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Bladder management in acute care of stroke patients: a quality improvement project.

Introduction

Stroke is a leading cause of disability and a major health concern for people of all ages. A stroke may affect any functional skill and usually results in a combination of deficits. However, following a stroke, attention is focused primarily on the resulting motor and sensoriperceptual problems. Bladder problems following a stroke are often ignored or accepted as an inevitable consequence.

Nurses have an important task of promoting the return of bladder function and continence. The nursing staff members in our stroke unit identify that the duration and severity of bladder dysfunction vary in each person after an acute onset of stroke, and recognize that the return of effective bladder function and continence depends on the extent and location of brain damage, and its effect on the person's functional capacity. However, bladder dysfunction after a stroke is not always inevitable, as is proven by our systematic and organized approach to bladder management in our stroke unit.

In 1992, the nursing staff members working in our stroke unit gained competency in the use of a portable ultrasound instrument to estimate bladder volume in patients who have difficulty passing urine after a stroke.[1] This technique of bladder scanning is now routinely used by our nurses in the assessment and management of patients with voiding problems.

This study aimed to demonstrate the effectiveness of our bladder retraining program. Five types of bladder function or voiding patterns are described in an outcome measurement scale which forms the basis for bladder management.

Method

For 13 consecutive weeks during May to August 1995, all patients admitted to our acute stroke unit were enrolled in the study. A sample population of 16 female and 26 male patients was obtained. Each patient's bladder function was assessed on admission and assigned a bladder score (BS) from an outcome measurement scale for bladder function (Tables 1,2). An individualized bladder program consisting of a Bladder scanning/Intermittent catheterizations (IMC)/Post-void residual (PVR) regimen, voiding strategies, pelvic muscle exercises and/or drug therapy was prescribed. The duration of TMC/PVR was recorded. When the patient's post-voided urine residual was below 100 ml on three consecutive days, the IMC/PVR regimen was deemed completed. A post IMC/PVR bladder score was recorded as well as the date of completion. Again, the patient's bladder status was assessed on discharge, a bladder score and date were recorded. The discharge locality and the total length of stay in the stroke unit were also obtained. Data collection was carried out by the author through a concurrent study of patient records using a data collection tool (Table 3).
Table 1. Outcome Measurement Scale for Bladder Function

Level Score Description
Total urinary 1 Atonic detrusor
retention High compliance bladder
 High risk for bladder overdistension
 Overflow leakage, may be mistaken as
 voids or incontinence

Partial urinary 2 Weak detrusor activity
 Incomplete bladder emptying with high
 urine residual>200 ml
 High risk for bladder overdistension

Functional 3 Intact detrusor function
incontinence Patient is unable to recognize bladder
 and environmental cues
 Incontinent of urine
 No or little urine residual<100 ml

Urge 4 Uncontrolled detrusor contractions
incontinence Patient may recognize the 'strong urge'
 to void frequently
 Low bladder capacity, 100-200 ml
 No or little urine residual<100 ml

Continence 5 Intact detrusor function
 Normal bladder capacity, 300-400 ml
 Patient has complete control of voiding
 No or little urine residual<100 ml
Table 2. Outcome Measurements of Bladder Function:
Guidelines for Scoring

Score
1 Total Urinary Retention
 The patient
 Has no voluntary and involuntary void.
 Requires regular intermittent catherization to empty
 bladder at 4,6 or 8 hours to prevent bladder
 overdistension.
 May require an indwelling catheter (IDC) to straight
 drainage in particular circumstances/as per medical
 consultant's order.

2 Partial Urinary Retention
 The patient
 Voids voluntarily or involuntarily.
 Has irregular voiding pattern.
 Retains urine>100 ml post void.
 Requires regular residual catherizations to empty
 bladder completely.

3 Function Incontinence
 The patient
 Voids involuntarily.
 Requires maximum assistance in toilet retraining using
 timed-voiding or prompted-voiding strategies.
 Requires supervision and/or moderate assistance to
 maintain the established voiding pattern and continence.
 May require continence appliances for containment.

4 Urge Incontinence
 The patient
 Voids frequently or incontinent.
 Experiences string 'urge' to void at low volumes,
 100-200 ml.
 Has no or little residual urine<100 ml.
 May require the use of anti-chlorinergics, pelvic muscle
 exercises, and/or
 bladder drill to resolve this problem.

5 Continence
 The patient
 Has complete control or voiding day and night.
 Has normal bladder capacity and voiding pattern.
 Has no or little residual urine<100 ml (slightly higher
 residual urine 100-200 ml may occur in patients with
 diabetes mellitus or prostatomagely).




