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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Enuresis: Nursing Diagnoses and Treatment Janet M. Teets Published online: 07 Jun 2010.
To cite this article: Janet M. Teets (1992) Enuresis: Nursing Diagnoses and Treatment, Journal of Community Health Nursing, 9:2, 95-101, DOI: 10.1207/s15327655jchn0902_4 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0902_4
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(2), 95-101 Copyright O 1992, Lawrence Erlbaum Associates, Inc
Enuresis: Nursing Diagnoses and Treatment
Downloaded by [University of Auckland Library] at 19:50 13 October 2014
Janet M. Teets, MSN, RN Miami University
Living with a child with enuresis is not a major or critical problem, but it is a difficult and frustrating one. Wet sheets, wet pajamas, and rooms that smell of urine all add to the dismay felt by child and parents. Enuresis is a common problem which affects 22% of 5 year olds and 10% of 10 year olds (Scipien, Barnhart, Chard, Howe, & Phillips, 1986). Boys are affected more often than girls. There tends to be few answers given in the health-care system for the problem other than, "he'll outgrow it." Community health nurses (CHNs), working in the clinic, in the school setting, or in the home, may find parents and sometimes the child asking for help with this problem. This article presents the most common nursing diagnoses that apply to the family of an enuretic, and nursing interventions that can guide the nurse in working with the family to secure successful methods of treatment. ALTERATION IN ELIMINATION
The primary nursing diagnosis would be alteration in elimination: nighttime incontinence related to unknown causes (Carpenito, 1992). Qpically the parents try to help the child stay dry during the night in a number of ways. They may awaken the child to take him to the bathroom. Often, however, they complain that the child is such a sound sleeper that he did not even awaken when walked to the bathroom. This method may soon be abandoned when the parents see little progress in the child's ability to urinate when aroused from a deep sleep. Parents may try limiting the child's fluids before bedtime. This, too, has been found to be ineffective, and may lead to power struggles and arguments. Asking the older child to do the unpleasant task of changing wet sheets may be tried; again, this is usually ineffective in stopping the bedwetting. Another method suggested to parents is bladder stretching exercises (Azrin & Besalel, 1981; Long, 1991; Ruble, 1981; Sadler, 1990). The child is asked to drink as much of his favorite beverage as he can and "hold it" for as long as he can. When the urge to urinate becomes very strong, he is to void, measuring the amount. Gradually, it is hoped he can increase his bladder capacity. Interestingly, because of either a small bladder or a hypersensitivity to the urge to urinate, even holding 300 cc -
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Requests for reprints should be sent to Janet M. Teets, MSN, RN, Assistant Professor, Department of Nursing, Miami University, 1601 Peck Boulevard, Hamilton, OH 4501 1 .
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of urine can be very uncomfortable. Starfield (1986) found a significant increase in functional bladder capacity over a 3- to 6-months time as a result of these exercises. However, because of the slowness in achieving good results, the family may become discouraged and quit.
