Download medicines adminstered under protocol

GROUP PROTOCOL FOR THE MANAGEMENT
OF CONSTIPATION IN PATIENTS IN CLOZAPINE CLINICS
Version 1
RATIFYING COMMITTEE
DATE RATIFIED
MAUP EXPIRES
EXECUTIVE SPONSOR
LEAD AUTHOR
Drugs and Therapeutics Group
29th October2014
October 2017
Executive Medical Director
Ray Lyon – Chief Pharmacist - Strategy
KEY POLICY ISSUES:



Key indication for the use of senna in clozapine clinics
What follow up is needed in the community
Staff eligible to work under the protocol
If you require this document in an alternative format, ie easy
read, large text, audio, Braille or a community language
please contact the Pharmacy Team on 01243 623349.
GROUP PROTOCOL FOR THE MANAGEMENT
OF CONSTIPATION IN CLOZAPINE CLINICS
Version:
1 – October 2014
Group Protocol drawn up by:
Name
Title
Jermine Clarke
Clozapine Clinic Nurse
Lesley Ball
Clozapine Clinic Nurse
Zo Payne
Practice Development Nurse
Ray Lyon
Chief Pharmacist - Strategy
Group Protocol authorised by:
(on behalf of the Trust).
Executive Medical Director
Tim Ojo
Executive Director of Nursing
Helen Greatorex
Chief Pharmacist
Ray Lyon
Appointed Practitioner in Charge
(on behalf of the ward)
Date Protocol agreed
October 2014
Proposed review date
October 2017
Date Protocol expires
October 2017
This protocol relates to the clozapine clinic at:
GROUP PROTOCOL FOR THE MANAGEMENT OF
CONSTIPATION IN PATIENTS IN CLOZAPINE CLINICS
1. CLINICAL CONDITION
1.1
Clinical condition
Passage of hard stools less frequently than the patient’s own normal
pattern. General information about constipation and how it can be treated, and
its more serious complications can be found here:
http://www.nhs.uk/Conditions/Constipation/Pages/introduction.aspx
1.2
Inclusion Criteria

Patients on clozapine.

Patients with symptoms of constipation.

The patient can swallow tablets
Checklist for constipation

Patient reports no bowel action for 2 – 3 days or passage of painful, hard
stools/need to strain.

Patient reported signs of constipation such as straining on defecation, abdominal
distension, discomfort and feelings of incomplete evacuation.

Patient reports of faecal incontinence (the leakage of liquid stools)

Observed signs of constipation such as flatulence, faecal odour, abdominal
distension, increased bowel sounds, visible peristalsis, pain, faecal smelling
breath and vomiting.

Patient reported signs of chest infection such as difficulty breathing, cough,
sputum production, coughing up blood, respiratory distress, wheeze, use of
accessory muscles or cyanosis. See exclusion criteria below.

In addition to this the patient may also have a raised temperature.
1.3
Exclusion Criteria

Patients not on clozapine.

The patient cannot swallow tablets.

Patient reporting signs of chest infection, (because constipation can rarely cause
pneumonia). See checklist above.

Patient already taking a stimulant laxative.
1.4

Known sensitivity to senna.

Known history of intestinal obstruction and/or current significant abdominal pain
with abdominal distension and/or vomiting and absence of flatulence.

Senokot (senna) syrup, for diabetic patients (due to sugar content).

Patients with a history of laxative abuse.

