Scenario

Floella George, is a 60-year-old lady. She is worried about being constipated and has been taking medication, Co-danthramer, that has been prescribed for her husband who is terminally ill. She asks if you will prescribe this for her.

Comment

Accountability

Writing a prescription implies an acceptance by the nurse prescriber of personal accountability for knowledge of the patient’s current and past medical history, current medications, and knowledge of the side effects and contraindications for the products prescribed. Therefore, the nurse has a responsibility to:

• Explore Floella’s medical history and current health status to identify if there is a real constipation problem.

• Educate Floella, if appropriate, with regards to the importance of dietary fibre and fluid intake.

• Advise on the laxative or rectal preparation prescribed, i.e. side effects, drug interactions, contraindications, administration and use.

Safe & effective prescribing

As part of an ongoing assessment process, Floella, needs to be asked the following to determine whether there is a real constipation problem:

Drug induced constipation, or constipation as a result of insufficient fluid intake must be identified. Sickness, nausea or abdominal pain raise suspicions of pathology and the patient should be referred to their GP (Derrett 2001).

Patients with any of the following symptoms need to be referred to their GP:

Constipation can frequently be treated successfully with non-pharmalogical methods and this should be the first step in the management of this problem. An increase in dietary fibre and fluid intake, where appropriate, should be considered and implemented. However, this is contraindicated in those patients who are impacted as this might cause bloating and faecal overflow.

Indications for laxatives:

• Pain on defaecation or straining, during illness or pregnancy or after surgery

• Frail elderly patients

• In conjunction with constipating drugs

• Haemorrhoids or anal fissures

• Bowel preparation for a diagnostic procedure (e.g. colonoscopy)

• As part of a treatment for intestinal parasites (Derrett 2001)

A bulk-forming laxative and a stimulant laxative, used individually or in combination, are effective for most clinical situations (Passmore et al.).

Faecal impaction generally requires the use of laxative suppositories or enemas.

It is important that Co-danthramer is discussed with Floella and that this drug is only prescribed for terminally ill patients. The carcinogenic risks of this preparation need to be highlighted, as well as the need for it to be prescribed in consultation with a physician.

If a laxative is prescribed, the following needs to be described to Floella:

• Side effects.

• Drug interactions.

• Contraindications.

• Administration and use of the product i.e. information on when the preparation will produce an effect, whether the product should be taken with extra fluid, at what times the product should be taken.

Ethics

The GP responsible for writing the prescription for Co-danthramer for Floella’s husband has a responsibility to ensure that the prescription is used in accordance with the preparations instructions. The nurse should report back to the GP informing him of the situation. It is important that both Floella and her husband understand why Floella should not take this drug.

Team work

• Inform the GP of the situation.

• Note discussion in patient records.

• Involve Floella’s husband for support e.g. with regard to dietary changes, fluid intake (if appropriate)

Evaluating effectiveness

Follow up by appropriate professional

References

Derrett C. Clinical diagnosis and management for the nurse prescriber. In: Courtenay M (ed.), Current Issues in Nurse Prescribing. London: Greenwich Medical Media, 2001: pp. 55–58

Passmore AP, Wilson-Davies K, Stoker C, Scott ME. Chronic constipation in long stay elderly patients: a comparison of lactulose and a senna-fibre combination. British Medical Journal 1993; 307: 769–771

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• Case 2: Constipation

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• Case 4: Scabies - Aging Skin Changes

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