When To Get Professional Help

The first question you should ask is whether the person who is constipated needs help from medical professionals.

Call the doctor or nurse during regular office hours if any of the following is true:

• Your child has not had a bowel movement in 3 or 4 days. Your child will be more uncomfortable as the constipation continues. If it is allowed to go on for more than a few days, it also will be more difficult to reverse. Reporting the usual bowel pattern and the day and type of the last movement helps the doctor or nurse to suggest medications and to advise you on other measures to take to help relieve the problem.
• Severe straining on the toilet or commode.
• Intermittent cramping with a full (rounded) abdomen. Reporting other symptoms and their severity alerts health care professionals to the need to assess whether other, more serious, problems are present. In these situations, constipation is a sign or side effect of these problems. Pain or vomiting can indicate an abdominal problem, such as a temporary blocking of a section of the bowel, or infection.

Call the doctor or nurse immediately if either of the following is true:

• Severe abdominal pain or an abdomen that feels harder than usual, and very full.
• Red blood around the outside of the stools. These symptoms can indicate that tearing has occurred in the tissue around the rectum, which can become the site of entry for a serious infection.

When you call, the doctor or nurse may ask you these questions:

1. How often are the usual bowel movements? The question assesses the degree of constipation.
2. When was the last bowel movement? What did it look like? Reporting what the last bowel movement looked like (watery or dry) tells the health care professional if food is being digested properly and if the stool has enough water in it as it passes along the long digestive and intestinal tract. In addition, color is very important to report. Very dark black stools could indicate blood in the stool.
3. Does your child normally take medicines to help move the bowels, such as stool softeners, Colace, or Senokot? It is important to report what bowel-movement aids your child is taking so the doctor or nurse will know what is working and what isn't, and suggest alternatives.
4. Does feeling constipated interfere with normal activities, such as walking or eating? The degree to which constipation is interfering with your child's comfort and activities is very important to report, because it guides the health care professional to prescribe stronger or gentler medi-cines and actions to relieve the constipation.
5. What other symptoms are there?
   • -distention or bloating of the abdomen
   • -pressure or sense of fullness in the rectal area
   • -small, frequent "smears" of stool
   • -small amounts of loose stools or "leaking," or diarrhea
   • -rectal pain with a bowel movement
   • -constantly feeling the need to have a bowel movement but unable to pass stool

   Answers to questions about other symptoms help describe the severity of the constipation. If there is no bowel movement for days but small amounts of diarrhea occur, then telling the health professionals about both problems may alert them to the possibility of impacted stool.

6. What medications did your child take in the past two or three days?
   • -narcotics
   • -stool softeners
   • -chemotherapy

   Some medicines can interrupt normal bowel activity, and the doctor or nurse will recognize which medicines might be contributing to constipation. Therefore, be sure to mention whether any medicines were started that week.

7. What and how much did your child eat or drink in the past 24 hours?

   Finally, if health care professionals know about food and fluid intake, they can judge if the constipation is leading to an emergency and requires a clinic visit. If they decide that relieving constipation is not an emergency, they may suggest an increase in fluids as well as many of the actions that are listed on the following pages.

Here is an example of what someone might say when calling:

"I am Aaron Ramirez, Tiffany Ramirez's father. My daughter is Dr. Luckenbaugh's patient, and she has been diagnosed as having Wilm's tumor. The homecare plan for constipation says to call if she hasn't had a bowel movement for four days. She feels as if she should go, but nothing happens."

What You Can Do To Help

There are two things you can do to help solve a constipation problem.

• Relieve constipation
• Prevent it in the future

Relieve constipation

If being constipated is not an emergency and you don't need to call a doctor or nurse, the next step is to help relieve constipation and discomfort.

• Give oral stool softeners and use them every day:

  Start with a dose in the morning and one in the evening. If that doesn't provide relief, add a third daily dose. Continue this regimen until it is effective.

  A stool softener draws water into the bowel and decreases the dryness of stools so that they can more easily move down the long intestinal tract. These can be tried if the child does not meet any of the "call right away" criteria. Tablets, syrups, or "sprinkles" can be bought at any pharmacy, there are many brands to choose, and Colace or Senokot tablets are frequently recommended for children or young people. If finances are a concern, ask the pharmacist about less-expensive options and ask clinic staff if they have samples.

