THE DEVELOPMENT OF AN EDUCATIONAL WEBSITE FOR THE PARENTS OF
CHILDREN EXPERIENCING CHRONIC CONSTIPATION

Ashley M. Daughenbaugh, R.N., B.S.N.

Submitted in Partial Fulfillment of the Requirements
For the Master in Science in Nursing Degree

Edinboro University of Pennsylvania

Approved by:

Conway, PhD, CRNP
Committe^Chairperson

ielsel, PhD, RN
ittee Member

Date

Abstract
The Development of an Educational Website for the Parents of Children

Experiencing Chronic Constipation

The purpose of this project was to develop an educational web-site for the parents
of children with chronic constipation. As the climate of health care continues to

change, patient education becomes a greater responsibility for health care providers,
assessing and meeting informational needs of patients and their families are integral
parts of health care practice (Canobbio, 1996). The nurse practitioner, at the forefront
of healthcare, can use this tool to help patient and their families to combat the feeling

of powerlessness that so frequently accompanies a health crisis (Davidhizer, 1992).
Chronic constipation in children is a frequent complaint in the primary care
setting (Kirchner, 1999). Both a physical and emotional problem, it exacts a huge toll

on the psychological well being of the family by eroding the self esteem of the child,

and also the parents and their belief that they can effectively parent (Di Lorenzo,

2000). There is a deficit of educational material on this topic, particularly on the
Internet. The Internet is the place to which more and more parents turn for medical
information and emotional support (Chi-Lum,1999).

ii
Acknowledgements

I would like to take this opportunity to sincerely thank all the people whose help and

support made completing this project possible. This is the culmination of four years

of hard work and sacrifice, not just by me, but by my family as well.
Loving thanks to my husband Todd, whose unwavering confidence in me kept me

trudging through the four long years of this Masters process. Thank you to my
children Logan and Aidan who have no memory of Mama not being a student. Thank
you to them for taking naps, entertaining themselves, and not burning the house

down while I studied or worked on the computer. Thank you to my wonderful

extended family and friends for providing dinners, babysitting, and moral support.

Special thanks to my Chairperson, Dr. Alice Conway Ph.D., CRNP, for believing so

enthusiastically in my project, that I couldn’t help but believe in it too. Thank you to
my committee member Dr. Janet Geisel Ph.D., R.N., for keeping me on the right
track. Thank you so much to Dr. Michael Webster M.D. and Lisa Scibetta CRNP for

taking the time to review my web site, and give me their very valuable suggestions
and feedback.

iii
Table of Contents
Content

Page

Abstract

Acknowledgements

Chapter 1: Introduction

Background of the Problem

Statement of the Problem

Theoretical Framework

Statement Purpose

Assumptions

Definition of Terms

Summary

Chapter 2: Review of the Literature

Constipation

Ramifications of Chronic Constipation

Physical

Emotional

Strategies For Prevention/Resolution

Understanding the problem

Strategies to try at home

When to seek help

Using The Internet For Medical Information

Growth of Internet users

14
14

Patient empowerment

Developing Effective Educational Materials

Summary

Chapter 3: Methodology

Model For Evaluating Printed Educational Materials

Predesign phase

Design phase

Pilot test phase

Implementation/distribution phase

Evaluation phase

Operational Definition.

Summary

Chapter 4: Web Site

Home Page

What is constipation?

Misconceptions

Acknowledgements

Under 6 months

Common causes

Prevention and treatment

High fiber foods

Calculate fluid needs

Helpful hints

References

Physiology.

Treatments

Danger signs

What to expect

Tests

Frequently asked questions

Links

41
42

Chapter 1

Introduction
This chapter provides a brief discussion about constipation in children and patient

/parent education. The Self-care Deficit Theory of Nursing developed by Dorothea
Orem (1995) serves as the theoretical framework for this scholarly project.

Background of the problem, the problem statement, purpose, assumptions, and
pertinent definitions are provided.
Background of the Problem

As the climate of health care continues to change, patient education becomes a

greater responsibility for health care providers, assessing and meeting informational
needs of patients and their families are integral parts of health care practice
(Canobbio, 1996). The nurse practitioner, at the forefront of healthcare, can use this

tool to help patient and their families to combat the feeling of powerlessness that so
frequently accompanies a health crisis (Davidhizer, 1992).
Approximately 28% of the population of the United States is constipated (Di
Lorenzo, 2000). Epidemiologic studies were not found for the pediatric population in

the United States, however, the United Kingdom reports chronic constipation in 34%
of their toddlers. According to parental surveys of Brazilian parents, 37% of their
children under the age of 12 were thought to have constipation. (Di Lorenzo,2000).
In the United States, chronic constipation is common in children and is the primary

diagnosis in 25% of children referred to pediatric gastroenterologists by their
primary care provider (Kirchner, 1999). The term constipation refers to difficulty

with the passage of stool. Individuals with constipation have stools that are dry hard

and difficult to pass (Berkowitz, 1996). Normal frequency and patterns of stooling
vary greatly, and are heavily influenced by environmental and emotional factors as

well as physiologic ones. Diet, medication and degree of hydration are factors, as are
environmental changes in a child’s life such as travel, a new home or school, birth of

a sibling, or family stress (Berkowitz, 1996).
Few benign medical conditions are as distressing as a disorder of defecation.
Parents attach great importance to their children’s successful stooling” (Di Lorenzo,

2000, p.4). Di Lorenzo describes the tremendous amount of frustration and parent

child hostility that is generated in dealing with chronic constipation. This frustration

expresses itself in decreased self-esteem, depression, loss of coping skills, and

anxiety.
Statement of the Problem

Chronic constipation in children is a frequent complaint in the primary care
setting (Kirchner, 1999). Both a physical and emotional problem, it exacts a huge toll
on the psychological well being of the family by eroding the self esteem of not only

the child, but of the parents and their belief that they can effectively parent (Di
Lorenzo, 2000). There is a deficit of educational material about this topic,

particularly on the Internet, which more and more is the place parents turn to for
medical information and emotional support (Chi-Lum, 1999/
Theoretical Framework
The Self-care Deficit Theory of Nursing developed by Dorothea Orem (1995)

provides the theoretical framework for this scholarly project. Self-care was described
by Orem as the actions persons performed in the interest of maintaining life, health,

and well being. Orem terms the power of the individual to engage in self-care and
capability for self-care as “ self-care agency”. In the care of children, or others
incapable performing self-care, Orem describes the role of the dependent-care agent,

