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