Downloaded by [University of Auckland Library] at 19:50 13 October 2014
Nursing Interventions
Treatment methods are not usually suggested until the child is at least 7 years old (Goldstein & Book, 1983). The most successful method of treatment that can be suggested to the family is the use of conditioning therapy or behavior modification techniques (Ack, Norman, & Schmitt, 1985; Gibson, 1989; Sadler, 1990; Shapiro, 1985). This usually involves attaching an electronic clip that is very sensitive to any wetness to the front of the underwear. When the child urinates even a drop, an alarm, attached to the wrist or shirt, immediately beeps until disconnected. NyTone@and Wet-Stopo are brand names of such alarms, and can be purchased from medical supply stores. Clinics that offer treatment programs specific to enuresis may rent or loan the devices as long as needed. In working with a family using conditioning, it is suggested they keep a diary of baseline data for 2 weeks before the alarm is used. By documenting the number of urinations, the amount of oral fluids and the number of enuretic episodes, the family may see patterns, and then also improvements. After the baseline data is collected, the alarm should be used every night, with the child being taught how it works. The parents are cautioned that they will probably wake up before the child when the alarm sounds, and will need to take him to the bathroom. This may happen for several nights, and perhaps more than once during the night. Gradually, however, the child should begin to wake up more quickly when the alarm sounds, and will begin to eventually wake up just as he begins to urinate. The family should keep a record of these occurrences, as well as how difficult it is to wake the child. Along with the use of the alarm, positive reinforcement is planned with the parents and child (Gibson, 1989). The behavior needed to get a reward should always be possible for this particular child. The number of dry nights in a week leading to a reward can be decided by looking at the diary. As the child experiences more dry nights, the number of dry nights per week needed for a reward should also increase. Another treatment method that has been tried alone, or in conjunction with conditioning, has been hypnosis (Hobbie, 1989; Robertson, 1980; Stanton, 1982). Child psychologists may practice hypnosis, as do selected pediatric nurse practitioners. Hobbie (1989) suggested that the hypnotist make a tape of hypnotic suggestions for the child to use every night at home, so that he can then gradually learn to repeat those same positive suggestions to himself without the use of the tape. The hypnotist stresses that the child can have good muscular control over his bladder, just as he does over other muscles in his body. The child is urged to use the positive suggestions to himself before going to sleep every night until dryness is achieved, and for any subsequent relapses.
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The most common method of treatment, although less successful than conditioning, has been the use of imipramine, a tricyclic antidepressant. It is thought to decrease the depth of sleep, allowing the child to wake up more easily to get to the bathroom (Ack et al., 1985). Ruble (1981) suggested that it can be highly effective in decreasing enuretic episodes within a few days, and will produce cures in 3 to 4 months. Newcomb (1991) questioned whether the tricyclics are effective for enuresis, but stated they may be helpful if behavior modification is not successful. Although good results have been reported with this method, Shapiro (1985) pointed out some of the dangers in that there are rare incidents of agranulocytosis, personality changes, atropine-like effects, cardiac irritability, and even sudden death.
BODY IMAGEISELF-ESTEEM DISTURBANCE
Another possible nursing diagnosis for the enuretic child may be altered body image and/or lowered self-esteem related to the inability to control urine at night (Carpenito, 1992). The child usually feels ashamed that he wets the bed. Because of this problem he will often be uncomfortable in spending the night with friends, fearing he will embarrass himself by waking up wet. He may feel reluctant to take friends to his room for fear they will discover the plastic sheet on his bed or will notice a urine smell. When the enuresis has continued for some time with no change, even after trying a variety of methods, a sense of powerlessness results for both the child and parents. They feel nothing will work to solve this perplexing problem. The child may become convinced there is something wrong with him or his body that could contribute to a lack in confidence in other areas of life. Similarly, the parents may feel guilty and ashamed because their child has not outgrown this baby stage, and believe that it must be due to their poor parenting. Nursing Interventions
In helping the child improve his body image or self-esteem, it is important to tell him that many children have this problem. He needs to be told that for some reason he did not form proper elimination habits when younger, but that he can learn new habits. It is important that the child understand that there is nothing wrong or weak about him, and that the problem can be solved. The parents need the same teaching. In solving some of the disagreeable aspects of enuresis, and to help the family feel a sense of control, the child and his parents can agree on methods that will eliminate any odor in his room, and discuss ways to successfully hide the problem while sleeping with friends. He may need support and encouragement that he can successfully spend the night at a friend's house without being discovered. For example, the child could always sleep in his own washable sleeping bag, or use some of the disposable incontinent underwear for overnight outings, slipping them on and off in the sleeping bag so no one can see. A matter-of-fact approach that respects
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the importance of this problem for the child and helps him problem solve with his parents will go far in improving his self-concept.
Downloaded by [University of Auckland Library] at 19:50 13 October 2014
ALTERATION IN PARENTING It is also possible that alteration in parenting related to the child's bedwetting may result (Carpenito, 1992). The parents may feel guilty, thinking that they caused the enuresis somehow through their parenting methods. They may feel ashamed that their child has this problem, and try to hide or deny it. Hoping that a change in their behavior will stop the bedwetting, they become more strict, and insist to the child that he could quit bedwetting if he only tried harder. If that does not help, they may become more permissive in discipline, hoping that will help. Besides being inconsistent in their approach to the child, they may use excessive punishment or ridicule.
