Bladder and bowel dysfunction are common problems in patients with underlying neurologic conditions, such as stroke, and multiple sclerosis [1].  It is not well documented but noted in individuals with traumatic and acute brain injury [2].  Assessing the nature and extent of bladder and/or bowel (B&B) symptoms at admission to an acute rehab facility or community-based care is integral to the success of rehabilitation of the neurologic patient population throughout the care continuum. There needs to be clear communication of the nature and extent of the symptoms between patient and clinician. The nursing assessment and ongoing documentation should accurately report the clinician’s and patient’s perceptions of their dysfunction, resulting in an appropriate nursing plan of care to achieve successful bladder and bowel control [3].  However, there is a paucity of information on the consistency of nursing documentation of lower urinary tract and bowel function in patients with neurologic disease who are undergoing rehabilitation.  The aim of this study was to determine if there were discrepancies between the patient’s perception and/or reporting of B&B symptoms and the nursing documentation of B&B symptoms as recorded in the patient’s medical record in the rehabilitation setting.  It was hypothesized that the B&B symptoms and perceptions will not be well described and/or will be absent from the documentation.

This was a descriptive correlation study conducted in 3 acute inpatient rehabilitation facilities and 1 post-acute residential facility in a large metropolitan city in Eastern United States.  Literature search yielded validated B&B symptom questionnaires and instruments that were reviewed to determine their applicability for this study.  No one questionnaire or tool met the criteria for a physical rehabilitation population.  Relevant assessment questions for nursing assessment and patient self-report of B&B symptoms and outcome measures for bladder and bowel were compiled into the Nursing Assessment of Bladder and Bowel Symptom (NABBS) questionnaire.  The NABBS tool was used to compare the patient self-report with the nursing documentation of symptoms in the patient’s medical record.   The study was a convenience sample of English-speaking male or female patients, recruited from each facility, with a primary neurologic diagnoses of traumatic brain injury (TBI), acute brain injury (ABI), stroke (CVA) and/or multiple sclerosis (MS).  Participants were recruited within ten days of admission. The post-acute care participants who met inclusion criteria were approached to participate in the study.  Following informed consent, each participant’s medical record was reviewed to determine diagnosis for eligibility.  The data (medical record review and patient interview) were collected on the same day by two data collectors. To ascertain cognitive ability, the Mini-cog was administered on all participants, but no participant was excluded based on a low score.

A total of 185 patients (101 females, 84 males) were interviewed and had their medical record reviewed.  The majority of patients had a diagnosis of stroke (n=115). Other neurologic diagnoses included MS (n=3), TBI (n=55) and ABI (n=12).  The majority of patients were Caucasian (see Figure 1).  Based on Mini-cog results, 44 % of the sample had cognitive issues.  Surprisingly, for this neurologic population, only 14 patients had documentation in their medical record of having undergone urodynamic tests performed within the past year.  124 medical records had no documentation as to urodynamic testing. There were significant differences between B&B symptoms documented in the medical record when compared to patient self-report (see Table 1).  Our findings show there was very limited agreement between patient reporting and nursing documentation of B&B symptoms.

Successful management of bladder and/or bowel problems in patients with neurologic disease depends on good nursing assessment and clear communication. However, this study showed little agreement between patient self-report and nursing documentation of B&B symptoms. Given the type of neurologic impairments and cognitive status in this sample, cognitive impairment could have affected the subjects’ comprehension and ability to recall past B&B symptoms. There is variability in the symptoms recorded in the medical records in this sample. We need to tailor the assessment to consider the patient’s comprehension and communication impairments.

Clear and concise documentation reflecting an accurate assessment of the patient’s perception/reporting of bladder and/or bowel symptoms and the nursing documentation is necessary before nurses can develop an effective nursing care plan for patients with neurologic condition who have bladder and/or bowel issues. There are no standard bladder and bowel assessment tools used across acute rehabilitation facilities. The use of an Electronic Medical Record truncates the data that can be entered for bladder and bowel assessment.
This study demonstrates the need for comprehensive bladder and bowel assessment tools and documentation requirements within the field of rehabilitation nursing and the integration of the nursing assessment that includes the patient’s cognition, comprehension and communication abilities when developing the bladder and bowel plan of care.

Sheldon P. Wyman, JF, Newman DK. (2017). Neurogenic lower urinary tract dysfunction. In: Newman DK, Wyman JF, Welch VW, editors. Core Curriculum for Urologic Nursing. 1st ed. Pitman (NJ): Society of Urologic Nurses and Associates, Inc; 503-518.
Wein, A.J. (2016) Pathophysiology and classification of lower urinary tract dysfunction: overview In: A.J.Wein, L.R. Kavoussi, A.W. Partin, C.A. Peters (Eds).  Campbell-Walsh urology, (11th Ed., pp.1685-1696). Philadelphia:  Elsevier Saunders.
Hentschke P. (2009). 24-hour rehabilitation nursing: the proof is in the documentation. Rehabil Nurs. May-Jun;34(3):128-132