臺灣博碩士論文加值系統

疼痛是癌症病人中最常見的症狀，約有80%的癌症病人需使用鴉片類止痛劑來控制疼痛。其中，嗎啡是治療重度癌症疼痛有效的首選方式，但是卻也伴隨許多副作用，其中以便祕最為常見，約有25-50%的發生率，也因此降低病人生活品質。由先導研究中發現體表給予冷刺激可以調整正常人之腸胃蠕動功能，因此，本研究旨在探討腹部冰敷對癌末病人因使用嗎啡導致便祕者之症狀、腸蠕動、焦慮和生活品質之作用。
本研究針對安寧病房中癌症末期病人因使用嗎啡導致便祕者，將其隨機分配為對照組(接受一般常規照護)及實驗組(接受一般常規照護外及腹部冰敷)，比較其接受介入措施前後各項指標之評值結果。完成第一天前測資料共有29位個案，最後完成所有問卷個案共15位。在二組基本資料無顯著差異的同質性基礎下，比較後得到下述結果。首先，以 PAC-SYM評估便祕症狀及其嚴重度，經統計發現實驗組之PAC-SYM整體分數有顯著降低，顯示其症狀嚴重度有改善(p=.000)；其次，客觀性測量腸蠕動次數，發現實驗組之腸蠕動次數有顯著增加，且改變率高達87% (p=.039)；再者，以醫院焦慮憂鬱量表(HADS)評估受試者焦慮和憂鬱情形，發現腹部冰敷明顯改善其焦慮情形(p=.010)，但對憂鬱情形則無作用(p=.153)，最後，使用便祕生活品質量表(PAC-QOL)測量受試者與便祕相關之生活品質，發現腹部冰敷顯著改善受試者之便祕整體生活品質(p =.002)，其中包括生理不適、心理不適、擔心和關注及滿意度之分項指標，皆達統計上明顯之改善(p =.001、p =.004、 p =.026、 p =.038)。
綜言之，腹部冰敷這項非侵入性護理措施，對安寧病房癌症末期病人因使用嗎啡導致便祕者，可明顯改善其症狀嚴重度、腸蠕動次數、焦慮情形及便祕整體生活品質。

Pain is the most common symptom of cancer patients, causing approximate 80% patients in a need of narcotics for pain control. Among these narcotics, morphine is the treatment of choice for severe cancer-related pain. However, the use of morphine usually accompanies with many adverse effects, including the most common one, constipation. Morphine-induced constipation (MIC) develops in 25 – 50% patients receiving morphine and attenuates their quality of life (QOL). Our preliminary study demonstrated that abdominal ice packing (AIP) could adjust bowel movement in normal subjects. The present study aimed to evaluate the effect of AIP on MIC in terms of severity of constipation-related symptoms, bowel movement, anxiety, depression and QOL.
End-stage cancer patients with MIC under hospice care were enrolled and randomized to control (receiving routine nursing care) and experimental (receiving routine nursing care plus AIP) groups. Twenty nine patients performed pre-test at day 1 and fifteen patients completed all the assays. All the end points between two groups were compared upon the basis of homogeneity in characteristics of subjects. The severity of constipation-related symptoms assessed by Patient Assessment of Constipation Symptoms (PAC-SYM) in experimental group was less than the controls (p =.000). Measurement of bowel movement by using stethoscope showed a marked increase, up to 87% increment, in experimental group (p =.039 ). Performance of AIP improved the state of anxiety (p =.010), but not depression (p =.153) via assessment with The Hospital Anxiety and Depression Scale (HADS). Furthermore, through the use of Patient Assessment of Constipation Quality of Life (PAC-QOL), we found that AIP significantly improved the QOL of these MIC patients in terms of total score (p =.002), physical discomfort (p =.001), psychosocial discomfort (p =.004), worries and concerns (p =.026), as well as satisfaction (p =.038).
In conclusion, AIP, a non-invasive nursing management, could improve the severity of constipation-related symptoms, bowel movement, anxiety and QOL in end-stage cancer patients with MIC during hospice care.

