Nursing Care Plan (NCP) for Constipation / Encopresis

Objective for Constipation/Encopresis

Constipation:
Constipation is when someone has trouble going to the bathroom to have a bowel movement. It’s like when traffic gets jammed up on the road. When someone is constipated, their poop can be hard, making it uncomfortable or difficult to go. This can happen if they don’t eat enough fiber (like fruits, vegetables, and whole grains), don’t drink enough water, or don’t get enough exercise. Sometimes, it’s because they’re nervous or stressed about something.

Encopresis:
Encopresis is a bit different but related to constipation. It usually happens in children. When a child is really constipated, their large intestine (the last part of the digestive system where poop is stored) gets so full that they can’t control it properly. As a result, they might have accidents, where poop leaks out at unexpected times. This isn’t because they’re lazy or not trying; it’s usually because they’ve been constipated for a long time and it’s gotten really serious.

Both constipation and encopresis can be uncomfortable and embarrassing, but there are ways to help, like changing what you eat, getting more exercise, and sometimes taking medicine. It’s also important for kids with encopresis to know it’s not their fault and they’re not alone. With the right care and support, they can feel better.

By the end of this lesson, you will be able to:

• Differentiate between constipation and encopresis.
  • Identify key clinical distinctions and manifestations of both conditions.
  • Gather relevant health history, and assess dietary habits, physical activity, and psychosocial factors.
  • Analyze the physiological changes contributing to chronic constipation and the development of encopresis.
  • Formulate evidence-based plans integrating dietary modifications, medication management, and psychosocial support.
  • Apply practical skills in supporting patients through lifestyle modifications, administering medications, and assessing intervention outcomes.

  Pathophysiology for Constipation/Encopresis

  Constipation:

  Constipation is a common gastrointestinal issue characterized by infrequent bowel movements, difficulty passing stool, or the sensation of incomplete evacuation. The pathophysiology involves several factors:

  1. Decreased Colonic Motility: Constipation often arises from a slowdown in the movement of stool through the colon. This can be due to various causes, including inadequate fiber intake, dehydration, or a lack of physical activity.
  2. Inadequate Water Absorption: Insufficient fluid intake can lead to the absorption of excess water in the intestines, resulting in hard and dry stools that are challenging to pass.
  3. Muscle Dysfunction: Dysfunction of the muscles in the rectum or pelvic floor can contribute to difficulty in expelling stool. Conditions such as pelvic floor dysfunction or rectal prolapse may play a role.

  Encopresis:

  Encopresis, often associated with chronic constipation, involves the involuntary passage of stool into inappropriate places, such as underwear. The pathophysiology is closely linked to constipation:

  1. Rectal Impaction: Prolonged constipation can lead to the accumulation of hard, impacted stool in the rectum. This impaction causes the stretching of the rectal walls, leading to decreased sensation and awareness of bowel movements.
  2. Overflow Incontinence: As the rectum becomes distended, liquid stool may leak around the impacted mass, leading to episodes of involuntary soiling. This occurs because the rectum is unable to contain the additional stool.
  3. Psychological Factors: Encopresis may also have psychological components. Children, in particular, may experience embarrassment or shame associated with their bowel habits, further complicating the condition.

  Etiology for Constipation/Encopresis

  Constipation:

  Understanding the causes of constipation involves unraveling a web of contributing factors that may vary among individuals. Here’s a breakdown:

  1. Dietary Habits: Insufficient intake of fiber-rich foods can contribute to constipation. Diets low in fruits, vegetables, and whole grains may result in reduced stool bulk and slower transit through the digestive system.
  2. Dehydration: Inadequate fluid intake can lead to the absorption of excess water in the intestines, resulting in dry and hard stools that are difficult to pass.
  3. Lack of Physical Activity: Sedentary lifestyles can slow down bowel movements. Regular physical activity promotes healthy bowel function by stimulating intestinal muscles.
  4. Medications: Certain medications, such as opioids, antacids containing aluminum or calcium, and some antipsychotics, can contribute to constipation by affecting bowel motility.

  Encopresis:

  Encopresis often emerges as a consequence of chronic constipation. The underlying causes are interconnected with the factors leading to constipation:

  1. Chronic Constipation: Prolonged constipation can result in the formation of hard, impacted stool in the rectum, leading to complications like encopresis.
  2. Rectal Impaction: The accumulation of fecal material in the rectum due to chronic constipation can cause rectal distension and impact the normal sensation of bowel movements.
  3. Psychosocial Factors: Emotional stress, anxiety, or fear related to bowel movements can contribute to constipation and, subsequently, encopresis. Children may experience shame or embarrassment, further complicating the situation.
  4. Environmental Factors: Changes in routine, such as toilet training or starting school, can sometimes trigger constipation and encopresis in children.