i.e. the parent or caretaker. She states that dependent care agency, is the ability of
responsible adults to meet the continuing demands for self-care of their dependents.
Using this theoretical framework, the dependent care agents might seek to access an

educational web site if they determine that they have what Orem terms a “dependent

care deficit". A dependent-care deficit is an unequal relationship between
capabilities (agency) of responsible adults and dependent person’s required self-care

demand (Hartweg, 1991).
Hartweg (1991) described eight universal self-care requisites identified by Orem,

number four being, “the provision of care associated with elimination processes and

excrement” (p. 21). In trying to meet the provision of care associated with
elimination processes and excrement, a parent or caregiver may realize that their
child is having difficulty with bowel elimination despite their doing everything they

know to do to solve the problem. At this time the parent, as the dependent -care

agent, may go to their nurse practitioner for help. The parent may need to know

more about the physiologic mechanism of constipation, or which home remedies are
safe to try, and which are not. The parent might need to know at what point to seek

medical help from their primary care provider, or they may want to know more about

any tests or treatments their primary care provider has ordered. The
acknowledgement by the parents that they have an educational dependent-care

deficit legitimizes the role and intervention of the nurse practitioner in what Orem
terms a supportive-educative nursing system (Hartweg, 1991).
Hartweg (1991) identifies Orem’s five general methods that persons use to assist
or help others:
acting for or doing for another; guiding another; supporting another, physically or
psychologically; providing for a developmental environment; and teaching another.”
(p.29)

In addition to these, another general method of assisting is in the form of guidance,

in which the patient is guided in making decisions about further medical
interventions. These are actions performed by the nurse practitioner in the

supportive-educative role. If the nurse practitioner deems it possible for the patient to
perform self-care actions, the supportive educative system is implemented (Hartweg,
1991).
The parent, as the dependent-care agent, acting on behalf of their child is

experiencing a health deviation, i.e. constipation. The parent experiences a
dependent-care deficit, or an inability to solve the problem on their own. The goal of

the nurse practitioner is to provide the support, guidance and education that will
ensure that the parent will be able to meet the health care needs of that child.

Statement of Purpose
The purpose of this project is to develop an educational website that will assist

parents of children with constipation to understand the physiological process and to
make informed and safe choices for their children.

5
Assumptions
For the purpose of this project, the following assumptions have been made:

1. Constipation is a common problem.
2. Parents are motivated to learn on behalf of their child.

3 Parents will access a website as a means of educating themselves.
4. A nurse practitioner’s education and experience prepares them to identify

an educational deficit and correct it.

Definition of Terms
The following terms have been defined for this study:

1. Constipation is the difficult passage of dry hard stool associated with a

decreased frequency in stooling (Berkowitz, 1996).
2. Encopresis is also known as stool soiling, as the result of constipation, the
child experiences a leakage of liquid stool around the mass of stool stuck in the

lower bowel into the underwear (Di Lorenzo, 2000).

Summary

Constipation in children is a common (Kirchner, 1999) and multidimensional

problem that affects the whole family (Di Lorenzo, 2000). The parent seeks out a

solution to this frustrating and physically uncomfortable problem on behalf of their
child. It is recognized, that in healthy children, bowel problems are typically
transient but, untreated, can spiral into physical, behavioral, and developmental

problems that could potentially last into the school years and become refractory to
empirical medical treatment (Issenman, Filmer, & Gorski, 1999). The nurse
practitioner has a valuable opportunity in providing education and support to families

6
experiencing this problem so that they may seek out professional intervention at the
appropriate time.

Dorothea Orem’s (1995) Self-care Deficit Theory of Nursing provides the

theoretical framework for this project. Assumptions and definition of terms have
been provided.

Chapter 2
Review of the Literature

The purpose of this project is to develop an educational web site to meet the
learning needs of parents whose children are experiencing chronic constipation. This
review of literature addresses the prevalence of the problem of constipation in
children and the physiologic process of elimination that can lead to constipation. It

also addresses the physical and emotional ramifications of chronic constipation,

including the effect on the child’s self-esteem and the parent/child relationship. This

review of literature also looks at strategies for prevention and resolution of
constipation, as well as the use of the Internet as a source of patient education and

teaching.
Constipation

Research indicates that complaints of constipation account for as much as 3% to
5% of pediatric out patient visits and as much as 25% of referrals to

gastroenterologists (Di Lorenzo, 2000; Issenman et al., 1999; Kirchner, 1999).

Constipation is common among healthy children and is usually first noted by parents

as their child approaches toilet training age (DI Lorenzo, 2000). At this time a child s
stool becomes more susceptible to hardness, dryness, or to having a longer transit

time (Issenman et al., 1999). A newborn has only the basic regulatory mechanisms to
control defecation, and it is not until the time of toilet training that the child is

capable of any conscious decision to contract or relax skeletal muscles thus
controlling the time and place of elimination (Di Lorenzo, 2000).

A basic understanding of the physiology associated with defecation is helpful to a

parent dealing with this process in their child (Di Lorenzo, 2000). Three to four
hours after food has been eaten it enters the cecum. It then takes several more hours

to reach the rectum. There are two normal motor patterns responsible for the
movement of the colonic contents. The first are segmental, non-propagated tonic and

phasic contractions that mix luminal contents. The second are very powerfill high
amplitude propagated contractions that propel stool to the rectum. This pattern of
motility increases after meals and on awakening. When the rectal wall is distended

by stool there is a reflex contraction of the internal anal sphincter pushing fecal
material into the anal canal. It is at this point that a conscious decision is made to

expel or postpone the stool. If the child chooses to postpone, there is voluntary
contraction of the external anal sphincter and the puborectalis muscle. Later, when
the child chooses to defecate, a voluntary contraction of the abdominal muscles is

needed to push the stool into the anal canal and once again produce a bowel
movement. The longer the bowel movement is delayed, the more water is absorbed

from the fecal material producing a drier, harder movement to pass.