目 錄
指導教授推薦書…………………………………………………………………
口試委員會審定書………………………………………………………………
授權書……………………………………………………………………………
誌謝………………………………………………………………………………iv
中文摘要…………………………………………………………………………vi
英文摘要…………………………………………………………………………viii
目錄………………………………………………………………………………ix
第一章 緒論……………………………………………………………………1
1.1 研究背景與動機………………………………………………………1
1.2 研究目的………………………………………………………………8
1.3 研究問題………………………………………………………………8
1.4 名詞界定………………………………………………………………9
第二章 文獻查證………………………………………………………………11
2.1 便祕之相關文獻………………………………………………………11
2.2 鴉片類藥物與便祕之探討……………………………………………15
2.3 嗎啡引起便祕之處置…………………………………………………20
2.4 溫度與腸胃蠕動及排便之關係………………………………………34
第三章 研究方法………………………………………………………………37
3.1 研究設計………………………………………………………………37
3.2 研究架構………………………………………………………………38
3.3 研究場所、對象………………………………………………………44
3.4 研究工具………………………………………………………………45
3.5 倫理上的考量…………………………………………………………49
3.6 資料收集過程…………………………………………………………50
3.7 介入措施………………………………………………………………53
3.8 資料處理與分析………………………………………………………53
第四章 研究結果………………………………………………………………57
4.1 研究對象基本資料……………………………………………………57
4.2 研究對象的便祕情形…………………………………………………67
4.3 研究對象的焦慮憂鬱情形……………………………………………77
4.4 研究對象的便祕生活品質情形………………………………………86
第五章 討論……………………………………………………………………104
5.1 介入措施對使用嗎啡癌末病人便祕狀況及腸蠕動的影響…………106
5.2 介入措施對使用嗎啡癌末病人焦慮憂鬱的影響……………………109
5.3 腹部冰敷對對使用嗎啡癌末病人便祕生活品質的影響……………110
第六章 結論與建議……………………………………………………………113
6.1 結論……………………………………………………………………113
6.2 研究建議………………………………………………………………114
6.3 研究限制………………………………………………………………116
參考文獻………………………………………………………………………… 119
附錄……………………………………………………………………………… 133
附錄一 基本資料表…………………………………………………………… 134
附錄二 藥物排便記錄表……………………………………………………… 135
附錄三 醫院焦慮憂鬱量表…………………………………………………… 137
附錄四 病人便祕症狀評估問卷……………………………………………… 139
附錄五 病人便祕生活品質評估問卷………………………………………… 140
附錄六Bristol糞便性質量表……………………………………………… 143

參考文獻
行政院衛生署(2005) •死因統計結果摘要衛生統計資訊網 • 2006年11月30日，取自http://www.goh.gov.tw/statistic/index,htm
邱淑玲、謝佩玲（2001）• 實用基本護理學（下冊）• 於蘇麗智總校閱，冷熱運用與護理（四版，1-15頁）• 台北：華杏。
林榮志、林佩儒、葉怡君（2006） • 以經穴按壓觀察對老人排便情形影響之初步探討• 中華推拿與現代康復科學雜誌，3（1），39-56。
陳麗麗、王純娟、蔡秀珠（1998）• 穴位按摩法對剖腹產後促進腸蠕動療效之初探• 護理研究，6(6)，526-534。
姚建安、邱泰源、陳慶餘（2002）• 嗎啡藥物動力學臨床應用• 安寧療護，7（3），213-223。
姚建安（2002）• 緩和醫療住院癌末病人主要家屬照顧者的需求重要性與滿意度的初探性研究• 未發表的碩士論文，台北：國立台灣大學預防醫學研究所。
陳玉黛、張元玫、白其卉（2006） • 穴位按壓應用於神經科便祕病患之成效初探• 實證護理，2（4），301-310。
陳蕙雅、許維邦、陳民虹（2007）• 吩坦尼貼片在癌症病患的正確使用• 基層醫學，22(8)，284-289。
陳雅惠、黃文泉（2000）•不同冷療療程對皮膚血流和皮膚溫度之影響• 大專體育，50，44-54。
葉麗雪（2006）• 腹部穴位刺激對改善護理之家老人便祕知先導試驗• 未發表的碩士論文，台中：中山醫學大學醫學研究所。
蔡振茂、陳淑珍（2003）• 便祕之中醫治療 • 中國中醫臨床醫學雜誌，9(4)，27-31。
蕭伃伶（2001）• 簡明基本護理學-原理與技術（下冊）• 於盧美秀總校閱，冷熱運用與護理（三版，650-663頁）• 台北：匯華。
《金匱要略•五臟風寒積聚病脈證並治》金匱要略 - 東漢 張仲景所著
《難經•五十五難》 難經 - 春秋戰國 扁鵲 所著
《醫宗必讀．積聚》醫宗必讀 - 明 李中梓 所著
Allan, L., Hays, H., Jensen, N.H., de Waroux, B.L., Bolt, M., Donald, R., & Kalso, E. (2001). Randomised crossover trial of transdermal fentanyl and sustained release oral morphine for treating chronic non-cancer pain. BMJ (Clinical research ed.), 322(7295), 1154-1158.
Annells, M., & Koch, T. (2003). Constipation and the preached trio: Diet, fluid intake, exercise. International Journal of Nursing Studies, 40(8), 843-852.
Arce, D. A., Ermocilla, C. A., & Costa, H. (2002). Evaluation of constipation. American Family Physician, 65(11), 2283-2290.
Avila, J.G. (2004). Pharmacologic Treatment of Constipation in Cancer
Patients. Cancer control : Journal of the Moffitt Cancer Center ,11(3 Suppl), 10-18.
Bennet, M., & Cresswell, H. (2003). Factors influencing constipation in advanced cancer patients: A prospective study of opioid dose, dantron dose and physical functioning. Palliative Medicine, 17, 418-422.


Bell, T.J., Panchal, S.J., Miaskowski, C., Bolge, S.C., Milanova, T., & Williamson, R. (2009). The prevalence, severity, and impact of opioid-induced bowel dysfunction: results of a US and European Patient Survey (PROBE 1). Pain Medicine, 10(1), 35-42.
Bisanz, A. (2007). Chronic constipation. The American Journal of Nursing, 107(4). 72B-72H.
Borum, M. L. (2001). Constipation: evaluation and management. Primary Care, 28(3), 577-90.
Brownstein, M.J. (1993). A brief history of opiates, opioid peptides, and opioid receptors. Proceedings of the National Academy of Sciences of the United States of America, 90(12), 5391-5393.
Cameron, J. C. (1992). Constipation related to narcotic therapy. A protocol for nurses and patients. Cancer nursing, 15(5), 372-377.
Chaturvedi, S. K., Maguire, G. P., & Somashekar, B. S.(2006). Somatization in cancer. International Review of Psychiatry, 18(1), 49-54.
Chen, L. L., Hsu, S. F., Wang, M. H., & Chen, C. L. (2003). Use of acupressure to improve gastrointestinal motility in women after trans abdominal hysterectomy. The American Journal of Chinese Medicine, 31(5), 781-790.
Cherny, N., Ripamonti, C., Pereira, J., Davis, C., Fallon, M., McQuay, H., Mercadante, S., Pasternak, G., & Ventafridda, V. (2001). Strategies to manage the adverse effects of oral morphine: An evidence-based report. Journal of Clinical Oncology, 19(9), 2542-2554.


Choi, Y. S., & Billings, J. A. (2002). Opioid antagonists: A review of their role in palliative care, focusing on use in opioid-related constipation. Journal of Pain and Symptom Management, 24(1), 71-91.
Dalal, S., Fabbro, E. D., & Bruera, E. (2006). Symptom control in palliative care- part I: oncology as a paradigmatic example. Journal of Palliative Medicine, 9(2), 390-408.
De Luca, A., & Coupar, I. M. (1996). Insights into opioid action in the intestinal tract. Pharmacology & Therapeutics, 69(2), 103-115.
Dennison, C., Prasad, M., Lloyd, A., Bhattacharyya, S. K., Dhawan, R., & Coyne, K. (2005). The health-related quality of life and economic burden of constipation. Pharmacoeconomics, 23(5), 461-476.
De Schepper, H. U., Cremonini, F., Park, M. I., & Camilleri, M. (2004). Opioids and the gut: Pharmacology and current clinical experience. Neurogastroenterology and Motility, 16(4), 383-394.
Dowlatshahi, K., Evander, A., Walther, B., & Skinner, D. B. (1985). Influence of morphine on the distal oesophagus and the lower oesophageal sphincter--a manometric study. Gut, 26(8), 802-806.
Dosh, S.A. (2002). Evaluation and treatment of constipation. The Journal of Family Practice, 51(6), 555-559.