• Give a mineral enema, Fleets enema, soap suds enema, or suppository for immediate relief, but only if directed by an oncology doctor or nurse. Enemas are the last step to try when relieving constipation. They evacuate the lower bowel, which helps the upper bowel move as well. If an enema is recommended, ask for specific instructions about how to do this for your child.

  If blood counts are low or if the lining of the rectum is already inflamed, an enema or suppository can cause further breakdown and lead to a serious infection. Therefore, these should only be used at times specifically recommended by your oncology doctor or nurse.

Prevent constipation

There are many things you can do to prevent constipation. If your child has been constipated recently, you should use these tips to prevent it.

• Gradually add foods high in fiber to the diet, such as:
  • -Whole grain cereals and breads
  • -Dried fruits, such as prunes and raisins
  • -Popcorn, nuts, and seeds
  • -Beans and legumes
  • -Raw fruits and vegetables

  High fiber-foods draw water into the stools. They also provide bulk-that is, they are made of materials that do not break down as the food passes through the intestines. For example, skins and coverings on nuts, beans, grains, fruits, and vegetables are not easily broken down, and these help form stools that are easily passed out of the body. If raw fruits and vegetables are hard to chew, try grating or cooking them.

• Add unprocessed bran to the diet. Bran stimulates bowel activity. Sprinkle it on cereal. Start with two teaspoons per day and gradually increase this amount up to two tablespoons per day. Be careful. Adding large amounts of bran to the diet too quickly might cause diarrhea and discomfort. Also, be sure to read the next item.
• Encourage your child to drink plenty of liquid every day. (Consult your doctor or nurse for the correct quantity to insert in a table of fluids.) Fluids add water to the stools and prevent dry hard stools. It's necessary to do this step along with the step above. You can encourage fluid consumption alone, but if your child is eating bran, it must be accompanied by more liquids.
• Offer hot or warm liquids such as tea, or lemon water. Hot or warm liquids stimulate the bowels. People often say that coffee makes them go to the bathroom. It's the combination of caffeine and hot liquid that causes this. Hot tea or hot lemon water also can be effective.
• Serve prune juice, other fruit juices or nectars. Prune juice, whether warm or cold, stimulates the bowels to work.
• Exercise, such as walking every day, also helps. Even a small amount of movement, such as walking in the house, helps stimulate muscles like the bowel. Talk to the doctor about the amount and type of exercise that is right.
• Avoid regular use of laxatives or enemas. Laxatives-bowel stimulants or irritant-may cause cramping and prevent the intestines from finding a regular pattern. These are different from stool softeners.
• Give one or two stool softeners every day. Giving one or two stool softeners every day will help prevent constipation. If the person is eating or drinking less and not feeling well enough to get exercise then stool softeners should be tried.
• Try diet and exercise tips first, then medicines, and follow a daily schedule just as you do with other medicines. Following a schedule of diet, exercise, and medicines to prevent constipation should be considered as important as taking other medicines. Daily attention to eating helpful foods, drinking liquids, and taking preventive medicines will add up to successful prevention.

Possible Obstacles

Think about ideas and attitudes that could prevent you from carrying out your plan to solve your child's constipation problem.

"I saw some liquid B.M. How could he be constipated?"

Response: Sometimes a child can be constipated but small amounts of liquid bowel movement can leak around the harder stool that is lodged in the lower bowel. Report the absence of normal stools and mention the small amountof liquid diarrhea, too. Constipation can become very uncomfortable for the child if left untreated.

Carrying Out and Adjusting Your Plan

Prepare in advance for constipation, especially if Vincristine or narcotics are prescribed, or if the person is less active. Use this homecare plan as a reference and begin to change diet and food habits to prevent constipation.

Checking on results

After new medicines are started, determine whether your child's bowel habits are changing. Is the constipation happening less frequently? When it does happen, do you both know what to do to relieve it? Are your actions to prevent constipation taking effect?

If your plan doesn't work

If your plan doesn't seem to be working or your child's constipation is getting worse, you can take three actions. Consider them in this order.

1. Check the "When To Get Professional Help" section of this care plan. If you answer yes to any of those questions, call the doctor or nurse according to instructions.
2. Develop a new strategy using this homecare plan.
3. If constipation continues, ask the doctor or nurse for help. Describe what you have done and what the results have been.

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