CU 8: HEALTH PROBLEMS OF SCHOOL-AGE CHILDREN

ENURESIS (BEDWETTING)

Intentional or involuntary urination during sleep in children beyond age of voluntary bladder control.

○ Must occur ≥2 times/week for ≥3 months; child ≥5 years.

urgency, discomfort, restlessness, urinary frequency.

ENURESIS (BEDWETTING) Symptoms:

Primary

ENURESIS (BEDWETTING) Types: – never had extended dry periods.

Secondary

ENURESIS (BEDWETTING) Types: occurs after established continence.

Monosymptomatic

ENURESIS (BEDWETTING) Types: – nighttime only.

Polysymptomatic

ENURESIS (BEDWETTING) Types: – daytime accidents or associated conditions (UTI, sleep apnea, constipation, neurologic impairment, emotional stress).

○ Rule out organic causes first: urinary

tract abnormalities, infections, neurologic

deficits, diabetes, chronic renal failure,

sickle cell disease.

■ Emotional factors may contribute

but rarely primary cause.

ENURESIS (BEDWETTING): Causes

300–350 ml

ENURESIS (BEDWETTING): Normal bladder capacity: age (years) + 2 oz; __ sufficient for a night.

○ Behavioral and environmental:

■ Limit fluids after evening meal; avoid caffeine/sugar after 4 PM.

■ Purposeful nighttime awakening

to void.

■ Motivational therapy and alarms

to condition waking reflex.

ENURESIS (BEDWETTING): Therapeutic Management

TCAs (imipramine/Tofranil)

ENURESIS (BEDWETTING): Drug therapy: – inhibit bladder urination, timed to avoid full awakening

Anticholinergics (oxybutynin)

ENURESIS (BEDWETTING): Drug therapy: – reduce uninhibited bladder contractions, helpful for daytime frequency.

Desmopressin acetate (DDAVP)

ENURESIS (BEDWETTING): Drug therapy: – nasal spray reduces nighttime urine volume; typically two sprays before bedtime.

○ Supportive management for child and

parents; child actively participates.

○ Avoid punishment; use positive

reinforcement to build confidence.

○ Reassure parents: enuresis is not caused

by emotional disturbance or poor

parenting.

○ Nurse provides consistent encouragement

through unpredictable treatment process

ENURESIS (BEDWETTING): Nursing Care Management

ENCOPRESIS

Repeated voluntary or involuntary fecal passage in inappropriate places ≥1/month for ≥3 months; child ≥4 years.

○ Not caused by physiological effects (laxatives) or general medical conditions.

Primary

ENCOPRESIS: Types – child never achieved continence by age 4.

Secondary

ENCOPRESIS: Types – occurs after established continence; more common in boys.

new sibling, moving, school

changes, unfamiliar toilets.

■ Chronic constipation → fecal

obstruction → painful bowel

movements → stool withholding

→ hard, large stools → loss of

urge to defecate.

ENCOPRESIS: Causes: Constipation due to environmental changes:

Hirschsprung disease, anorectal lesions, malformations, rectal prolapse, hypothyroidism, hypokalemia, hypercalcemia, lead intoxication, myelomeningocele, cerebral palsy, muscular dystrophy, IBS.

ENCOPRESIS: Causes: Digestive/medical:

voluntary retention after painful defecation, fear-pain cycle, disturbed parent-child relationship.

ENCOPRESIS: Causes: Emotional/psychogenic:

fear of school bathrooms, schedule disruption, stress.

ENCOPRESIS: Causes: School/stress-related exacerbations:

Identify cause: history, physical exam, rectal exam; abdominal radiography if needed

ENCOPRESIS: Therapeutic Management

Lubricants

ENCOPRESIS: Therapeutic Management: Relieve constipation/fecal impaction: __ mineral oil (avoid if dysphagia/vomiting).

Osmotic laxatives:

ENCOPRESIS: Therapeutic Management: Relieve constipation/fecal impaction: ___ lactulose, sorbitol, PEG (MiraLax), magnesium hydroxide.

high-fiber foods, increased fluids, reduce dairy if needed.

ENCOPRESIS: Therapeutic Management: Dietary:

encourage sitting 10–15 min after meals, quiet activity, comfortable and non-threatening environment, footstool to relax abdomen.

ENCOPRESIS: Therapeutic Management: Establish toilet routine:

○ Thorough history: onset, frequency,

circumstances, toilet success.

○ Educate parents: normal defecation

physiology, developmental toilet training,

treatment plan.

○ Bowel retraining: mineral oil, high-fiber

diet, regular toileting routine.

○ Positive reinforcement: stickers, praise,

special activities.

○ Ensure adequate fluids; encourage

fiber-rich snacks.

○ Family counseling: reassure most

problems resolve, relapses during stress

possible.

○ Behavior modification techniques; tailor

plan to family’s situation.

ENCOPRESIS: Nursing Care Management

ENCOPRESIS

Ensure adequate fluids; encourage fiber-rich snacks.

ENCOPRESIS

Family counseling: reassure most problems resolve, relapses during stress possible.

ENCOPRESIS

Behavior modification techniques; tailor plan to family’s situation.