  Desired Outcome for Constipation/Encopresis

  Constipation:

  Establishing clear and achievable desired outcomes is essential for guiding nursing interventions and assessing the effectiveness of care. Here are the key goals for managing constipation:

  1. Regular Bowel Movements: The primary goal is to achieve regular and predictable bowel movements. This involves addressing factors such as dietary habits, fluid intake, and physical activity to support healthy bowel function.
  2. Soft, Formed Stools: Promoting the passage of soft and formed stools reduces discomfort and facilitates easier evacuation. Adequate fiber intake and hydration contribute to stool consistency.
  3. Improved Bowel Motility: Enhancing colonic motility is crucial for preventing constipation. Through lifestyle modifications and, if necessary, medications, the aim is to restore and maintain a healthy rate of stool transit through the digestive system.
  4. Patient Education: Empowering individuals with knowledge about maintaining bowel health, recognizing early signs of constipation, and implementing preventive measures.

  Encopresis:

  Addressing encopresis involves achieving outcomes that not only resolve the immediate symptoms but also prevent recurrence. The desired outcomes include:

  1. Resolution of Encopresis Episodes: The primary goal is to eliminate the involuntary passage of stool and promote regular bowel movements. This involves addressing the underlying causes, such as chronic constipation.
  2. Rectal Impaction Relief: Through appropriate interventions, relieving rectal impaction and restoring normal rectal sensation are crucial for preventing further complications and improving overall bowel function.
  3. Psychosocial Well-being: Mitigating the emotional impact of encopresis by addressing any shame or embarrassment associated with the condition. Providing psychological support to individuals, especially children, and their families.
  4. Preventive Strategies: Educating individuals and families about preventive measures, including maintaining a balanced diet, staying hydrated, and addressing psychosocial factors that may contribute to constipation and encopresis.

  Constipation / Encopresis Nursing Care Plan

  Subjective Data:

  • Abdominal pain
  • Loss of appetite
  • Pain when having a bowel movement
  • Avoidance of bowel movements (withholding, especially in public)
  • Repeat bladder infections (girls)

  Objective Data:

  • Large, dry stools that are difficult to pass
  • Less than three bowel movements per week
  • Bright red blood on the surface of the stool
  • Bedwetting or daytime wetting

  Nursing Assessment

  Constipation:

  A comprehensive nursing assessment is foundational for understanding the nuances of constipation. Here’s a structured approach:

  • Health History:
    • Thoroughly explore the patient’s health history, including any chronic conditions, medications, and dietary habits.
    • Inquire about the frequency and consistency of bowel movements, any associated pain or discomfort, and previous experiences with constipation.
    • Assess the patient’s dietary intake, paying particular attention to fiber-rich foods, hydration, and the consumption of fluids throughout the day.
    • Identify any recent changes in diet that may contribute to constipation.
    • Explore the patient’s level of physical activity and exercise routine. Sedentary lifestyles can impact bowel motility.
    • Examine the patient’s medication list for drugs known to cause constipation, such as opioids, antacids, and certain antidepressants.
    • Document the patient’s typical bowel pattern, including the time of day and any associated symptoms, such as bloating or abdominal pain.

    When assessing encopresis, the focus extends beyond the physical symptoms to include psychosocial elements:

    • Psychosocial History:
      • Explore the patient’s emotional well-being, particularly any feelings of shame, embarrassment, or anxiety related to bowel habits.
      • For children, involve parents or caregivers in discussions about psychosocial factors.

