Stroke is a leading cause of disability and a major health concern for the older population. The term "stroke" refers to a complex of symptoms that - result from cerebral damage. This damage or destruction of brain cells occurs when the blood supply is disrupted by thrombus, embolus, hemorrhage, or compression. 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 sensory problems.
Bladder dysfunction, which frequently accompanies a stroke, is often ignored or accepted as an inevitable consequence. Fbr the stroke victim, bladder dysfunction is a distressing, disabling problem with major implications for the quality of life after a stroke. The physical complications of bladder dysfunction (ie, infection, skin breakdown, and urosepsis) have serious implications for the recovery process and participation in rehabilitation programs. The effect of voiding problems on social and emotional wellbeing also has a major effect on outcome. Adults are devastated by the loss of control over voiding. Activities are often decreased by the fear of accidents, interrupted by frequent toileting trips, or confined to places close to toileting facilities. These restrictions in activity frequently interfere with participation in rehabilitation efforts and reintegration into the community and family. Added strain to family resources occurs when management of voiding requires assistance. Large amounts of time, energy, and money are often spent in frequent checks on toileting needs, multiple trips to the bathroom, procurement and care of special equipment and supplies, and laundry and cleaning chores. Continence is a major factor in deciding whether a person can be cared for at home.
Nursing has the important tasks of promoting continence and instructing patients in effective, efficient management of bladder dysfunction. The nursing staff in our stroke unit identified the need for a systematic, organized approach to bladder management. This article describes our efforts to achieve that goal and the results we obtained.
SUMMARY OF DATA CONTROL GROUP
SUMMARY OF DATA EXPERIMENTAL GROUP
A literature review revealed two major types of voiding problems after a stroke: incontinence and urgency/ frequency. The most common problem is urinary incontinence. Surveys of the occurrence of incontinence after a stroke have indicated that 60% to 80% of the persons studied were incontinent during the first 2 weeks after a stroke.1'3 Although urgency and frequency often contribute to incontinence, they are also a frequent complaint when incontinence is not present. A urodynamic study of 39 patients, post-stroke, revealed that 26 of the patients complained of urgency/ frequency and incontinence, while 13 reported dy suria or retention.4 In the literature, urinary retention is rarely mentioned as a problem. However, Mossman5 reported that atonic bladder dysfunction is a potential problem in the initial days after a stroke.
TIME BETWEEN VOIDINGS THIRD DAY AFTER CATHETER REMOVAL
TIME BETWEEN VOIDINGS DAY OF CATHETER REMOVAL
Once we identified the types of bladder dysfunction experienced, we then looked to the nature of these problems as a framework for intervention. A major source of voiding problems after a stroke is neurogenic bladder dysfunction. Neurogenic dysfunction results from damage to the cerebral micturition center or disruption of the neural pathway between the bladder and the brain centers involved in voiding.
The type of neurogenic dysfunction associated with a stroke is uninhibited bladder activity. With an uninhibited bladder, bladder wall contractions strong enough to empty the bladder occur after only small amounts of urine have collected. The person may not be aware that the bladder is about to empty. Sometimes awareness of impending voiding occurs just immediately prior to actual onset of the urine stream. Incontinence results from inadequacy or absence of warning. Frequency and urgency may also result from impaired cerebral control over bladder wall contractions; ie, the person is unable to control these contractions effectively.
Stroke deficits other than those directly affecting the micturition center can also cause voiding problems. Correct interpretation of the message to void, understanding the implication of the message, and performance of the necessary steps to void under socially appropriate conditions require action and interpretation by many parts of the brain. A stroke can adversely affect thought processes such as attention, concentration, judgment, and decision making - any of which may alter the ability to follow up on messages to void. Incontinence or distention may result from the failure to respond to signals of the need to void.
However, voiding after a stroke is complicated by a variety of other causative and contributing factors. Disruption of structural and functional aspects of the urinary tract, such as bladder neck dysfunction, diminished bladder capacity, and urinary tract infection, may result in or add to frequency, urgency, or retention. Fecal impaction and the loss of gravity drainage when the patient does not void in a sitting position also interfere with the ability to empty the bladder effectively. The age and physical condition of many stroke victims place them at high risk to develop these conditions.
Other factors that affect voiding behavior after a stroke are related to emotional reactions. Apathy, depression, lability, and irritability may interfere with the desire or ability to void. Acceptance of the misconception that voiding dysfunction, particularly incontinence, is expected and unavoidable in disability may also play a role. Even when the desire and ability to void are present, environmental conditions may interfere. The availability and accessibility of toileting facilities and of necessary help to use those facilities are major concerns. Physical mobility deficits and disruption in communication skills after a stroke often contribute to the impact of the environment.