Nursing Intervention Helping the parents and child understand what is known about causes of enuresis is important. Shapiro (1985), in reviewing the literature, found that several causes have been suggested, including: psychiatric problems, urinary tract infections, allergies, pinworms, obstructive uropathy, and urethralhaginal reflux. When investigated, however, none were found to be a significant cause. Shapiro did conclude that children with enuresis probably have small bladders, or are deep sleepers with uninhibited bladder contractions, and heredity may play some part in the cause. Because there is a possibility that a physical problem may be causing the enuresis, a medical workup of the child is necessary to rule out physical causes. Equally important in helping the parents deal with enuresis is to encourage them to express their frustrations and fears. Voicing the fear that they somehow must have caused this problem, which is sometimes erroneously viewed as a psychological problem, can provide much relief. When the facts are presented, and they recognize their frustration, anger, and powerlessness as normal reactions to a common problem, they become more free to problem solve and work on solutions. The nurse must also make sure they understand that spankings or humiliations will not stop the enuresis and will only lead to further negative effects on the parent-child relationship.
Case Example J. was a 10-year-old boy when he and his mother sought treatment for enuresis at the psychology clinic of a Children's Medical Center. J. had achieved dryness during the day when he was 2 1/2 years old, but had never achieved consistent night dryness. Over the years the parents had tried a variety of methods. One method was to get him up to walk to the bathroom to urinate after he had been asleep for an hour;
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however, he would not arouse easily, and if the parents did manage to get him to walk to the bathroom, he would rarely comply with the request to urinate. Limiting fluids was tried, but that made no difference on the number of dry nights, and sometimes resulted in arguments. When J. was 7, the family asked their family doctor to let them try a trial of Tofranil. After 4 days of taking it, and 4 wet nights, the mother felt the child was becoming very short-tempered, and acting as though he was not getting enough sleep, so the medicine was stopped. The family tried Tofranil at other times when J. was older, once for a 2-week period, but he never achieved any dryness. When J. was 9, the Azrin and Besalel (1981) "dry-bed training" method was tried. Azrin and Besalel gave several testimonials of quick cures, but, although the training techniques were followed to the letter, J. continued to wet the bed. The family doctor suggested an intravenous pyelogram and urinalysis to rule out physical causes; these proved to be negative, and the doctor told the family that J. would "outgrow" it. A sense of defeat and depression enveloped the family. J. would refuse to spend overnights with friends, and spent less time with them. The parents occasionally made disparaging remarks to him about the odor and his lack of urinary control. When J. was 10, his mother heard that Childrens Hospital psychology department provided treatment, and arranged for an appointment. In the office J. was given psychological testing and his mother was interviewed for an extensive developmental and psychosocial history. During the next appointment the psychologist reported the results of the tests to the parents, stating that there were no psychological or emotional problems present, and reassured the parents that they had not caused the enuresis by their parenting. The first 2 weeks of treatment consisted of keeping a diary of baseline data of frequency of urinations during the day, fluids ingested, and frequency of bedwetting. After reviewing the data the psychologist explained the use of the electronic NyToneB clip that J. would wear on his underwear at night. Initially, the parents woke up before J. when the NyTonem alarm rang, and walked him to the bathroom and helped him get dry underwear and sheets. Occasionally he would wet two times a night. For 3 weeks the alarm went off most nights, with the parents having to wake him and get him to go to the bathroom. At first, he was very hard to waken, but gradually woke up more easily, and after 4 weeks he occasionally went to the bathroom himself after being awakened by the alarm and a parent. After 3 weeks he sometimes stopped urinating when the alarm rang with just the first drops of urine. Positive reinforcement was also used. The agreement was made between J. and his parents that if he was dry for 3 nights during a l-week period, he would get to purchase a toy. Later, as he was dry more often, the length of time increased that would result in a reward. The psychologist emphasized that at all times the reward should be achievable for J. After 6 weeks of wearing the alarm, J. still had some wet nights, although the frequency was definitely less. At this time the psychologist suggested hypnosis. In the office she hypnotized J. with his mother present, and emphasized to him that he would achieve muscular control over his bladder, just like the good muscular control he had achieved over his legs in playing soccer. She also made a tape that he was
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to listen to each night at home, so that gradually he would hypnotize himself. Using the tape helped him stay dry, so that in a couple of weeks the psychologist suggested they stop using the NyTonem alarm, but continue with the self-hypnosis. After 4 months, six office visits, and several phone calls for consultation, J. had achieved night dryness. The psychologist cautioned the parents that an occasional wet night might occur when J. was ill or especially tired, but if that did happen, he should do the self-hypnosis again, or the family might set up a reward system briefly again. At a 1 year follow-up, J. had had 6 wet nights since treatment. During the next year he was wet 2 or 3 nights only, and since that time has been totally dry.