Patients under 18 years of age.
Action to be taken if patient is excluded from treatment under protocol
Immediately contact GP (or GP on-call service out of hours) if there are signs of
chest infection
otherwise
Consult with the patient’s GP 9.00 am – 5.00 pm Monday to Friday.
Provide advice regarding high fibre diet, increasing fluid intake and increasing
exercise if appropriate.
1.5
Action to be taken if patient refuses treatment under protocol
Provide advice regarding high fibre diet, increasing fluid intake and increasing
exercise if appropriate. Inform the care coordinator and ask them to discuss with
the patient’s GP if problem continues.
2. STAFF AND LOCATION
2.1
Location
Clozapine clinics trustwide.
2.2
Staff
Qualified nursing staff that have been signed off as competent by the Appointed
Practitioner in Charge of the clozapine clinic, following training and successful
completion of the 'Key Aspects of Pharmacy' questionnaire for senna.
2.3
Continued Training Requirements.
Not required unless changes to protocol
3
TREATMENT
3.1
Name of medicine
Senna or Senokot®
3.2
Legal status (POM, P or GSL)
GSL (General sales list)
3.3
Dose or dose range and criteria for determining dose
1 – 2 tablets daily, preferably given at night. Recommend the patient takes
2 tablets unless patient’s normal regime specifies otherwise or particularly strong
effect of higher dose previously.
3.4
Method of route of administration
Oral
3.5
Frequency of administration
Only to be given once daily (maximum dose).
3.6
Quantity to supply
Supply one bottle of two tablets and recommend the patient takes the
recommended dose at bedtime. If the dose recommended is one, the patient
should be advised to destroy the unwanted tablet by flushing it down the toilet.
3.7
Follow-up treatment

Document the supply of senna in the patient’s electronic record.

Inform the patient’s consultant or deputy that the patient has constipation and
a dose of senna has been supplied and the care coordinator asked to follow
up the patient initially.

Contact the patient’s care co-ordinator to:
o Inform them that senna has been supplied.
o Ask them to confirm with the patient whether they had a bowel
movement.
o Ask them to reinforce the advice regarding; diet, fluid intake etc. (as
above).
o Ask them to encourage the patient to see their GP if the problem is not
resolved.

Document the conversation with the care coordinator.

Inform the GP that senna has been supplied and that the care coordinator will
be following up the patient initially.

3.8
Reinforce the advice regarding: diet, fluid intake and exercise on a regular
basis.
Side effects and potential drug interactions
May cause abdominal cramp.
3.8
3.9
Instruction on identifying and managing possible adverse outcomes

Ask the care coordinator to follow up and report back any adverse effects.

Ask the care coordinator to discuss any adverse effects with the patient’s GP
and record this in the patient’s electronic record.
Arrangement for referral for urgent medical advice

Contact the patient’s GP in normal working hours

Contact the on call GP service outside working hours.
4.
INFORMATION AND DOCUMENTATION
4.1
Advice (including written advice) to be given to patient or carer before or after
treatment. A letter explaining this information is attached with this protocol.
4.2

Verbal instruction of drug being administered.

Advise that urine may become cloudy/discoloured.

Advise that senna usually takes up to 8 – 12 hours to have effect.

Advise the patient or carer to inform the care co-ordinator of any bowel action
or abdominal pain when contacted.

Provide patient information leaflet on ‘constipation’.
Details of treatment records required.

Record entry in case notes. This should record the presence of constipation,
and senna supplied in line with MAUP (or equivalent statement).

Record discussion with the care coordinator and any other healthcare
professional if appropriate.
5.
MANAGEMENT AND MONITORING
5.1
Advisory group approving the protocol

