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Assessment-Guided Therapy of Urinary Incontinence After Stroke (CE)
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Urinary incontinence (UI) frequently occurs after stroke and often remains an extensive problem for these patients and their relatives even after discharge from the hospital. Therapeutic interventions, such as behavioral training, can help manage UI. Recently, a multimodal application of nursing interventions was recommended (Wilbert-Herr, Hürlimann, Imhof, & Wilbert, 2006). The primary goals of the study discussed in this article were to introduce therapeutic interventions of UI management into clinical rehabilitation practice based on a structured process of interdisciplinary caregiving and test the treatment effect. Forty-four patients who had suffered a cerebrovascular accident (CVA) were included in the study. Nursing interventions included distinction of stress or urge UI and the assessment of different forms of UI. The latter intervention was based on the functional independence measure (FIM Item G—bladder management), the protocol of micturition, urine dipstick, and ultrasound measurement of post-void residual urine (PVR). Interventions were applied according to the recommendations of the 3rd International Consultation on Incontinence. An algorithm of the interdisciplinary process was implemented, and the nursing staff received specific education regarding the interventions. Twenty-one (47%) of the patients in the study were diagnosed with UI; 67% of these patients achieved the targeted level of continence by individually tailored interventions, which consisted of a systematic nursing assessment and standards for prompted voiding, timed voiding, and habit training. Planned processes, including screening procedures, assessment, profile of continence, intervention, and education and evaluation, increase the likelihood of positive results of rehabilitation of patients after CVA. Additional intervention studies are suggested to investigate the effectiveness of the algorithm used in this study.
Urinary incontinence (UI) is not an uncommon occurrence for patients who have suffered a stroke and is an extensive problem for these patients and their families. UI affects patients' well-being, increasing feelings of depression and isolation, and complicating their future medical and nursing care (Brittain, 1998). One study showed that 32%–79% patients who had suffered a stroke were incontinent when they were admitted to the rehabilitation hospital, and 25%–28% of those patients were still incontinent at discharge (Brittain, Peet & Castleden, 1998). In another study on family care, UI was identified as a crucial issue for family members providing care to a relative who has suffered a stroke (Kesselring et al., 2001). In a study looking at first-time stroke patients who had been admitted to a postacute inpatient rehabilitation program, only 6.3% of patients who were continent were discharged to a nursing home; 43% of patients who were incontinent were discharged to nursing homes (Kuijk, Linde, & Limbeek, 2001). A variety of therapeutic interventions, such as behavioral training, are available to treat UI, though the effectiveness of these therapies is not well documented (Wilbert-Herr, Hürlimann, Imhof, & Wilbert, 2006).
A review of the current literature on UI (Wilbert-Herr, Hürlimann, Imhof, & Wilbert, 2006) revealed that a multimodal approach (i.e., educating nurses, using a problem-solving process, and delivering care based on an assessment procedure and guidelines) is most constructive for promoting continence after stroke. According to Wikander, Ekelund, and Milsom (1998), assessment-guided therapy of incontinence can be successful. Validated assessments to discover incontinence are described by the International Continence Society (ICS; Avery et al., 2004) and the scientific committee of the International Consultation on Incontinence (ICI; 3rd ICI, 2005). In addition, the Netzwerk für Qualitätsentwicklung in der Pflege [German Network for Developing Quality in Nursing] (DNQP) recommends a standard of care, developed by experts in the field, to promote urinary continence in nursing care (DNQP, 2006). According to Donabedian's criteria of quality (1980), the standard of care consists of three dimensions: quality in structure, process, and outcome. For that reason, the DNQP Standard was chosen as the basis of this study. Thomas and colleagues (2005) similarly concluded that structured assessment and intervention implemented early on during the rehabilitation process may reduce incontinence. Williams, Assassa, Smith, Shaw, and Carter (1999) and Newman and colleagues (2005) recommended targeted education to caregivers to promote continence. Although this recommendation was not specifically aimed at nurses, they are often responsible for caring for patients who have suffered a stroke. Our study integrated the recommendations from the literature review (Wilbert-Herr et al., 2006) into clinical rehabilitation practice by developing a structured process for caregiving and evaluating its practicability.
