Pharmacological Management of Constipation and Abdominal Pain in End of Life Care

This assignment focuses upon pharmacological management of a patient in end of life care. The patient is suffering from bowel cancer and has been affected with abdominal pain and constipation. The assignment discusses regarding the various aspects of pharmacological management. Here, emphasis have been placed upon the overall health condition of the patient, as the pharmacological management becomes considerably difficult when the patient is suffering from a number of co-morbid conditions.

Running head: PHARMACOLOGICAL SCIENCE
Pharmacological science
Name of the student
Name of the university
Author’s note

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Table of Contents
Introduction............................................................................................................................2
Synopsis:....................................................................................................................................3
Patient management plan...........................................................................................................4
Assessment of patient condition through clinical reasoning cycle........................................4
Considering the patient situation................................................................................................4
Collection of cues or information..............................................................................................4
Processing of the information....................................................................................................5
Identification of the problems/issues.........................................................................................5
Establishment of goals...............................................................................................................5
Taking action..............................................................................................................................6
Evaluation of outcomes..............................................................................................................6
Critical discussion of pharmacological management of constipation....................................6
Pharmacological management of abdominal pain.................................................................8
Discussion of alternate therapies and procedures....................................................................10
Conclusion............................................................................................................................11
References............................................................................................................................12

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Introduction
The current assignment focuses upon pharmacological management of a patient in
end of life care. The assignment discusses regarding the various aspects of pharmacological
management. Here, emphasis have been placed upon the overall health condition of the
patient, as the pharmacological management becomes considerably difficult when the patient
is suffering from a number of co-morbid conditions. For instance, in case of acute
gastroenterology pain, the medicines may not be effective in management of the patient
condition (Weinberg, Smalley, Heidelbaugh & Sultan, 2014, p.1147). The assignment
focuses upon the removal of strong medicines, which could initiate side effects in the patient
when continued for longer period of time and provision of alternate medication strategies.
However, a number of hindrances are faced over here such as lack of cooperation from the
patient as well as loss of hope of recovery. Some of these may act as discouraging aspects in
the delivery of care.

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Synopsis:
The current study focuses upon the aspect of pharmacological management for an end
of life patient suffering from bowel cancer. Here, JR is an 80 years old female patient
diagnosed with bowel cancer and has been affected with abdominal pain and constipation.
The bowel cancer of JR is at an advanced stage and has been accompanied by a
number of co-morbid conditions such as – urinary tract infection, incontinence of urine and
faecal, constipation, abdominal pain, hypertension and increased anxiety. The rejection to
take chemotherapy can further alleviate the problem. However, she wants to discontinue with
the use of the same and lead a comfortable and pain free life.
Though, the patient has been on chemotherapy along with radiation therapy for a
while.
The abdominal pain and situation of constipation required the patient to use excess
PRN medications. However, it had little therapeutic effect on the patient. Some of the
medicine doses which were administered to the patient over here were endone 5 mg bd;
panadole 500 mg X 2 bds; Movicol one X BD; Oxazepam; atorvastatin. The patient also
reported allergy for keflex, which caused nausea in the patient.
The patient is supported through the crisis by her husband and two children. The
patient also had a past history of smoking which could contributed significantly in the
development of colon cancer in the patient.
Therefore, in order to relieve the patient from the present health situation it was
required that an effective pain control mechanism be designed for the patient. Hence, the
assessment will be mainly upon the control of pain owing to bowel cancer and constipation in
the patient.

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Patient management plan
Identified
problems
Goals and specific outcome
criteria
Patient and nurse practitioner
actions
Time for
follow up
Constipation  Relieve the symptoms of
constipation in the patient
Outcome :
 Patient should show less
dependence upon
laxatives
The nursing professional
should put the patient under an
effective care process where
medicine administration will be
balance with physiotherapy
sessions to normalise the bowel
movements pattern of the patient
JR.
The follow up
should be done
on weekly
basis.
Abdominal
pain
 The pain in the patient to
be controlled with the
help of effective
medication management
 The pain to be measured
with the help of a Braden
scale
Outcome:
 The patient should be able
to report less pain
The patient to be provided with
cognitive behavioural and
therapeutic approaches which
will help the patient develop a
less critical response to pain.
The entire
process to be
followed up on
a weekly basis.
(Source: Author)
Assessment of patient condition through clinical reasoning cycle
In order to administer effective constipation management and pain control treatment
to the patient it was required to access the clinical condition of the patient. For the purpose of
which the clinical reasoning cycle could have been used over here. The clinical reasoning
cycle could be divided into a number of steps a few of them have been discussed over the
following sections.
Considering the patient situation
The patient here had been suffering from bowel cancer and was previously subjected
to chemotherapy and radiation therapy. Additionally, excess use of PRN medications has
been seen to result in additional abdominal discomfort in the patient (Mayer et al., 2015,
p.1915).