Ramifications of Chronic Constipation
Ramifications of chronic constipation are both physical and emotional, putting

strain on the family that must deal with it (Di Lorenzo, 2000). The following,

discusses those ramifications.
physical Anything that interrupts the basic regulatory mechanism associated
with defecation can lead to constipation (Di Lorenzo, 2000). Although usually a

benign course, there is evidence that in some children, constipation poses a real risk

of becoming a chronic gastrointestinal disturbance that can have long-range effects
on toilet training (Issenman et al., 1999). The toilet training process itself can for a

variety of reasons be the primary cause of stool withholding behavior, hence,

constipation (Issenman et al., 1999). Reasons as simple as not getting the proper
leverage sitting on an adult size commode (due to feet not touching the ground) or
withholding due to excessive parental pressure can contribute to the problem. The
child is then set up for what is considered to be the number one cause of chronic

constipation in children, a painful or frightening evacuation (Di Lorenzo, 2000;
Issenman et al., 1999).
Children, as concrete thinkers, react to unpleasant experiences with repeated and

often successful attempts to avoid those experiences again (Di Lorenzo, 2000). Being
abstract thinkers, it is difficult for a child to understand that if a bowel movement

hurts a little now, letting it out, will have long-term benefits. A constipated child
would prefer to postpone defecation forever (Di Lorenzo, 2000). This type of

constipation is termed “functional” or “behavioral”, and the children who experience

it, have normal colonic motility (Di Lorenzo, 2000, Kirchner, 1999). The only
abnormal motor activity in most children with chronic constipation is found in the
rectum, which may become so dilated due to with holding, it no longer has the

muscular force to propel the stool properly (Di Lorenzo). What was initially a

conscious decision to withhold becomes autonomic. Symptoms of constipation may
include some or all of the following: (a) No bowel movement for several days or
daily bowel movements that are hard and dry, (b) cramping abdominal pain, (c)
nausea, (d) vomiting, (e) weight loss, (f) liquid or solid, clay-like stool in the child’s

underwear-a sign that stool has backed up. When episodes of constipation last for
more than three weeks they are considered to be chronic (Berkowitz, 1996).

Emotional. Chronic disorders put children and their families at high risk for
psychosocial and or management problems. The stresses of any chronic health

problem affect all members of the family, it is a perpetual and demanding companion
(Futcher, 1998). Parents attach great importance to their child’s successful stooling.
It is not uncommon for an anxious parent to call their primary care provider (PCP) in

the middle of the night if they feel their child is struggling with defecation. <cMost of
us have met parents so focused on their child’s bodily functions that they are able to
recall number, timing, and character of each delivery, describing the event with an

emphasis similar to the one used to recall the child’s first steps or words” (Di
Lorenzo, 2000, p. 4-5). Both Di Lorenzo and Issenman et al. (1999) describe the

parent/child hostility during the battle of wills that often takes place at this time. This

is especially evident when children develop fecal soiling as a consequence of their
constipation. Both note diminished self-esteem, depression, loss of coping skills, and

anxiety in both parent and child. If this chronic condition is not delt with effectively,
and is allowed to stretch into the school years, a failure to maintain social bowel
continence is associated with intense parental disapproval, feelings of embarrassment
or shame, and difficulty in social situations (Issenman et al., 1999).

Strategies For PreventionZResolution

Parents need to understand the problem and be given safe strategies to deal with it
effectively (Austin-Kessner, 1990). By learning how to have some control over the

events affecting their child’s life, parents can combat the powerlessness that is often

associated with a chronic health problem (Davidhizer, 1992).
Understanding the problem. In the literature, Austin-Kessner (1990), Davidhizar

(1992), and Futcher (1988) all indicate that having some understanding of a problem
helps caretakers to deal more effectively with it. Davidhizer (1992) indicates
strongly that knowledge of an illness and resources available, positively impacted

the feelings of powerlessness among family member caregivers. Futcher (1988)
states that illness gives a child an inappropriate power over their parents. It follows

that providing parents with information about a child’s problem, and equipping them
with strategies to deal with it, would reestablish the appropriate balance of power.

Austin-Kessner (1990) describes a stage of “demystification” parents go through

when their child faces a health challenge. This occurs when parents actively seek
information about their child’s condition. During this stage parents learn the facts

and begin to realize that other problems could be worse. She goes on to say that,

during this process of learning about the problem and its treatments, parents
generally feel less anxious, guilty, and more in control.

Strategies to try at home. The literature agrees that the first step in dealing with
constipation in children is to manipulate the diet; this first step can be done safely
and easily by the parents prior to seeking care from their PCP (Berkowitz, 1996, Di

Lorenzo 2000, Issenman et al., 1999). The goal of dietary management is to help the
child to establish a varied and nutritionally well balanced diet, with high fiber meals

and adequate fluid intake (Nelson, J. K„ Moxness, K. E„ Jensen, M. D., &

Gastineau, C. F. 1994). As noted in the MayoClmi^Q^ (Nelson et al.,

12
1994), quantitative recommendations for fiber intake in children have not been
established, however the American Academy of Pediatrics Committee on Nutrition

states, a “substantial amount of fiber should be eaten by all children over the age of
one to ensure normal taxation” (American Academy of Pediatrics, 1981, p.573).
Recommendations state that children’s diet include enough fiber (vegetable, fruits,

and whole-grain breads and cereals) so that bulk left in the in the bowel encourages
and stimulates evacuation. Classifications of foods according to increasing bulk are

as follows: protein, fat, milk, digestible carbohydrate, and digestible carbohydrate
with nondigestible material (Nelson et al., 1994).

Fluid intake is essential to bowel function and is especially important with a
higher fiber diet, most children do not regularly drink adequate amounts of fluid

(Nelson, et al., 1994). The minimum requirement of fluid for children approximates

60 ml/kg of body weight per day. Excessive fluid intake is considered to be 2 1/2
times this amount.

A bowel-training program is necessary to establish a regular bowel habit (Di
Lorenzo, 2000, Issenman et al. 1999). It is recommended that a child be taught not to

wait to have a bowel movement, the child should sit on the toilet for 5-10 minutes at
about the same time every day, preferably after a meal. The child should be able to
plant his or her feet firmly on the floor for proper leverage; this may require the use

of a footstool.
Over the counter laxative products are available to treat constipation in children,

but the choice of laxatives depends on the age of the child, and how bad the

constipation is (Berkowte. 1996, Di Lorenzo, 2000). Laxative use may complicate

or worsen the child’s situation in the long run if not used properly or with discretion.
They agree that parents seek advice of their child’s PCP before choosing or using an

over the counter laxative.
When to seek help. The differential diagnosis of constipation is age related and

depends on assessment of the factors that have led to the conclusion that constipation

is occurring. When the constipation first presents itself at the time of toilet training,

if stooling has to that point been normal, it is highly suggestive of functional
constipation. When constipation develops in a child under the age of six months
there are at least four differential diagnoses that must be considered. They are
Hirschsprung disease, hypothyroidism, imperforate anus, and infantile botulism.

