Week 10: elimination, nutrition, and dehydration

Bowel elimination

passage and dispelling of stool through the intestinal tract by means of intestinal smooth muscle contraction

Urinary elimination

passage of urine out of the urinary tract through the urinary sphincter and urethra​

Functional problems

passage of urine out of the urinary tract

through the urinary sphincter and urethra​

Clinical manifestations of constipation

**infrequent and difficult passage of stool

-Two or fewer defections per week​

-History of excessive stool retention or retentive posturing​

-History of painful or hard bowel movements​

-Presence of a large fecal mass in the rectum​

-Large diameter stools​

-At least one episode of incontinence after the acquisition of toileting skills​

-History of large diameter stools (that may obstruct the toilet)

Constipation risk factors

-Limited daily fluid intake​

-Sedentary lifestyle​

-Poor fiber intake​

-Consumption of foods known to cause hard stools​

-Excessive dairy products​

Other causes of constipation

-Lead poisoning​

-Underactive thyroid function​

-Celiac disease​

-Abnormal calcium levels

Toddler/preschool triggers for constipation

-Learning to control body function​

-Transition to cow’s milk​

-Withholding behaviors

School age triggers for constipation

-Diet​

-Toileting habits​

-Activity​

-Abuse​

-Changes to routine

Withholding/retentive behaviors

Voluntary contraction of external sphincter “holding it in”

Causes of retentive behaviors

-he or she is afraid of the toilet ​

-doesn't want to take a break from play. ​

-uncomfortable using public toilets.​

-Painful bowel movements caused by large, hard stools also may lead to withholding​

-If it hurts to poop, your child may try to avoid a repeat of the distressing experience

Identifying retentive behavior

-Crossed legs(scissoring)​

-Tiptoe with legs stiff​

-On hands and knees​

-Sitting on heel​

-Potty dance​

-Lifting off the toilet seat ​

-Stiff posture with legs locked (salute)​

-Sitting on coccyx with legs in stiff posture

Health history Qs for constipation

-When was their last bowel movement? ​

-Describe the stool? ​

-How often do they usually stool in a week? ​

-Does it hurt to defecate?​

-Is the stool large or hard?​

-Any small lose stools or stains in underpants?

Physical exam for constipation

-Ausculate hyper or hypo depending on where you listen ​

-Palpate – may feel firm fecal mass​

-Assess pain

Encopresis

-Abnormal elimination pattern characterized by the recurrent soiling or passage of stool at inappropriate times by a child who should have achieved bowel continence​

-Liquid stool leaking around a large/hard/impacted stool mass ​

-Seen in chronic constipation​

-As common as 1 in 100 kids​

1st line constipation treatment

-↑ Fluids ​

-↑ fiber​

-Age + 5 = grams of fiber needed per day​

-Many children do not even meet the minimum​

-Dietary modifications:​

→ Infants: 2 oz pear, apple, prune juice​

→ Increase physical activity and fluid intake​

→ Remove constipating foods​

Follow up treatment for constipation

-Next: Medications which increase water release into colon or soften stool​

→ Miralax, Docusate sodium, Sennakot​

-Clean out​

→ Enemas: work on lower part of colon to release hard stool​

-“jump start” – help get things moving as medications and 1st line treatments take time to work​

-Laxatives​

Laxatives

-Increase peristalsis: Bisacodyl – use short term only! ​

-Quicker effect than stool softeners ​

-Long term use can lead to dependence ​

Education for pt and family on constipation

School age kids​

-anatomy of GI tract​

-Talk with the older child about barriers to going to the bathroom​

Families: ​

-physiology of bowel movements​

-Stretching of rectum and colon

Constipation medication education

-purposes and dose adjustment

-length of treatment​

Collaboration for constipation

-School notes to ensure they have access to the bathroom or a private toilet ​

-GI psychologists

Constipation behavioral modification

-Interrupt the withholding behaviors​

-Encourage toilet sitting after meals and at scheduled times​

-Toilet sits for 5-10 minutes after all meals​

-Feet supported on step stool “squatty potty”​

-Develop potty box with toys for potty sits for younger kids​

-Age-appropriate incentives

Expected time for constipation resolution

-The longer the problem ~ the longer the treatment​

-Minimum of 2-6 months of aggressive therapy​

-If dependent on laxatives, 1-4 months to wean off​

-Poor adherence with treatment recommendations will prolong therapy​

-Even after problem is resolved there is 50% chance of reoccurrence in 1st year ​

-This can become an ongoing problem & consistency is required to prevent reocurrence​

Enuresis

-Repeated involuntary voiding by a child old enough that bladder control is expected/after mastery of toilet training​

-Bedwetting!

-Night (nocturnal) vs day (diurnal)​

Primary enuresis

-Never dry​

-Related to maturational delay, small functional bladder capacity

Secondary enuresis

-Dry for 6 months then bedwetting starts​

-Related to stress, infection, sleep disorders​

-Example: 10 year old boy starts wetting the bed (was potty trained since 3)

Enuresis treatment options

-Limit fluid in evening​

-Toileting right before bed​

-Avoid caffeine​

-Avoid constipation​

-Bladder exercises​

-Timed voids​

-Enuresis alarm​

-Reward system​

-Medications

Medications for enuresis

-Desmopressin (anti-diuretic)​

-Oxybutynin (anti-spasmodic) ​

GER

-Defined as the passive backward flow of gastric contents upward into the esophagus that can occur with or without regurgitation or vomiting​

-Considered a normal, physiological process – but can become problematic​

-Effortless, painless spitting often within 40 minutes of eating​

-GERD occurs when there is tissue damage from GER

Causes of GER

-Short and narrow esophagus​

-Weak esophageal sphincter that does not close adequately​

-Delayed gastric emptying time​

-May progress to tissue damage from low pH of gastric acid

GER/GERD risk factors

-Prematurity​

-Delayed maturation of lower esophageal neuromuscular function​