From June 2006 to December 2006, 44 patients who had sustained an acute cerebrovascular accident (CVA) were admitted to the department of neurorehabilitation in the rehabilitation hospital Zuercher Hoehenklinik Wald, a major rehabilitation facility in Switzerland. Patients entered the hospital after leaving an acute neurocare unit. There were 19 female and 25 male patients with an average age of 75 (43–92) years. The average time postonset was 22 (8–66) days. The stroke involved the left hemisphere of the brain in 45% of patients and the right hemisphere in 48% of patients; 7% of patients had bilateral lesions.
According to the structured process created for this study to treat CVA patients, all patients are initially screened for possible incontinence. If incontinence exists, a detailed assessment is performed and the treatment is planned accordingly. A profile of continence is developed for each patient and interventions are planned. The nursing team involved in this study received a teaching program before the study began and an evaluation of the process was performed after the study concluded.
Multidisciplinary cooperation was established using an algorithm that included UI screening, extended assessment, and a guide of interventions (Figure 1). The algorithm identified areas of responsibility for nursing and medical staff. This algorithm was developed for this process.
The goal of the screening procedure was to identify any UI in the admitted patients. The screening was performed on the day of admission and included the nursing assessment for stress and urge incontinence (Bent et al., 2005; Donovan et al., 2005), allowing the nurse to establish an initial diagnosis of incontinence.
If the patient was suffering from aphasia or cognitive disabilities, the nurse assessed for signs of incontinence using observation and integrated the results into the assessment of the Functional Independent Measure (FIM™; Hamilton, Laughlin, Fiedler, & Granger, 1994), Item G (bladder management). The FIM (Hamilton et al.) is an 18-item, 7-level measure of physical functioning and social cognition domains. The FIM uses the level of assistance and the individual's needs to grade functional status from total independence (7) to total assistance (1). A score of 1–5 indicates a form of incontinence that requires nursing care and treatment, and the level of nursing care for physical functioning and social cognition should be assessed. The FIM score is a reliable assessment tool, using everyday terminology to describe disability, and is sensitive enough to change over the course of rehabilitation.
Included in the screening is a urine dipstick to detect a urinary tract infection and an ultrasound examination of the bladder to measure postvoid residual urine (PVR). Initially, the ultrasound measurement of PVR was cross-tested with a postvoid single catheterization. If a urinary tract infection was detected or PVR exceeded 100 ml, the process of care was temporarily turned over to the medical practitioner for physician-initiated treatment.
The nursing documentation included a detailed description of the patient's incontinence and categorized the various forms of UI as well as the planned outcome profile of continence.
The International Consultation on Incontinence Questionnaire–Urinary Incontinence–Short Form (ICIQ-UI-SF) assessed frequency and extension of UI and its burden on everyday life from the patient's perspective. The assessment is subdivided into three questions and uses a 0–20-point score (0 represents continence and 20 indicates that the patient feels a very high burden from the UI). Presently, the ICIQ-UI-SF is used for all groups of patients in this study (Avery et al., 2004; ICIQ, 2006). Additional questions concerned medications, which can influence incontinence, and assessed whether patients had accidentally leaked urine before the CVA had occurred. Patients' preferences for nursing interventions were included in the tailored plans of treatment. A protocol of micturition provided additional help for a differential diagnosis of UI and served as documentation of the course and evaluation of the outcome. The protocol of micturition is a 24-hour written record of any assisted or unassisted visit to the toilet.
If the patient suffered from aphasia or had cognitive disabilities, the nurse completed the ICIQ-UI-SF using observation or by obtaining information from relatives and running a protocol of micturition.
Profile of Continence
All of the screening and assessment information was adapted to a continence profile (DNQP, 2006) based on models presented by Fonda (1999) and Palmer, Czarapata, Wels, and Newman (1997). The possible profiles were continence, independently reached continence, dependently reached continence, independently compensated incontinence, dependently compensated incontinence, and not compensated incontinence.
