Toilet Training

Developmental Needs

The urinary and intestinal systems need to be intact

Functions of the Kidney

Control of sodium balance Controls chloride balance Controls water balance Controls potassium balance Excretes organic acids Conserves bicarbonates Excretes waste products

Physical and Health Impairments

Cerebral palsy Spina Bifida or spinal cord injury Congenital abnormalities Duchene muscular dystrophy

Prerequisites for Toileting

Stability in pattern of elimination Daily 1- to 2-hour periods of dryness A chronological age of 2 years or

older

“Bladder training” Void on a time table Regulate fluid intake Encourage fluids about ½ hr prior to voiding Avoid excessive intake of citrus juices,

carbonated, artificially sweetened, or caffeine beverages

Schedule diuretics in morning Avoid using diapers Provide positive reinforcement

Approaches for Toileting

Traditional methods: rely on toileting students when they are likely to experience bowel or bladder tension

Rapid methods: require students to consume extra fluids, creating more frequent bladder tension and thus additional opportunities for toileting

Stages of Toilet Training

Regulated Toileting Self-initiated Toileting Toileting Independence

Assistive Devices for Toileting

Stand alone toilets Devices that fit over toilets Risers Pads and supports

Assistive Strategies

Environmental Arrangement

Assistive Strategies

Environmental Arrangement Transfers

Assistive Strategies

Environmental Arrangement Transfers Positioning

Assistive Strategies

Environmental Arrangement Transfers Positioning Abdominal Massage

Assistive Strategies

Environmental Arrangement Transfers Positioning Abdominal Massage Medication

Principles for Toilet Training Familiarize the student with the toilet Associate toileting activities with the

bathroom Establish times to use the bathroom Determine whether a boy should sit or

stand to urinate Reinforcing success Teach child to perceive feelings of fullness Teach proper hygiene

Trip Training Method (Azrin & Foxx)

Positive reinforcement Positive practice to inhibit

inappropriate toileting behavior Immediate feedback for inappropriate

urination Increase in quantities of liquids Scheduling

Trip Training methods

Pretraining data Setting the schedule Instruction Bowel Training

Toileting Problems Urinary tract infections Constipation Impaction Diarrhea Over hydration Intestinal parasites Skin breakdown Pica and Fecal smearing

Constipation

Fewer than 3 bowel movements/week Small, dry, hard stool, no stool Slow movement through GI tract

allowing for reabsorption of fluid Straining, pain, cramps, decreased

appetite, headache Must identify regular elimination

pattern

Causes of constipation Insufficient fiber and fluid intake Immobility or inactivity Irregular defecation habits Change in routine, emotional

disturbance Lack of privacy Chronic use of laxatives medications

Types of Laxatives Bulk-forming: increase bulk in intestines Emollient/stool softener: delays drying,

allows fat and water penetration of feces Stimulant/irritant: irritates mucosa or nerve

endings to induce propulsion Lubricant Saline/osmotic: draws water into intestine

to stimulate peristalsis

Laxative Contraindictions

Nausea Cramps Colic Vomiting Undiagnosed abdominal pain

Fecal Impaction

A mass or collection of hardened, puttylike feces in the rectal folds

Results from prolonged retention and accumulation of fecal material

Oil retention enema, cleansing enema, suppositories, softeners

Last resort: manual removal

Signs of fecal impaction

Passage of liquid stool (seepage) Desire to defecate but unable Rectal pain Distended abdomen Anorexia Nausea/vomiting

Diarrhea

Passage of liquid stools with increased frequency

Rapid movement through the GI tract Spasmodic cramps, increased bowl

sounds, mucus, nausea, vomiting, irritation of rectal area, fatigue, weakness, malaise

Causes of diarrhea

Stress, anxiety Medications Allergy Food intolerance Disease surgery

Bowel incontinence

Loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter

Flatulence Presence of excessive flatus in the

intestines and inflation of the intestines Abdominal distension Causes: bacterial action, swallowed air, and

gas diffusion from the blood stream Foods surgery, narcotics can cause

flatulence Treatment: antiflatulent agent such as

antacids

Management issues

Individualized Health Plan Augmentative Communication Diet Activity Level Gender of personnel helping student Training in inclusive settings

Urinary Catheterization/Devices

Process of inserting a tube into the bladder to eliminate urine

Sterile Catheter CIC: long, thin tube is inserted

through the urethra and into the bladder on an intermittent basis

Problems and emergencies

Infection Inability to pass the catheter Omission of catheterization No urine Urine between catheterization Soreness, swelling, discharge Bleeding

Credé

Manual compression of the bladder Used with individuals with decreased

bladder tone who have decreased outlet resistance

Prescribed by a physician No equipment. However, a folded towel

may be used. Used in conjunction with CIC

Ostomies and Colostomies

Colostomies and other ostomies

Ostomy: artificial opening Three types

Ostomies of the urinary system Ostomies of the small intestine Ostomies of the large intestine

Equipment

Colostomy bags Iliostomy bags Ureterostomy bags Skin barrier

Strategies

Emptying bags Changing bags

Problems and emergencies

Gas and odor Leakage Skin problems around stoma Bleeding from stoma Diarrhea or vomiting Obstruction Change in stoma appearance