Page 139 - ACCCN's Critical Care Nursing

116 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

which helps to maintain gut motility. Chapter 19 con-
tains an in-depth discussion on the principles of enteral Practice tip
feeding.
If a rectal tube is considered necessary, then use of a commer-
Drugs cial product consisting of a specific rectal tube and drainage
system is advised, rather than an ‘adapted version’, which may
The use of sedatives is often an ascribed cause of constipa-
tion in critically ill patients. This is not due to their direct inadvertently cause damage.
effect, but due to the subsequent immobility of patients
when sedatives are used. Opiates, which are often used
to control pain, slow propulsive gut contraction. The Practice tip
main drugs that cause constipation in critical care settings
are analgesics, anaesthetic agents, anticonvulsants, diuret- When undertaking bowel assessment you should also consider
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ics and calcium channel blockers. While it is difficult the patient’s normal diet and any laxatives routinely taken, as
to avoid giving these drugs, their judicious use in this information may influence any bowel regimen developed
tandem with other preventive measures will help for the patient.
avoid constipation.

Constipation URINARY CATHETER CARE
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Although there is no consensus, constipation may be Urinary catheters are inserted into most critically ill
defined in general as decreased frequency of defecation patients, and are the commonest cause of infection in the
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or bowel movements, with a hard, dry stool. Non- ICU. In principle, urinary catheters should be inserted
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pharmacological methods to reduce constipation include only when deemed clinically necessary, and should be
exercise or moving, increasing fluid intake, and adding removed as soon as they are no longer required clinically.
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dietary fibre. These means should be implemented rou- However, most critically ill patients require accurate moni-
tinely before the need to use laxatives arises. There are toring of their urinary output and fluid balance, and a
many types of laxatives available, which can be given to catheter is required for this reason. There are a number of
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prevent or treat constipation. Bulk-forming agents work possible alternatives to urinary catheterisation, such as
by increasing faecal size; stimulants, such as senna, intermittent catheterisation, suprapubic catheterisation,
increase peristalsis; and osmotic agents draw fluid into use of a male/female urinal or penile sheath and/or incon-
the gut. Stimulant laxatives should not be given with tinence pads, although often these are not suitable for
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faecal impaction, which should be treated using enemas. critically ill patients. Because the practice of urinary cathe-
In general, existing protocols advise that treatment of terisation is so common, catheter care can sometimes be
constipation should commence with senna administra- relegated to a low priority. The consequences of inadequate
tion. If senna is ineffective after 2–3 days, lactulose should catheter care can be distressing and detrimental to the
be commenced. 91,92,96 patient, resulting in inflammation, infection and injury.
Diarrhoea ASSESSMENT: URINARY CATHETERISATION

Diarrhoea can be a major problem for intensive care Following assessment indicating that a urinary catheter is
patients, and in severe cases may lead to electrolyte imbal- required, its size and type should be determined. In addi-
ances, dehydration, malnutrition (see also Chapter 19) tion to their primary purpose of urine drainage, urinary
and skin breakdown. Furthermore, it can be very distress- catheters may be used to monitor temperature and assess
ing for the patient, who may also suffer from distension, intra-abdominal pressure which may affect catheter
nausea and cramp-like pain. Investigations should be choice. Catheters are made from several different types of
implemented to determine the cause of the diarrhoea and material, which have varying properties, and the choice
the patient should be managed with appropriate precau- of catheter often depends on an estimation of how long
tions to prevent cross contamination if the cause is infec- it will be required. Catheters are classified as either short-
tious. If laxatives are being given they should be stopped, or long-term. Short-term catheters should be changed
and a stool specimen should be obtained for microbio- after 14–28 days, according to the manufacturer’s guide-
logical examination. Antimotility drugs may be used, lines, whereas long-term catheters may be left in place
except with bloody diarrhoea or proven infection with E. for up to 12 weeks. The minimum length of a male
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Coli. 96,100 Appropriate re-hydration should be imple- catheter is 380 mm, and for a female it is 220 mm. 106
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mented. If patients are being fed enterally there may be
a reduction in episodes of diarrhoea if fibre-enriched feed The general rule is to use the smallest size necessary that
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is used. Fecal containment devices should be used in will drain the contents of the bladder, although narrow-
severe cases of diarrhoea in conjunction with all other bore tubes flex easily, which can be problematic in male
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measures to support the patient’s comfort. The patient catheterisation where the urethra rounds the prostate
should be assessed for suitability for using the inconti- gland. Larger-diameter catheters may be required to drain
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nence system as per the manufacturer’s guidelines. An haematuria and clots. All procedures involving the
appropriate bowel therapy regimen and monitoring of catheter and drainage system should be documented in
these systems should be implemented to optimise the clinical notes, including size and type of catheter,
functioning. balloon size and the date of insertion.