Slide 1 Continence And Stroke Central South Regional Stroke Program September 2007 Funded by the Ministry of Health and Long Term Care

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Continence Continence And Stroke And Stroke

Central South Regional Stroke Central South Regional Stroke ProgramProgram

September 2007September 2007

Funded by the Ministry of Health Funded by the Ministry of Health and Long Term Careand Long Term Care

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Session OverviewSession Overview

The types of stroke. The types of stroke. The common changes that result from The common changes that result from

stroke.stroke.The link between stroke and continenceThe link between stroke and continenceThe types of incontinence.The types of incontinence.Strategies to support a resident’s success in Strategies to support a resident’s success in

being continent.being continent.

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What is a StrokeWhat is a Stroke

An An interruption of the supply of blood and interruption of the supply of blood and oxygen to an area of the brain.oxygen to an area of the brain.

This causes the brain cells in an area to die, This causes the brain cells in an area to die, and reduces the brain function in that area.and reduces the brain function in that area.

The area of the body controlled by the The area of the body controlled by the damaged area in unable to function properly.damaged area in unable to function properly.

There are two types of stroke.There are two types of stroke.

http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#efhttp://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

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What is a Stroke?What is a Stroke?

A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996

A stroke can A stroke can happen when a happen when a blood clotblood clot blocks blocks a blood vessel in a blood vessel in the brain.the brain.

80% of strokes are 80% of strokes are this type.this type.

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What is a Stroke?What is a Stroke?

A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996

A stroke can also A stroke can also happen when a happen when a blood vessel blood vessel breaksbreaks and results and results in in bleedingbleeding in the in the brain.brain.

20% of strokes are 20% of strokes are this type.this type.

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Risk factors you can do Risk factors you can do something about…something about…

High blood pressureHigh blood pressureHigh blood High blood

cholesterolcholesterolHeart diseaseHeart diseaseDiabetesDiabetes

Being overweightBeing overweightExcessive alcohol Excessive alcohol

useusePhysical inactivityPhysical inactivitySmokingSmoking

Pearson et.al., (2002) AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases Circulation, 106, 388-391.

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What does a What does a resident who has resident who has had a stroke look had a stroke look

like in LTC?like in LTC?

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What are some of the losses What are some of the losses due to stroke?due to stroke?

paralysis or weakness on one side of paralysis or weakness on one side of the body; the body;

vision problems; vision problems; trouble speaking or understanding trouble speaking or understanding

language; language;


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inability to recognize or use familiar inability to recognize or use familiar objects objects

tiredness; tiredness; depression; depression;


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exaggerated or inappropriate emotional exaggerated or inappropriate emotional responses; responses;

difficulty learning and remembering new difficulty learning and remembering new information; and information; and

changes in personality. changes in personality.


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Stroke StatisticsStroke Statistics

There are between 40,000 and 50,000 There are between 40,000 and 50,000 strokes survivors in Canada each year.strokes survivors in Canada each year.

10% (4-5,000) of strokes survivors each year 10% (4-5,000) of strokes survivors each year require long-term care. require long-term care.

40% (16-20,000) of strokes survivors each 40% (16-20,000) of strokes survivors each year are left with a moderate to severe year are left with a moderate to severe impairment.impairment.

http://ww2.heartandstroke.ca/Page.asp?PageID=33&ArticleID=1078&Src=news&From=SubCategoryhttp://ww2.heartandstroke.ca/Page.asp?PageID=33&ArticleID=1078&Src=news&From=SubCategory

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Stroke Stroke can cause a can cause a loss of bowel and loss of bowel and bladder control.bladder control.

http://www.medicine.mcgill.ca/Strokengine/module_ui_intro-en.html

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Urinary Incontinence is Urinary Incontinence is common in strokecommon in stroke

40-60% of stroke survivors are 40-60% of stroke survivors are incontinent after having their incontinent after having their

stroke.stroke.

Thomas LH, Barrett J, Cross S, French B, Leathley M, Sutton C, Watkins C. Prevention and treatment of urinary incontinenceafter stroke in adults. Cochrane Database of Systematic Reviews 2005, Issue 3.

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Over time bladder Over time bladder continence can continence can

improve.improve.

