A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE OF MOTHERS REGARDING ENURESIS IN
THERE CHILDREN OF AGE 3 TO 7 YEARS IN SELECTED
RURAL AREA OF TUMKUR
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
Mrs INDERJEET KAUR
MENTAL HEALTH NURSING
Akshaya College of Nursing,
Tumkur, Karnataka.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1. Name of the Candidate : Mrs Inderjeet Kaur
And address M.Sc Nursing, 1st Year
Akshaya College of Nursing,
Tumkur, Karnataka.
2. Name of the Institution : Akshaya College of Nursing
3. Course of Study : M.Sc. Nursing 1st year,
And Subject MENTAL HEALTH NURSING
4. Date of Admission to :27-10-2010
Course
5. Title of the Topic : “A study to assess the effectiveness of self instructional module on knowledge of mothers regarding enuresis in there children of age 3 to 7 years in selected rural area of Tumkur”
6. INTRODUCTION
Enuresis, more commonly called bed-wetting, is a disorder of elimination that involves the voluntary or involuntary release of urine into bedding, clothing, or other inappropriate places. In adults, loss of bladder control is often referred to as urinary incontinence rather than enuresis; it is frequently found in patients with late-stage Alzheimer's disease or other forms of dementia. 1
Enuresis is a condition that has been described since 1500 B.C. People with enuresis wet their bed or release urine at other inappropriate times. Release of urine at night (nocturnal enuresis) is much more common than daytime, or diurnal, wetting. Enuresis commonly affects young children and is involuntary. Many cases of enuresis clear up by themselves as the child matures, although some children need behavioural or physiological treatment in order to remain dry. 2
There are two main types of enuresis in children. Primary enuresis occurs when a child has never established bladder control. Secondary enuresis occurs when a person has established bladder control for a period of six months, then relapses and begins wetting. To be diagnosed with enuresis, a person must be at least five years old or have reached a developmental age of five years. Below this age, problems with bladder control are considered normal. 3
Several studies have investigated the association of primary enuresis and psychiatric or behaviour problems. The results suggest that primary nocturnal enuresis is not caused by psychological disorders. Bed-wetting runs in families, however, and there is strong evidence of a genetic component to involuntary enuresis. Unlike involuntary enuresis, voluntary enuresis is not common. It is associated with such psychiatric disorders as oppositional defiant disorder, and is substantially different from ordinary nighttime’s bed-wetting. Voluntary enuresis is always secondary. 4
Behaviour modification is often the treatment of choice for enuresis. It is inexpensive and has a success rate of about 75%. The child's bedding includes a special pad with a sensor that rings a bell when the pad becomes wet. The bell wakes the child, who then gets up and goes to the bathroom to finish emptying his bladder. Over time, the child becomes conditioned to waking up when the bladder feels full. Once this response is learned, some children continue to wake themselves help from without the alarm, while others are able to sleep all night and remain dry. A less expensive behavioural technique involves setting an alarm clock to wake the child every night after a few hours of sleep, until the child learns to wake up spontaneously. In trials, this method was as effective as the pad-and-alarm system.4
Although enuresis cannot be prevented, one side effect of the disorder is the shame and social embarrassment it causes. Children who wet may avoid sleepovers, camp, and other activities where their bed-wetting will become obvious. Loss of these opportunities can cause a loss of self-esteem, social isolation, and adjustment problems. A kind, low-key approach to enuresis helps to prevent these problems.5
6.1 NEED FOR THE STUDY
Bed wetting or medically known as enuresis is a condition in which children empty the bladder involuntary and wet the bed at an age beyond which the sphincter control is normally developed. An occasional event of bedwetting should not cause undue parental concern. When bedwetting occurs frequently, it is defined as enuresis.6
Doctors frequently consider bedwetting as a self-limiting problem, since most children will outgrow it. Children 4 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 18 years old have a spontaneous cure rate of 16% per year. Adult rates of bedwetting show little change due to spontaneous cure. Persons who are still enuretic at age 18 are likely to deal with bedwetting throughout their lives.
