# Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in the right cerebral hemisphere. He did not receive reperfusion therapy. He has left-sided weakness, is alert, and has hypertension. He passed a bedside swallow screen yesterday. On day 5 he has urgency and voids 80 to 120 mL every 1 to 2 hours. A bladder scan done right after he voids shows 380 mL. He has no fever and no burning on urination. Which interpretation should guide the nurse's next action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630319  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in the right cerebral hemisphere. He did not receive reperfusion therapy. He has left-sided weakness, is alert, and has hypertension. He passed a bedside swallow screen yesterday.

On day 5 he has urgency and voids 80 to 120 mL every 1 to 2 hours. A bladder scan done right after he voids shows 380 mL. He has no fever and no burning on urination. Which interpretation should guide the nurse's next action?

## 보기

1. Urge incontinence that will improve with fluid restriction
2. Normal voiding for the first week after a stroke
3. Stress incontinence from weak pelvic floor muscles
4. Incomplete emptying with urine retained after voiding **✔ 정답**

**정답: 4**

## 해설

Stroke can cause urgency together with incomplete bladder emptying. Small, frequent voids with a large post-void residual on bladder scan mean urine is being retained, so the nurse reports it and a plan such as timed voiding with intermittent catheterization is used, avoiding an indwelling catheter. Restricting fluids concentrates urine and raises the risk of infection.

## 심화 해설

The key finding on day 5 is a pattern of frequent small voids combined with a large post-void residual. A bladder scan obtained immediately after voiding shows 380 mL of urine still in the bladder, while the patient only passes 80 to 120 mL each time. This means the bladder is not emptying effectively. The correct interpretation is incomplete emptying with urine retained after voiding, which is a form of urinary retention rather than a primary storage problem.

Pathophysiology after stroke

Normal micturition depends on coordinated activity among the cerebral cortex, brainstem centers such as the pontine micturition center, and spinal cord pathways. A stroke can disrupt this network. In a right hemispheric ischemic stroke, the lesion may impair the brain's ability to coordinate detrusor contraction with sphincter relaxation. The result is often detrusor-sphincter dyssynergia or a poorly sustained detrusor contraction, so the bladder contracts but does not empty completely. The patient then feels urgency again as the residual volume quickly refills toward bladder capacity, producing the small, frequent voiding pattern described.

Urinary retention after stroke is common and may occur even when the patient is alert and able to void spontaneously. The retained urine acts as a reservoir for bacterial growth, which increases the risk of urinary tract infection. This is why identifying retention early matters for patient safety.

Interpreting the bladder scan

A post-void residual is the volume of urine left in the bladder immediately after voiding. In general clinical practice, a PVR above 100 mL is considered significant, and values above 200 mL indicate clinically important incomplete emptying. This patient's PVR of 380 mL is markedly elevated.

| Finding | Interpretation | Clinical meaning |
| --- | --- | --- |
| Voids 80–120 mL every 1–2 hours | Small frequent voids | Bladder fills quickly because it never empties |
| PVR 380 mL after voiding | Large residual volume | Incomplete emptying / urinary retention |
| No fever, no dysuria | No current infection signs | Retention is functional, not infectious |
| Alert, right hemispheric stroke | Central bladder control impaired | Neurogenic bladder dysfunction |

Key point! Urgency with a large PVR is not the same as urge incontinence. Urge incontinence implies the bladder empties involuntarily; here the bladder does not empty adequately at all.

Why the other options are incorrect

Urge incontinence would present with involuntary urine loss associated with a strong desire to void, but the defining feature of this case is the large residual volume. Fluid restriction is also inappropriate. Restricting fluids concentrates urine, irritates the bladder mucosa, and raises infection risk, especially when urine is already being retained.

Normal voiding for the first week after stroke is not supported by the data. While transient bladder dysfunction can occur, a PVR of 380 mL is abnormal and requires intervention, not observation alone.

Stress incontinence results from weak pelvic floor support and presents with urine leakage during coughing, sneezing, or exertion. This patient has no such symptoms, and the post-void residual points to a neurologic emptying problem rather than a structural sphincter weakness.

Nursing actions and rationale

The nurse should report the elevated PVR and anticipate a bladder management plan. The preferred approach is timed voiding with intermittent catheterization. Scheduled catheterization empties the bladder completely at regular intervals, prevents overdistention, and lowers infection risk compared with an indwelling catheter. An indwelling catheter should be avoided when possible because it carries a higher risk of catheter-associated urinary tract infection.

Watch out! A patient can void urine and still have significant retention. Do not assume that passing urine means the bladder is emptying. Bladder scanning after voiding is the standard way to detect this hidden retention.

Early recognition of urinary retention in stroke patients supports functional recovery and reduces complications such as infection, bladder overdistention, and autonomic dysreflexia risk in susceptible patients. Regular bladder scan monitoring, especially in the first days to weeks after stroke, is a practical nursing measure to guide bladder care.

## 임상 시나리오

Post-Stroke Urinary RetentionInterpreting small voids with large residual
After stroke, detrusor-sphincter dyssynergia can cause incomplete bladder emptying. The key finding is 80–120 mL voids with a 380 mL post-void residual on bladder scan, meaning the bladder is retaining urine rather than simply storing it normally.

Report the finding and plan for timed voiding or intermittent catheterization. Avoid an indwelling catheter when possible to reduce infection risk.

CautionDo not restrict fluids to manage urgency; concentrated urine raises the risk of urinary tract infection. Retained urine itself is a reservoir for bacterial growth.

## 핵심 개념

- **Post-void residual** — Volume of urine remaining in the bladder immediately after voiding, measured by bladder scan or catheterization.
- **Detrusor-sphincter dyssynergia** — Incoordination between detrusor contraction and sphincter relaxation, often causing incomplete bladder emptying after neurologic injury.
- **Urinary retention** — Inability to empty the bladder completely, leading to residual urine and increased risk of urinary tract infection.
- **Bladder scan** — Noninvasive ultrasound device used to estimate bladder volume, especially post-void residual.
- **Neurogenic bladder** — Bladder dysfunction caused by neurologic injury such as stroke, affecting storage or emptying.

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