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Collection of cues or information
The patient was put on some of the regular medications such as endone 5 mg which
was provided to the patient for effective pain control. The Panadole was also administered to
the patient for effective pain management as the paracetamol helped in the controlling of
pain. The movicol was administered for the management of constipation in the patient. The
patient was also put on anti-anxiety drugs such as oxazepam for the management of anxiety
in the patient. However, as argued by Beaugerien and Itzkowitz (2015, p.1452), excessive
intake of anti-anxiety drugs could have strong impact upon the digestive system by a altering
the HCL secretion capacity of the stomach and produce further negative symptoms in
colorectal cancer. Additionally, higher doses of analgesics could also lead to intestinal
cramping or intestinal contractions.
Processing of the information
The vital signs in the patient could be related to the clinical conditions as follows:
Abdominal pain – the abdominal pain could arise due to bowel incontinence in the patient
Constipation- the constipation or the inability to pass gas or stool could be referred to the
presence of bowel obstruction in the patient.
Identification of the problems/issues
In this respect, the patient had been suffering from bowel cancer which made daily
life difficult for the patient. The patient suffered from incontinence in the passing of bowel
and suffered from incontinence. Due to this, the patient suffered from increased amount of
abdominal pain and had to depend on huge amount of pain killer for controlling her pain.
However, as supported by Cho et al. (2015, p.712), increased uptake of paracetamol could
lead to intestinal coiling in the patient. Some of the most common causes of constipation are
inadequate fluid intake and excessive intake of pain medications (Nalliah et al., 2017, p.139).
However, considering the condition of the patient JR the constipation could be due to
improper bowel movement, which could be again attributed to bowel obstruction.
Establishment of goals
In order to deal with the current health situation of the patient a number of goals could
be designed. Some of which have been represented as follows:

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 The patient to be provided with effective counselling sessions in order to alter or
change the attitude of the patient towards pain which could reduce the feeling of
anxiety towards pain in the patient
 The symptoms as well as the amount of pain faced by the patient to be monitored with
the help of Braden scale.
 The lifestyle and eating patterns of the patient could be closely monitored as the
focus should be to increase the quantity of roughage in the diet of the patient
 The patient need to be moved around more freely as being bound to the bed can
obstruct the faecal movement in the patient further, as the bowel fails to move
effectively through the intestine.
 The entire process to be followed up on a weekly basis.
Taking action
Here the goals would be reduce the pain symptoms in the patient by effective
medication management. Additionally, reducing the dependence on painkiller or increasing
the gap between the administrations of two such doses could be relieving the symptoms of
constipation in the patient.
Evaluation of outcomes
At the end of the assessment the patient should report reduction in pain along with
better expulsion of waste through the body.
Critical discussion of pharmacological management of constipation
In order to discuss regarding the management of constipation though medication it is
necessary to understand the causes and side effects of constipation. Constipation is expressed
in several forms and the symptoms vary from individual to individual (Salvatore et al., 2016,
p.68). These could be explained on the basis of stool frequency, stool form as well as
difficulty with evacuation. Therefore, all these conditions could be described under a
common condition known as irritable bowel syndrome. In majority of the cases, some of the
conditions expressed by the patient are thought to be simply a part of irritable bowel
syndrome. However, as supported by Misale et al. (2015, p.112), the condition could be
much chronic in patient with cancer. As the bowel obstruction makes evacuation difficult for
the patient. Hence, a number of different symptoms are noted in the patient such as