Approximate bedwetting rates are:
· Age 5: 20%
· Age 6: 10–15%
· Age 7: 7%
· Age 10: 5%
· Age 15: 1–2%
· Age 18–64: 0.5–1%.7
Many parents report that their bedwetting children are heavy sleepers. Research in this area has produced some contradictory results. Studies show that children wet the bed during all phases of sleep, not just the deepest (stage four, or stages three and four). A recent study, however, showed that enuretic children were harder to wake up Some literature does show a possible connection between sleep disorders and ADH production. Insufficient ADH might make it more difficult to transition from light sleep to being awake.7
Medical literature states and studies show that punishing or shaming a child for bedwetting will frequently make the situation worse. This can cause increased bedwetting incidents, leading to more punishment and shaming. In the United States, about 25% of enuretic children are punished for wetting the bed. In Hong Kong, 57% of enuretic children are punished for wetting. Parents with only a grade-school level education punish bedwetting children at twice the rate of high-school- and college-educated parents.8
Bedwetting is common for children, affecting more boys than girls. The condition occurs in 30% of children at the age of 4, 10% at the age of 6, and drops to 1% by the age of 18. Although children develop bladder control at different rates, most boys can control their bladder during the day and night by the age of 6, and most girls by the age of 5. When a child who is old enough to have bladder control urinates accidentally while sleeping,
Parents and family members are frequently stressed by a child's bedwetting. Soiled linens and clothing cause additional laundry. Wetting episodes can cause lost sleep if the child wakes and/or cries, waking the parents. A European study estimated that a family with a child who wets nightly will pay about $1,000 a year for additional laundry, extra sheets, disposable absorbent garments such as diapers, and mattress replacement.9
Bed-wetting can lead to behaviour problems because a child may feel guilt and embarrassment. It's true that child should take responsibility for bed-wetting. But child shouldn't be made to feel guilty. It's important for child to know that bed-wetting isn't his or her "fault." Punishing child for wetting the bed will not solve the problem. Remind child that it's okay to use the bathroom during the night. Place nightlights leading to the bathroom so child can easily find his or her way. Cover the child's mattress with a plastic cover to make cleanup easier. If accidents occur, praise child for trying and for helping clean up.10
Many parents are unsure about when to start toilet teaching or "potty training." Not all kids are ready at the same age, so it's important to watch your child for signs of readiness, such as stopping an activity for a few seconds or clutching his or her diaper. Most children begin to show these signs between 18 and 24 months, although some may be ready earlier or later than that. And boys often start later and take longer to learn to use the potty than girls.11
Bedwetting, medically known as nocturnal enuresis, is a common situation among children up to 5-6 years. The problem ceases to exist as the child grows beyond that age. However, it is when bedwetting continues to exist even after the child is mature enough to remain dry in bed that it turns into a problem. It is not necessary that a child urinates in bed because he/she drinks excess water before going to bed or has some behavioral problems. Rather, bedwetting is mostly seen as a delay in the normal development of child, which can lead to a feeling of shame and embarrassment in the child. In such a situation, it is necessary for the parents to understand the causes behind bedwetting and take appropriate measures to correct the same.11
Thus the researcher decided to assess the effectiveness of self instructional module on knowledge of mothers regarding enuresis in there children of age 3 to 7 years in selected rural area of Tumkur.
6.2 REVIEW OF LITERATURE
Review of literature is the reading and organizing of previously written materials relevant to the specific problems to be investigated; framework and methods appropriate to perform the study12
A study was conducted in developing country to determine “whether
parents are receiving knowledge guidance on toilet training”. Analysis of data was
based on 25 minutes telephonic interview consisting if 2017 respondents. A stratified
random digit dialing design was used to obtain sample of parents with children
between 3-5 years. Discussion with a nurse on about 6 parental guidance topics
revealed varied results on not using the information. New born (35%), crying (65%),
sleep pattern (59%), encouraging (77%), discipline (36%), and toilet training (66%).
