Edith is an 83 year old lady who prior to her stroke led an active life. She chaired various committees and worked as a volunteer in the local Chest, Heart & Stroke Scotland (CHSS) shop. She also helped out with three boisterous grandchildren. She had a left middle cerebral artery infarct about 6 months ago and had mild difficulty walking. She was discharged home after two weeks with visits from the community stroke rehabilitation team.
During a domiciliary visit from the stroke rehabilitation team the stroke liaison nurse observes that Edith’s mood is low When gently questioned Edith tells her she has not been attending her normal social activities, her committee work has been suspended and she has not yet returned to the Chest, Heart & Stroke shop. On further probing Edith reveals that at her last hospital appointment she was unable to tolerate the 90 minute journey to the outpatient department. This resulted in an episode of urinary incontinence. She then went on to reveal problems with her bladder prior to this but these had always been managed well until her stroke.
After her experience she now feels anxious about going out anywhere unless she is certain of toilet facilities. She has been up during the night to the toilet which is interrupting her sleep patterns and she feels very tired.
Edith is anxious about returning to the CHSS shop. Her husband is concerned that Edith has withdrawn and lost her enthusiasm for her day to day activities. Edith is reluctant to disclose to her husband and is finding it difficult to continue to conceal the continence anxieties by ‘padding herself’.
A week following admission Robert is much more comfortable, less confused and his appetite is beginning to return. Repeat bladder scans indicate that his bladder is emptying almost completely and his bowels are moving with regular oral laxatives. Robert no longer needs intermittent catheterisation (in/out). His dietary intake is improving and he is becoming more mobile which is helping to maintain regular bladder emptying and bowel movements. Robert has been commenced on finasteride to treat his enlarged prostate.
Robert is becoming more distressed and agitated. He has had further episodes of faecal incontinence and his skin is red and vulnerable to breakdown
He has only taken sips of water and some yogurt
Following examination his prostate is also found to be slightly enlarged
When you ask Mrs Smith for more information she states that recently she has noted that her husband has been getting up once or twice overnight to pass urine. She also mentions that he has always been prone to constipation he often takes prunes and in the past has bought Senna tablets at the local chemist if required.
Note the information is incomplete for Tuesday, Saturday and Sunday. This highlights the importance of detail to aid correct identification of the problem.
Select the image above for a larger version of the stool chart.
Q. Based on the Bowel Chart above, which one of the list best describes Roberts problem?
From Robert’s case study consider:
