Report in NCM 102-A

Common Health Problems in Toddlers Utilizing The Nursing Process:

CONSTIPATION

ASSESSMENT: DESCRIPTION OF THE CONDITION: Constipation is a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard,dry stool. PATHOPHYSIOLOGY: Normal defecation occurs when stool moves into the rectum,causing rectal distention and relaxation of the internal anal sphincter. The conscious awareness of rectal distention results in contraction of the voluntary muscles of the external sphincter and increased intra-abdominal pressure result in defecation. CONSTIPATION tends to be self-perpetuating. As stool retained, the simultaneous process of stretching the rectal wall and dereasing sensory feedback leads to less frequent bowel movements, which result in further stool retention and large stools. As water reabsorbed, the stool becomes hard er and bowel movements may become painful. As this cycle progresses, the external and internal sphincters become compromised. Sensitivity to rectal distention and control of rectal evacuation diminish, and the child soon loses the urge to have a bowel movement.

RISK FACTORS: Defecation habits Physical activity Eating/feeding pattern Fluid intake Use of Drugs

SIGNS AND SYMPTOMS: Difficulty to pass stool Hard formed stool Abdominal pain Straining with defecation Pain in defecation Nausea and vomiting Headache Hypoactive or hyperactive bowel sounds Distended abdomen;abdominal tenderness Abdominal dullness

DIAGNOSTIC PROCEDURE: Abdominal x-ray - a diagnostic test to evaluate the amount of stool in the large intestine. Barium enema - a procedure performed to examine the large intestine for abnormalities. A fluid called barium (a metallic, chemical, chalky, liquid used to coat the inside of organs so that they will show up on an x-ray) is given into the rectum as an enema. An x-ray of the abdomen shows strictures (narrowed areas), obstructions (blockages), and other problems. Anorectal manometry - a test that measures the strength of the muscles in the anus, nerve reflexes, ability to sense rectal distention, and coordination of muscles during defecation. Rectal biopsy - a test that takes a sample of the cells in the rectum to be

examined under a microscope for any problems. COMMON DRUGS OR MEDICATION FOR CONSTIPATION: Dietary changes take time to become effective, and until they do, your child will likely need to be on a stool softener. These medications are often used long term as maintenance therapy and are considered to be safe, effective and non-habit forming or addictive. You do want to avoid chronic use of stimulant laxatives, such as Bisacodyl, ExLax or castor oil. An osmotic type laxative, which works by drawing extra fluid into the colon to soften the stool, is usually safer for long term use. Commonly used constipation medications include:

Milk of magnesia: contains magnesiuim hydroxide, an osmotic laxative with a chalky tasting that is not tolerated by all children. It may be helpful to mix with 12 teaspoons of Tang or Nestle Quick. Or mix into a milk shake. Mineral Oil: a lubricant that you can mix with orange juice. May cause leakage and staining of underwear. Docusate: available as Colace and Surfak, and is a lubricating laxative. Also available with a stimulant laxative in the combination medicine Peri-Colace. Malt Soup Extract: or Maltsupex, it has an unpleasant odor, but is easily mixed with formula for younger infants. Senokot: a stimulant laxative Bisacodyl: a stimulant laxative available as Correctol and Dulcolax.

Other medications that are available by prescription include:

Lactulose: an osmotic laxative Miralax: a tasteless, osmotic laxative that contains polyethylene glycol and is usually used for two weeks or less at a time.

In addition to a stool softener, it may also help to give added fiber by mixing Metamucil or Citrucel with 8 ounces of water or juice, or another bulk forming laxative or fiber supplements. Keeping in mind the main goal of your child having a soft stool each day, your child may need to take his medication for a long period of time and often up to 4-6 months. One of the biggest mistakes parents make in treating their children's constipation is stopping their medication once they begin having soft stools. If stopped too early, your child is likely to relapse and become constipated again. Instead of stopping the medication, if your child is regularly having loose stools or diarrhea, the dosage should be decreased by 25%. So if he is taking 1 teaspoon of milk of magnesia and is regularly having loose stools, then decrease it to 3/4 of a teaspoon. Don't make too many changes based on a single stool though. Once your child is having regular soft stools, you can then talk with your Pediatrician about decreasing the dosages of the laxative that your are using. This is usually done gradually, often by decreasing the dose by 25% every 12 months. Stopping the laxatives too quickly can result in your child becoming constipated again. It is also important to continue your child's nonconstipating diet during and after the laxatives are stopped.

PROBABLE NURSING DAIGNOSIS: Acute Pain related to abdominal pressure.straining to defecate and trauma to delicate tissue. Deficient Knowledge regarding to dietary needs, bowel function and medication effect. Constipation related to weak abdominal musculature,gastrointestinal obstructive lesions,pain in defecation,diagnostic procedure. Constipation related to pain from anal fissure

NURSING INTERVENTION: Assess current pattern of elimination.note color,odor,consistency,amount and frequency of stool to provides a baseline for comparison, promoted recognition of changes. Instruct parents to boost their childs fiber intake to improve consistency of stool and facilitate passage through colon. Promote adequate fluid intake to promote passage of soft stool. Instruct the parents to encourage their child to crawl,cruise, or walk everyday to get the blood flowing to all of her organs. Massage your toddlers belly.measure three finger-widths below her navel and apply gentle but firm pressure there with your fingertips. Press until you feel a firmness or mass. Maintain gentle but constant pressure for about 3 minutes. Instruct the parents to dont pressure their toddler to toilet train before shes ready.pushing her to use the potty can make her afraid or resentful.and she

could wind up withholding bowel movements. If they notice that their toddler is doing this, instruct them to increase the amount of fiber she eats, back off on the training and wait to try again until theyve spotted the signs shes really ready. Administer stool softerner, mild stimulants or bulk forming agents,as ordered or routinely,when appropriate. Apply lubricant/anesthetic ointment to anus,if needed.

EVALUATION: Parent verbalizes that toddler show responses to interventions and change in bowel pattern and character of stool. Modification to plan of care, if necessary. Establishes regular soft bowel movements.

RESOURCES: 1. Donna L. Wong and Marilyn Hockenberry-Eaton:Wongs essentials of pediatric nursing 6th edition Page:891-893 2. Adele Pilliteri:Maternal and Child Health Nursing 2nd edition Page:1406-1408 3. www.babycenter.com/0_constipation_11419.bc 4. www.babycenter.com/0_constipation_11419.bc?page=2 5. www.childrensmemorial.org/depts/gastroenterology/digestion/constip.aspx 6. Pediatrics.about.com/cs/conditions/l/aa070501a.htm 7. Nicki l. Potts and barbara l. Fandleco:Pediatric Nursing:Caring for childeren and their family Page 759 8.Marilyn E. Doenges, Mary Frances Moorhouse, and Alice C. Murr: Nurses pocket Guide 12th edition Page:223-227