ROLE OF THE CHN
CHNs working in a well-child clinic, or caring for families in the home may hear questions about bedwetting. The nurse can be instrumental in helping the family find solutions. After a careful assessment of the problem, including a medical workup to rule out physical problems, the nurse should begin to work with the family on the nursing diagnoses. The simple measures may be suggested, such as taking the child to the bathroom once in the night every night or setting an alarm to awaken the child. The behavior modification rewards should begin. The nurse can help the family track any progress on a periodic basis. In addition, providing the needed information on incidence and lack of any definitive causes must be done, as well as providing opportunities to increase the child's self-esteem and improve the parents approach to the problem. The nurse can help the family obtain the alarm system if they choose to try this method. If these measures are not successful, a referral to a child psychologist, enuresis, or sleep disorders clinic would be warranted. Besides nursing interventions already given, the nurse should include a few general suggestions for the family: 1. Do not expect the child to stop wetting quickly or overnight. It may take some time to drop the inappropriate habit of releasing urine while asleep, and to substitute a better one. 2. Continue with a helping method, such as waking the child to go to the bathroom, for some time. Again, formation of new habits take time. 3. Attempt to work with the child as much as possible. Power struggles will achieve nothing. The child does not choose to wet the bed, and would love nothing better than to keep dry at night. 4. Relapses, or a few subsequent bedwetting incidents after the treatment has been successful, are common. If this happens, the conditioning techniques or other successful methods originally used should be used again. The family does need to know that accidents may occur occasionally, especially when the child is sick.
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There are many families with enuretic children who could use help in dealing with this problem. Too often they are told that the child will outgrow it and to not worry. Although most children do outgrow bedwetting, many months and years of a sense of shame and failure could be avoided by making use of the proven successful treatment methods. The nurse can be instrumental in helping the family help themselves, or to seek outside help, if they so choose.
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REFERENCES Ack, M., Norman, M. E., & Schmitt, B. D. (1985). Enuresis: The role of alarms and drugs. Patient Care, 19, 75-90. Azrin, N. H., & Besalel, V. A. (1981). Parent's guide to bedwetting control: A step by step method. New York: Simon & Schuster. Carpenito, L. J. (1992). Nursing diagnosis: Application to clinical practice (4th ed.). Philadelphia: Lippincott. Gibson, L. Y. (1989). Bedwetting: A family's recurrent nightmare. MCN: American Journal of Maternal Child Nursing, 14(4), 270-272. Goldstein, S., & Book, R. (1983). A functional model for the treatment of primary enuresis. School Psychology Review, 12(1), 97-101. Hobbie,'~.(1989). Relaxation techniques for children and young people. Journal of Pediatric Health Care, 3(2), 83-87. Long, B. C. (1991). A drug free program for nocturnal enuresis. Urologic Nursing, Il(l), 15-16. Newcomb, P. (1991). Tricyclic antidepressants and children. Nurse-Practitioner: American Journal of Primary Health Care, 16(5), 26-30. Robertson, W. (1980). Hypnotizing children. Australian Journal of Clinical Hypnotherapy, 1(2), 103104. Ruble, J. A. (1981). Childhood nocturnal enuresis. The American Journal of Maternal Child Nursing, 6(1),26-31. Sadler, C. (1990, September). Getting dry. Community Outlook, 33, 35. Scipien, G., Barnhart, M., Chard, M., Howe, J., & Phillips, P. (1986). Comprehensivepediatric nursing. New York: McGraw-Hill. Shapiro, S. R. (1985). Enuresis: Treatment and overtreatment. Pediatric Nursing, 9(3), 203-207. Stanton, H. E. (1982). Changing the personal history of the bed-wetting child. Australian Journal of Clinical and Experimental Hypnosis, 1q2) 103- 107. Starfield, B. (1986). Increase in functional bladder capacity and improvement in enuresis. Journal of Pediatrics, 72, 483-487.