TIME UNTIL ONSET OF VOIDING
AVERAGE PVR VOLUME (IN ML)
Despite the diversity in dysfunction and the variety of causative and contributing factors, only one major treatment modality, an indwelling urinary catheter, is usually mentioned in the literature. Continual urinary catheterization is often necessary in the acute phase following a stroke to monitor urine output closely, and to prevent overdistention of the bladder and incontinence; but continual catheterization has been associated with bladder problems such as urinary tract infection, difficulty in initiating voiding, and incomplete emptying of the bladder once the catheter is removed. The importance of removing an indwelling urinary catheter as soon as possible has been well supported. However, the best method for catheter removal has not been clearly identified.
Reconditioning regimens prior to catheter removal have been developed in an effort to minimize or alleviate voiding problems after catheter removal. These regimens involve clamping the catheter for a specified period and then draining it so that the bladder goes through filling/emptying cycles. Our nursing staff, as well as the literature reviewed, was divided on the issue of whether clamping routines were beneficial.
Clinical studies evaluating the effect of clamping routines are limited. 6-7The most extensive study evaluated the effect of progressive clamping regimens on postoperative urinary dysfunction in 110 persons who had either postabdominal peritoneal resection or low anterior bowel resection. Urinary dysfunction was defined as the inability to empty the bladder adequately. The 6day clamping program produced a statistically and clinically significant difference in voiding dysfunction rates, but only in female subjects who had had abdominal perineal resection. The authors concluded that bladder dysfunction related to loss of bladder support structures was less likely to respond to a reconditioning program than was dysfunction caused by neurogenie damage from surgery.7,8 Perhaps the neurogenic dysfunction from a stroke would also respond favorably to a reconditioning program.
Support that a clamping routine might be effective in removing a urinary catheter after stroke came from a study by Dunn on stroke survivors.8 This study involved 20 subjects with urgency and urge incontinence who exhibited uninhibited or unstable bladder functions. Under spinal anesthesia, the bladder was distended to a pressure equal to the patient's systolic pressure for 30 minutes. The distension procedure was repeated four times on each subject and the bladder was emptied between treatments. At the end of each period, bladder capacity was measured, fourteen of the 20 patients obtained almost complete relief of symptoms, and five subjects noted improvement.
There appear to be no studies evaluating clamping regimens for catheter removal in stroke patients. Since there has been some support that clamping routines might be helpful, and because catheter removal is so often the first step in bladder management programs, a clinical study was designed to evaluate the effect of a clamping routine on voiding after catheter removal in stroke patients. The specific voiding behaviors of concern were time from catheter removal to onset of voiding, time between voidings, and postvoided residuais (PVR). The population for the study consisted of stroke patients with an indwelling catheter who were admitted to a rehabilitation hospital. Patients who were incontinent prior to their stroke, diagnosed with additional neurological disease, unable to communicate, or under the age of 50 were excluded. A total of 28 patients met criteria for admission to the study; all consented to be participants. Subjects were randomly assigned to one of two groups: the control group had their catheters removed without a clamping regimen, and the experimental group underwent a reconditioning program prior to catheter removal. The reconditioning program lasted 12 hours, and the clamped catheter was released every 3 hours to empty the bladder. Data was collected on the identified voiding behaviors the day of catheter removal and again 2 days later.
A total of 13 subjects completed each protocol. One subject in each group was transferred out for medical illness prior to completion of data collection. Using chi square and the Fisher test, no significant differences were found between the groups regarding age, sex, number of strokes per person, time the catheter was in place prior to removal, presence of urinary tract infection, medications used, or presence of diagnosed renal disease. The groups did differ with respect to stroke location and the prevalence of diabetes (Tables 1 and 2). It is doubtful that the difference in location of the stroke has implications, since there is tittle to support the idea that there is only one cerebral bladder control area. Although the control group contained significantly more diabetics than the experimental group, no differences were found in voiding behaviors when data controlling that variable were analyzed.
Data analysis using Mann-Whitney U revealed no significant difference between the groups in the voiding behaviors studied. A comparison of the groups is depicted in Figures 1 through 4. One of the most interesting findings is the difficulty subjects experienced voiding after catheter removal . Approximately one third (9 of 28) of the subjects did not void within the first 8 hours after their catheter was removed.
Efforts were made to stimulate voiding by encouraging a fluid intake of at least 1500 mL per day, through cues such as running water, and allowing time in the bathroom. Four subjects who failed to void were in the clamping group and five were in the control group. There was no significant difference between those who voided within 8 hours and those who did not with respect to location of stroke, number of strokes, age, sex, urinary tract infection, or time catheter was in place prior to removal. Another interesting finding was the inconsistencies in effective emptying experienced by the subjects. Fourteen of the subjects had PVRs that fluctuated from normal to abnormal.