Pseudo-obstruction may also be present in children prior to toilet training age, but is

also seen in older children. These children may have a history of abdominal
distension, pain, and intestinal paresis (Berkowitz 1996).

Much of the literature supports the recommendation that parents seek professional

advice of their PCP if their child’s constipation fits any of the following descriptors
(Berkowitz, 1996, Di Lorenzo, 2000, Issenman et al. 1999).
1.

The child is under six months of age.

The child’s constipation doesn’t respond to dietary changes or bowel

training.
Episodes of constipation last longer than three weeks.

The child has stool soiling.

If at any time, constipation is accompanied by fever, abdominal pain, vomiting or
blood in the stool.

Using The Internet For Medical Information
The public has embraced the use of personal computers and the idea of

connectivity via the Internet (Baker, 2000). Th. internet provides a. additional
medium for healthcare education.
Growth of Internet Users. The number of Web users grows daily, in 1997, 43%

of all adult Internet users accessed health care information via the Internet (Chi-Lum,
1999). Of these numbers 65% were looking for information for themselves or a
family member, 81% were looking for health information from renowned experts
from major medical centers, and 77% were interested in finding information for
consulting with their own physician.
Patient Empowerment. The latest computer technology plays an important role in

educating the health care consumer (Chi-Lum, 1999, Kozma, 1999). It may help

patients and their health care provider diagnose a medical condition, and in the future
could allow consumers to access their individual pharmacy profiles or medical

charts.
Developing Effective Educational Materials

Farrell-Miller and Gentry (1989), offered several suggestions for enhancing
readability in educational materials. Choosing words with fewer than three syllables

makes text less difficult to read. The amount of information and length of text should

be limited to as few pages as possible. Print should be at least 14 point and the style

plain, ornate styles such as italics, boldface or script should be avoided. Illustrations
or photographs ate attention getting and enhance readability as long as they are

clearly drawn or represented.

15
A model for designing and evaluating educational material was developed by

Bernier and Yasko (1991). This model has frive phases that mirror the nursing
process in a circular path from assessment to evaluation. The phases include,

predesign, design, pilot test, implementation/distribution, and evaluation.

Effective educational materials help promote the relationship between the patient
and their health care provider as well as enhance patient knowledge and self-care

(Farrell-Miller & Gentry, 1989). They allow the educator to provide ready access to
the information in a consistent and clear format.

Summary

This chapter discusses the impact of education on the parent’s ability to deal with
their child’s chronic constipation. It reviews the physiologic mechanism involved in

the elimination process, and addresses the physical and emotional impact of the
problem. Safe guidelines of strategies parents can try themselves are presented, as
well as when it appropriate to seek intervention. Use of the Internet for the access of

medical information and recommendations for developing effective educational
materials is covered as well. The model for developing and evaluating educational

materials, EPEM, by Bernier and Yasko (1991) was described.

16
Chapter 3

Methodology
This chapter describes the methodology used in the development of this

educational website on chronic constipation in children. The model, Evaluating

Panted Education Matenals (EPEM) developed by Bernier and Yasko (1991) is used

as the basis for developing this project. Operational definitions are given. The
designs, in the form of the web-site outline, and instrumentation, or the actual hard

copy of the web site, are laid out.

Model for Evaluating Printed Education Materials
The five phase EPEM model (Bernier & Yasko, 1991) was applied as the basis

for the development of this educational website. The phases include; the predesign

phase, the design phase, the pilot testing phase, the implementation phase, and
finally, the evaluation phase. Factors to promote readability by Farrell-Miller &
Gentry (1989) were instituted throughout this project.
Predesign phase. During the predesign phase, the purpose, educational goals and

objectives, as well as the intended audience was decided. The need and benefits of

such an educational project were supported by the literature.

Design phase. The design phase involves the research and decision making
process, where by educational content and objectives for the project are established.

In the design phase, the most pertinent information was selected based on the review

of literature. Content was organized in a logical sequence to promote the flow .nd
readability of the information. Factors implemented throughout the design that

promote readability include; (a) keeping sentences short, (b) expressing one idea at a

17
time, (c) avoiding complex grammatical structures, (d) writing in a conversational

style, using the active voice, (e) writing using the second person, (f) keeping words
under three syllables as much as possible, (g) limiting technical terminology, (h)

having the sentences flow horizontally, in a print no smaller than 14 point (Farrell-

Miller & Gentry, 1989). Readability for this project is estimated at a ninth grade

reading level.
Content, as guided by the literature, includes a definition of constipation, and a
comparison with what might mimic it. A simple explanation of the physiologic
mechanisms involved with the stooling process is also included. Family stress as the
result of chronic constipation is addressed, as is safe strategies toward prevention or

resolution of the problem for families to try on their own. There is a list and

explanation of danger signs and instructions as to when it would be appropriate to
contact the child’s primary care provider for help. This website also includes links to

other educational websites that parents might find helpful. This web site was
designed using Microsoft Front Page software. It can be accessed at

http//: frontpage, velocity, net/todd.

Pilot test phase. The pilot test phase of this project involved having the first draft
of the website reviewed by a pediatric physician and pediatric nurse practitioner. The

health professionals were asked to give feedback on the clarity and accuracy of the
content. This feedback was used to evaluate and revise the first draft of the website.

After review of the web site content, the following suggestions were made and
implemented. Navigational buttons were added to the web pages directing parents of

children under the age of six months to seek medical care and evaluation for their

baby. On the page describing the causes of constipation, the order of the causes were
rearranged to read, “Painfol/unpleasant” experience, followed by “Improper

leverage and “Parental pressure”. A note was added to indicate that the cause could
be a result of a medical condition.

A recommendation was made that a caution be added, stating that cereals and
fiber added to the diet without adequate fluid intake, can make firmer stools. In the

section on bowel training, the recommendation for ten minutes of toilet sitting after
meals was changed to one to two minutes per year of age, but not to exceed a
maximum of ten minutes.

It was suggested that hydrophilic laxatives be referred to as stool softeners, and

the term laxative be reserved for stimulants and cathartics. Emphasis was placed on

the importance of follow up care, and on the fact that a cure for constipation is not a
single event, but a process that occurs over time. Additional recommendations for
improving the readability and clarity were made and implemented as well.

