VOL: 97, ISSUE: 30, PAGE NO: 54
Ray Addison, RN, FETC, Cert.H.Ed, BSc, is is nurse consultant, bladder and bowel dysfunction at Mayday University Hospital, Croydon, Surrey
Lizzie Dodd, RN, is ward manager;Frank McGurrin, RMN, RN, DMS, MBIB, MBA, is director of nursing/deputy chief executive;Jumoke Abili is a registrar, andValerie Jones is stroke consultant, Mayday University Hospital, Croydon, SurreyOur 20-bed ward serves three consultants (neurology, rehabilitation and stroke), with 15 beds for stroke patients and five for neurology/rehabilitation. Before the opening of the ward the continence service was invited to consider their involvement in this new venture. Three years on, a sustainable model of continence service has emerged which has become accepted, established and valued.
Our 20-bed ward serves three consultants (neurology, rehabilitation and stroke), with 15 beds for stroke patients and five for neurology/rehabilitation. Before the opening of the ward the continence service was invited to consider their involvement in this new venture. Three years on, a sustainable model of continence service has emerged which has become accepted, established and valued.
Stroke and incontinence
Incontinence is common following a stroke and recognised as a poor prognostic indicator (Wade and Langton-Hewer, 1985; Jongbloed, 1986). Brocklehurst et al (1985) found that out of 135 stroke patients 40% were incontinent within the first two weeks of diagnosis and 24% were still incontinent a year later. Incontinence was more common in those patients who were also dependent and immobile. Borrie et al (1986) described that at one week post-stroke 60% were incontinent - a poor prognostic indicator that was also linked strongly with mental impairment, motor deficit and impaired mobility. Ten years later confirmation is still being found that incontinence is common and that urinary incontinence has a negative impact on outcome (Ween et al, 1996).
Burney et al (1996) identified that urinary retention was also common following an acute stroke, although this resolved with time. Gebler et al (1993) classified incontinence after stroke into three: urge incontinence related to an overactive bladder (detrusor hyper reflexia), functional incontinence caused by cognitive or communication problems and overflow incontinence caused by hyporeflexia or medication.
Our continence service model
The long-term implications of incontinence after a stroke will affect the outcomes. This model of continence service has emerged to meet patient need:
- Regular ward meetings are held most Fridays for about one hour;
- These meetings include the nurse consultant in bladder and bowel dysfunction, the ward manager/sister and the registrar. Sometimes nursing students are present;
- Using a specifically designed monitoring form completed by night staff, we review the previous seven nights' activity on average for about 16 patients;
- During the meeting we agree interventions for each individual and document and produce an action plan. Reviewing and prescribing medication is one of the most common aspects of our interventions;
- We have identified the range of interventions used on patients with bladder and bowel dysfunction. Some of these are used more often in combination.
The majority of patients have some degree of bladder and or bowel dysfunction. Many have incurable conditions and diseases that impact on their activities of daily living and hence their quality of life. Rehabilitation is the key to success for this client group who not only have bladder and bowel dysfunction but often other disabilities which they and their families find very distressing.
The nurse consultant role
Our model of continence service provides the opportunity for clinical consultancy on a large scale. An entire ward of 20 patients can be discussed on a regular basis. The model demonstrates professional respect for the clinical expertise, knowledge and skills brought to the ward by the nurse consultant and provides opportunities for informal teaching and work-based learning.
Why just monitor night activity?
Night staff are on duty for 10 hours. This method makes use of their skills and knowledge to provide data. This is an essential contribution to the individual action plans and eventual patient outcomes.
Nocturia is a complex health issue. First, there is true nocturia which directly relates to bladder dysfunction and age (Addison, 1999a). Secondary nocturnal voiding must also be considered as a cause of nocturia. Pain and insomnia fall into this category but are not linked to bladder pathology (Addison, 1999a). Lastly, there is nocturnal polyuria, where over one-third of the total 24-hour output of urine is produced at night (Addison, 1999a) as a result of cardiac, circulatory and blood pressure problems. It is possible for patients to have a combination of all three. The appropriate interventions vary according to the type of problem or combination found on the monitoring chart. As stroke patients are predominantly elderly and cardiac problems more prevalent, night-time monitoring is particularly useful (Addison, 1999b).
Urinary tract infection is also a common problem. It is diagnosed from increased voiding activity at night, which is written on the chart. Detrusor instability is common in strokes; anticholinergic therapy is extensively used for this. Zhan et al (1988) indicated that unstable bladder contractions were found with volumes under 200ml in stroke patients, causing urgency and frequency, which again can be detected at night.
The goal of management for the incontinent stroke patient is to restore a socially acceptable level of continence, maintaining urinary storage at low intravesicle pressures and minimising the risk of infection (Burney et al, 1996). We strive to do this, affording patients the dignity to undertake their daily activities, such as physiotherapy and occupational therapy. The monitoring chart provides surveillance and sensitivity in picking up increased nocturnal voiding related to infection or detrusor overactivity.
What are the benefits?
There are many benefits to this continence model:
- The monitoring chart provides important objective data that is reliable and shows nocturnal activity, facilitating audit and re-evaluation;
- Its aids our assessment process, which is the key to identifying types of dysfunction, initiating appropriate care and achieving successful outcomes;
- Weekly meetings provide time for effective communication, particularly useful for patients with complex needs. They facilitate appropriate interventions, onward referral and further consultation;
- Relatives, carers and health care staff are given realistic information about bladder and bowel dysfunction and methods of treatment, management and containment;
- A portable ultrasound machine was purchased for the ward and is used to assess voiding in most patients;
- There is a very low usage rate of urinary catheters. All catheterised patients are on intermittent bladder emptying via a catheter valve to maintain bladder tone, function and sensation (Coleman-Gross, 1992; Addison, 1999b). The two main indications for catheterisation are retention, usually associated with outflow obstruction. We rarely use catheters to manage incontinence.
- Manual evacuations and enemas are very rarely required to treat constipation and faecal incontinence is rarely a problem for stroke patients on our ward. Macrogol laxative therapy is commonly used to maintain bowel function and prevent constipation. It is also used to establish regular bowel function in patients admitted with severe constipation;
- Bowel activity at night is not normal, so if noted on the monitoring chart it is investigated and dealt with;
- Cranberry juice is available to all patients twice daily. It is used to minimise the effect of urinary tract infection in this high-risk group (Burney et al 1996; Addison 1999c).
- It is usual for anybody over the age of 60 to pass some urine at night. If patients show no night-time voiding this is abnormal and is investigated (Addison, 1999a);
- Anticholinergic therapy is better controlled by the use of the monitoring chart to show effectiveness. It is always stopped in patients with urinary tract infection, where it is contraindicated;
- Diuretic therapy has been effective when used during the afternoon to treat nocturnal polyuria. Why is the model successful?
Having nurse consultant input on bladder and bowel dysfunction is valued and continues to be accepted by both medical and nursing staff. It has become part of the ward culture. Even when staffing is low, the monitoring chart is seen as a priority and is completed. It contributes to the success of patient outcomes as well as to an environment in which high-quality rehabilitation care is provided.