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Enuresis: Nursing Diagnoses and Treatment Janet M. Teets Published online: 07 Jun 2010.
To cite this article: Janet M. Teets (1992) Enuresis: Nursing Diagnoses and Treatment, Journal of Community Health Nursing, 9:2, 95-101, DOI: 10.1207/s15327655jchn0902_4 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0902_4
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(2), 95-101 Copyright O 1992, Lawrence Erlbaum Associates, Inc
Enuresis: Nursing Diagnoses and Treatment
Downloaded by [University of Auckland Library] at 19:50 13 October 2014
Janet M. Teets, MSN, RN Miami University
Living with a child with enuresis is not a major or critical problem, but it is a difficult and frustrating one. Wet sheets, wet pajamas, and rooms that smell of urine all add to the dismay felt by child and parents. Enuresis is a common problem which affects 22% of 5 year olds and 10% of 10 year olds (Scipien, Barnhart, Chard, Howe, & Phillips, 1986). Boys are affected more often than girls. There tends to be few answers given in the health-care system for the problem other than, "he'll outgrow it." Community health nurses (CHNs), working in the clinic, in the school setting, or in the home, may find parents and sometimes the child asking for help with this problem. This article presents the most common nursing diagnoses that apply to the family of an enuretic, and nursing interventions that can guide the nurse in working with the family to secure successful methods of treatment. ALTERATION IN ELIMINATION
The primary nursing diagnosis would be alteration in elimination: nighttime incontinence related to unknown causes (Carpenito, 1992). Qpically the parents try to help the child stay dry during the night in a number of ways. They may awaken the child to take him to the bathroom. Often, however, they complain that the child is such a sound sleeper that he did not even awaken when walked to the bathroom. This method may soon be abandoned when the parents see little progress in the child's ability to urinate when aroused from a deep sleep. Parents may try limiting the child's fluids before bedtime. This, too, has been found to be ineffective, and may lead to power struggles and arguments. Asking the older child to do the unpleasant task of changing wet sheets may be tried; again, this is usually ineffective in stopping the bedwetting. Another method suggested to parents is bladder stretching exercises (Azrin & Besalel, 1981; Long, 1991; Ruble, 1981; Sadler, 1990). The child is asked to drink as much of his favorite beverage as he can and "hold it" for as long as he can. When the urge to urinate becomes very strong, he is to void, measuring the amount. Gradually, it is hoped he can increase his bladder capacity. Interestingly, because of either a small bladder or a hypersensitivity to the urge to urinate, even holding 300 cc -
-
Requests for reprints should be sent to Janet M. Teets, MSN, RN, Assistant Professor, Department of Nursing, Miami University, 1601 Peck Boulevard, Hamilton, OH 4501 1 .
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Teets
of urine can be very uncomfortable. Starfield (1986) found a significant increase in functional bladder capacity over a 3- to 6-months time as a result of these exercises. However, because of the slowness in achieving good results, the family may become discouraged and quit.
