06.09 Constipation and Encopresis (Incontinence)

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Study Tools

Bristol Stool Chart (Image)
Severe Constipation on X-ray (Image)
Transient Incontinence – Common Causes (Mnemonic)
Promotion and Evaluation of Normal Elimination (Mnemonic)

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Hey everyone in this lesson we're going to be talking about constipation and encopresis.

So let's just start by covering some definitions of these two topics. Constipation is basically just a change in stool patterns where stools are more infrequent, inconsistent and difficult to pass. And usually for a diagnosis of constipation these problems need to be over a period of 2 weeks or more.

Encopresis is the involuntary passage of stool, so kids are having a bowel movement at socially unacceptable places. The most common cause of this is chronic constipation. Kids with chronic constipation are likely to have fecal impactions and can have involuntary leaking of stool around the impaction. Encopresis can also occur as a result of emotional stress or trauma, but this is pretty rare.

I want to really quickly highlight some common causes of constipation in children. Some of these are unique to pediatrics so it's just important to be aware that they can cause this issue. The first one is Hirschsprung disease. in Hirschsprung disease what's happening is that those kids are missing important nerve cells in the colon so they're not able to sense or know when they need to have a bowel movement.

Next is any kind of spinal cord lesion and these children are also going to have difficulty sensing when they need to go to the bathroom. An example of this is spina bifida.

Cystic fibrosis can also cause constipation and this is because CF causes problems with digestion and absorption of nutrients. There will be an increased amount of mucus in the stool which can cause things to block up and become constipated.

Medications are also a common cause of constipation in kids. We often see this issue with kids who are on antiepileptic medications. This is especially true if this child is also bedbound and isn’t able to be active and help keep the bowels moving.

Really though, what we see most often is functional constipation and what I mean by this is just that no disease process can be seen and no obvious cause has been found to be causing the constipation. With functional constipation the primary causes are dietary, environmental, and psychosocial and we'll talk more in detail about those in just a second.

Our assessment of a patient with constipation really starts by asking about the characteristics of the stool. A really helpful tool when talking to families about this is what you see over here on the right which is the Bristol stool chart. We need to know how often they are going and if they experience pain when going. Other things you want to find out about are if the child has had any blood in the stool, which can happen with straining, and then also if they've had any episodes of encopresis or leaking of stool involuntarily.

Parents will likely report a decreased appetite and bouts of abdominal pain that seem to come and go. You also need to ask parents pretty detailed questions about the kids diet and their toileting habits. For the diet, we need to know how much fiber and water they are getting. Regarding toilet habits, we need to know if there have been any changes to the routine. One of the most common things we see is kids becoming constipated when they start school because this is a change in routine and they may have some anxiety about it.

For the newborn, make sure to assess for meconium ileus. This just means they haven’t passed their first stool within 24 hours of birth. Common causes of this are Hirschsprung disease and Cystic Fibrosis.

Treatment of constipation depends on how severe it is. If the constipation has gotten so severe that the stool has become impacted the child may need an enema. Otherwise laxatives can be used. Polyethylene-Glycol is the laxative that is best tolerated by kids because it can be mixed in their favorite drink, including juice and soda if necessary.

Once the constipation and discomfort has been relieved it’s super important for the kid and family to make dietary changes. So they need to increase fiber in their diet and increase fluids. Drinking too much cow’s milk can lead to constipation too so make sure they aren’t drinking too much cow’s milk!

Then they need to address any bowel habits that may be contributing to the constipation. Most of the time the most important thing is to help break the pain and fear cycle that has developed during the constipation. Kids who have pain when they go to the bathroom get scared of going so they hold it and become more constipated. So we’ve got to create a routine and have some laxatives on board to help them learn it doesn’t have to be painful. A star chart is a great way to come up with a schedule as well as give some positive reinforcement.

Your priority nursing concepts for a pediatric patient with constipation are elimination, gastrointestinal and liver metabolism and human development.
Okay guys, let’s go through the key points for this lesson! First you’ve got to know that constipation is a change in bowel function where there is a decrease in frequency and an increase in stool hardness. Sometimes, if the constipation is severe enough there can be involuntary leaking of stool. The medical term for this is encopresis.

Most of the time this is caused by dietary and environmental issues. So things like lack of fiber, and pain and anxiety about toileting. A few other causes to be aware of are Hirschsprung disease, Cystic Fibrosis and Spina Bifida.

Treatment of constipation, may require enemas and laxatives at first to help relieve the pain and anxiety. Then it’s really important to increase fiber in the diet, increase fluids and help the child create healthy bowel habits.

That's it for our lesson on constipation in pediatric patients. Make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. Happy Nursing!
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