Drossman, D.A. (2006). The functional gastrointestinal disorders and the Rome III process. Gastroenterology, 130(5), 1377-1390.
El Ouazzani, T., & Mei, N. (1979). Vagal thermoreceptors in the gastro-intestinal area. Their role in the regulation of the digestive motility. Experimental brain research. Experimentelle Hirnforschung. Expérimentation cérébrale, 34(3), 419-434.

Fallon, M., & O'Neill, B. (1997). ABC of palliative care-constipation and diarrhea. British Medical Journal,315(7118), 1293-1296.
Fielding, H., Kyaterekera, N., Skellern, G.G., Tettey, J. N., McDade, J. R., Msuya, Z., et al. (2000). The compatibility and stability of octreotide acetate in the presence of diamorphine hydrochloride in polypropylene syringes. Palliative Medicine,14(3), 205-207.
Frank, L., Kleinman, L., Farup, C., Taylor, L, & Miner, P. Jr. (1999). Psychometric validation of a constipation symptom assessment questionnaire. Scandinavian Journal of Gastroenterology, 34,870-877.
Friedman, J.D., & Dello Buono, F.A. (2001). Opioid antagonists in the treatment of opioid-induced constipation and pruritus. The Annals of Pharmacotherapy, 35(1), 85-91.
Gail, W. S. (2005). Handbook of Psychiatric Nursing 6th edition. St. Louis: Mosby.
Glia, A., & Lindberg, G. (1997). Quality of life in patients with different types of functional constipation. Scandinavian Journal of Gastroenterology,32(11), 1083-1089.
Goldstein, A., & Naidu, A. (1989). Multiple opioid receptors: ligand selectivity profiles and binding site signatures. Molecular Pharmacology,36(2), 265-272.
Goodman, M., & Wilkinson, S. (2005). Constipation management in palliative care: a survey of practices in the United Kingdom. Journal of Pain and Symptom Management, 29, 238-244.
Grotz, R. L., Pemberton, J. H., Talley, N. J., Rath, D. M., & Zinsmeister, A. R.(1994). Discriminant value of psychological distress, symptom profiles, and segmental colonic dysfunction in outpatients with severe idiopathic constipation. Gut, 35(6), 798-802.
Grov, E. K., Dahl, A. A., Moum, T., & Fosså, S. D. (2005). Anxiety, depression, and quality of life in caregivers of patients with cancer in late palliative phase. Annals of oncology,16(7), 1185-1191.
Hanks, G.W., de Conno, F., Cherny, N., Hanna, M., Kalso, E., McQuay, H.J et al. (2001). Morphine and alternative opioids in cancer pain: the EAPC recommendations. British Journal of Cancer, 84(5), 587-593.
Harari, D., Norton, C., Lockwood, L, & Swift, C. (2004). Treatment of constipation and fecal incontinence in stroke patients: randomized controlled trial. Stroke,35(11), 2549-2555.
Hawley,P. H., & Byeon, J. J. (2008). A comparison of sennosides-based bowel protocols with and without docusate in hospitalized patients with cancer. Journal of Palliative Medicine, 11(4), 575-581.
Herndon, C. M., Jackson II, K. C., & Hallin, P. A. (2002). Management of opioid-induced gastrointestinal effects in patients receiving palliative care. Pharmacotherapy, 22(2), 240-250.
Heitkemper, M., & Wolff, J. (2007). Challenges in chronic constipation management. The Nurse Practitioner, 32(4), 36-42; quiz 42-3.
Hung, T. T., Mykletun, A., & Dahl, A. A. (2002). Are anxiety and depression related to gastrointestinal symptoms in the general population. Scandinavian Journal of Gastroenterology, 37, 294-298.
Holzer, P. (2007). Treatment of opioid-induced gut dysfunction. Expert Opinion on Investigational Drugs, 16(2), 181-194.
Johnson, D. A. (2006). Treating chronic constipation: how should we interpret the recommendations. Clinical DrugInvestigation, 26(10), 547-557.
Kaufman, P. N., Krevsky, B., Malmud, L. S., Maurer, A. H., Somers, M. B., Siegel, J. A. et al. (1988). Role of opiate receptors in the regulation of colonic transit. Gastroenterology, 94(6), 1351-1356.