Downloaded by [University of Auckland Library] at 19:50 13 October 2014
Nursing Interventions
Treatment methods are not usually suggested until the child is at least 7 years old (Goldstein & Book, 1983). The most successful method of treatment that can be suggested to the family is the use of conditioning therapy or behavior modification techniques (Ack, Norman, & Schmitt, 1985; Gibson, 1989; Sadler, 1990; Shapiro, 1985). This usually involves attaching an electronic clip that is very sensitive to any wetness to the front of the underwear. When the child urinates even a drop, an alarm, attached to the wrist or shirt, immediately beeps until disconnected. NyTone@and Wet-Stopo are brand names of such alarms, and can be purchased from medical supply stores. Clinics that offer treatment programs specific to enuresis may rent or loan the devices as long as needed. In working with a family using conditioning, it is suggested they keep a diary of baseline data for 2 weeks before the alarm is used. By documenting the number of urinations, the amount of oral fluids and the number of enuretic episodes, the family may see patterns, and then also improvements. After the baseline data is collected, the alarm should be used every night, with the child being taught how it works. The parents are cautioned that they will probably wake up before the child when the alarm sounds, and will need to take him to the bathroom. This may happen for several nights, and perhaps more than once during the night. Gradually, however, the child should begin to wake up more quickly when the alarm sounds, and will begin to eventually wake up just as he begins to urinate. The family should keep a record of these occurrences, as well as how difficult it is to wake the child. Along with the use of the alarm, positive reinforcement is planned with the parents and child (Gibson, 1989). The behavior needed to get a reward should always be possible for this particular child. The number of dry nights in a week leading to a reward can be decided by looking at the diary. As the child experiences more dry nights, the number of dry nights per week needed for a reward should also increase. Another treatment method that has been tried alone, or in conjunction with conditioning, has been hypnosis (Hobbie, 1989; Robertson, 1980; Stanton, 1982). Child psychologists may practice hypnosis, as do selected pediatric nurse practitioners. Hobbie (1989) suggested that the hypnotist make a tape of hypnotic suggestions for the child to use every night at home, so that he can then gradually learn to repeat those same positive suggestions to himself without the use of the tape. The hypnotist stresses that the child can have good muscular control over his bladder, just as he does over other muscles in his body. The child is urged to use the positive suggestions to himself before going to sleep every night until dryness is achieved, and for any subsequent relapses.
Downloaded by [University of Auckland Library] at 19:50 13 October 2014
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The most common method of treatment, although less successful than conditioning, has been the use of imipramine, a tricyclic antidepressant. It is thought to decrease the depth of sleep, allowing the child to wake up more easily to get to the bathroom (Ack et al., 1985). Ruble (1981) suggested that it can be highly effective in decreasing enuretic episodes within a few days, and will produce cures in 3 to 4 months. Newcomb (1991) questioned whether the tricyclics are effective for enuresis, but stated they may be helpful if behavior modification is not successful. Although good results have been reported with this method, Shapiro (1985) pointed out some of the dangers in that there are rare incidents of agranulocytosis, personality changes, atropine-like effects, cardiac irritability, and even sudden death.
BODY IMAGEISELF-ESTEEM DISTURBANCE
Another possible nursing diagnosis for the enuretic child may be altered body image and/or lowered self-esteem related to the inability to control urine at night (Carpenito, 1992). The child usually feels ashamed that he wets the bed. Because of this problem he will often be uncomfortable in spending the night with friends, fearing he will embarrass himself by waking up wet. He may feel reluctant to take friends to his room for fear they will discover the plastic sheet on his bed or will notice a urine smell. When the enuresis has continued for some time with no change, even after trying a variety of methods, a sense of powerlessness results for both the child and parents. They feel nothing will work to solve this perplexing problem. The child may become convinced there is something wrong with him or his body that could contribute to a lack in confidence in other areas of life. Similarly, the parents may feel guilty and ashamed because their child has not outgrown this baby stage, and believe that it must be due to their poor parenting. Nursing Interventions
In helping the child improve his body image or self-esteem, it is important to tell him that many children have this problem. He needs to be told that for some reason he did not form proper elimination habits when younger, but that he can learn new habits. It is important that the child understand that there is nothing wrong or weak about him, and that the problem can be solved. The parents need the same teaching. In solving some of the disagreeable aspects of enuresis, and to help the family feel a sense of control, the child and his parents can agree on methods that will eliminate any odor in his room, and discuss ways to successfully hide the problem while sleeping with friends. He may need support and encouragement that he can successfully spend the night at a friend's house without being discovered. For example, the child could always sleep in his own washable sleeping bag, or use some of the disposable incontinent underwear for overnight outings, slipping them on and off in the sleeping bag so no one can see. A matter-of-fact approach that respects
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the importance of this problem for the child and helps him problem solve with his parents will go far in improving his self-concept.
