For the purpose of this assignment I have changed the chosen patients name to Scott to maintain patient confidentiality (Nursing & Midwifery Council 2004). Scott is a young boy that is 7 years of age who stays at home, in the suburbs of Aberdeen, with his mother and father and has no siblings. His mother is unemployed and father works offshore so is often not at home for long periods of time. Scott was admitted to hospital after having not had any bowl movements for a week and the previous week having only passed two stools. He reported pain whilst he passed these stools along with anal bleeding.
This was not the first time he had been admitted to hospital with these symptoms in the past year. These symptoms lead to his diagnoses of suffering from chronic constipation. It was found that there were no underlying organic causes for his constipation. The modern diet of children, with a lack of fibre, can be the cause of constipation (SULLIVAN, P. B. et al, 2006). This could be true in Scott’s case as he is fussy with what foods he eats which may be a contributing factor to his constipation.
Constipation is very common throughout childhood and constipation is internationally reported to affect 0. % to 36% of children (Smith and Derrett 2006). Many factors can influence constipation in children such as pain, dehydration, issues with toilet training, dietary and fluid intake and history of constipation within their families (NICE GUIDELINES). There are many symptoms for constipation and these can vary slightly in infants and children. When assessing constipation it is important that any more serious underlying causes are ruled out such as Hirschprungs’s disease, Cystic fibrosis, metabolic causes, heavy-metal poisoning or sexual abuse.
This is because normal treatment for constipation in these cases will not always be the first course of action. Constipation that has no organic cause or cannot be explained by any physiological abnormalities is described as idiopathic constipation. This is almost always the diagnosis in children over the age of one (Biggs and Dery 2006). When assessing a child with constipation a discussion with the parents or guardians and child will help collect information. Stool patterns should be discussed (NICE 2010).
Less than 3 proper stools per week, overflow soiling, odour more unpleasant that normal, rabbit dropping type stools or large infrequent stools are symptoms which should be noted. The Bristol Stool Chart can be used to help assess stool patterns as it classifies stool into 7 types with types 4 and 5 being normal and types 1 – 3 suggesting constipation. Distress, pain and straining whilst passing stools are also important in assessing constipation. The NICE guidelines state that if two or more of the previous symptoms are found then the child is to be diagnosed with constipation.
Any previous medical history should also be addressed, like in Scott’s case, as his most recent stay in hospital was the second time in the past year that he had been admitted to hospital for constipation. Also diet should be discussed as a diet low in fiber can have a major impact and be a cause of constipation. Any family history in relation to constipation should be discussed. A physical examination can also be used to help assess the problem and would help in discovering any ‘red flags’ that could indicate that the constipation would require further investigation.
The NICE guidelines also outline methods of assessing the problem that shouldn’t be carried out. Scott was assessed using the aforementioned methods. First his previous medical history was discussed. This uncovered that not only had he previously been admitted to hospital with this problem but that he didn’t often have regular bowl movements. He was experiencing difficultly when passing stools over the previous weeks and he found it very painful which lead to him trying to avoid using the toilet. This avoidance of passing stools because of fear of the pain can advance to stool retention and further reduce bowl movements (Biggs and Dery 2006).
Scott’s stools were compared to the Bristol Stool Chart and found to be type 1. On discussing his diet and during his stay in hospital it was apparent that he was quite fussy about what he ate so this could perhaps have lead to a low fiber intake, which can cause constipation. However there is not currently a British recommendation for fiber intake (Sullivan, P. B. et al 2011). Scott after finding no underlying problems for his symptoms was treated for constipation. Treatment for constipation in children involves having a clear understanding of the factors affecting the individual.
In some cases more than one approach may be taken. In managing constipation the steps taken are to get rid of any impaction, to establish regular bowl movements that cause no pain for the child and to try to prevent any further episodes of constipation. Firstly disimpaction of the build up fecal matter should be dealt with. There are different methods to manage this but usually medication will have a positive result without the need for surgical intervention. (NICE 2010). Laxatives are important as first line treatment and should commence as soon as possible (Rogers 2011).
Movicol Paediatric Plain (Movicol PP) has been shown to be an effective and safe treatment for children presenting with impaction (Hardikar, 2007). Enemas and rectal suppositories, although effective in treating impaction, are very invasive and can upset the child having a negative effect in trying to get them to pass stools. These would only be used in cases when all other oral medication has failed to clear the retained stool. After the retained stool has been cleared Movicol PP is often used for month after to help maintain regular bowl movements.
The NICE guidelines recommend that this may take several months and in some cases children may require laxative therapy for several years to prevent relapse. Family education is important in the maintenance of healthy bowl movements and also education of the child if he or she is old enough. Dietary and behavioral advise can be given to help the parents or guardians to understand why the child has had a problem with passing stools. Dietary changes such as increasing fiber intake and generally maintaining a healthy diet is often advised.
This as well as encouraging drinking water regularly is usually advised to prevent dehydration, which can be a cause of constipation. (Rogers 2011). Another important issue to be addressed is toileting habits. Toileting after meals should be encouraged and the childs’ comfort on the toilet should also be addressed to reduce straining. Regular exercise can also have a positive affect in maintaining healthy bowels. Poor follow up on patients progress is a main reason for failure in treatment which is why nurses can be invaluable in ensuring success of treatment and management of children with constipation (Burnett et al, 2004).
Scott was treated during his stay in hospital with Movicol PP however this in itself presented a problem, as he was very reluctant to drink it because he really didn’t like the taste. This was dealt by rewarding him when he drank all of his medication using a sticker chart as a visual encouragement. Also the nurses would play games with him surrounding drinking his Movicol to give him a positive view of drinking it to try to stop him thinking about the unpleasant taste.
This worked successfully and Scott was soon drinking it with little encouragement. Scott’s stools were monitored to ensure returning o normal and drinking plenty of fluids was encouraged. The nurses tried to educate his parents on why this had happened and how to prevent it happening in the future. When his stools became less painful to pass he became less frightened to use the toilet, his fear being a main reason of his fecal impaction. Scott although living with both his parents he was normally cared for by his mother as his father worked offshore so was away for long periods of time. Scott was confident around other children in the ward but around his mother became slightly reserved.
On discussion with Scott and his mother it was found that she would sometimes get frustrated with him when he wouldn’t go to the toilet and when he experienced overflow soiling which was something, which was out of his control. This would be a stressful environment for Scott, which could have worsened the situation as well as affect his mental health. Another main factor affecting Scott’s health is his diet. He didn’t eat as much as he should and when he did eat he would prefer to eat sweets and snacks rather than proper meals.
This issue was addressed with his mother. Scott was kept in hospital longer due to child protection issues that were raised by a nurse regarding his mother. These issues were resolved but the negative interactions between Scott and his mother would have a serve impact on his mental health. A positive factor influencing Scott’s general health was that he was very outgoing and did well in school, which was a boost to his self-esteem. He talked of achievements in school and how well he got on with his classmates.
Scott is quite an intelligent boy so educating him on things he could do to help himself not have to experience this problem again was easy to do. Scott saw his father as a role model so he would have a great part to play in Scott’s health. His father could support him in managing the problem. His family being supportive is important, as punishing Scott for the issues surrounding his constipation would only worsen the problem. Scott got quite emotional and had very negative thoughts surrounding using the toilet. These could be related to early life when he was toilet trained and be a contributing factor to his constipation.