06.09 Constipation and Encopresis (Incontinence)

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

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So, we’re gonna talk about constipation and Encopresis. The difference between constipation is that constipation and encopresis have the same qualities except for encoporesis can cause a step further. So, a child who’s already been potty trained, will now be soiling their pants with stool. And it will be a loose stool that has gone around the hard constipated stool that the child had held in there for so long. So, constipation, infrequent hard to pass stool. Encopresis is the leakage.

So, what kind of an assessment are we gonna be doing on these children? Well, for starters, they’re gonna be complaining of abdominal pain. They may have a distended belly. So, here’s our child. They’re gonna be saying their belly hurts, my tummy hurts, their belly might be distended, it maybe firm. What you’re gonna wanna do, is you’re gonna wanna auscultate their bowel sounds and all four quadrants. But likely, what you’re gonna find in each quadrant is that the bowel sounds are hypoactive. The definition of hypoactive is between 2-4 noises, bowel noises within 1 full minute. So, permanent. Normal bowel sounds, what we would consider if we were turning active bowel sounds is between 5 and 15 noises or the tinkering. However, whatever, where do you wanna use. So, 5-15 per minute. So, you’ll listen, you’ll palpate it’s probably gonna be firm. It may not be, the child may say that it hurts really bad, they may not hurt them at all, you’re gonna assess how many times have they had, you know, when is the last time they had a bowel movement? And then, you’re gonna get a X-ray on them. So, X-rays are really important. And when you get the X-ray, the X-ray literally shows like how much poop and you will be able to see it especially in the large intestine, how much poop is inside of that child? There will be a lot less gas spaces and there will be more compact inside.

So, what do we do for a child who has a constipation or Encoporesis? So, basically, we want to increase the amount of fiber and fluids that they are having in their diet. So, fiber foods include things like fruits, have a lot of fibers, spaghetti is an example that something that has a lot of fiber. You wanna do legumes like beans and things like that to increase the fiber that they have and then fluids. You wanna increase drinking. And not just any kind of drinking, ‘cause children will love that sugary water, you know, juice like drinks. If that’s all you can get down, then, yes, that’s what you give them. But if you can promote water, that would be the best kinds of fluids that you could give them and if they’re in the hospital and unable to increase oral intake, then you would give them IV intake. The other thing that you can do is you can educate the parents on creating a toileting schedule. So, whether the child goes to the bathroom or not, you have certain times throughout the day in which the child will go to the bathroom. So, let’s say, you know, they wake up at let’s say, 8 AM, they must sit on the toilet. Noon, they sit on the toilet. And then at 5 o’clock, they sit on the toilet and then maybe even one more before bed like 9 o’clock before bed. I don’t know kids schedules very well. But if that were appropriate time frame, we want to make sure that the parents know. You sit them on the toilet even if they say they don’t have to go and it gets them more into a schedule of going into the bathroom.

Now, usually, if I get a child in the emergency department, we’re gonna be, and it’s like a severe constipation where we’re fairly concerned. We’re gonna give them an enema and enemas are, well, depending on the age, it can be very psycho-socially very detrimental to that child. So, you wanna, it’s a difficult thing for even an adult to do. But we wanna be really well practiced on how to give an enema because you don’t wanna really make the experience even more irritating for that child a it is already is. So, you will take whatever it is that’s ordered, whether it’s fleets, soap suds, whatever type of enema it is and you will mix it up, put it in a bag, then you will lube the catheter and lay the child on their left side. So, left side for positioning. And then, you want to have their right leg flats. So, left side, right leg flat. And then, you want to lube the catheter and place it for an infant. It’s 1 - 1.5 inches for infant and for an older child, you want to put about 2 - 3 inches in there. Now, no matter the age, you do not wanna surpass 4 inches. So, 2 - 3 for an older child. Now, you want to be giving the enema about 12 inches above their waist line and you wanna give it at about 100 mL per hour. This could potentially be too fast of a rate for them, slow it down. And the child will complain of cramping if it’s an infant and they can’t really complain. Their legs are going to curl up to their abdomen and they’re gonna be very very fussy because that cramping is very uncomfortable. So, just slow down the amount of rate. And you can do that by gravity, by moving the bag closer to their waist line or you use like a clamp to kind of pinch off a little bit of it. You’ll want to stop and give them a rest if they are complaining a little bit. So, you can clamp it off completely and allow the child to rest during a period of time.

So, again, constipation, encopresis. Constipation is when the child is having no bowel movements and encopresis is the same thing except for there’s leakage now coming into their pants and they’re soiling themselves where they were once actually toilet trained. They are now having stool and they are loose liquid stool in their pants. You wanna their bowel sounds, press on their abdomen, get an X-ray of their abdomen and assess what kind of treatment to go forward. You educate parents on increased amounts of fiber and fluids and toileting schedule and then also mom and dad can give enemas if constipation is something that consistently happens. Also, you can give it in the hospital and wanna lay them on the left side with their right leg flexed. And you wanna put it in only 1-3 inches depending on the size, no more than 4 inches. You wanna run it at no more than a 100 mL/hour.
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