[TABULAR DATA 3 NOT REPRODUCIBLE IN ASCII]

Results

A total of 42 patients, 16 female and 26 male, of ages 46 - 88 years, was studied. Five critically ill patients, one female and four male, were admitted with indwelling catheters. Three of these five patients died within 2 - 3 weeks after admission, one male patient was discharged to a nursing home with the indwelling catheter, and one other male patient who received bladder management post-removal of indwelling catheter remained incontinent on discharge to a country hospital. Of the thirty-seven patients who received bladder management, thirty-one became continent and only six male patients remained incontinent on discharge. Three of these six patients had anterior circulation stroke involving the entire area supplied by middle cerebral artery, the other three patients had stroke involving the basal ganglia, striate capsule and putamen respectively. These six patients were discharged to other subacute rehabilitation facilities. Two female and one male patients developed urge incontinence after the IMC/PVR regimen and were treated with low-doses of anticholinergics and pelvic muscle exercises; they achieved continence within 5 days. Two male patients required low doses of prazocin and double voiding technique to effect bladder emptying due to the presence of slight prostate enlargement. Our bladder management yielded a success rate of 84% in resolving bladder problems in patients with acute stroke (Tables 4-6).
Table 4. Results

Male: N=16 / Age: 46-82 years Female: N=26 / Age: 56-88 years

Extent & Location of Stroke:
 Male Died Incontinent post BM
TACs 7 2 2
PACs 13 0 4
LACs 1 0 0
POCs 4 0 0

 Female Died Incontinent post BM
TACs 8 1 0
PACs 6 0 0
LACs 1 0 0
POCs 1 0 0




Clinical Stroke Syndrome: TACs = Total Anterior Circulation Sysndrome PACs = Partial Anterior Circulation Syndrome POCs = Posterior Circulation Syndrome LACs = Lacunar Syndrome BM = Bladder Management
Table 5. Results

IDC on admission:
 5 patients, 1 female and 4 male
 3 died in a period of 2-3 weeks
 1 male patient was discharged to nursing home
 1 male patient received BM post IDC renmoval, but
 remained incontinent by date of discharged

Bladder Managment:
 37 patients
 15 female patients achieved continence
 16 male patients achieved continence
 Only 6 male patients remained incontinent

Success rate: 84%
Average duration of IMC/PVR 8 days




[TABULAR DATA 6 NOT REPRODUCIBLE IN ASCII]

The results of this study also indicated that 23% of the male patients did not achieve urinary continence with the bladder retraining program whereas all the female patients did achieve continence. This group of male patients appeared to have limited capacity to reacquire voluntary control of voiding owing to severe neurological limitations, mobility and self-care deficits. However, it is not possible to tell, on the basis of this study, how typical this observed phenomenon is with other male patients who have similar stroke-related deficits. Such information can only come with additional studies or follow-up study of these patients' state of continence in their rehabilitation facilities.

Summary

Bladder dysfunction is a distressing and disabling problem with major implications for the quality of life after a stroke. Infection, skin breakdown and urosepsis are such bladder-related physical complications that have serious implications for the recovery and rehabilitation process. Furthermore, the healthcare cost related to voiding problems is immense in addition to the devastating effects on the person's social and emotional well-being. Our results support that bladder dysfunction in the acute phase of stroke must be managed by a protocol of bladder scanning, intermittent catheterizations, post-void residual (IMC/PVR) regimens which serves as a reconditioning strategy in bladder retraining. The use of indwelling catheters for the treatment of urinary retention and prevention of incontinence should be strongly discouraged. Monitoring voiding pattern and checking consecutive post-voided residual urine to evaluate the effectiveness of bladder emptying is indicated in all patients after a stroke.

References

[1.] Chan H: Noninvasive bladder volume measurement. J Neurosci Nurs 1993; 25(5):309-312.

[2.] Philips BM, Pearman JW: Intermittent cathetenzations of acute spinal patients by nurses. Paper presented at the Australasia Regional Scientific Meeting International Medical Society of Paraplegics, 1996.

Questions of comments about this article may be directed to. Harriet Chan, RN, PO Box 738, Applecross, Western Australia 6153. She is a clinical nurse specialist in the Clinical Neurosciences Division at Royal Perth Hospital in Western Australia. Copyright [C] American Association of Neuroscience Nurses 0047-2603/96/2903/0187$1.25
COPYRIGHT 1997 American Association of Neuroscience Nurses
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1997 Gale, Cengage Learning. All rights reserved.

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Author:Chan, Harriet
Publication:Journal of Neuroscience Nursing
Date:Jun 1, 1997
Words:1500
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