BELIEVE MIDWIFERY SERVICES, LLC
TITLE:
CONSTIPATION
EFFECTIVE DATE: August, 2012
POLICY STATEMENT
BLOOD BORNE PATHOGEN
EXPOSURE CATEGORY:
I (Involves exposure to blood, body fluids, or tissues)
FUNCTION: Care of Clients
EQUIPMENT:
1. Laxative Rx
POINTS OF EMPHASIS:
Laxatives are used to ease or stimulate defecation. It is important to distinguish between two terms: laxative effect
and catharsis. The term laxative effect refers to production of a soft, formed stool over a period of 1 or more days. In
contrast, the term catharsis refers to a prompt, fluid evacuation of the bowel. Hence, a laxative effect is leisurely and
relatively mild, whereas catharsis is relatively fast and intense.
Constipation is defined in terms of symptoms, which include hard stools, infrequent stools, excessive straining,
prolonged effort, a sense of incomplete evacuation, and unsuccessful defecation. A common cause of constipation is
poor diet - specifically, a diet deficient in fiber and fluid. Other causes include dysfunction of the pelvic floor and
anal sphincter, slow intestinal transit, and use of certain drugs (opioids, anticholinergics, some antacids).
In most cases, constipation can be readily corrected. Stools will become softer and more easily passed within days of
increasing fiber and fluid in the diet. Mild exercise, especially after meals, also helps improve bowel function. If
necessary, a laxative may be employed - but only briefly and only as an adjunct to improved diet and exercise.
Anti-diarrheals
Diarrhea can be acute or chronic. Acute diarrhea is most frequently caused by a viral infection. Bacterial diarrhea is
less common. A common kind of diarrhea termed “traveler’s diarrhea” occurs from exposure to non-familiar enteric
bacteria, e-coli. Diarrhea may also occur secondary to salmonella, shigella, Campylobacter or Giardia.
PROCEDURE:
1. When treating constipation, start by reviewing the client’s medication regimen and lifestyle habits.
a. Some medications have constipation-inducing properties.
b. Certain lifestyle changes can relieve constipation such as an increase in dietary fiber, bulk and
fluids, and regular exercise and bowel habits.
2. For the client who needs pharmacologic treatment, a bulk-forming laxative is usually the first choice. The
client must have plenty of fluids for this to be effective.
a. Bulk-forming laxatives such as Metamucil and Citrucel are available OTC.
3. In addition to the bulk-forming laxatives, a surfactant laxative (docusate sodium) may also be helpful.
4. Laxatives can be appropriate during pregnancy for treatment of constipation, but should be used carefully
because GI stimulation might induce labor and during lactation, laxatives may be excreted into the
breastmilk.
a. If pharmacologic assistance is needed during pregnancy, the bulk-forming laxatives and the
glycerin suppositories (stool softeners) are the safest during both pregnancy and breastfeeding.
The bulk-forming are first-line due to low systemic absorption.
b. Methylcellulose (Citrucel) is category B and psyllium (Metamucil) is category C.
c. Surfactant or emolliuent laxatives such as Docusate sodium (Colace, Dulcolax, Fleet Sof-Lax,
Phillips’ stool softener) are category C.
d. All other laxatives are contraindicated in pregnancy.
BELIEVE MIDWIFERY SERVICES
PRACTICE GUIDELINES
PRACTICE GUIDELINE
5.
Page 2 of 3
Contraindications include abdominal pain, nausea, cramps or other symptoms of appendicitis, regional
enteritis, diverticulitis, and ulcerative colitis. Laxatives are also contraindicated for patients with acute
surgical abdomen. In addition, laxatives should not be used in patients with fecal impaction or obstruction
of the bowel, because increased peristalsis could cause bowel perforation. Lastly, laxatives should not be
employed habitually to manage constipation.
Herbal Remedies
1. Aloe, buckthorn bar, cascara sagrada bark, flaxseed, psyllium seed husk (blonde), psyllium seed (black or
blonde), rhubarb root, senna leaf or pod are all useful for constipation.
2. Home remedies include soap or oil enemas, rubbing the abdomen in a clockwise fashion, bran, apples,
prunes, and warm prune juice.
Bulk-Forming Laxatives
6. The bulk-forming laxatives (methylcellulose, psyllium, polycarbophil) have actions and effects much like
those of dietary fiber. These agents consist of natural or semisynthetic polysaccharides and celluloses
derived from grains and other plant material. The bulk-forming agents belong to a therapeutic group, and
produce soft, formed stool after one to three days of use. Bulk-forming agents have the same impact on
bowel function as dietary fiber. Following ingestion, these agents, which are nondigestible and
nonabsorbable, swell in water to form a viscous solution or gel, thereby softening the fecal mass and
increasing its bulk. Bulk-forming agents are preferred agents for temporary treatment of constipation. They
are widely used for IBS and diverticulosis.
a. Should be administered with a full class of water or juice.
b. Psyllium, methylcellulose, and polycarbophil are the primary bulk-forming laxatives.