Process of Intervention
The interventions in this study were established to help patients maintain or reach a strived profile of continence. The sequence of interventions used in this study is based on the ICI Guidelines Initial Management of Neurogenic Urinary Incontinence (Figure 2) and Management of Urinary Incontinence in Frail Older Persons (3rd ICI, 2005).
A list of nursing interventions and continence devices was developed according to the recommendations from the literature review (Wilbert-Herr et al., 2006) and the ICS (3rd ICI, 2005) and the definitions and procedures for all of the interventions were based on international definitions. For instance, habit training is toileting assistance provided by a caregiver to adults with UI. It involves the identification of incontinence, a person's natural voiding pattern, and the development of an individualized toileting schedule that preempts involuntary bladder emptying (Ostaszkiewicz, Johnston, & Roe, 2004).
During training, the nursing team first learned about UI. A training catalogue had been developed that covered anatomy and physiology of the urinary tract, the urinary tract's pathological conditions, and the various forms of UI (particularly neurogenic incontinence and UI in older, frail people) and treatment. The second part of training involved teaching clinical skills to identify risks and signs of UI, which included screening questions, urinalysis with dipstick, measuring the PVR urine with a mobile ultrasound system (BladderScan®, Verthon, Bothell, WA), assessing the patient using the ICIQ-UI-SF and the continence profile (DNQP, 2006), and using a guideline for interventions (Wilbert-Herr, 2006; 3rd ICI, 2005).
A questionnaire about the project was distributed to all staff nurses involved in the study after it concluded, which included 32 yes-no questions about the lessons from their initial teaching, the flowchart of the multidisciplinary process, the patient screening and assessment processes, the micturition protocol, the interventions, and the evaluation of the process of care. Written comments and suggestions for improvement were welcomed. The medical practitioners received a different evaluation that included 15 questions and an interview.
Forty-four patients were admitted to the rehabilitation hospital during the study and, on average, their length of stay was 33.5 (7–69) days. All patients were screened for UI. Micturition disorders (e.g., lower urinary tract dysfunction [LUTD]) were found in 25 patients based on the screening results; 21 of these 25 patients had UI. Patients with UI received a differential assessment of their incontinence situation. The remaining four patients without UI presented with different complaints of LUTDs. The continence profile, based on the assessment, was recorded for each patient, and all incontinent patients were prescribed a plan of care for maintaining or reaching a profile of continence, which was also documented. During the treatment interventions for UI, patients' environments and devices, such as commodes, raised toilet seats, bars, and frames, and handheld urinals, were adapted to fit their care demands for continence promotion. The interventions were used systematically, and the most commonly used nursing care interventions were habit training and prompted voiding. The most common medical care interventions were administering anticholinergic medication and observing the PVR. In the DNQP's Modified Standard of Care (2006), outcome E6 explains that the "profile of continence is reached. The possible level of continence with the greatest possible independence of the patient is guaranteed." To achieve this outcome, all staff nurses were trained in systematically promoting continence with a defined target (or level of continence). Sixty-seven percent (n = 14) of patients had achieved continence according to the continence profile (DNQP, 2006), and 52% (n = 11) of patients had an FIM–Item G (bladder management) level of 6 or 7 (i.e., continence; Table 1) at the conclusion of the study. The ICIQ-UI-SF assessment showed that on average, patients had improved their feelings of burden by 3 points.
Evaluation of the Nursing Training and Multidisciplinary Process
Ten out of the 16 nurses involved in the study completed the questionnaire. In general, the nurses found the process to be positive, though they did express some constructive criticism. The teaching and multidisciplinary processes were regarded as helpful, as was the list of interventions. Conversely, nurses commented that the assessment and micturition protocol were too complicated for everyday use. Using the mobile ultrasound to measure PVR was universally regarded as an improvement and nurses felt it should be integrated into daily routine.
The two medical practitioners who were involved in the study also completed the questionnaire. They found that the flow chart was helpful for orientation; however, in practice, the interaction between the various professionals and patients was more involved than what appeared on the flowchart. Patients reported to nurses and medical practitioners about their micturition dysfunction. Medical interventions were initiated when the PVR was higher than 150 ml. When the PVR was higher than 100 ml, a control of the PVR was repeated. The medical practitioners commented that screening patients when they are admitted to the hospital places high demands on them because they undergo multiple additional assessments on the same day for rehabilitation planning. Consequently, it was recommended by the interdisciplinary care team that screening should occur on the second day after admission, critical PVR up to 100 ml should be limited, and PVR measurement for control of retention should be repeated.