Tmplemention/distrubution phase The completed website was posted on the

Internet. Patient care providers were then invited to use the site for the educational
needs of their patients.

Evaluation phase. This final phase in the development of this website might be
achieved via questioner to pediatricians, nurse practitioners, and family physicians.

An e-mail address is provided on the web site for questions and comments. Feedback

from these sources would be useful in gauging the value and effectiveness of this
educational website.

Operational Definitions
For the purposes of this study, the following operational definitions are used.
1. Children are people from the age of six months to 18 years of age.

2. Caregivers are any adults who are in a legal and moral position to make health

care decisions for a child in their care.
Summary
In summary, the methods used in development of this scholarly project were

based on the EPEM model developed by Bernier & Yasko (1991), and factors
promoting readability by Farrell-Miller & Gentry (1989). Content was determined by

the review of literature. Operational definitions, design, and instrumentation are
provided.

Welcome to The Constipation Page
. Common causes

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Danger signs!
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children experiencing problems with constipation.

Click here if your child is under 6 months of age.

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The painful passage of dry hard stool:
The most reliable sign of constipation is discomfort with the passage of a bowel
movement.

The inability to pass stools:
These children may have a desperate urge to move their bowels, they may have
discomfort in their rectal area, but even with straining, are unable to pass anything.

Infrequent bowel movements:
Going four or more days without a bowel movement may be considered constipation,
even if the child has no pain, however, in some children this may be normaL Th,s is
particularly common in exclusively breast fed infants after the first few months.

Click here if your child is under 6 months of ageL

4. Discuss with your health care provider.

Stool soiling:
Soiling of underwear with liquid or
impacted with stool.

clay-like feces may be a sign that the child is

Click here for common misconceptions!

Misconceptions
—

Common Misconceptions:

Many parents assume that all large or hard bowel
movements are a sign of constipation. Unless your
child experiences pain, an inability to pass the stool, or infrequent movements (longer
than 4 days between movements), this may be a normal pattern for your child.
Note: Some breast fed babies after the second month or so will pass normal, large soft
stool at infrequent intervals (sometimes as long as seven days). Although they may
strain and grunt, they do this without pain.

Click here if your child is under 6 months of age.

Back

Acknowledgements
This web site is the culmination of four years of hard work and sacrifice by me, and
the people I love . It is also the final requirement for my Masters Degree in Nursing
from Edinboro University of Pennsylvania. I would like to take this opportunity to
thank all the people whose help and support made this web site (and graduation)
possible.

First and foremost, I want to thank my husband, Todd, whose unwavering confidence in
me kept me trudging through the four long years of this Masters process.
Thank you to my children, Logan and Aidan who have no memory of Mama not being a
student. Thank you to them for taking naps, entertaining themselves, and not setting the
house on fire when Mama was studying or working on the computer.
Thank you to my family and friends, for providing dinners, babysitting and moral support.
I couldn't have done it without you.

Special i hank You To:
My committee members, Dr. Alice Conway Ph.D., CRNP and Janet Geisel Ph.D., R.N., for
keeping me on track and for all their help and support.

Dr. Michael Webster, M.D., for taking the time to review my web site and for all the

helpful feedback.
Lisa Scibetta, CRNP also for taking the time to review my web site and provide feedback
and suggestions.
Ashley

Back

Is Your Child Under 6
Months

of Age?
If your child is under six months of age, this Web site is
not for you!
It is important for your baby to be examined by their doctor or nurse practitioner so
that a more serious underlying problem can be ruled out before your child is treated
for constipation.
Home

What Causes Constipation?
i

What is it?

Tests

Misconceptions

□ □□□

Prevent & Treat

FAQ

Danger Signs!
Links

Helpful Hints

Anything that disrupts your child's usual routine can
potentially lead to constipation.
Many older children (those beyond potty training) first experience constipation with
the start of school. The pressure of having to ask permission, or stress of using a public
restroom causes some children to try to hold their stool until they get home. This
withholding results in a larger, harder, and drier stool.

This same cycle can be applied to many situations in a child's life, for example,
vacations, holidays, or just not wanting to come in from play.

A Painful Experience.

exXXnc^whtentoa°sf< aST§ *
St°°l Or havin§ an unPleasant
experience while passing it, is the number one cause of chronic
constipation in children. For what ever the reason, be it a change in
nasXea
parental Pressure. diet, or illness, the child
passes a large hard stool causing him or her a lot of pain. The child
then becomes fearful of another painful event and begins to withhold
their bowel movements causing them to become larger and harder and
more likely to be painful when they come out. This withholding cycle is
called "functional” constipation.

improper Leverage.
A reason as simple as not getting the proper leverage sitting on an adult size commode
( due to feet not touching the floor) can contribute to constipation. Placing a step stool
under your child's feet may give them the leverage needed to produce a bowel
movement.

Parental Pressure.
When a parent places a great deal of importance in their child having a bowel
movement, or having a bowel movement on the potty, the child may choose to withhold
their stool in an effort to maintain control over something they feel belongs only to

them.
Many parents find that the strategy that works best for-then, and
reinforcement, praise, and maybe a small reward w en t e c i P
tjre dav goes a
movement in the potty. Not making this goal the focus of the ch,Ids enure day goes

long way in reducing parental pressure.
Punishment, rarely produces the desired effect, stress and fear make poor teaching

tools.
Medical Condition.
There are number of medical conditions

-^nhXTmX^T0"

your child. Only your child's doctor or nurse practitioner
Click here for when to_see_your healthcare_prQYldeL_

Preventing and Treating Constipation at Home
ClickJd^eForTrea^
Prescribe

Look Below For What You Can Try At Home!

The first step in fixing a problem is understanding it. Click here to have a look at
what goes on in the body to produce a bowel movement, and how things get jammed
up with constipation!

What Is It?

To Expect

Tests

Misconceptions

Common Causes

FAQ

Danger Signs!
Links

Helpful Hints

Two Step Strategy To Try at Home
The easiest and safest method for helping your child with constipation involves two
steps, changing your child's diet, and bowel training.

<4- Diet Change- Constipation is often due to to a diet that does not
include enough variety, fiber and fluids. Drinking or eating too
many milk products can also contribute to constipation.
For babies 6 months or older adding strained too*“““"“ice
such as cereals, apricots, prunes, peaches, pears, plums beans, peas, orsp.
daily. Avoid strained carrots, squash, bananas, and app

For older chhdren (more than 1
vegetable at least three times each
pears, apricots, beans, celery, peas, caumi
r Child's diet Bran is an excellent natural stool softener,
Add whole grains to your child s diet.

it and other natural whole grains can I
Raisin bran, bran or whole wheat muffins,

»-'oatd5U,SeJ-">“y0UrChlW'sd'et

sxsrr) Me --“‘S/xr

Warning: Avoid any foods that your child can not easily chew!

