Introduction
This paper presents the case of a four-year-old girl, Molly, suffering from chronic constipation, and who has been admitted to clean her bowels through the use of laxatives. The case study will broadly look at the child’s condition with a specific focus on the condition, assessment of the child, nursing and management of the condition as well as the evaluation of the care and interventions given. In this case, the case study presents the process of assessment, care, and treatment of the child right from the admission to the time of discharge. Additionally, the case study also puts into consideration the role of the family and caregiver in the management and treatment of child’s condition.
Initial complaint
Constipation is a condition whereby, bowel movements become infrequent or difficult (Chatoor, 2009). The condition affects between 5 to 30 percent of children, a situation that makes it a common problem among children (Van den Berg et al., 2006). Some of the main causes of constipation include; insufficient intake of diet fiber, dehydration, inactiveness, drugs such as narcotic pain drugs and antidepressants, Irritable Bowel Syndrome (IBS), milk, excessive use of laxatives, colon or rectum problems, and conditions/ diseases, like for example, neurological disorders and systemic conditions (Chatoor, 2009).
Assessment
The assessment to be carried out in the case of Molly will entail a number of tests to assess the presence, severity, cause of, and relevant treatment for the condition.
The assessment procedure will, first of all, entail the basic process of checking the weight, Blood Pressure, Temperature, Pulse rate and Respiration (TPR) and SpO2.
The other procedure will entail acquiring a constipation history which will entail asking questions such as, how often does constipation take place, does constipation occur after eating any particular food, does the child always soil herself, how do you treat or manage the condition and how long does it last? Another important question will be how often the child passes stool as well as to acquire a description of the stool in terms of for example size or hardness. It will also be important to find out the various symptoms associated with the process of defecation in the child, for example, if there is any pain, strain or bleeding when passing stool (Rubin, 2004). At this point, it will be important to check for any anal fissures, and to inquire if they have been present in the past. A diet history will also be important to assess the child’s feeding habits and nutrient intake. Information on other issues such as the frequency of drinking water and activeness of the child will also be important.
Other assessments will entail:
- Conducting an abdominal x-ray/ radiography to find out if there are any abdominal problems that could be causing the constipation.
- Ruling out the presence of any neurological problem by checking the nerve functions.
- Finding out if the child has experienced any problems as a result of the imperforate anus correction as well as the colostomy reversal procedures.
- Examining the rectum to assess impaction.
- Assessing the frequency and extent of laxative use to manage the condition.
- Finding information about the child’s ADHD: its severity, if dexamphetamine has been the only drug used, and for how long the condition has been there.
Management
From the assessments made, the main possible causes of the constipation could be the use of dexamphetamine drugs for the management of the child’s Attention Deficit Hyperactivity Disorder (ADHD), the earlier done anal and colostomy corrections done, inadequate drinking of water and poor diet and feeding habits. The diet history indicates a frequent intake of an unbalanced meal that is mainly composed of fast foods and lots of junk. Despite, eating a lot of fruits, Molly has been found to consume chips, a burger, cake, soda or 7up lemonade among other junk foods at least twice daily. According to the mother, the child only agrees to eat a small portion of cooked food. The entire family is also heavily dependent on junk foods.
The use of the drug, dexamphetamine, to manage Molly’s behavioral problems could be another cause of her chronic constipation (Butefisch et al., 2002). The drug, according to Vitiello (2008) is a psycho stimulant mainly used in the treatment of disorders like Narcolepsy and ADHD. The usage of the drug in the treatment and management of these conditions has been found to have a number of that include constipation, diarrhea, dryness of the mouth and vomiting. The symptoms can be eliminated by changing the drug or dosage. This action will however only be undertaken if the constipation continues after proposed care and management plan fails. Managing the problem will in this case require a diet and lifestyle change and a change of the ADHD drug.
Management plan
After the diagnosis has been made, it is important that carers are informed of the results obtained, and given all the information they need. The carers or parents will be assured that the condition is treatable and manageable. They will be actively involved in the entire treatment process which will include making decisions related to the care and treatment to be given to the child. This is as outlined in the NICE guideline (2009).
The entire management process will entail an optimistic approach by the nurse, and that is non accusatory, sympathetic and that includes active and continuous involvement, follow up and active discussions with the parents and carers of the patient (NICE guideline, 2009). Through out the management process, the patient’s TPR, BP and weight will be monitored to ensure stability and to assess progress.
The management procedure will also entail disimpaction. Here, the accumulated feaces in the rectum will be gotten rid of, mainly through the use of laxatives (Borowitz et al., 2003). An osmotic laxative such as polyethylene glycol (PEG) 3350 and electrolytes such as Movicol Paediatric Plain will be introduced, and dosage increased slowly depending on the effectiveness (Bell & Wall, 2004). Intolerance to this type of laxative could be dealt with by substituting it with a stimulant one. The substitute could be administered solely or combined with luctulose. Ineffectiveness of the osmotic laxative after a fortnight will require the addition of a stimulant laxative such as bisacodyl suppositories or sodium picosulfate (Rubin & Dale, 2006). An assessment of the child’s progress will be done weekly, with a lack of improvement calling for the intervention of a pediatrician (Clayden, Keshtgar, Carcani-Rathwell &Abhyankar, 2006).
Another important part of the management process will be toilet training and dealing with the incontinence. The first step in managing the incontinence will entail making the parent understand the condition and its unconscious occurrence. Managing the condition will involve toilet training and the practice of regular, unhurried bowel release (Hockenberry & Wilson, 2011). The child will in this case be encouraged to toilet regularly after every meal. Rewards such as the use of star charts will be used to encourage the child to constantly toilet after every meal. In this case, a reward will be given to the child after every successful toileting. A bowel diary and chart will be used for recording (Williams & Wilkins, 2006). The use of this process of toilet training, as brought out by Cohn (2006) makes part of behavior modification.
Dietary advice and encouragement of complete lifestyle change will be another important factor in the management of this condition. The dietary advice will involve the a nutritional counselor or dietician, who will focus on the need for balanced family meals and what a balanced meal should entail, the recommended diet for the treatment and management of constipation. The advice will entail the intake of fibers as well as fluids (Speridiao et al., 2003).
Family education will also be provided to ensure that the members have all information related to constipation and its management, good nutrition, exercise and their role in the care process and understand the various symptoms such as the faecal incontinence (Biggs & Dery, 2006). Other important processes of the management procedure will include:
- The encouragement of exercise both during care and as lifestyle change.
- The use of play therapy and activity.
- Physiotherapy.
Evaluation of care
This paper was about the care and management of constipation, with focus being on young children. The care and management plan was focused both on the patient as well as on the carers or family members. The following are ways through which the success and efficacy of the care plan given will be evaluated;
- The faecal incontinence will stop.
- Successful toilet training and regular toileting for the child.
- Increased weight in child
- Improved family diets which will be assessed through a follow up diet history.
- Increased activity in child
- Increased positivity, knowledge and understanding, with regard to the condition, among family members. The family members are able to understand the various symptoms the child is experiencing, as well as know how to help her and to manage them.
Conclusion
This paper was about the treatment and management of constipation. The paper has briefly defined constipation and mentioned its various causes. The causes have further been brought out and expounded through the case study. Through the assessment made on the child’s condition in this case study, suitable interventions and ways to treat and manage the condition have been identified. The paper has brought out the various interventions to chronic constipation in children and has helped me have a deeper understanding on pediatric constipation, its causes, etiology, care, management and treatment.
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