mangledcobwebSoftware and s/w Development

Dec 14, 2013 (8 years and 1 month ago)


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:


Fecal impaction



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
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

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

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.


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

Memory loss and confusion

Lightheadedness and mental fogginess/inability to

Wandering/inability to sustain a train of thought

Incoherent speech

Visual and auditory hallucinations/illusions


Euphoria or Dysphoria

Respiratory depression

Warning Signs/Sx of Anticholinergic

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


Bowel Dysfunction:

Contributing Factors

Genetic predisposition

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

Low fiber diet

Limited fluid intake

Disruption in routine

Ignoring the urge

Lack of privacy

Sedentary life style

Bowel Dysfunction:

Contributing Factors



Neurological conditions such as Parkinson’s disease or
multiple sclerosis

Overuse of antacid medicines containing calcium or


Eating disorders

Colon Cancer

Bowel Dysfunction:

Contributing Factors


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

Overuse of laxatives can weaken the bowel muscles:




Glycerin suppositories


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



Cramping and belly pain that comes and goes

Pain occur around or below the belly button


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?


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


), which can require surgery

to be removed


All of the symptoms of obstruction may be present


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



Megacolon: Signs/Sx

Constipation of very long duration

Abdominal bloating

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

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


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


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



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

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


take medication with known anti
effects/nervous system depressants:

pain medications

muscle relaxants

anxiety medications (benzodiazepines)

sleeping agents (Benadryl/diphenhydramine)

EPS prophylactic agents (Cogentin/benztropine,

psychotic medications


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
activity e.g.

(antipsychotic) and



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

Personal and family history of bowel problems

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

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

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

Suggestions on

Approaching the Subject

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

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


High fiber diet


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

Keep track of bowel movements


Mental health is essential to overall health and other
physical health

Physical health is essential to mental health and


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


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


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,

The medical examiner said the 14
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.