Although the study was limited by the small sample size, difficulty in obtaining data on the exact time of voidings after the onset of urination, and the fact that only one clamping protocol was used, recommendations on bladder management after stroke a were obtained from the data collected. These findings support the removal of indwelling catheters without clamping protocols and reinforce the importance of closely monitoring voiding after catheter removal as well as having an alternative management strategy.
In our unit, those who did not void within 8 hours were placed on an intermittent sterile catheterization routine (ISC). Every 6 to 8 hours, if they could not void, their bladders were emptied by in-and-out catheterization. Six of the nine were eventually able to empty their bladders effectively and became continent. The time needed for improved bladder function ranged from 1 to 28 days.
Evaluation of the use of ISC in stroke was found in only one other study. Marks and Bohr9 evaluated the ability to empty the bladder and the presence of infection in 30 subjects post-stroke on ISC. ISC was begun regularly, and the interval between catheterizations was increased as PVR volumes decreased. After a 2-week trial, if voiding had not begun, bethanechol was prescribed; for persistent incontinence, oxybutynin was used. All subjects received ascorbic acid and methenamine. Twenty-seven (90%) of the subjects were eventually able to void satisfactorily. All had sterile urine after ISC started. The authors concluded that ISC offered the advantage of reducing exposure to bladder infection from a catheter during a clamping program.
Garrett and Scott evaluated bladder function after stroke in patients admitted to our stroke unit who did not have an indwelling urinary catheter (unpublished data). Post-voided residual urines were collected on 100 consecutive admissions. Adequate bladder function was defined as three consecutive PVRs less than or equal to 50 mL. In the 85 subjects for whom data collection was completed, 48 had elevated PVRs; of the 48, 42 patients were voiding. Without PVRs, many of these patients' bladder problems would not have been discovered until complications developed.
As a result of our study, the Garrett and Scott study (unpublished data), and our review of the literature, we now evaluate bladder function more closely on all stroke admissions. This evaluation is accomplished by use of PVRs twice daily in those who void and ICSs every 8 hours for those who do not void. Efforts are made to ensure fluid intake of at least 1500 mL per day. PVRs are continued until three consecutive volumes less than 50 mL are produced. The frequency of ISC is increased to every 6 hours if catheterization volumes exceed 350 mL to 400 mL. We rarely have had large catheterization volumes with our stroke patients. Since clamping has not made a difference in voiding, and routine use of ISC/PVR prevents overdistention, catheters are removed without clamping regimens.
ISC/PVR does not eliminate the need for additional urological evaluation and other nursing management techniques. Urological workups are required if retention or incontinence continues after 2 to 3 weeks with the intervention outlined previously. Timed voiding and habit retraining continue to be used frequently. Medications are tried for persistent bladder hypotonia and spasticity. Patient and family education concerning bladder function, dysfunction after stroke, and prevention of complications, such as urinary tract infections and skin breakdown, remain important. In the rare case in which ISC is needed after discharge, the family or other caregiver is educated. Through the close observation of voiding status and implementation of ISC/PVR regimens, nursing has been provided with the necessary data to plan appropriate nursing intervention as well as to prevent overdistention. Clearly, nursing can make the difference in success or failure of bladder management.
- 1. Borne M, Campbett A, Caradoc-Davises T, Spears G. Urinary incontinence after stroke: A prospective study. Age Aging. 1986; 15:177-181.
- 2. Brocklehurst JC. Andrews K. Richards B. Laycock PJ. Incidence and correlates of incontinence in stroke patients. J Am Geriatr Soc. 1985:33:540.
- 3. Adams M, Baron M. Gaston MA. Urinary incontinence in the acute phase of cerebral vascular accident. Nurs Res. 1966; 15(2):100-107.
- 4. Tsuchida S. Noto H, Yamaguchi O. ltoh M. Urodynamic studies on hémiplégie patients after cerebrovascular accident. Urulogv. 1983;2I(3):315-3I7.
- 5. Mossman, PL. Urinary dysfunction following a stroke. In: A Problem Oriented Approach itt Stroke Rehabilitation. Springfield. Ill; Charles C Thomas: 1976.
- 6. Williamson ML. Reducing post-catheterization bladder dysfunction by reconditioning. Journal of Neurosurgiral Nursing. 1982; 31(D:26-30.
- 7. Oberst M. Graham T. Geiler N. Stearns M, fierran E. Catheter management programs and postoperative urinary dysfunction. Res NursHealth. 1981:4:1975-1981.
- 8. Dunn M. Smith JC. Ardran GM. Prolonged bladder distension as a treatment of urgency and urge continence of urine. British Journal of Urology. 1 974: 46:645-652 .
- 9. Marks RL, Bahr GA. How to manage neurogenie bladder after stroke. Geriatrics. 1977; 50-54.
SUMMARY OF DATA CONTROL GROUP
SUMMARY OF DATA EXPERIMENTAL GROUP