Note: Adding fiber to the diet without increasing fluids can lead to harder stools.
Increase the amount of water your child drinks. Click here to calculate your
child's fluid needs.

4- Bowel Training-You can help your child establish a regular bowel
pattern by sitting on the toilet after meals.
(Calculate the amount of time your child should sit by multiplying your child’s age by 1-2
minutes, for example, a 3 year old would sit for 3-6 minutes. )
For children who are toilet trained. You can encourage your child to establish a
regular bowel pattern by sitting on the toilet for for several minutes after meals,
especially after breakfast. This is the time when the natural contractions of your child s
bowels are stimulated by eating. Taking advantage of these natural contractions makes it
easier, and more likely that your child will be able to produce a movement. Click .here to
learn more!

Note: No child should sit for more then 10 minutes
Click here for helpful hints!

Fiber Rich Foods
|1. yBran cereals
yTopping this list are Bran Buds and All-Bran, 100% Bran,
yRaisin Bran, Most and Cracklin' Bran are also excellent
sources.
[2. Whole-wheat and other whole-grain cereal products.
jjRye, oats, buckwheat and stone-ground cornmeal are all
yhigh in fiber. Bread, pastas, pizzas, pancakes and muffins
amade with whole-grain flours.
|3. yPlums, pears, and apples
yThe skin is edible, and are all high in pectin.

:4o Brash or frozen green peas

Dried fruit, topped by figs, apricots and dates
yRaspberries, blackberries and strawberries

Raisins and prunes

8. ySweet potato

9. OChemes

ylO. Broccoli-very high in fiber!
H.yGreen snap beans, pole beans, and broad beans
y(These are packaged frozen as Italian beans, in Europe they ]
yare known as haricot or french beans.)

•12.ySweet corn, whether on the cob or cut off in kernels

;13.yMango
M.yGreens
^Including spinach, beet greens, kale, collards, swiss chard
yand turnip greens.

;15.yAsparagus
H 6. Baked potato with the skin
y(The skin when crisp is the best part for fiber.) Mashed and
yboiled potatoes are good, too-but not french fries, which
^contain a high percentage of fat.
XXXUUIXXUXZXXXXXXXXXXXXXXXXXXXX'

XXXXXXXXXXXXXXXXxxxxxuxxxixxxxxxxx* *'* **“* * •••••••*•‘

h7jDried beans, peas, and other legumes
nThis includes baked beans, kidney beans, split peas, dried
hlimas, garbanzos, pinto beans and black beans.
i18.||Carrots

•19

Fresh or frozen lima beans, both Fordhook and baby limas

20.^Brussels sprouts
Back

Calculate Your Child's Daily Fluid Needs

}

L'.e'i

h_ __ ___
Age.

Wt.

______________

Total water or fluids in 24 hrs.

Milliliters
i

ounces

8 oz. cups

6 mo.

16lbs.

950 - 1,100 ml.

28.5 - 33.0 oz.

3 - 4

9 mo.

19lbs.

1,100 - 1,250 ml.

33.0 - 37.5 oz.

4 - 5

1 yr.

21 lbs.

1J 50 ; 1,300 ml.

34.5 - 39.0 oz.

4.5 - 5

2 yr.

26 lbs.

1,350 - 1,500 ml.

40.5 - 45.0 oz.

5 - 6

4 yr.

36 lbs.

1,600 - 1,800 ml.

48.0 - 54.0 oz.

6- 7

44 lbs.

1,800 - 2,000 ml.
2,000 - 2,500 ml.
2,200 - 2,700 ml.
2,200 - 2,700 ml.

6 yr.
10 yr.

63 lbs.

I 14 yr.
18 yr.

99 lbs.
119 lbs.

54.0 - 60.0 oz.

7 - 7.5 j

60.0 - 75.0 oz.

7;5.9

66.0 -81.0 oz.

8-10

66.0 - 81.0 oz.

y^pful Hints
Back

Helpful Hints To Make Life Easier...Helpful Hints To Make Life Easi,

Making the addition of fiber and fluids to you child’s diet, and bowel
training a little more fun helps your child to be a willing participant and
makes managing their constipation a little easier on everyone.
The following tips are things that I and other parents have had success with.

4
4
4
4

4
4

Sugary and or caffeinated drinks are not a good way to increase fluids in you child's
diet. If your child likes water, encourage drinking some between meals or when
thirsty. Otherwise, offer your child diluted fruit juice , gradually adding more
water than juice. (This suggestion is only for supplemental drinking, follow your
health care provider’s instructions for your child's proper nutrition)
Giving your child a fanny pack with a water bottle holder is a good way to
encourage your child to drink more fluids. Kids love this novel way to get a drink.
( Hint: Pack an extra shirt till they get the hang of it)
Another fun way for a kid to drink is through a straw. Multicolored or twisty straws
make it extra fun!
Raw vegetables are a great way to add fiber to your child's diet, but pose a choking
risk for many. Try grating carrots, cucumber, or zucchini on the small side of your
grater, add a little salad dressing or a dab of ranch dip to it.

Kids are more likely to eat vegetables if they are hungry, and if there is nothing
else. Try offering vegetables before you serve the main meal, call them appetizers
and have your kids eat them with tooth picks.

Many kids don’t like the taste or texture of whole grain breads, they can learn to
like them with some persistence from you. For a snack, try breaking fresh whole
wheat bread into pieces, and rolling them into bread balls serve then with

something for your kids to dip in, like salsa, ranch or French dressing or peanut
butter.

444
4•4

Add wheat germ to yogurt or your child’s usual cereal for some added fiber.

For kids who use the big potty and whose feet don't reach the floor, have a stool in
the bathroom for them to rest their feet on. This allows your child to get the
proper leverage needed to expel their bowel movement.
Having a timer in the bathroom set to the number of minutes you want your child
to sit, allows them to see how much time there is left, and helps to eliminate the
"can I be done yet?"