      Nursing Interventions and Rationales

      • Obtain medical and bowel history from the parent
      • Determine if constipation is an effect of other treatments or is functional. Many supplements (iron) and medications may cause constipation. Get information about regular bowel habits or changes in diet or routine.
      • Assess abdomen:
        • Look for distention
        • Listen for slow bowel sounds
        • Feel for palpable mass or tenderness
        • The child may have a palpable mass on the left side that is indicative of constipation. The backup of stool may cause trapped gas and lead to distention of the abdomen as well.
        • Assess vital signs
        • Determine baseline. Severe constipation can lead to perforation and peritonitis – vital signs can indicate signs of infection.
        • Assess the anus and rectum for signs of bleeding
        • Small fissures around the anus from the pressure of or from passing large stools may cause bright red, superficial bleeding. These fissures can become infected if not treated.
        • Administer stool softeners or laxatives; suppositories or enemas as needed
        • To soften stool and help pass impacted stool, a regular stool softener may be added to the patient’s daily routine to help encourage normal bowel habits.
        • Suppositories or enemas may be given to help relieve severely impacted feces.
        • Encourage warm tub bath
        • The warm water helps to relax the muscles in the rectum and soothe the perianal area.
        • Educate patient or caregivers on diet and lifestyle modifications
          • Increase dietary fiber intake
          • Decrease or avoid cow’s milk to check for intolerance
          • Encourage fruits and vegetables
          • Avoid processed foods or fast food
          • Avoid large amounts of fruit juice as it has a large amount of sugar which can lead to constipation
          • Encourage adequate intake of water
          • Encourage regular activity
          • Promote bowel training
          • Provide plenty of time and a comfortable atmosphere for bowel movements
          • Dietary changes help the colon process stool and help make the stool more easy to pass.
          • Sugar and processed foods are convenient but lead to constipation.
          • Activity and exercise help promote peristalsis and the passage of stool.
          • Routines are important for children, so setting times for bowel movements can help eliminate the need to withhold stool.
          • Children need to have plenty of time, especially if passing hard stools. Rushing can cause them to withhold and make constipation worse.

          Evaluation

          Constipation

          Effectively evaluating the outcomes of constipation management involves a systematic approach

          Bowel Movement Patterns

          • Regularly assess and document changes in the patient’s bowel movement patterns. Note the frequency, consistency, and ease of evacuation.
          • Evaluate if there is an improvement in stool quality, moving towards softer and well-formed stools.

          Patient Feedback

          • Engage in open communication with the patient to gather feedback on their experiences. Ask about any relief from discomfort or improvement in overall well-being.

          Dietary Modifications:

          • Evaluate the impact of dietary modifications. Assess whether the patient has successfully incorporated fiber-rich foods and increased fluid intake.

          Medication Effectiveness:

          • If medications were prescribed, assess their effectiveness in promoting bowel regularity while monitoring for any side effects.

          Patient Education:

          • Gauge the patient’s understanding of preventive measures and lifestyle changes. Assess if they can independently implement strategies for maintaining bowel health.

          Evaluating the resolution of encopresis involves a comprehensive approach:

          Reduction in Involuntary Soiling:

          • Monitor the occurrence of involuntary soiling episodes. A reduction in frequency indicates progress in managing encopresis.

          Rectal Impaction Relief:

          • Assess for relief of rectal impaction through physical examination and patient-reported symptoms.

          Psychosocial Well-being:

          • Evaluate improvements in psychosocial well-being, particularly for children. Reduction in feelings of shame or anxiety related to bowel habits indicates positive outcomes.

          Family Involvement:

          • Assess the involvement of family members in supporting the management plan. Collaborate with parents or caregivers to ensure a conducive environment for the child’s success.

          References

          • https://www.mayoclinic.org/diseases-conditions/encopresis/symptoms-causes/syc-20354494
          • https://www.mayoclinic.org/diseases-conditions/constipation-in-children/symptoms-causes/syc-20354242
          • https://www.niddk.nih.gov/health-information/digestive-diseases/constipation-children/symptoms-causes

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          Example Nursing Diagnosis for Constipation / Encopresis

          1. Constipation: This diagnosis directly addresses the issue of constipation, including its causes, contributing factors, and interventions to promote regular bowel movements.
          2. Risk for Impaction: Chronic constipation can lead to fecal impaction. This diagnosis highlights the risk and the need for preventive measures.
          3. Deficient Knowledge: Some patients may lack knowledge about healthy bowel habits and factors contributing to constipation. This diagnosis addresses the educational needs of the patient.

          Transcript

          Hey, you guys, in this care plan, we're going to be discussing constipation and encopresis. What we're going to cover in this care plan is a description of the diagnoses, the subjective and objective data related to them, and then your nursing interventions and rationales.

          Alright, so constipation is actually a really common problem for children and this is especially true for our toddlers and preschoolers. So, you're looking at kids from the age of one up to probably around five years of age. And this is because during this age range, they are toilet training. They're learning how to not be picky eaters and all these things combined, make them at increased risk for constipation. By definition, constipation is when a child has less than two or three bowel movements per week and typically, the stools are going to be very hard and dry and difficult to pass. Sometimes, they can actually be so large that they block the toilet. I know that's difficult to imagine for these tiny people, but it is true. Now, if it becomes really, really bad, the child may experience something called encopresis. Encopresis is when the child involuntarily passes stool into their underwear and you can read a little bit more about how these things happen in our etiology section here.