Kirkham, S.R., & Abel, J. (1997). Placebo-controlled trials in palliative care: the argument against. Palliative Medicine, 11(6), 489-492.
Klaschik, E., Nauck, F., & Ostgathe, C. (2003). Constipation –modern laxative therapy. Support Care Cancer,11,679-685.
Kurz, A., & Sessler, D. (2003). Opioid-induced bowel dysfunction pathophysiology and potential new therapies. Drug, 63(7), 649-671.
Larkin, P.J., Sykes, N. P., Centeno, C., Ellershaw, J. E., Elsner, F., Eugene, B et al. (2008). The management of constipation in palliative care: clinical practice recommendations. Palliative medicine,22(7), 796-807.
Lau. P. Y. Y., Fung, B., Meng, W. C. S., Leung, R., Yip, A.W. C., So, S. P., et al. ( 2006). Efficacy of multidisciplinary approach in treatment of constipation: a pilot study. Hong Kong Medical Journal, 12(6), 415-418.
Lees, N.,& Lloyd-Williams, M. (1999). Assessing depression in palliative care patients using the visual analogue scale: a pilot study. European Journal of CancerCare, 8(4). 220-223.
Lee, P.Y., Chen, Y. J., Liu, C. P., Tsai, L. Y., & Lai, Y. L. (2003, March). Effect of Abdominal ice packing on bowel movement in normal volunteers and terminal cancer patients receiving narcotics- preliminary results of a phase I-II clinical trial. Osaka International Convention Center, 5th Asia Pacific Hospice Conference, Osaka, Japan.
Lembo, A., & Camilleri, M. (2003). Chronic constipation. The New England Journal of Medicine, 349(14), 1360-1368.
Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: an update. Advances in Nursing Science, 19(3), 14-27.
Longstreth, G. F., Thompson, W. G., Chey, W. D., Houhgton, L. A., Mearin, F., & Spiller, R. C. (2006). Functional bowel disorders. Gastroenterology, 130(5), 1480-1491.
Mancini, I., & Bruera, E. (1998). Constipation in advanced cancer patients. Supportive Care in Cancer, 6(4), 356-364.
Maltoni, M., Scarpi, E., Modonesi, C., Passardi, A., Calpona, S., Turriziani, A et al. (2005). A validation study of the WHO analgesic ladder: a two-step vs three-step strategy. Supportive Care in Cancer,13(11), 888-894.
McMillan, S. C. (2004). Assessing and managing opiate-induced constipation in adults with cancer. Cancer Control, 11(3 Suppl), 3-9.
McNicol, E., Horowicz-Mehler, N., Fisk, R. A., Bennett, K., Gialeli-Goudas, M., Chew, P. W., Lau, J., & Carr, D. (2003). Management of opioid side effects in cancer-related and chronic noncancer pain: A Systematic Review. The Journal of Pain, 4(5), 231-256.
McNicol, E. D., Boyce, D., Schumann, R., & Carr, D. B. (2007). Mu-opioid antagonists for opioid- induced bowel dysfunction. Cohrance Database of Systematic Reviews, (2), CD006332.
Meshkinpour, H., Selod, S., Movahedi, H., Nami, N., James, N., & Wilson, A. (1998). Effects of regular exercise in management of chronic idiopathic constipation. Digestive Diseases and Sciences, 43(11), 2379-2383.
Miles, C. L., Fellowes, D., Goodman, M. L., & Wilkinson, S. (2006). Laxatives for the management of constipation in palliative care patients (Review). Cochrance Database of Systematic Review, 4, 1-20.
Mittal, R. K., Frank, E. B., Lange, R. C., & McCallum, R.W. (1986). Effects of morphine and naloxone on esophageal motility and gastric emptying in man. Digestive Diseases and Sciences, 31(9), 936-942.
Muijsers, R. B., & Wagstaff, A. J. (2001). Transdermal fentanyl: an updated review of its pharmacological properties and therapeutic efficacy in chronic cancer pain control. Drugs, 61(15), 2289-2307.
Mustafa, S. M. D., & Thulesius, O. (2001). Cooling-induced gastrointestinal smooth muscle contractions in the rat. Fundamental & Clinical Pharmacology, 15, 349-354.
