COMMUNITY HEALTH SERVICE ASSESSMENT & CARE PLAN


Patient Information Label / Continence Assessment

Assessors name: Date of assessment: / /

Presenting Issue / Problem:
From clients point of view:______
______
______
How much of a bother is it to you? ______
______
Motivated to improve continence? Yes / No
Duration of problem: ______
Caused by / Aggravated by: / Prompts: Transient causes of
Incontinence.
D = Delirium
I = Infection – UTI
A = Atrophic genital changes
P = Drugs
P = Psychological
E = Endocrine
R = Restricted mobility
S = Stool impaction/constipation
Is it improving / stable / worsening?______
Is it worse day/night? ______
Usual Bladder Pattern
Definition: Normal voids per day = 3 – 6 times. Night normal = 1 Frequency is > 8 times per day.
Number of daytime voids: ______Number of night voids: ______Frequency? Yes / No
Ability to perform toileting independently: Yes / No Ability to perform toileting if prompted: Yes / No
Usual Bowel PatternPrompt: Be careful about the inquiry to elicit “normal” for the client.
Usual bowel habit:______
Are your bowels, laxative or diet regulated? Yes / No Do you have problems with?
Constipation: Yes / No Diarrhoea: Yes / No Faecal incontinence: Yes / No
FILLING DISORDER - Urge or Urge Incontinence
Definition: Warning time interval between first sensation of filling and urgent need to empty is short or so urgent that normal activities need to be interrupted and a toilet needs to be found immediately.
Amounts: Small – (few drops) Moderate – (wet pants) Large – (soaked)
How long can you hold between voids? ______
How long can you hold on after feeling the desire to void? < 2 mins  2-3 mins  > 5mins 
Would you be wet if you did not go to the toilet immediately? Yes / No
Do you feel an urgent desire to void when you hear running water or put your key in the front door? Yes / No
VOIDING DISORDERS - Dribbling / Overflow / Straining
Definition: Symptoms of difficulty when voiding eg: Neurological conditions or male problem.
Having to wait for flow of urine to start. Diminished force. Having to use abdominal pressure / manual expression. Small passive leak of urine when you think you has finished.
Do you have a reduced stream? Yes / No / Strain to pass urine? Yes / No
Do you leak immediately after your stream has finish? Yes / No / Any hesitancy? Yes / No
Do you feel your bladder empties completely? Yes / No / Aware of bladder leaking? Yes / No

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Patient Information Label / Continence Assessment
Stress Incontinence
Definition: Symptom of leaking urine without the desire to pass urine.
Do you leak urine when laughing, sneezing, coughing, on physical exertion, lifting, getting up from a chair to stand?______
Amount of urine loss: Please circle: Small ( few drops ) Medium ( wet pants ) Large ( soaked pants )
Loss of urine when laughing, sneezing, coughing. Yes / No
With physical exertion, on lifting, standing up. Yes / No Ability to interrupt flow. Yes / No
Urine history
History of urinary Infection: Yes / No Painless haematuria: Urgent referral to Urologist.
Urine spec: Result & date: ______Dysuria?Yes / No Haematuria?Yes /No
* Stop Assessment if patient has UTI. Proceed when patient is clear from infection or on long-term prophylactic antibiotics.
PHYSICAL ASSESSMENT
Vaginal assessment: Menopause: Yes / No Vaginitis: Yes / No
Skin Condition:Groin – red / excoriated Thighs – red / excoriated Buttocks – red / excoriated
Do you get a dragging feeling in the vaginal area? Yes / No Abdominal palpations Yes / No
Fluid intake: (Reading) ______
How much do you drink each day?______
What type of drinks do you drink? ______
Environmental & Lifestyle Issues
Toilet access?______Bed protection: ______
Commode: Yes / No Urinal: Yes / No Adequate laundry facilities? Yes / No Slipper pan: Yes /No
Hx of smoking: Yes /No Depression: Yes / No Impaired mental ability? Yes / No
Any sexual problems related to incontinence Yes / No ______
Urologist / Gynaecologist
Have you been seen by Urologist / Gynaecologist? Yes / No Prompt:Check clinical record.
Cystoscopy: Yes / No Date: / / Urodynamics: Yes / No Date: / /
Ultrasound: Yes / No Date: / / Urethral dilatation Yes / No Date: / /
Bladder Dairy
Bladder diary given? Yes / No Result of bladder diary: ______
______
Pads used: Yes / No Type of pads used: ______Absorbency of pads: ______
Number of pads used in 24 hour period: ______Post void residual: ______

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Patient Information Label / Continence Assessment

Past Medical & Surgical History

Please tick appropriate box

Medical / Surgical / Obstetric History
Arthritis 
Asthma / COPD 
Diabetes 
Neurological (Specify) 
______
Hypertension 
Spinal injury 
Radiotherapy  / Uterine / Bladder
Prolapse Repair 
T.V.T 
Colposuspension 
Hysterectomy 
Abdominal 
Vaginal 
TURP 
Radical Prostatectomy  / Pregnancies No: ___
Forceps 
Breech 
Caesarean 
Episiotomy 
Epidural 
2nd Stage (over 2 hrs) 
Large Baby (over 4kg) 

Medication

List the medication that may effect Continence

Alert: Diuretic –Anticholinergic –Oestrogens –Sedatives – Hormone Therapy –Hypertension effect continence.

Start Date: / Medication: / Dose: / Frequency:

Summary of Continence Assessment

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Patient Information Label / Continence Assessment
Filling Disorder Treatment
Urge / Urge incontinence / or mixed problem

Bladder retraining / Use bladder dairy
( information in continence folder )

Consider Ditropan and topical vaginal Oestogen

Treat up to 3 months for motivated patients

No improvement refer back to GP

OR
Urine loss > 400mls trial pads provide product.
Urine loss < 400mls provide information to purchase product.
Voiding Disorder Treatment
Dribbling / Overflow / Straining / Passive leakage

Bladder diary

Bladder scan / or in out catheter
If post void residual over 100mls
(Discuss with Continence nurse)

Refer to GP / ? Hytrin / Consider pads or self intermittent catheterisation / Consider referral to Urology department
Stress Incontinence
Stress Incontinence
PRE +/ - Life style issues
Refer to Women’s health Physio / Continence Nurse
Consider pads

CHS/CA Page 4