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abdominal cramping and pain in the tummy. In the current study the patient has been seen to
be dependent mainly upon painkillers and analgesics for the controlling of pain. However,
excess dosage of the painkillers has been seen to trigger involuntary contractions in the
stomach wall which could further alleviate the condition of pain within the patient. On the
contrary, bowel obstruction makes normal passage of faeces difficult for the patient. Hence,
the patient has to be dependent upon the external medicine sources for facilitating proper
bowel movements. In this respect, JR was given a range of medications for controlling the
symptoms of constipation and pain. However, none of the medications were found to produce
sufficient relief in the patient. Recently focus has been shifted upon the use of alternate
medicines made out of plant extracts for relieving the symptoms of constipation and
abdominal pain in the patient (Muldrew et al., 2018, p.515). Some of these pharmacological
interventions could be discussed in the present context. The movicol was administered to
relieve the symptoms of constipation in the patient.
However, there are a number of side effects of the administration of movicol such as
bloating of the abdomen, abdominal pain accompanied by a feeling of nausea and vomiting.
Therefore, the patient had to be put on an effective and alternate medication pattern. As
mentioned by Star &Boland (2018, p.13), more emphasis needs to be put on the
administration of herbal medication or laxatives made out of plant extracts as they have
been associated with reduced side effects. The FDA had recently approved the
administration of bulking agents, which are mainly organic polysaccharides and act by
encouraging water retention in the stool (Chua & Nieh, 2017, p.62). Some such herbal
remedies which could have been suggested to JR over here are- Psyllium, Bran,
Methylcellulose, Calcium polycarbophil, stool softeners, ducosate, stimulant laxatives,
osmotic laxatives etc.
Psyllium is the husk of the seed of Planatago ovata, which have shown improved
results in controlling some of the events of faecal impaction (Chang et al., 2017, p.1120). As
reported by Lacy et al. (2016, p.1402), out of the three placebo controlled trials two have
shown improved in evacuation techniques. However as argued by Lacy et al. (2016, p.1402),
the psyllium husk has been seen to take considerably longer amount of time for producing
the desired results. On the other hand bran has been found to be less effective in reduction or
controlling the rate of bowel obstruction. However as argued by Prommer (2015, p.420),
some of these drugs have been found to be ineffective in people with strong faecal impaction.

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As mentioned by Drew, Cao & Chan (2016, p.173), methylcellulose laxatives have been
found to be more effective in people with chronic obstruction.
In this context, the use of dulcolax drops has been particularly useful in relieving the
constipation in the patient. The dulcolax drop helps in stimulates the bowel and helps in the
formation of soft tools. The active ingredient sodium picosulphate has been particularly
beneficial in relieving the symptoms of constipation in the patient. Research has shown that
the drug could be effectively taken by children as well as adult of all age groups on a regular
basis and the rate of side effects have been comparatively less.
Since, some of these drugs have been seen to produce relatively lesser or no side
effect, they have been prescribed in patients with chronic bowel obstruction. However, in the
lack of knowledge regarding the exact medication patterns and doses the pronouncement of
the effect in the patient may not be well understood. A number of clinical studies and trials
have placed importance upon the use of polyethylene glycol derivatives for controlling the
severity of constipation and reducing abdominal pain in the patient(Oczkowski, Duan,
Groen, Warren & Cook, 2017, p.721). As argued by Hofman et al. (2015, p.1778), in 40%
of the cases the administration of PEG has resulted in the occurrence of diarrhoea in bowel
cancer patients.
However, JR had a number of health co-morbidities which made medication
management difficult in the patient. She reported urinary tract infection and faecal impaction,
which made the administration of herbal drugs and curatives difficult for the patient. As
mentioned by Punt, Koopman & Vermeulen (2017, p.235), excessive intake of such dry
husks have been worsen the situation of urine incontinence in the patient with bowel cancer.
Additionally, huge amount of restrictions are faced by the healthcare
professionals with respect to the medication management in end of life care patients. Some of
these barriers are presented due to differential opinions possessed by the patients regarding
certain therapies and medications. The patients who are going though the end of life crisis
find little hope in the treatment methods and procedures which are expressed in the form of
non-cooperation with the medical fraternities, which makes yielding the end result even more
difficult.

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Pharmacological management of abdominal pain
Pain management is medicine branch that deals with the improving the quality of life
as well pain reduction through the effective pharmacological management. Management of
pain is very vital for the patients having cancer because even after undergoing surgery one in
three patients are experiencing pain after treatment. The patients that are affected with the
advanced cancer are most likely to suffer from severe pain. Other than the radiotherapy and
the chemotherapy there are other types of treatment procedures called targeted therapy,
immunotherapy, and surgery (Jamison & Edwards, 2012, p.62).
The targeted therapy for the colorectal cancer is also called the monoclonal antibody
therapy. The bioengineered proteins come from the monoclonal antibodies that help in
increasing the body’s immune system and helps in the identification, destruction, attack and
of the colorectal cancer cells. Monoclonal antibodies therapy can be used alone or in
combination with the other types of therapy like chemotherapy. There are several kinds of
drugs that that help in the treatment of the metastatic colorectal cancer.
 Bevacizumab (Avastin)- this medicine prevents the tumour from further growth by
blocking the growth of the blood vessels in to the tumour cells. This helps in
effectively cutting off the supply of nutrients from reaching the tumour cells.
 Panitumumab (Vectibix)- this medicine targets the epidermal growth factor receptor
and thus effectively preventing the signals from moving inside the colorectal cancer
cells. this medicine thus effectively prevents the growth and division (Hagan, Orr &
Doyle, 2013, p.3).
 Cetuximab (Erbitux)- this medicine works by attaching to a protein called the
epidermal growth factor receptor, as this cell exits on the surface of the cells. This
type of therapy prevents the signals from reaching the colorectal cancer cells, which
further prevents the cells growth and division (Farzaei, M. H., Bahramsoltani, R.,
Abdollahi, M., & Rahimi, 2014, p.558).
 The other types of the drug used for the targeted therapy are the Zaltrap, Stivarga.
These medicines also cut off the blood supply and prevents the signal passage
respectively (Hagan, Orr & Doyle, 2013).
Immunotherapy, for the treatment of the colorectal cancer is made for the purpose of
enhancing the body’s immune system and recognize, attack and finally kill them. Checkpoint
inhibitors can be used to for the disruption of the signalling receptors that cleverly disguise