Niwa, T., Nakao, M., Hoshi, S., Yamada, K., Inagaki, K., Nishida, M., et al. (2002). Effect of dietary fiber on morphine-induced constipation in rats. Bioscience, Biotechnology, and Bbiochemistry, 66(6), 1233-1240.
O'Donnell, L. J., Virjee, J., & Heaton, K.W. (1990). Detection of pseudodiarrhoea by simple clinical assessment of intestinal transit rate. BMJ,300(6722). 439-440.

Pappagallo, M. (2001). Incidence, prevalence, and management of opioid bowel dysfunction. The American Journal of Surgery, 182(5A Suppl):11S-18S.
Panchal, S. J., MÜller-Schwefe, P., & Wurzelmann, J. I. (2007). Opioid- induced bowel dysfunction: Prevalence, pathophysiology and burden. International Journal of Clinical Practice, 61(7), 1181-1187.
Petticrew, M., Rodgers, M., & Booth, A. (2001). Effectiveness of laxatives in adults. Quality in Health Care, 10(4), 268-273.
Pigot, F., Castinel, A., Juguet, F., Marrel, A., Deroche, C., & Marquis, P. (2001). Quality of life, symptoms of dyschezia, and anatomy after correction of rectal motility disorder. Gastroentérologie Clinique et biologique, 25(2), 154-160.
Plaisance, L., & Ellis, J. A. (2002). Opioid induced constipation management is necessary but prevention is better. American Journal Nursing, 102(3), 72-73.
Preece, J. (2002). Introducing abdominal massage in palliative care for the relief of constipation. Complementary Therapies in Nursing & Midwifery, 8(2), 101-105.
Quigley, C. (2004). Opioid switching to improve pain relief and drug tolerability. Cochrane database of systematic reviews (Online), (3), CD004847.
Radbruch, L., & Elsner, F. (2004). Clinical experience with transdermal fentanyl for the treatment of cancer pain in Germany. The Keio Journal of Medicine, 53(1), 23-29.
Ralphs, J. A., Williams, A. C., Richardson, P. H., Pither, C. E., & Nicholas, M. K. (1994). Opiate reduction in chronic pain patients: a comparison of patient-controlled reduction and staff controlled cocktail methods. Pain, 56(3), 279-288.
Ramesh, P. R., Kumar, K. S., Rajagopal, M. R., Balachandran, P., & Warrier, P. K. (1998). Managing morphine-induced constipation: a controlled comparison of an ayurvedic formulation and senna. Journal of Pain and Symptom Management, 16(4), 240-244.
Rickles, K., & Rynn, M. (2001). Overview and Clinical Presentation of Generalized Anxiety Disorder. Psychiatric Clinics of North America, 24(1), 1-17.
Ritschel, W. A., & Erni, W. (1977). The influence of temperature of ingested fluid on stomach emptying time. InternationalJournal of Clinical Pharmacology and Biopharmacy, 15(4), 172-175.
Robinson, M. K., Ziegler, T.R., & Willmore, D.W. (1999). Overview of intestinal adaptation and its stimulation. European Journal of Pediatric Surgery,9(4), 200-206.
Rosza, Z., Mattila, J., & Jacobson, E. D. (1988). Substance P mediates a gastrointestinal thermoreflex in rats. Gastroenterology, 95(2), 265-276.
Schepper, H. U. DE., Cremonini, F., Park, M. I., & Camilleri, M. (2004). Opioids and the gut: pharmacology and current clinical experience. Neurogastroenterology and Motility, 16, 383-394.
Schug, S. A., Zech, D., Grond, S., Jung, H., Meuser, T., & Stobbe, B. (1992). A long-term survey of morphine in cancer pain patients. Journal of Pain and Symptom Management, 7(5), 259-266.
Skare, T. L. (2004). Practice guidelines for transdermal opioids in malignant pain. Drugs, 64(23), 2629-2638.
Smith, S. (2001). Evidence-based management of constipation in the oncology patient. European Journal of Oncology Nursing, 5(1), 18-25.
Sugita, K., Izu, K., &Tokura, Y. (2006). Erythema multiforme-like drug eruption caused by sennoside. International Journal of Dermatology, 45(9), 1123.
Sweeney, J. L., Hewett, P., Riddell, P., & Hoffmann, D.C. (1986). Rectal gangrene: a complication of phosphate enema. The Medical Journal of Australia, 144(7), 374-375.