This study demonstrates the importance of UI assessment. It also stresses the necessity of screening for other micturition disorders, which can influence the course of rehabilitation.
Generally, the study was successful; 67% (n = 14) of patients achieved continence, according to the definition of their continence profile, within 30 days. This rate of continence is higher than results reported from traditional individualized therapy (Wilbert-Herr et al., 2006). When the study concluded, the entire team felt that they were working more effectively to manage UI. The plans of care for individual patients were more specific, but used a more standardized format. Staff members also found the use of standardized terminology to be beneficial because it facilitated the professional assessment. The various interventions in toilet training such as prompted voiding, timed voiding, and habit training improved the individualized promotion of continence. Nurses reported that using the mobile ultrasound system as a diagnostic tool was particularly valuable. The ultrasound appliance was used not only for screening but for controlling the urine volume in the bladder after removing indwelling catheters, allowing nurses to manage this task independently from medical practitioners.
The definitions of UI regarding the profile of continence outlined earlier in this article were used in nurses' daily practice. For patients who had a functional dependence in care, the ICS definition of UI (i.e., any involuntary leakage of urine; Abrams et al., 2002) can be too limited. After a stroke, many patients are only continent with the help of caregivers. If there is no caregiver readily available, the patient presents with functional UI. The Standard of Experts (DNQP, 2006) discusses UI but neglects micturition disorders. Because the screening is based on the Standard of Experts the LUTDs, such as prostatic hpyerplasia, are neglected. In the future, LUTDs need to be more specifically assessed, especially nocturia, which impairs night sleep and can disturb the rehabilitation process.
This study uses FIM (Hamiltion et al., 1994) and ICIQ-UI-SF (Avery et al., 2004) to assess for UI. Sometimes, the ICIQ-UI-SF can be too limited for assessing patients after a stroke, particularly when they are suffering from cognitive disorders. In addition the ICIQ-UI-SF can be too extensive and impracticable. Considering the restricted staff resources and varied tasks involved in promoting patients' independence in activities of daily life, future assessments should be shorter and bear in mind that rehabilitation outcomes are correlated with successfully treating UI. The various interventions for treating UI need to be defined precisely and nurses must receive systematic training to implement them.
Treating UI in a patient after he or she has sustained a stroke can be improved by instituting a structured process that consists of team education, assessments, and guidelines. Our study involved a small number of patients; a larger controlled trial should be conducted to corroborate the preliminary findings presented in this article. This study involved a thorough review of the literature and serves as a model of evidence-based medicine and nursing. Reducing the complexity of the process described in this article may increase the feasibility of its use in future clinical routine. As a result of our findings, screening of patients with CVA has been modified to include the global assessment for LUTDs.
We would like to thank all of the patients and caregivers who participated in this project.
About the Authors
Isabella S. Herr-Wilbert, RN, is an advanced practice nurse/clinical nurse specialist and former head of rehabilitation nursing at the Neuromuscular Clinic of the Rehabilitation Center Zurcher Hohenklinik Wald in Wald-Falfigberg IZH, Switzerland. She is currently head of the department of development in nursing at the Paracelsus-Spital in Richterswil, Switzerland. Address correspondence to her at email@example.com.
Lorenz Imhof, PhD MScN, is professor of nursing and head of the Department of Research and Development in Nursing, Department of Health Care at the Zurich University of Applied Sciences in Winterthur, Switzerland.
Margret Hund-Georgiadis, MD, is a privatdozent, neurologist, and researcher at the Neuromuscular Clinic of the Center of Rehabilitation Zurcher Hohenklinik Wald in Wald-Falfigberg IZH, Switzerland.
Dirk Michael Wilbert, MD, is professor of urology and head of the Department of Urology at the Clinic Linth in Uznach, Switzerland.
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