Thomas LH, Barrett J, Cross S, French B, Leathley M, Sutton C, Watkins C. Prevention and treatment of urinary incontinence after stroke in adults. Cochrane Database of Systematic Reviews 2005, Issue 3.

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There may be improvement in There may be improvement in their bladder/bowel functiontheir bladder/bowel function

Upon discharge from hospital : 25% of stroke Upon discharge from hospital : 25% of stroke survivors are incontinentsurvivors are incontinent

1 year: 15% of stroke survivors are incontinent1 year: 15% of stroke survivors are incontinent


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Types of IncontinenceTypes of Incontinence

1.1. Physical incontinencePhysical incontinence2.2. Functional incontinence Functional incontinence

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Physical IncontinencePhysical Incontinence

Urinary FrequencyUrinary FrequencyUrgency Urgency (sudden compelling desire to pass urine which is difficult to (sudden compelling desire to pass urine which is difficult to

defer)defer)

Urge IncontinenceUrge Incontinence (involuntary leakage)(involuntary leakage)


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Functional IncontinenceFunctional Incontinence

Patient has either decreased mental ability Patient has either decreased mental ability or decreased physical ability and is unable or decreased physical ability and is unable to make it to the bathroom in time.to make it to the bathroom in time.

Turhan et.al., Impact of stroke etiology, lesion location and aging on post-stroke urinary incontinence as a predictor of functional recovery, International Journal of Rehabilitation Research 2006, Vol 29 No 4

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To remain continent a resident To remain continent a resident must…must…

Know they have to voidKnow they have to voidCommunicate their need to a caregiverCommunicate their need to a caregiverBe motivatedBe motivated

Brittain et.al., (1998) Stroke and Incontinence, Stroke, 29, 524-528

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To remain continent a resident To remain continent a resident must…must…

Be able to Be able to – bear weight bear weight – assist in transferring to a toilet or commodeassist in transferring to a toilet or commode– or use an appropriate applianceor use an appropriate appliance

Delay voiding until the appropriate timeDelay voiding until the appropriate time Initiate voiding voluntarilyInitiate voiding voluntarily


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Impact of Stroke on Continence Impact of Stroke on Continence CareCare

Inaccurate interpretation of messages and Inaccurate interpretation of messages and sensations from the brain to the bladder.sensations from the brain to the bladder.

Decreased thinking abilities (insight, impulse Decreased thinking abilities (insight, impulse control)control)

Decreased functional abilityDecreased functional ability


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Stroke and Incontinence LinkStroke and Incontinence Link

Frequent coughing (difficulty swallowing)Frequent coughing (difficulty swallowing)Problems speaking (aphasia)Problems speaking (aphasia)


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Other Causes of IncontinenceOther Causes of Incontinence

Fecal impactionFecal impactionDrug therapyDrug therapyDiureticsDiureticsPoor diabetes controlPoor diabetes controlUrinary tract infectionsUrinary tract infectionsLow estrogen levels in womenLow estrogen levels in womenPre-morbid conditionsPre-morbid conditions


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Incontinence StrategiesIncontinence Strategies

Use of individualized assessment and goal settingUse of individualized assessment and goal setting (Thomas LH, Barrett J, Cross S, French B, Leathley M, Sutton C, Watkins C. Prevention and treatment of urinary incontinence after stroke in adults. Cochrane Database of Systematic Reviews 2005, Issue 3.)

Scheduled toileting– before/after meals, q2h, and Scheduled toileting– before/after meals, q2h, and prn (MOHLTC standard)prn (MOHLTC standard) ((Ostaszkiewicz J, Johnston L, Roe B. Timed voiding for the management of urinary incontinence in adults. Cochrane Database of Systematic Reviews 2004, Issue 1.)