Downloaded by [University of Auckland Library] at 19:50 13 October 2014
ALTERATION IN PARENTING It is also possible that alteration in parenting related to the child's bedwetting may result (Carpenito, 1992). The parents may feel guilty, thinking that they caused the enuresis somehow through their parenting methods. They may feel ashamed that their child has this problem, and try to hide or deny it. Hoping that a change in their behavior will stop the bedwetting, they become more strict, and insist to the child that he could quit bedwetting if he only tried harder. If that does not help, they may become more permissive in discipline, hoping that will help. Besides being inconsistent in their approach to the child, they may use excessive punishment or ridicule.
Nursing Intervention Helping the parents and child understand what is known about causes of enuresis is important. Shapiro (1985), in reviewing the literature, found that several causes have been suggested, including: psychiatric problems, urinary tract infections, allergies, pinworms, obstructive uropathy, and urethralhaginal reflux. When investigated, however, none were found to be a significant cause. Shapiro did conclude that children with enuresis probably have small bladders, or are deep sleepers with uninhibited bladder contractions, and heredity may play some part in the cause. Because there is a possibility that a physical problem may be causing the enuresis, a medical workup of the child is necessary to rule out physical causes. Equally important in helping the parents deal with enuresis is to encourage them to express their frustrations and fears. Voicing the fear that they somehow must have caused this problem, which is sometimes erroneously viewed as a psychological problem, can provide much relief. When the facts are presented, and they recognize their frustration, anger, and powerlessness as normal reactions to a common problem, they become more free to problem solve and work on solutions. The nurse must also make sure they understand that spankings or humiliations will not stop the enuresis and will only lead to further negative effects on the parent-child relationship.
Case Example J. was a 10-year-old boy when he and his mother sought treatment for enuresis at the psychology clinic of a Children's Medical Center. J. had achieved dryness during the day when he was 2 1/2 years old, but had never achieved consistent night dryness. Over the years the parents had tried a variety of methods. One method was to get him up to walk to the bathroom to urinate after he had been asleep for an hour;
Downloaded by [University of Auckland Library] at 19:50 13 October 2014
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however, he would not arouse easily, and if the parents did manage to get him to walk to the bathroom, he would rarely comply with the request to urinate. Limiting fluids was tried, but that made no difference on the number of dry nights, and sometimes resulted in arguments. When J. was 7, the family asked their family doctor to let them try a trial of Tofranil. After 4 days of taking it, and 4 wet nights, the mother felt the child was becoming very short-tempered, and acting as though he was not getting enough sleep, so the medicine was stopped. The family tried Tofranil at other times when J. was older, once for a 2-week period, but he never achieved any dryness. When J. was 9, the Azrin and Besalel (1981) "dry-bed training" method was tried. Azrin and Besalel gave several testimonials of quick cures, but, although the training techniques were followed to the letter, J. continued to wet the bed. The family doctor suggested an intravenous pyelogram and urinalysis to rule out physical causes; these proved to be negative, and the doctor told the family that J. would "outgrow" it. A sense of defeat and depression enveloped the family. J. would refuse to spend overnights with friends, and spent less time with them. The parents occasionally made disparaging remarks to him about the odor and his lack of urinary control. When J. was 10, his mother heard that Childrens Hospital psychology department provided treatment, and arranged for an appointment. In the office J. was given psychological testing and his mother was interviewed for an extensive developmental and psychosocial history. During the next appointment the psychologist reported the results of the tests to the parents, stating that there were no psychological or emotional problems present, and reassured the parents that they had not caused the enuresis by their parenting. The first 2 weeks of treatment consisted of keeping a diary of baseline data of frequency of urinations during the day, fluids ingested, and frequency of bedwetting. After reviewing the data the psychologist explained the use of the