Among total 37% parents had not discussed on any of theses topics. About 39% of
parents had discussion on toilet training and 37% had not discussed on toilet training,
needed more information on toilet training.13
A study was conducted on Nocturnal enuresis and its treatment among primary-school children in Oromieh, Islamic Republic of Iran. . A questionnaire was answered by parents of 3500 selected students at the annual school enrolment in summer 2004. The frequency of nocturnal enuresis was 7.7%. Enuresis frequency was significantly higher among boys (8.6%) than girls (6.7%). Treatment methods used were: medication, water restriction, awaking for voiding and enuresis alarm in 57.8%, 18.1%, 11.5% and 2.6% of cases respectively. The frequency of nocturnal enuresis is similar to other studies but treatment methods were different.14
A cross sectional study was conducted on Prevalence and perception of nocturnal enuresis in children of a rural community in southwestern Nigeria. Four hundred parents/guardians were interviewed and information obtained on 644 children aged 6-12 years. Overall enuresis prevalence was 17.6% (19.9% among boys and 14.9% among girls). The reported causes of nocturnal enuresis included urinary tract infection (33.5%), excessive play (27.5%) and deep sleep (25%). A majority (74.5%) of the respondents would use herbs or traditional medicine to treat enuresis, while only 6.8% of the respondents sought orthodox healthcare facilities for its management. Only 18 (25%) of the 71 parents/guardians with enuretic children had ever consulted a health worker. The misconceptions and inappropriate enuresis management methods among the parents/guardians require health education intervention.15
A study was conducted on Enuresis services, carers' knowledge and attitudes services in southern Derbyshire. A specialist enuresis service was already running in this area and the continence nurse advisor (children's services) had noted a high number of referrals complaining about lack of knowledge prior to attending clinic and a lack of clarity and continuity of advice given by other health professionals. The specialist continence service needed to be needs-led and validated as an appropriate and adequate service. Following a literature search and pilot study, a questionnaire was sent to parents of children who had been referred to the clinic in the previous year. Analysis was performed using the SPSS statistical package. Results showed a high value being given to the specialist nurse-led service by parents and children and a high amount of conflicting, non-evidence based advice being given to parents and carers from various health professionals prior to referral to the specialist nurse. The results of the study led to the formulation of recommendations to improve services available to children with enuresis, their parents and carers.16
The cross-sectional survey was conducted on the public basic schoolchildren in Aden, Yemen, in the period November 2007-April 2009. Data were obtained by using pre-recoded questionnaire, which was completed by parents. The response rate was 73.7% (656 students); 113 (17.2%) cases of nocturnal enuresis were encountered. Nocturnal enuresis de-creased by age from 31.5% at 6-8 years to 8.7% at 15+ years (P < 0.05). Primary nocturnal enuresis affected 76.1%, of which the majority of children were bedwetting every night. Positive family history of nocturnal enuresis, deeper sleep, daytime enuresis, tea drinking, being non working father or with less education showed significant association with the occurrence of enuresis in the students. Stressful events in the previous 6 months of the study were twice more frequently noted. The study concluded that the prevalence of nocturnal enuresis in Aden public school children and its associated factors are almost comparable with that reported in epidemiological studies from various countries. Health education will encourage the parents to be aware, cope with this problem and seek appropriate medical advice.17
A study conducted on “Parents practice on child oriented approach to toilet training” at Harvard Medical School. Results of toilet training obtained from records of 1,170 children over a 10-year period are summarized. This as instituted at 2-5 years of age and depended on his physiologic and psychological readiness. Initial success in both bowel and urinary control in 79.5% and 12.3% in bowel control alone and 8.2% in urinary control. First accomplishment at an average of 27.7 months. Daytime training between 2 and 21/2 years in 80.7% of this group. Nighttime training accomplished by 3 years in 80.3% of cases. Age of completion of all training was 33.3%. Males took 2.46 months longer for complete training.18
A research conducted on “Assisted Infant Toilet Training in a Family Setting”. Independent toilet training usually starts at age 18 months or later. In 18 developing countries and in Asia, assisted toilet training traditionally starts between one and three months and is completed within approximately one year. This research reports a male infant who started assisted toilet training at age 33 days, in a family setting. During the first days, the mother made observations of the infant’s bowel movement schedule and the cues he provided, from which she learned when to assist him to eliminate in the bathroom. During this process, the infant was held in an “in-arms” position. Successful toilet training was completed at five months. This case reported that early infant toilet training is possible in a family setting if the mother properly learns the infant’s natural elimination timings and signals. 19 A study was conducted to analyze “if family situation, personal habits and toilet training methods can influence achievement of bladder control”. A questionnaire with 41 questions was distributed to 4332 parents of children completed 3 years of age. Response rate was 76.7%. Results shown that two groups of children were identified, one with lower urinary tract symptoms (3404) and one with complaints of day time and night time wetting and urinary tract infection (928). They termed groups as the ‘control’ and ‘symptom’ groups respectively. Data shown significant differences in toilet training between children with and with no lasting problems of bladder control. Postponing the onset of the training after 24 months of age probably increases risk of later problems with bladder control.20
A study was done on “toilet training and your child’s temperament are
more likely culprits”. Study followed 380 children for 3 years as they mastered toilet
training between ages of 17 and 19 month at start of the study. Toilet training in
daytime completion was nearly 37 months. There was a wide range between 22-54
months. Almost 25% refused to have a bowel movement on toilet training study. 93%
of children who refused to have bowel movements had hard bowel movements
experienced constipation. Schonwald suggested that the biggest factors were
constipation and difficult temperament traits. 21