Drugs and Therapeutics Group
5.2
Lines of accountability
Clinic manager
Clinical Service Managers.
5.3
Method to report any adverse drug reactions to the doctor
Communicate with the patient’s GP and the clozapine clinic.
5.4
Audit Arrangements
Clinical audit.
5.5
Review Date and by Whom
Every three years by the Drugs and Therapeutics Group or earlier if significant
new evidence on senna use is made available.
6.
Staff authorized to work under the Group Protocol
I have read the group protocol and agree to use it: -
Nurses agreeing to and
authorized to work under the
protocol
Name
Signature
Appointed Practitioner in
Charge assessing competence
Name
Signature
Date
KEY ASPECTS OF PHARMACY QUESTIONNAIRE
(To be completed without access to the Protocol or drug text books, eg BNF.)
Key aspects of pharmacy for Senna
Professional's name:
Grade:
1.
Symptoms/criteria under which the patient will be eligible for treatment under the Protocol
2.
Forms and strengths available
3.
Mode of action
4.
Exclusion
criteria
5.
Dose
7.
What potentially significant side effects and drug interactions are there?
8.
What written/verbal advice must be given to the patient/carer on the identification and
management of significant potential side effects?
6.
Route of administration
I confirm that at the time of completion the answers provided showed an acceptable level
knowledge.
Name:
Signature:
Designation:
Date:
Constipation
Constipation is the term used to describe difficulty going to the toilet or opening the
bowels. We probably all suffer from this for short periods during our lives, but for some
it becomes a chronic or recurrent problem.
What is normal?
Some people would regard it as normal to open their bowels three or four times a day,
while for others normality would be once a week. Certainly, the human body can
function quite well at either extreme, but most people probably open their bowels
every day or every couple of days. It is wise not to get obsessed by the need to open
the bowels daily, but if you experience a change of bowel habit that persists then you
should seek the advice of your doctor.
Cause
Change of diet or dehydration and a change of daily schedule may lead to
constipation. Certain medications, especially clozapine and some pain killers may lead
to problems. Sometimes the cause is a bowel disorder, but this is the exception, rather
than the rule.
General Background
Over recent years it has become apparent that people who eat more fibre are less
prone to various bowel diseases and also are likely to be healthier in other ways. Fibre
tends to diminish transit time (ie the length of time it takes for something that is eaten
to pass right through the system) and thus reduce constipation. Funnily enough, if you
take more fibre it will tend to normalise bowel habit, and may well cut down the
frequency of motions in somebody tending towards diarrhoea.
In general it is wise to eat small meals often and plenty of fresh fruit and vegetables,
as well as having plenty to drink (one and a half to three litres of fluid daily). Foods
containing fibre include brown rice, wholemeal pasta, wholemeal/brown bread,
potatoes with their jackets, etc. It is also wise to take regular exercise or at least
remain active. You should not make a habit of putting off the "call of nature", as this
can make the body's natural functions more sluggish.
If you require this document in an alternative format, i.e.
easy read, large text, audio, Braille or a community
language please contact the Pharmacy Team on 01243
623349.
Treatment
Sometimes people become so constipated that they or their doctor feel that other
action is required. There are various medicines/tablets to help constipation (laxatives):



Fibre supplements, which come as powder, which makes up a small drink,
granules, tablets containing bran or indeed raw bran.
Osmotic laxatives, which act by drawing more fluid into the bowel.
Irritative preparations which tend to introduce contractions of the bowel eg
Senna.
You may need to use one or more of these together.
October 2014
Insert address
Dear Dr (insert GP Name)
On (insert date) a patient from your practice (insert patient name, address Dob and NHS
Number) presented with the following symptoms of constipation (delete as applicable)






Patient reported no bowel action for 2 – 3 days or passage of painful, hard stools/need
to strain.
Patient reported signs of constipation such as straining on defecation, abdominal
distension, discomfort and feelings of incomplete evacuation.
Patient reported faecal incontinence (the leakage of liquid stools)
Observed signs of constipation such as flatulence, faecal odour, abdominal distension,
increased bowel sounds, visible peristalsis, pain, faecal smelling breath and vomiting.
Patient reported signs of a chest infection such difficulty breathing, cough, sputum
production, coughing up blood, respiratory distress, wheeze, use of accessory muscles
or cyanosis.
Patient had a raised temperature.
As part of our protocol for management of constipation, the patient was given (insert senna
dose) and advised to






Contact the GP surgery to make an appointment discuss this.
Eat small meals often and plenty of fresh fruit and vegetables.
Have plenty to drink (one and a half to three litres of fluid daily).
Eat more foods containing fibre, including brown rice, wholemeal pasta,
wholemeal/brown bread and potatoes with their jackets left on.
Take regular exercise or at least remain active.
Not make a habit of putting off the "call of nature.
The patient’s consultant psychiatrist has been notified. Please contact (insert name and
contact number) if you would like further information
Yours Sincerely