Swegle, J. M., & Logemann, C. (2006). Management of common opioid-induced adverse effects. American Academy of Family Physicians, 74, 1347-1354.
Sykes, N.P. (1998). The relationship between opioid use and laxative use in terminally ill cancer patients. Palliative Medicine, 12, 375-382.
Tack, J., MÜller-Lissner, S., Bytzer, P., Corinaldesi, R., Chang, L., Viegas, A., et al. (2005). A randomised controlled trial assessing the efficacy and safety of repeated tegaserod therapy in women with irritable bowel syndrome with constipation. Gut, 54(12), 1707-1713.
Talbot-Stern, J. K., Green, T., & Royle, T. J. (2000). Psychiartric manifestations of systemic illness. Emergency Medicine Clinics of North America,18(2), 199-209.
Tamayo, A. C., & Diaz-Zuluaga, P. A. (2004). Management of opioid-induced bowel dysfunction in cancer patients. Support Care Cancer, 12, 613-618.
Tofil, N. M., Benner, K.W., Faro, S. J., & Winkler, M. K. (2006). The use of enteral naloxone to treat opioid- induced constipation in a pediatric intensive care unit. Pediatric Critical Care Medicine, 7(3), 252-254.
Tong, H., Isenring, E., & Yates, P. (2009). The prevalence of nutrition impact symptoms and their relationship to quality of life and clinical outcomes in medical oncology patients. Supportive Care in Cancer, 17(1), 83-90.
Villanova, N., Azpiroz, F., & Malagelada, J. R. (1997). Perception and gut reflexes by stimulation of gastrointestinal thermorceptors in humans. Journal of Physiology, 502(1), 215-222.
Wald, A., Hinds, J. P., & Caruana, B. J. (1989). Psychological and physiological characteristics of patients with severe idiopathic constipation. Gastroenterology, 97(4), 932-937.
Wald, A. (2007). Chronic constipation: advances in management. Neurogastroenterology and motility : the official Journal of the European Gastrointestinal Motility Society, 19(1), 4-10.
Walsh, T. D. (1990). Prevention of opioid side effects. Journal of Pain and Symptom Management, 5(6), 362-367.
Webster, L. R., Morlion, B., Jansen, J. P., Hermanns, K., Sabatowski, R., Snidow, J et al. (2007, February). Correlation of symptom relief with global improvement of opioid-induced bowel dysfunction: results of a phase IIb study of the PAM-OR antagonist, alvimopan, in non-cancer pain. Paper presented at the American Academy of Pain Medicine 23rd Annual Meeting. New Orleans, LA.
Weschules, D. J, Bain, K. T., Reifsnyder, J, McMath, J. A, Kupperman, D.E., Gallagher, R. M et al.(2006). Toward evidence-based prescribing at end of life: a comparative analysis of sustained-release morphine, oxycodone, and transdermal fentanyl, with pain, constipation, and caregiver interaction outcomes in hospice patients. Pain Medicine, 7(4), 320-329.
Wingo, P. A., Tong, T., & Bolden, S. (1995). Cancer statistics, 1995. CA: A Cancer Journal for Clinicians, 45(1), 8-30.
Williams, M.L., & Payne, S. (2003). Aqualitative study of clinical nurse specialiast’ views on depression in palliative care patient. Palliative Meicine, 17, 334-338.
Wisten, A., & Messner, T. (2005). Fruit and fibre (Pajala porridge) in the prevention of constipation. Scandinavian Journal of Caring Sciences, 19(1), 71-76.
Wirz, S., & Klaschik, E. (2005). Management of constipation in palliative care patients undergoing opioid therapy: Is polyethylene glycol an option ? American Journal of Hospice & Palliative Medicine, 22(5), 375-381.
World Health Organization. (2007). WHO definition of palliative care.
Retrieved October 5, 2007, from http://www.who.int/cancer/palliative/definition/en/
Zigmond, A. S.,& Snaith, R.P. (1983). The hospital anxiety and depression scale. Acta psychiatrica Scandinavica, 67(6). 361-370.
Zuo, X. L., Li, Y. Q., Shi, L., Lv, G. P., Kuang, R.G., Lu, X. F., et al. (2006). Visceral hypersensitivity following cold water intake in subjects with irritable bowel syndrome. Journal of Gastroenterology, 41, 311-317.