic) use of laxatives



Frequent complaints of constipation


Approaching the Question

of Bowel Dysfunction:


How to approach this topic
----

which tends to be
uncomfortable for both the person asking the questions
and the person of whom they are being asked.




One example:



“The medications you are taking can make it difficult
for you to have a bowel movement. That can have very
serious consequences.

It is important for you to keep
track of any issues you might be having.”






“When is my constipation a more
serious problem?”


Only a small number of patients with constipation have
a more serious medical problem



If constipation persists for more than
two weeks
, a
physician or nurse practitioner should be seen to
determine the source of the problem and treat it



If constipation is caused by colon cancer, early detection
and treatment is very important





Healthy Assumption


Assume that all vomiting clients (especially those in
high risk categories) to have a bowel obstruction



A person with schizophrenia may have altered pain
perception and therefore may not notice bowel issues

Self
-
management strategies


Monitoring Questions:


Are you having less that 3 bowel movements a week?


Do you strain a lot when you are trying to have a
bowel movement?


Do you have lumpy hard stools or a sensation of not
getting it all out more than 25% of time?


Use of a monthly “calendar” might be helpful to keep
track


Suggestions on

Approaching the Subject


Treat this issue like any sensitive and confidential
clinical issue. Find a private place and suitable time to
talk



Tell the client that you want to discuss the client’s bowel
management issue



Explain that it is part of the client’s overall health and it
is oftentimes a difficult and private subject to discuss



Explain that because clients sometimes are too
embarrassed to discuss bowel management issues,
some encounter problems which could have been
prevented if dealt with sooner


Clinically Precise and Sensitive Wording


Words and how they are used are very important to how
your conversation will move forward



Use words like: “bowel movement”, “stool”, “constipation”,
and “diarrhea”



What are some other words that you can use to discuss
this topic in a kind and sensitive way?


All Risk Groups Need


Education:


High fiber diet


Exercise


Drinking fluids (6
-
8 ounces water or other non
-
carbonated fluids
--
not to excess)


Keep track of bowel movements

Reminder


Mental health is essential to overall health and other
physical health



Physical health is essential to mental health and
recovery

Reminder


Develop primary/specialty care resources available



Develop relationships in community



Develop protocols for consistent collaboration and
prevention/wellness services


For example, finance/billing: Review use of
Behavioral Health (Community) Medicaid and
inclusion of collaborating in indirect service costs


Reminder


Encouraging services that include identification and
monitoring of other physical health issues:



Amended job descriptions



Updated policies and forms



Staff performance indicators and evaluation



Amended mission and vision




CASE STUDIES


See Handout

Case Study 1


Joseph is an African
-
American male in his mid 50s. He
has a long history of Schizoaffective disorder with
multiple hospitalizations. Joseph lives in a group home.
He smokes heavily and has a diagnosis of COPD. He
often complains of indigestion, bloating and
constipation and he was treated for fecal impaction
about 8 months ago.



He is currently prescribed Seroquel, Haldol, and
Cogentin. He has been also taking medication for
constipation and heartburn. Joseph has not had a bowel
movement for the past 14 days.


Case Study 1


You are a CPST worker



Create a set of specific talking points on how to
approach Harry



Role play this interaction with a partner next to you.
Take turns playing the CPST worker and Joseph



Have fun role playing. Be imaginative but realistic


Case Study 2


Harry is a Caucasian male in his late 20s. He was diagnosed
with paranoid schizophrenia four years ago with history of
multiple involuntary hospitalizations. During the past 12
months, Harry was prescribed Prolixin, Risperdal Consta,
Zyprexa, Cogentin and anti
-
anxiety medication.



Harry has been complaining of GI symptoms such as
heartburn, indigestion and constipation for the past several
months and was prescribed Mylanta and Milk of Magnesia for
GI related problems.



Yesterday, a CPST worker observed Harry to have diarrhea
during transport to a housing appointment and just this
morning the same CPST worker observed Harry vomited in
his apartment.

Case Study 2


You are that CPST worker



Create a set of specific talking points on what you would
say to Harry



Role play this interaction with a partner next to you.
Take turns playing the CPST worker and Harry



Have fun role playing. Be imaginative but realistic


Case Study 3


Sarah was a 14 year old teenager hospitalized at a state
mental facility. She was diagnosed with Autism and
Schizophrenia. Sarah passed away on February 13,
2006.



The medical examiner said the 14
-
year
-
old died of
severe intestinal blockage that medical records showed
went unnoticed by doctors and nurses.



Sarah vomited several times the night before she died.
The next morning, staffers found her body with an
enlarged abdomen and brown substance oozing from
her mouth. Sarah had no pulse and was lying in vomit.

Case Study 3


You are a member of the Critical Incident Committee,
the committee that examines critical incidences at the
hospital and to recommend quality improvement
measures to the Medical Director of that state
psychiatric facility.



What are some early warning signs and symptoms that this
patient may have exhibited or reported?



How would you as a line staff at the hospital approach the
patient when you see her not eat for the past day or so?



Recommend some specific and sensitive talking points in
broaching the subject of bowel management with the patient.