Adequate fluid intake – 1500ml/day (MOHLTC Adequate fluid intake – 1500ml/day (MOHLTC standard)standard)

Making sure the resident is close to a washroomMaking sure the resident is close to a washroom

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Adaptable clothing Adaptable clothing Communication – resident can tell you Communication – resident can tell you

what they needwhat they needAdaptive devices – commode, grab Adaptive devices – commode, grab

bars, use of urinals, bed pansbars, use of urinals, bed pans

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Use incontinent products when needed Use incontinent products when needed Encourage independence and self-care Encourage independence and self-care Environment promptingEnvironment promptingPrivacyPrivacyDementia care strategies – Dementia care strategies – responsive behaviour responsive behaviour

strategies, PIECESstrategies, PIECES

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AllieAllie

Allie has been recently admitted to Cozy Acres with a Allie has been recently admitted to Cozy Acres with a diagnosis of stroke. This is the first time that you diagnosis of stroke. This is the first time that you have worked with Allie and have not been able to have worked with Allie and have not been able to review her chart. The RN lets you know that Allie is review her chart. The RN lets you know that Allie is incontinent. Allie is able to walk with assistance but incontinent. Allie is able to walk with assistance but she has fallen before. Allie needs you to help her she has fallen before. Allie needs you to help her with washing and getting dressed. Allie needs with washing and getting dressed. Allie needs assistance ambulating to the washroom and assistance ambulating to the washroom and removing her clothing. Allie is unable to tell you that removing her clothing. Allie is unable to tell you that she needs to use the toilet, however she is able to she needs to use the toilet, however she is able to accurately report Y/N responses. Allie often accurately report Y/N responses. Allie often identifies when she needs to be changed by identifies when she needs to be changed by moaning or gesturing to staff.moaning or gesturing to staff.

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AllieAllie

What are two possible losses that Allie has What are two possible losses that Allie has experienced as a result of her stroke that experienced as a result of her stroke that may be affecting her incontinence.may be affecting her incontinence.

What can you do about this situation?What can you do about this situation?

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Next Steps…Next Steps…

You are the eyes, ears and voice of your You are the eyes, ears and voice of your home.home.

Be aware of the diagnosis of your residents.Be aware of the diagnosis of your residents.Take this stroke information and use it with Take this stroke information and use it with

the residents that you work with.the residents that you work with.Share this stroke information and care Share this stroke information and care

strategies with other staff.strategies with other staff.Follow-up in 2 months with the home’s best Follow-up in 2 months with the home’s best

practice champions.practice champions.

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More InformationMore Information

Acute Changes and StrokeAcute Changes and Stroke Continence and StrokeContinence and Stroke Dementia and StrokeDementia and Stroke Falls and StrokeFalls and Stroke Pain and StrokePain and Stroke

Please contact: Please contact:

Rebecca Fleck or Kim YoungRebecca Fleck or Kim YoungCommunity and Long Term Care Specialist Community and Long Term Care Specialist Central South Regional Stroke ProgramCentral South Regional Stroke Program905-521-2100 x 44127905-521-2100 x 44127

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AcknowledgementsAcknowledgements Best Practices long term care advisory groupBest Practices long term care advisory group Best Practices long term care evaluation groupBest Practices long term care evaluation group Best Practice Continence Working Group, Haldimand NorfolkBest Practice Continence Working Group, Haldimand Norfolk Charmaine Martin, Hamilton Health Sciences, Acute Care Nurse PractitionerCharmaine Martin, Hamilton Health Sciences, Acute Care Nurse Practitioner Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term Care Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term Care

Central South RegionCentral South Region Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care Central Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care Central

West. West. Central South Regional Stroke ProgramCentral South Regional Stroke Program Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro-ambulatory Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro-ambulatory

CentreCentre Melanie Fall Stratton, Regional Stroke Program, Program Manager,Melanie Fall Stratton, Regional Stroke Program, Program Manager, Kim Young, Regional Stroke Program, Community and Long-term Care Kim Young, Regional Stroke Program, Community and Long-term Care

SpecialistSpecialist Rhonda McNIcoll-Whiteman, Hamilton Health Sciences, Stroke Best Practice Rhonda McNIcoll-Whiteman, Hamilton Health Sciences, Stroke Best Practice

Co-ordinatorCo-ordinator Lisa Colizza, Regional Stroke Program, Regional Stroke Development SpecialistLisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation CoordinatorNancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Carol Pereira, Regional Stroke Program, LTC Project CoordinatorCarol Pereira, Regional Stroke Program, LTC Project Coordinator

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Documents

Slide 1 Continence And Stroke Central South Regional Stroke Program September 2007 Funded by the Ministry of Health and Long Term Care