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the cancer cells from the immune system. There is a drug called the pembrolizumab
(Keytruda) and it is used to treat the patients with metastatic colorectal tumour that is in
inoperable condition. Such patients also have genetic features called the mismatch repair
deficiency or microsatellite instability-high. This defect has been in 90 percent of the patients
along with the patients that have lynch syndrome. The immune therapy helps in the treatment
of the patients and the responses sometimes vary (Lynch & Murphy, 2016, p.72).
Surgery for the colorectal cancer treatment is one most common form. The surgery
involves the removal of the tumours and also the section of the colon in which the tumour is
found (Rajapakse, Liossi & Howard, 2014, p.175). Sometimes it becomes necessary to
remove the entire colon along with the healthy intestine and the lymph nodes. The patients
that undergo the surgery receive the radiation therapy or chemotherapy before or after the
surgery procedures (Peters, Muir & Gibson, 2014, p.1170). These therapies altogether can
shrink the tumour and are effectively used to target the tumour cells that are left even after
the surgery (Lee et al., 2017, p.206).
A randomized control trial was conducted to using the different types of the drugs
available for the treatment of the colorectal cancer. It was found that the treatment procedure
of utilizing the drugs is found to be much more effective for the overall survival of the
patients and in leading a disease free life (Akhtar et al., 2014, p.177). In case all other
methods of treatment fail Targin 5/2.5 mf tablets could be suggested to the patient. It is
mainly suggested in case of chronic pain when other medication therapies have failed to
reduce the pain. The slow release of oxycodone and naloxone has been effective in
controlling the acute pain. As mentioned Star & Boland (2018, p.15), the slow release ensures
that the patient can combat with the consequence of drug overdose.
Discussion of alternate therapies and procedures
A number of alternate procedures and therapies could be suggested for coping with
the deteriorating health condition of JR. JR had been bound to bed and at the progressive
stage of bowel cancer. Her physical conditions provided her with little scope to spend time
with her family. Additionally, the lack of hope and positivity to recover fully further affected
the mental well being of JR. Therefore, apart from the medication and remedies which were
provided to her she could have been put into effective counselling sessions. As mentioned by

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Chua & Nieh (2016, p.62), the counselling sessions were supposed to restore faith and
positivity in the patient.
Additionally, implementing effective physiotherapies in the daily care routine of the
patient can facilitate effective movements of bowel (Chang, Lembo & Sultan, 2014, p.1170).
However as supported by Afrin et al. (2012, p.169), in the end of life palliative care it is
more important to focus upon reduction of the pain in the patient with bowel cancer and
provide them with a holistic and positive care regimen. Therefore, apart from
pharmacological interventions focussing upon the diet of the patient and including more
roughage in the diet of the patient can help in the elimination of waste from the body (Akhtar,
Chandel, Sarotra & Medhi, 2014, p.177).
Conclusion
The assignment argues regarding the various clinical and pharmacological aspects for
the end of life palliative care. However, the pharmacological intervention and methods have
been found to be associated with a number of limitations. Some of these limitations are
offered due to lack of resources as well as insufficient cooperation from the participants. In
this respect, a number of alternate medication strategies and procedures have also been
highlighted over here. For example, maintaining the diet of the patient in an effective manner
by incorporation of more roughage implementing more effective counselling sessions for the
patient. This can help in generating the hope of survival in the patient based upon which the
patient show better responses to the altered medicines. Additionally, a number of clinical
conditions of the patient needs to be taken into consideration before changing of the
medication doses as changing the medicines in case of co-morbid health conditions may
illicit strong responses.

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