Working towards a multidisciplinary approach to managing ...€¦ · Working towards a...
Transcript of Working towards a multidisciplinary approach to managing ...€¦ · Working towards a...
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Working towards a multidisciplinary
approach to managing constipation
Managing Chronic Constipationand Soiling in ChildrenInformation booklet for parents/carers
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Constipation
• Constipation is a very common condition that affects approximately 10% of children.
• The most common reason for soiling is constipation.
• Of children who soil, 95% also have chronic constipation
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Background
• Increasing numbers of children were being admitted and readmitted to the inpatient service with a diagnosis of “constipation”
• The main reasons the bowel becomes faecally loaded again is the constipation is undertreated, inconsistent education and lack of appropriate & timely follow up.
• Different regimens were being used and thus there was no standardised practice.
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Background
• It is a massive challenge to the family, especially if associated with soiling (these children may have other complex medical issues)
• If managed from the start, simple constipation may not become chronic, as the chronicity of constipation is mostly preventable .
• Chronic constipation is an issue within the community, and within both paediatric and gastroenterology clinics.
• Mixed messages are given to families and the community
• We felt the care needed to be improved!
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• The pathophysiology of functional constipation involves painful bowel movements, leading to faecal withholding and a possible fear of toileting
• Large, withheld stools ultimately cause more pain, leading to more withholding, creating a vicious cycle of disordered defaecation and toilet avoidance.
• If untreated, this problem can progress to rectal dysfunction and incomplete rectal emptying, learnt avoidance of the normal urge to void, and recurring involuntary faecal incontinence.
Background
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• The majority of children admitted to the unit with constipation are seen by our Enrolled Nurse (specialist in constipation management) who educates families on constipation and for toileting support
• Constipation management does not get enough time to be addressed in a general paediatric clinic, unless it is the only reason the child is presenting, which is not common.
• Multiple other issues occurring with these families need to be addressed by Paediatricians in the clinic (i.e. often at the end of the consult, the comment from parents/carer is “by the way my child also has trouble pooing”).
• A Clinical Nurse (portfolio of Constipation Management) in the Paediatric Clinic follows up on the children admitted to the ward and those who present to the clinic.
Background
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So….How did we begin?
• Our Clinical Nurse and Enrolled Nurse attended a workshop in Melbourne - then the journey started!
• Rebecca Khan workshop: OT in Brisbane – runs her own clinic – “Kids that Go”
• Key messages received from the workshop– Patient and parent education– Consistency in plan – Frequency of visits after clearance – Enemas need to be avoided if possible – Medication routine– Toileting routine– Consequences of chronic constipation on children and
their family
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What we did next• We started to look at our own practice and the
practices in different public hospitals
• We found there is:– individual management (dependent on physician)
– no regular follow up
– repeat admissions for clearance
• The message to families seems to be “if there are hard stools, take more laxative”, ? education or addressing challenges and family intervention
• Other hospitals– limited by resources - one nurse consultant is looking forward to having a copy of our book
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Creation of the booklet
We had multiple meetings to review the ‘Department of Queensland Health’ booklet which was adapted to our environment.
Authors included –• Paediatric Consultant – Dr Noha Soliman
• Clinical Nurse – Ruth Willis
• 2 x pharmacists – Rosina Gergis and Mark Minervini
• Enrolled Nurse - Maggie Phillips
• Consumer Representative – Sandra Kitchener
• An External Occupational Therapist – Debbie Atkins
• Outpatient Clinic, Clinical Nurse – Sandra Hii
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What is in the booklet
The Flinders Medical Centre – Paediatric Unit booklet contains:
– Managing Chronic Constipation and Soiling in Children
– Medical Management
– Medications
– Choose your Poo chart
– Diet and Fluids
– Exercise/Toilet set up/routine/posture
– Diary
– Resources
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Management plan
• Other medical issues like asthma, seizures, anaphylaxis have a plan of management, but chronic constipation did not.
This written management plan will assist with:
• Parent information
• GP awareness of management
• Intranet → constipation action plans – the doctor can use the same management plan template.
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Constipation – what is in the book!
Medical ManagementThere are three main steps to managing constipation:
STEP 1: CLEAR OUT the blockage of faeces.
• Medicines
• A possible visit to hospital to have a ‘washout’ STEP 2: MAINTENANCE
• of soft stools and regular toilet timeSTEP 3: RESCUE PLAN
• Relapses are common, it is important to teach parents/carers to recognise symptoms and respond
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Management plan
• The back page of the plan is the Bristol Stool Chart, for parents to monitor the child’s bowel consistency and size
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What we currently do in acute Management
• Assessment by the medical team – looking for possible ‘red flags’
• When referred, our Enrolled Nurse discusses the booklet whilst the child is an in-patient with the family
• She provides education and support with the in-patient and family
• Medical staff discuss the medication and management plan with the family/carers
• Toilet retraining is most effective after bowel clearance
• When and where to start retraining? - This is best achieved in the community and in their own setting.
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Our Aim
• Educate other staff – within the department
• Half day workshop in the near future inclusive nurses, medical, allied health, GP
• Outpatient management ??
• Multi D: – Keen people: dietitian – psychology- nurses –
paediatrician – OT – ( Resources and time needed)
• Model of care – Meetings in progress with the above interested discipline
• Outpatient vs community and how to integrate
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Our aim
• Chronic functional constipation is a long-term condition that needs ongoing management by the parent and child, with the child increasing in independence as they get older (our hope is to stop constipation becoming a long-term condition)
• Our aim is to recognise constipation early, to give parents/carer’s appropriate, consistent education and management, facilitate ongoing follow up and support , and prevent the condition from becoming chronic
• And for those who suffer from long term constipation –to resume intensive management and address the emotional and behavioural consequences.
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Consumer feedback on the booklet
• “Very well written”
• “Easy to understand”
• “Great work to everyone involved”
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Questions?