Make Citrucel Gelatin Rounds (also works with Metamucil).
Empty a 4oz. package of flavored gelatin into a heat resistant bowel. Add 4 rounded
tablespoons of Citrucel to the gelatin and mix together thoroughly. Add 1 cup boiling
water and follow gelatin directions on package. Pour gelatin/Citrucel mixture into a
standard size muffin tin. It should make 6 individual rounds. Refrigerate per gelatin box
instructions.
Children age 6 years and under should have no more than 1 round per day. Children age
6 years and up should have no more than 2 per day. Take with at least two 8oz cups of
fluid.

33
Physiologic process

Physiologic Process
Back

JWW-

Many parents feel that by understanding what is going on
in their child’s body helps them to help their child with the
problem.

First Food, Then Poop

After your child eats, it is a 3 or 4 hour process for the food to leave your child's
stomach, wind around through the small intestines, and enter the cecum (the first part of
the large intestine). It then takes several more hours to reach the rectum, where it can
be expelled ( pooped out).
While traveling from the cecum to the rectum, the stool in your child's intestines is
moved along by powerful muscular contractions that mix it( so that water and nutrients
can better be absorbed into your child's body) and propel it forward toward the rectum.
These muscular contractions are strongest after meals, and on awakening.

When the stool reaches the rectum, and the
rectal wall becomes distended, there is a reflex
contraction that pushes the fecal material into the
anal canal. This reflex contraction happens naturally
in you child's body and is not under his or her
conscious control. At this point the child has the
Stomach
urge to have a bowel movement. Your child at this
point can make a conscious decision to go to the
Smail intestine
potty and expel it, or to postpone it. If your child
chooses to postpone having a bowel movement, he
Cecii mor she uses a voluntary contraction of the internal
anal sphincter and other muscles to push it back out Rectum
of the anal canal. The longer the bowel movement
is postponed, the more water is absorbed from it, it becomes drier and larger as it
compacts with the stool that builds up behind it. Later, when your child chooses to
defecate, he or she must now make a conscious and voluntary contraction of their
abdominal muscles to push stool into the anal canal and to once again produce a bowel
movement.

8 reatments Your Health Care Provider Might Try
Your health care provider may choose one or more of the following common treatments
for your child. It is recommended that none of these be tried with out some guidance
from the health care provider who knows your child and can help you determine which is
best suited for him or her. You doctor or nurse practitioner can guide you as to dosage
and length of treatment.

Stool Softeners and Laxatives: can be used as part of a bowel training
program prescribed by your health care provider. There are several
different types grouped by what they do in the intestines. The stool
softeners, also called bulk forming and hydrophilic can be used safely for an
extended period of time with guidance from your doctor or nurse
practitioner. Stimulant laxatives are only intended for occasional use.
Bulk forming - acts like dietary fiber. Products such as Metamucil,
Citrucel, malt suppex and others increase the stool bulk, and allow it to
absorb more water, creating a larger softer movement.

Hydrophilic - attract water to the bowel. Products such as Milk of
Magnesia, Phospho-soda, lactulose and others act by pulling water into the
bowel resulting in the passage of soft-formed feces.

Stimulant - promote accumulation of water in the bowel and stimulates
intestinal contractions. Products such as Dulcolax, Sennacot, mineral oil and
others act by both pulling water into the bowel and by stimulating the
muscular contractions of the intestine to propel it’s contents out.
Note: Avoid giving kayro syrup to babies due to the risk of botulism spore
contaminating the product.

Enemas: Enemas should only be given on the advice of your health care provider.
They are useful if your child is having rectal pain and is need of immediate relief, or
as the first step of a bowel training program to relieve acute constipation and
impaction. Note: Enemas with soapsuds, hydrogen peroxide, or tap water are
dangerous to children. They can result in seizures, bowel damage or deat .
If your health care provider has given the OK to give an enema, a normal
saline enema is the safest for children. These can be purchased at the Pharmacy or
grocery store and come in pediatric size.

Back

IBB

banger Signs I
The following signs may indicate that something

\more serious than constipation is going on with
your child. If your child is experiencing any of
WS
following signs or symptoms, he or she needs
to be evaluated by a health care professional.

■BBH

What Is
|

Tests

Misconceptions

Prevent & Treat

Common Causes

FAQ

Links

Helpful Hints

Cail your child’s health care provider during regular hours if:
4 The child is under six months of age.
4- The child's constipation doesn’t respond to dietary changes or bowel training.

4 Episodes of constipation last longer than three weeks.
4 The child has stool soiling.

Call your child's health care provider Immediately if:
4 At any time, constipation is accompanied by fever, abdominal pain, vomiting or
blood in the stool.
4 Your child develops extreme pain.

Pain becomes constant and persists for more than 2 hours.

What To Expect From Your Child's

Health Care Provider
Home

; ■

Common Causes

; TAQ

Tests
Misconceptions

Prevent & Treat
Links

. Helpful Hints

Your child’s doctor or nurse practitioner will consider many factors
when diagnosing and treating your child’s problem. The following
information provided by you, can help your health care provider
understand the problem your child is experiencing.

What symptoms is your child having that leads you to believe he or
she is having a problem?
When did the problem start?
How often does your child move his or her bowels, and how difficult
is it for them to produce the stool?

4■4-

How is this different from how your child has been prior to the
problem?

What does your child eat?
What and how much does your child drink?

How active is your child?

What have you tried at home to solve the problem?
Are there any other problems or symptoms in addition to your child’s
constipation that you have noticed?

What to Expect at a Visit:
You should expect your healthcare provider to ask some or all of the
above questions.

44-

Your doctor or nurse practitioner will then perform a physical exam of
your child, including a rectal exam.

4’4

Your health care provider will then develop a plan of action for your
child based on the things you ’ve discussed and the findings of the
physical exam.

You should expect to follow up with your child's doctor or nurse
practitioner to assess how your child is responding to whatever
treatment was prescribed.
Note: The cure for constipation is not a single event but a process that occurs
over a significant period of time. It is not unusual for a child who would
appear "cured" to have multiple relapses. Follow up with your child’s health
care provider is crucial over the long term. Treatment frequently needs to
be adjusted, what worked the first time around with your child might not
be the treatment of choice for subsequent episodes. Discuss a "crisis plan"
with your child's doctor or nurse practitioner that tells you what to do and
when, if your child should relapse.