          So, our number one goal for a patient who has constipation or encopresis is for them to experience a normal bowel pattern. We want them to have soft form, easy-to-pass stools. A second goal that we would have here is to have decreased anxiety. These children can really get worked up and have a lot of difficulties with this and that just creates a really bad cycle for them where they continue to get constipated because they keep having anxiety, so we really want to work to break that cycle.

          Alright, let's get started by looking at the specifics of our care plan. We'll start with the subjective data here. So, one of the major things that you're going to see in children with constipation is abdominal pain and sometimes, that pain can be really severe and it can actually decrease their level of activity. Sometimes parents notice that the pain kind of comes and goes, and this is especially true around mealtime. You can see something that would link to that in a bit, but you'll also see that it has a loss of appetite as a consequence. So, you may see children that are eating less because of this pain around mealtime. Other subjective data is that they may experience pain. We may notice that they are avoiding bowel movements, especially in public and then for some of our girls with constipation, they may have repeat bladder infections.

          The objective data that's associated with this diagnosis is first, those large dry stools that we mentioned and then again, thinking about how many bowel movements they're having per week, so it's less than three. Then sometimes if they have continual issues with this, they may develop anal fissures. If that happens, they may notice that there's blood on the surface of the stool, or they notice that when they're wiping, it's typically bright red blood. And again, in severe situations, they may experience bedwetting or even daytime wetting. Now, let's take a look at our interventions and rationales. So, the very first thing that you want to do is just really talk to the parents. You need to talk to them and obtain a medical and bowel history to sort of find out what a potential cause might be. We need to know why these children are experiencing this. So, some common causes to be on the lookout for are medications. Some common ones that you may see are like iron. Iron is going to potentially cause constipation and then, some of our anti-seizure medications as well. You also want to be aware of some really concerning neurological causes. So, thinking about things like spina bifida and then Hirschsprung's disease is another one to be aware of. That may present at birth with a delayed meconium. The most common cause of constipation in kids is something that we call functional constipation and because of that, it's really important to ask families about their bowel habits, about toilet training and diet, because that's what functional constipation is. It just means that it's caused by lifestyle things like diet and activity.

          Then you want to move on to really assess the abdomen and the main things that you want to do are first, to look for abdominal distension. Secondly, you want to listen to bowel sounds and then third, you want to palpate and feel for any kind of palpable mass. Now, what you're looking for here is often that if you feel a palpable mass on the left side, that is usually indicative of constipation. Next, you want to assess the patient's vital signs. If the child is in a lot of pain, you may notice an increase in heart rate and an increase in respiratory rate as well. In more severe situations, if the constipation has led to something like a bowel perforation, you want to be on the lookout for signs of shock. So, the things you want to be looking for there are, again, increased heart rate, increased respiratory rate, and then delayed capillary refill time, and eventually, decreased blood pressure.

          To continue our assessment, we want to make sure that we assess the anus and rectum for any signs of bleeding and when we're doing this, we're thinking about the possible complications like fishers and rectal bleeding. So when you take that history from the parent, we need to talk to the parent and find out if they have seen any bright red bleeding in the stool or even on the toilet paper when the child is wiping, then need to assess the anus and rectum and just look for signs of bleeding, because remember these need to be treated because we don't want them to get infected. Medications that you are going to expect to see in a child that's constipated are your stool softeners and laxatives, suppositories and enemas may be given if there is a fecal impaction and if constipation becomes a chronic problem. Stool softeners, and laxatives may be given on a daily basis to help prevent that. Oftentimes, that is a really good way to help break that cycle of anxiety that we talked about by making sure that we can relieve the pain and the child becomes comfortable with that process. Again, a really practical thing that we can do for parents is to encourage them to give their child a warm tub bath. These are very easy ways for a parent to step in and do something. It helps relax the smooth muscle in the rectum and suit the perineal area, and just makes the child more comfortable and reduces their anxiety.

          Our last intervention here is super, super important. So we really want to make sure that we take time to educate parents on this. Like I said, most of the time, the issues for constipation are functional. So again, it's about bowel habits, toilet training and diet. So our last intervention here is about making sure parents know about lifestyle modifications that they can make for their child. Important things to get across to them are the importance of decreasing sugar and processed food. They need to avoid excess dairy, which can contribute to that and encouraging exercise and making sure that the child stays well hydrated are going to go a really long way to helping prevent constipation. Really getting them into a routine is going to allow them to be comfortable and not avoid this problem.

          Okay, that's it for our care plan on constipation and encopresis. Remember we love you guys. Go out and be your very, very best self today and as always, happy nursing!

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