constipation and faecal soiling continence advisory service : bobbie jones gill prior jane dickson
TRANSCRIPT
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Constipation and Faecal Soiling
Continence Advisory Service :Bobbie Jones
Gill PriorJane Dickson
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Bowel Function
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Normal Bowel control
First year – reflex activity
• Second year – gradual awareness of need to empty bowel
• Third year – ability to defer bowel opening
• Fourth year – ability to delay bowel opening, and to defecate voluntarily
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Normal Bowel Function
• 99% of babies pass meconium within the first 48hrs of birth
• 16 weeks – average of 2 stools / day
• Weaning results in a firmer stool
• Range of 1-3 / day to 2-3 / week
• Soft and easy to pass
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Faeces moves into the sigmoid colon and previously empty rectum
Defecation occurs
Holding on
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Common Bowel Problems• Constipation:
Defined as the infrequent passage of hard stools that is difficult to pass. The passing of stools may be painful and less frequent than is normal for that child
• Slow Transit Constipation: Slower than average movement of stool throughout the large bowel.
• Faecal Soiling The repeated passage of stools, whether involuntary or intentional in a socially unacceptable place in a child over 4 years of age (or equivalent developmental age).
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Contributing factors of constipation
• Reduced fluid intake
• Reduced fibre intake
• Reduced exercise
• Holding on/ ignoring the urge – often initiated by passing of large/painful stool
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Contributing factors of constipation
• Missed training opportunity
• Delay in passage of normal stool
• Anal Fissure
• Toileting phobias or fear
• Child abuse
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Functional faecal retention
• usually associated with soiling
• follows from ‘holding on’ unless managed
appropriately
• child ‘forgets’ mechanics of normal defecation
• May require long term treatment and follow up
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Constipation – Signs and Symptoms
Symptoms of increasing faecal loading
• Abdominal distention and pain
• Irritability
• Anorexia
• Faecal Soiling
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Slow transit constipation - Signs and Symptoms
• Large soft stools
• Frequency 3 per week to 1 per 3 weeks
• Abdominal distention
• High incidence of faecal incontinence
• Symptoms of severe constipation within a year
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Assessment
• Check for:– daytime urinary problems
– nocturnal enuresis
– appetite / fibre intake
– fluid intake - how much milk?
– any medical problems
– any current medication
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Red Flags
• ‘Red flag’ symptoms include: – More than 48 hours before passing meconium as a
neonate – Abdominal distension especially if failing to thrive – Infrequent small or ribbon stools – Constant leaking especially if linked with urinary
leaking too – Failed management with appropriate standard
intervention (with compliance)
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Communication
• able to indicate what is happening – (not necessarily verbal)
• language used for toileting can be unique to each family
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Mobility
• Get to the toilet
• Remove clothing
• Get up onto the toilet
• Wipe bottom
• Replace clothing
• Wash hands
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Social
• Be able to follow instructions
• Have the ability to communicate
• Wish to please parents/carers
• Want to be like their peers
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Environmental issues
• School toilets
• Toilet accessibility
• Peer pressure
• Clothing
• Lack of privacy
• Attitudes of others
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Treatment Goals
• To establish regular bowel habits
• To reduce stool retention
• To restore normal control over bowel function
• To reduce concerns within the family
• To help reduce conflict within the family
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Treatment – Constipation
Education
• Proposed course of treatment
• Normal variation in bowel habits
• Symptoms may get worse initially
Evacuation (if required)
• Disimpaction with oral laxatives and enemas
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Increase Movicol Dose
Increase Movicol Dose
Maintain Movicol Dose
Maintain Movicol Dose
Decrease Movicol Dose
Decrease Movicol Dose
Stop taking Movicol for a day or two
Movicol Maintenance Regime
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Impaction RegimeChildren (2 – 11 years):
Number of MOVICOL-Half Sachets
Age (years) Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
2 – 4 2 (1) 4 (2) 4 (2) 6 (3) 6 (3) 8 (4) 8 (4)
5 - 11 4 (2) 6 (3) 8 (4) 10 (5) 12 (6) 12 (6) 12 (6)
A course of MOVICOL-Half (OR half adult MOVICOL dose) is for up to 7 days as follows:
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Treatment – Constipation
Maintenance
• Medication may be required
for 6-12 months, even longer.
• Increase fibre and fluid intake
• Increase activity in the child
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Treatment – Slow Transit Constipation
• Remove obstruction
• Fibre supplement – initially
• Laxatives
• Antegrade Colonic Enema
• Colectomy
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Treatment Plan Overview
• Ensure adequate fluid intake
• Ensure balanced diet with adequate amounts of fibre
• Encourage regular toileting – minute sits
• Encourage correct toileting position
• Consider environmental factors e.g. access to school toilets
• Management strategies
• Refer to health care professional
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