Tests Your Health Care Provider May Order
Home

What Is It?

|Common Causes

FAQ

Prevent & Treat

Links

Helpful H:nts

Depending on the your child’s history and physical exam

findings, your child ’s doctor or nurse practitioner may

order any of the following tests:

X-ray- also called a flat plate of the abdomen (stomach

area). This test shows stool, fluid, and air in you chiids intestines. It may
rule out any obvious obstructions from narrowing or growths. It may provide

your doctor or nurse practitioner with information that will lead them to
order more advanced tests for your child.

Blood Test- to check for a problem with your chi Ids thyroid
function. An under active thyroid is associated with constipation.

Frequently Asked Questions
;

■til

What Is .It?

Common Causes

| What To Expect

Tests

Misconceptions '

/ Helpful Hints

Prevent & Treat
Links

is this a serious problem?
In healthy children, bowel problems are typically transient; but left untreated, can
spiral into physical, behavioral, and developmental problems that could be resistant to
treatment and last well into the school age years. In most cases, with the help of the
parents and health care provider, any serious long term problems can be avoided.

Will my child out grow this?
In most cases,"yes", children outgrow chronic constipation with your help. If a child
receives proper intervention, work can be done to prevent the problem from escalating
into a physical and behavioral dilemma. Ignoring the problem will not make it go away.
For most children, chronic constipation becomes a problem around the potty training
years, when he or she can't understand the necessity of moving their bowels. Children
are very concrete thinkers and if they find the defecation process unpleasant or painful,
they would just as soon postpone it forever. Treatment is designed to soften the stool so
that moving the bowel is not a painful experience, and also includes behavior
modification that encourages the child to develop habits conducive to a regular bowel
pattern.

Isn’t my child just being disobedient or willful by withholding when he
and i both know he has to go?
Although there is a behavioral component to chronic constipation, a child who is truly
fearful of the experience may be incapable of relaxing the rectal sphincter enough to let
a bowel movement pass. No amount of yelling, insisting, or punishment can make it
happen. In fact, by reacting with anger promotes a power struggle that only serves to
complicate the problem.

What is stool soiling or Encopresis (enco-pree-sis)?
Encopresis, sometimes called stool soiling, is the term given to the repeated involuntary
passage of liquid or clay-like stool into the child’s clothing (underwear). This applies to a
child who should be toilet trained on the basis of age or developmental level. This
usually occurs when the child with chronic constipation develops a fecal impaction.
Liquid or soft clay-like stool is able to pass around the impaction and is not held in by the
child's chronically over stretched sphincter muscle.

My seven year old has stool soiling, he claims that he is not aware that
it has happened. We’ve tried everything we can think of, but nothing
has helped. Is it really possible that this is happening without him
knowing it?
When the anal sphincter is chronically overstretched for a period of time, the muscles
of the rectum become lax and the nerves that convey normal sensations are dulled (see
Physiology). In addition, a child who wants to please his parents or is embarrassed about
something he can't control, may block the unpleasant event as a way to protect his
self-esteem. So in short, the answer is yes for both physiologic and emotional reasons, a
child may be unaware that stool soiling is occurring.

Links
Whatlslt<<9

Common Causes

Prevent & Treat

FAQ
Helpful Hints

These are a few health related links that you might find interesting or
helpful:

Bowel function and Dietary fiber
Kids Health

National Parent Information Network
Bright Futures

PEDINFO: An Index of the Pediatric Internet
American Association of Pediatrics

Helpful Reading for Parents and Children
Everyone Poops by Taro Gomi, Kane/Miller Book Publishers, 1993.
Once Upon a Potty (boy & girl versions) by Alona Frankel, Harper Festival, Harper Collins
Juvenile Books, 1988.
Constipation in Childhood by Grahm Clayton & Ulfur Agnaarsson, Oxford University Press,
1991.

Journal Article
Childhood Constipation: Finally Some Hard Data About Hard Stools, Pediatrics Volume
136, Number 1, January 2000.

Comments about this site? E-mail me at:
ashley1966@msn.com

References

American Academy of Pediatrics. (1981). Plant fiber intake in the pediatric diet.
Pediatrics 67, 572-578.

Austin-Kessner, J. (1990). Assessment of coping mechanisms used by parents and
children with chronic illness. Maternal Child Nursing 15, 98-102.
Baker, D. B. (2000). PCASSO. A model for safe use of the Internet in healthcare.
Journal of American Health Information Management Association 71 (3), 33-38.

Berkowitz, C. D. (1996). Pediatrics a primary care approach. Philadelphia, PA:
W.B. Saunders Company, a Division of Harcourt Brace & Company.

Bernier, M. J., & Yasko, J. (1991). Designing and evaluating printed education

materials: Model and instrument development. Patient Education and Counciling, 18
(9), 253-263.
Canobbio, M. M. (1996). Mosby’s handbook of patient teaching St. Louis,
MO. Mosby-Year Book, Inc.

Chi-Lum, B. (1999). Friend or foe? Consumers using the Internet for medical
information. Journal of Medical Practice Management 14 (4), 196-8.

Davidhizer, R. (1992). Understanding powerlessness in family member
caregivers of the chronically ill. Geriatric Nursing 13 (2), 66-9.
Di Lornezo, C. (2000). Childhood constipation: Finally some hard data about
stools! Journal of Pediatrics 136 (1), 4-7.

Farrell-Miller, P., Gentry, P. (1989). How effective are your patient education
materials? Guidelines and evaluating written educational materials. The Diabetes

Educator 15 (5), 418-22.

Futcher, A. J. (1988). Chronic illness and family dynamics. Pediatric Nursing
14 (5), 381-385.

Hartweg, D. L. (1991). Dorothea Orem Self-care Deficit Theory. Newbury
Park, CA: Sage Publications, Inc.

Issenman R. M., Filmer B. F., Gorski P.A. (1999). A review of bowel and
bladder control development in children: how gastrointestinal and urologic

conditions relate to problems in toilet training. American Academy of Pediatrics 103
(6), 1346-1352.

Kirchner, J. T. (1999). Digital rectal exam in children with constipation.
American Family Physician 60 (5), 1530.

Kozma, C. M. (1999). The Role of the Internet in Patient Empowerment.
Managed Care Interface 12 (3), 73-74.

Nelson, J.K., Moxness, K. E., Jensen, M. D., Gastineau, C. F. (1994). Mayo

clinic diet manual, a handbook of nutrition practices. (7th ed.). St. Louis, Missouri:
Mosby-Year Book, Inc.
Orem, D. E. (1995). Nursing concepts of practice. (5th ed.) St. Louis,
Missouri: Mosby-Year Book, Inc.

A'i