CONTINENCE CARE SERVICE

BLADDER AND BOWEL ASSESSMENT

Date of Assessment:______

GP:______
PHN: ______

Referred by: ______

Information obtained from: Client ‪ Carer ‪

1stLanguage______Interpreter required Yes/No

Lives alone______Lives ______

Known Allergies: ______

Presenting problem as reported by client: ______

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Duration of present problem: ______

Associated with any life change:______

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Relevant History

Medical

/

Yes

/

No

/

Surgical

/

Yes

/

No

Diabetes

/

Cystoscopy

Heart Disease

/

Urethral dilatation

Respiratory

/

Pelvic Floor repair

Neurological

/

Bladder Surgery

Dementia/

Alzheimers

/

Vaginal./abdominal. Hysterectomy

Depression/Anxiety

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Gynaecological surgery

Physical & Sensory Disability

/

Prostatectomy

Intellectual Disability

/

Bowel Surgery

Musculoskeletal

/

Other

More Details:______

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Client’s Name ______DOB______

Any other relevant history:______

PSA Results(if known): .

Current Medication: (include over the counter medication)______

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Psycho-social effects of Incontinence(please circle)

Anxious ‪ Embarrassed ‪ Denial ‪ Depressed ‪ Coping ‪

Does incontinence affect your lifestyle?Social /Family/ Intimacy

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Previous Treatment (including medication) ______

Quality of Life

If you were to spend the rest of your life with your continence problem just the way it is now, how would you feel about that?

Quality of Life due to urinary symptoms / Delighted / Pleased / Mostly satisfied / Mixed equally satisfied and dissatisfied / Mostly dissatisfied / Unhappy / Terrible
Initial / 1 / 2 / 3 / 4 / 5 / 6 / 7
Discharge / 1 / 2 / 3 / 4 / 5 / 6 / 7

The following information should be obtained from use of a Frequency / Volume Chart.

Average Fluid intake over 24 hours ______mls Average number of voids/day______

Type of drinks______

______

Minimum bladder capacity ______mls Maximum bladder capacity ______mls

Number of wet episodes in 24 hours ______

Are fluids restricted?Yes ‪No ‪ Specify ______

Do you smoke? Yes ‪ No ‪ Specify: ______per day

Client’s Name______DOB______

Diet: Normal Yes No Special ______Weight ______BMI______

Degree of Incontinence

Is there any protection worn at the moment?Yes / No ‪ Is it adequate for your needs? Yes / No Specify type & amount ______

Are you in receipt of home delivery of products from the HSE? Yes / No

TYPES OF URINARY INCONTINENCE

Stress Incontinence

Do you leak urine when you cough, sneeze, laugh, move suddenly? ______

Do you leak when you get up from chair of bed? ‪ ______‪

Is this leakage small amounts of urine? ______

Urgency Incontinence

Do you go to the toilet more than 7 times daily? (frequency) ______‪

Are you able to hold on once you feel the need to pass urine? (urgency) ______

How long can you hold on after you feel the need to pass urine?

Up to 1 minute ______

Up to 3 minutes ______

Up to 5 minutes______‪ ‪

Do you leak urine before you reach the toilet? (Urge Incontinence) ______‪

Do you have to get up to pass urine more than twice at night? (Nocturia) ______‪

Is anxiety contributing to frequency?______Mixed Urinary Incontinence

Does this client have Mixed Urinary Incontinence? ______

What is the predominant symptom for the client? Stress urinary incontinence or Urgency ‪

Passive / Reflex

Does your bladder empty without warning / sensation? ______

Are you aware of need to pass urine? ______

Are you aware of being wet? ______

Poor Bladder Emptying

Do you have difficulty in beginning to pass urine? ______

Do you have to strain to pass urine? ______

Do you dribble after having passed urine? ______

Do you feel your bladder does not completely empty? ______

Do you get recurrent Urinary Tract Infections? ______‪ ‪

Client’s Name ____________DOB______

Functional Factors

Independent / Needs Help / Dependent / Specify
Mobility
Dexterity
Washing/bathing
Toileting
Good / Average / Poor / Specify
Hearing
Vision
Speech
Cognitive Ability

Investigations / Physical Examinations

Urinalysis / Record abnormal deposits / Comments
Colour / Smell
Glucose / If positive – BM stick / BM result > 4 refer to GP
Ketones
S. Gravity
Blood / If positive advise to check urine in 1 week with GP
PH
Protein / If positive check BP / BP:
Nitrate / If positive send MSU/CSU
Leucocytes / If positive send MSU/CSU

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Symptoms:Dysuria ‪Yes / NoHaematuria Yes / No ‪ Cystitis ‪Yes / No

M.S.S.U. / C.S.U. Yes / No Date______Result ______

Post void residual: ______mlsbladderscan or catheter (please circle)

Client’s Name:______DOB______

Bowel Assessment

Usual Bowel Habit: ______

Any changes in bowel habit: (if yes explain) ______

Is it related to any of the following?

Recent changes in Lifestyle□Medications□Diet/Appetite□

Fluid intake□Recent illness□other□

Duration of symptoms: ______

Have symptoms worsened: ______

Stool Type: Bristol Stool Scale: ______Colour: ______

Any of the following present: Mucus □Odour □Fat □Undigested food □

Haemorrhoids □Blood □Other □ ______

Faeces sent for MC&S Yes/No Result______

Medication? (laxatives / anti-motility / constipating) ______

Use of Pads: ______

Relevant Medical / Surgical History

Ulcerative ColitisYes □No □ Rectal / Anal surgery Yes □ No □

IrrritableBowelSyndromeYes □No □ Details ______

CrohnsYes □No □ Haemorrhoids Yes □ No □

DiverticulitisYes □No □ Bowel SurgeryYes □ No □

ColonoscopyYes □No □ Details ______

Results ______ColostomyYes □No □

Bowel Symptoms

Faecal Urgency / Yes / No / Ability to defer / Flatal Control? / Yes / No
Faecal Incontinence / Yes / No / Solid / Liquid / Passive soiling / Yes / No
Excessive Wiping / Yes / No / Details:
Staining / Yes / No / Details:
Straining at stool / Yes / No / Manually assist / PR / Perineum / Other
Incomplete emptying / Yes / No / Details:
Pain / Yes / NO / Anal / Rectal / Abdominal
Rectal bleeding / Yes / No / Details:
Sensation: ability to
Distinguish stool/flatus / Yes / No / Absent / Reduced / Normal

Client’s Name ______DOB: ______

Any other relevant information:

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Summary:

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Care Pathway /Care Plan:

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Name of Leaflets given and explained:______

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Onward referral (tick as appropriate and keep a copy of any referral letters sent)

G.P.‪Occupational Therapy‪Physiotherapy‪

PHN ‪Social Services‪ Other

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Assessment completed by: ______Title ______

Date ______PlannedReview date:______

HEALTHY BLADDER AND BOWEL CLINIC – CARE PLAN

Name: ______DOB: ______

Progress since last visit: ______

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Care Plan: ______

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Signed ______Title ______

Date: ______Time: ______

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