electronic NyToneB clip that J. would wear on his underwear at night. Initially, the parents woke up before J. when the NyTonem alarm rang, and walked him to the bathroom and helped him get dry underwear and sheets. Occasionally he would wet two times a night. For 3 weeks the alarm went off most nights, with the parents having to wake him and get him to go to the bathroom. At first, he was very hard to waken, but gradually woke up more easily, and after 4 weeks he occasionally went to the bathroom himself after being awakened by the alarm and a parent. After 3 weeks he sometimes stopped urinating when the alarm rang with just the first drops of urine. Positive reinforcement was also used. The agreement was made between J. and his parents that if he was dry for 3 nights during a l-week period, he would get to purchase a toy. Later, as he was dry more often, the length of time increased that would result in a reward. The psychologist emphasized that at all times the reward should be achievable for J. After 6 weeks of wearing the alarm, J. still had some wet nights, although the frequency was definitely less. At this time the psychologist suggested hypnosis. In the office she hypnotized J. with his mother present, and emphasized to him that he would achieve muscular control over his bladder, just like the good muscular control he had achieved over his legs in playing soccer. She also made a tape that he was
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to listen to each night at home, so that gradually he would hypnotize himself. Using the tape helped him stay dry, so that in a couple of weeks the psychologist suggested they stop using the NyTonem alarm, but continue with the self-hypnosis. After 4 months, six office visits, and several phone calls for consultation, J. had achieved night dryness. The psychologist cautioned the parents that an occasional wet night might occur when J. was ill or especially tired, but if that did happen, he should do the self-hypnosis again, or the family might set up a reward system briefly again. At a 1 year follow-up, J. had had 6 wet nights since treatment. During the next year he was wet 2 or 3 nights only, and since that time has been totally dry.
ROLE OF THE CHN
CHNs working in a well-child clinic, or caring for families in the home may hear questions about bedwetting. The nurse can be instrumental in helping the family find solutions. After a careful assessment of the problem, including a medical workup to rule out physical problems, the nurse should begin to work with the family on the nursing diagnoses. The simple measures may be suggested, such as taking the child to the bathroom once in the night every night or setting an alarm to awaken the child. The behavior modification rewards should begin. The nurse can help the family track any progress on a periodic basis. In addition, providing the needed information on incidence and lack of any definitive causes must be done, as well as providing opportunities to increase the child's self-esteem and improve the parents approach to the problem. The nurse can help the family obtain the alarm system if they choose to try this method. If these measures are not successful, a referral to a child psychologist, enuresis, or sleep disorders clinic would be warranted. Besides nursing interventions already given, the nurse should include a few general suggestions for the family: 1. Do not expect the child to stop wetting quickly or overnight. It may take some time to drop the inappropriate habit of releasing urine while asleep, and to substitute a better one. 2. Continue with a helping method, such as waking the child to go to the bathroom, for some time. Again, formation of new habits take time. 3. Attempt to work with the child as much as possible. Power struggles will achieve nothing. The child does not choose to wet the bed, and would love nothing better than to keep dry at night. 4. Relapses, or a few subsequent bedwetting incidents after the treatment has been successful, are common. If this happens, the conditioning techniques or other successful methods originally used should be used again. The family does need to know that accidents may occur occasionally, especially when the child is sick.
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There are many families with enuretic children who could use help in dealing with this problem. Too often they are told that the child will outgrow it and to not worry. Although most children do outgrow bedwetting, many months and years of a sense of shame and failure could be avoided by making use of the proven successful treatment methods. The nurse can be instrumental in helping the family help themselves, or to seek outside help, if they so choose.
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