Surfactant Laxatives
7. The surfactants (docusate sodium) are laxatives that produce soft stool several days after onset of treatment.
Surfactants alter stool consistency by lowering surface tension, which facilitates penetration of water into
the feces.
a. Daily use has the potential for creating bowel dependence.
b. Mineral oil has also been used for this purpose but frequent use can decrease absorption of fat
soluble vitamins and deficiency. Mineral oil can also cause aspiration pneumonia.
Stimulant Laxatives
8. The stimulant laxatives (bisacodyl, castol oil) have two effects on the bowel. First, they stimulate intestinal
motility - hence their name. Second, they increase the amount of water and electrolytes within the intestinal
lumen. They act on the colon to produce a semifluid stool within 6 to 12 hours.
a. Bisacodyl [Correctol, Dulcolax, Feen-a-mint, others] is unique among the stimulant laxatives in
that it can be administered by rectal suppository as well as by mouth. Oral bisacodyl acts within 6
to 12 hours. Hence, tablets may be given at bedtime to produce a response the following morning.
Bisacodyl suppositories act rapidly (in 15 to 60 minutes).
Drug Class and Generic
Name
Bulk-Forming
Methylcellulose
Trade Names
Citrucel
Traveler’s Diarrhea and Diarrhea secondary to Bacteria
Dosage Forms
Powder
Dosage and
Administration
BELIEVE MIDWIFERY SERVICES
PRACTICE GUIDELINES
PRACTICE GUIDELINE
Page 3 of 3
1. Most acute diarrhea episodes are self-limiting; therefore, symptomatic relief is all that is required for the
average person. If the cause is secondary to a toxin (food poisoning) the diarrhea will not resolve until the
toxin is evacuated from the gut. Thus, anything that would slow peristalsis may do more harm than good.
2. If you are sure that the client has simple acute diarrhea and they are requesting pharmacologic relief, stool
thickeners such as loperamide (Imodium) or Kaopectate can be helpful. Bulk-forming laxatives can also
help by creating a less watery, firmer stool. Bismuth subsalicylate (Pepto-Bismol) is protective to the bowel
for mild diarrhea, but doesn’t have the effect of slowing peristalsis. Patients should be cautioned that Pepto
Bismol is a salicyclate (as is aspirin) and may lead to gastric irritation.
3. Bacterial traveler’s diarrhea is a benign, self-limiting condition usually lasting 3-5 days. Parasitic traveler’s
diarrhea lasts longer, >7 days.
a. If non-pregnant, first line of treatment for bacterial is a quinolone antibiotic (Cipro). Azithromycin
or rifaximin may also be used. Treatment duration is for 1-3 days.
b. For pregnant patients or those allergic to quinolones, Azithromycin is also first line.
c. Faster relief is obtained when both an antibiotic and a medication that slows intestinal transit time
(Loperamide, Imodium) are given together.
d. In dysenteric diseases and chlorea, the duration and severity of the disease can be lessened with
tetracycline, sulfamethoxazole 800/trimethoprim 160 (Septra DS, Bactrim DS) or a fluroquinolone
(ciprofloxacin, Cipro).
e. Similar treatment can be used for salmonella in at risk populations. Giardia and E. histolytic are
well-recognized etiologies of infectious diarrhea and are treated with different dosages of
metronidazole (Flagyl).
Diarrhea in Pregnancy and Lactation
1. Loperamide [Immodium] is pregnancy category B and is first-line therapy for diarrhea during pregnancy
and lactation.
2. Diphenoxylate (Lomotil) is pregnancy category C and caution is advised during breastfeeding due to
limited studies.
3. While Bismuth Subsalicylate (Pepto-Bismol, Kaopectate) is commonly used for diarrhea, its effectiveness
is uncertain. Due to the salicylate component, it should be avoided during pregnancy and lactation.
REFERENCES:
Drugs and lactation database (LactMed), United states library of medicine, Toxicology data network (TOXNET).
Retrieved from http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Edmunds, M. & Mayhew, M. (2004). Pharmacology for the primary care providers. (2nd, ed.). St. Louis: Elsevier.
Epocrates Online. (2009). Retrieved from https://online.epocrates.com/home
Holland, N. & Adams, M. (2003). Core concepts in pharmacology. New Jersey: Prentice Hall.
Lehne, R.A. (2013). Pharmacology for Nursing Care, (8th edition). Philadelphia: Elsevier Health Sciences.
Pelletier, C. (2003). Pharmacology: Smart charts. New York: Lange.
Hale, T.W. (2008). Medications in mother’s milk, (13th ed.). Amarillo, TX: Hale Publishing.
Hale, T.W. (2011). Breastfeeding mothers. In T.King & M.Brucker (Eds), Pharmacology for women’s health )pp.
1146-1169). Sudbury: Jones and Bartlett Publications.
Kay, M. & Vasundhara. T. (2009). Common gastrointestinal problems in children. American College of
Gastroenterology. http://www.acg.gi.org/patients/gihealth/pediatric.asp
Originated: August, 2012
Penny Lane MSN, CNM
DATE:
DATE: