MEDICAL HISTORY (From Page 1)

CONTINENCE ASSESSMENT

PATIENT LABEL
PH: ______
ETHNICITY: ______/ GP: ______
REFERRED BY: ______
ASSESSED BY: ______
DATE: ______
MSQ SCORE (opt):______
COMMUNITY SERVICES CARD: YES / NO
CONSENT: YES / NO
1. MEDICAL HISTORY: (see last page for prompts)
Operations:
______
______
______/ Illnesses:
______
______
______
______
2. CURRENT MEDICATION:
______
______
______
______ / Natural or Herbal Remedies:
______
______
______
______
3. BACK GROUND:
Weight:______
Diet: ______
Exercise: ______
Sexual Relationship:______
Menopausal or Post Menopausal:______
Are you a smoker?______/ Overweight can be a cause of incontinence
Is exercise restricted due to incontinence?
Is incontinence causing relationship problems?
Sexual abuse?
4. SLEEPING PATTERNS:
Do you sleep well? Yes/ No
Does your bladder wake you? Yes/No
5. URINARY INFECTION:
Urine test recently?
Recent UTI?
Dysuria?
Haematuria?
Urine Odour? / Acute UTI very likely to cause incontinence
Pain or burning while actually passing urine?
Blood in Urine
Odour indicates UTI
6. FLUID INTAKE:
How many cups of drink a day? ______
Time of last drink before sleep? ______
What type of fluids? ______/ e.g. tea, coffee, alcohol - diuretics, coca cola.
7. MAIN URINARY COMPLAINT:
What do you think started your problem?
______
How long have you had a problem? ______
Is it improving/stable/worsening? ______
Is it worse in the day or night? ______/ From patient’s point of view, or the Care givers
8. VOIDING HISTORY:
a) Frequency? Yes/No
Daytime voids =
Nocturnal voids =
b) Urgency?
Day sometimes / always
Night sometimes / always
Why do you hurry to the toilet? ______
______/ Number of times urine passed
Day average 3-6 times
Night normal = once? woken by bladder or toilets
because already awake.
Having to hurry to pass urine
9. URGE INCONTINENCE:
Times / Day =
Do you get warning that you need to pass urine?
______
Average time can hang on______
How much is lost? Small - Moderate - Large
Ever whole bladder emptying?______
Nocturnal enuresis (bed wetting)
Nights per week: ______
Are pads or aids used? Yes / No
Type:______
Number per day:______
Are aids effective Yes / No / Urine leakage as result of urgency
Warning time between the first sensation of bladder filling and an urgent need to empty the bladder is curtailed, i.e. a 10 minute warning instead of 1hour, or so urgent that normal activities have to be interrupted and a toilet found immediately.
Amount: Small = a few drops
Moderate = wet pants
Large = soaked
Nocturnal enuresis = bed wetting while asleep
Source of supply: ______
Problems: ______
______
10. BLADDER SCAN:
Pre void amount: ______
Post void residual:______
11. STRESS INCONTINENCE
Do you lose urine when walking, sneezing, coughing, lifting, pulling, pushing?
How much? small moderate large
Parity? ______
Obstetric complications? i.e. forceps, big baby, long labour, sutures. ______
______/ Symptom of leaking urine coincidentally with physical exertion.
Amount: Small = a few drops
Moderate = wet pants
Large = soaked
12. OBSTRUCTION:
Hesitancy
Intermittency
Poor stream
Feeling of incomplete emptying
Straining
Post micturition dribble / Symptoms of voiding difficulty:
Hesitancy = having to wait for flow of urine to start.
Intermittency = flow stops and starts.
Poor flow = diminished in force.
Straining = having to use abdominal muscles to empty bladder.
Post micturition dribble = small leak of urine when you think you have finished most usually when clothing has been replaced.
13. PROLAPSE:
Cystocoele
Rectocoele
Urethrocoele
Prolapsed uterus
Enterocoele
Comments:
______
______ / Symptoms which may be present:
Any feeling of lump or bulge in the vagina
Any lower back pain that eases when patient lies down
Pelvic pain or pressure
Pain or lack of sensation during sex
14. OVERFLOW INCONTINENCE: Yes / No
May be suspected if small amounts of urine passed frequently or flooding occurs when standing up. / Use bladder scanner to establish status or percussion and palpation of bladder.
15. BOWEL HABITS:
Bristol Stool Chart Type
Are bowels regular? ______
Are laxatives used? ______
Any faecal incontinence? ______
Continued overleaf -
15.continued -:
Any changes in bowel habits? i.e. alternating diarrhoea/constipation, smaller thinner stools, feeling of not emptying bowel completely, mucous or blood in stools, feeling of bloating.
______
______/ Careful enquiry to elicit “normal” for patient
Constipation related more to difficulty of passing motions and their consistency than to frequency of defaecation.
Severe constipation with impaction considerably disrupts bladder function
16. ENVIRONMENT:
Commode or urinal used? ______
Toilet access? ______
Stairs? ______
Laundry facilities: ______
17. ACTIVITIES OF DAILY LIVING:
Problems with mobility?______
Type of aid used to walk ______
Any self-care problems? ______
Toileting / Transfers / On /Off
Are you receiving home helpor personal cares?
How often? ______
Any recent changes in residence / home etc
______/ Review eyesight, hearing, manual dexterity, difficulties with clothing, bathing/showering ability.
Is a Needs Assessment required?
Increase in difficulty to get to the toilet.
18. SOCIALNETWORK:
Living alone? ______
Usual activities ______
______
Is incontinence causing financial hardship? ______
Are you receiving a disability allowance? ______
Other Health Professionals involved:______
______
______/ Are these restricted by incontinence
May need Social Worker assistance
19. SUMMARY OF PROBLEMS:
1.______
2.______
3.______
4.______
Continued overleaf -
19. continued -:
CAREPLAN:
1.______
2.______
3.______
4.______
5.______
6.______
7.______
8.______/ List common causes which need excluding e.g. infection, constipation.
Summarise urinary problem as either, urge, stress, obstruction, overflow or mixed.
List functional problems e.g. mobility difficulties, loss of eyesight.
Document suggestions of memory loss, depressive or psychological problems.

MEDICAL HISTORY – (from page 1)

H:CONTINENCE-OSTOMY-STOMA/continence assessment-NPH

Abdomino perineal resection
Cardiac

ca bladder
ca prostate
Dementia
Diabetes

Hysterectomy
Radiotherapy

Multiple sclerosis
Neurological problems
Parkinsons
Prolapse

Prostatectomy
Spinal surgery

Stroke

Total hip joint replacement

H:CONTINENCE-OSTOMY-STOMA/continence assessment-NPH

MENTAL STATUS QUESTIONNAIRE

(Do not use this form if patient already has diagnosis of dementia)

SCORE

AGE allow one year error
TIME allow consultation of clock or watch and error up to 1hour
ADDRESS for recall at end of test – this should be repeated by the patient to ensure it has been heard correctly – 100 Gladstone Road
YEAR allow previous year
HOME ADDRESS
RECOGNITION OF 2 PERSONS nurse, relative
DATE OF BIRTH day and month only
YEAR OF FIRST WORLD WAR
NAME OF PRESENT PM
COUNT BACKWARDS FROM 20 – 1 no errors, no clues
Total

Score 1 for each correct answer

Score 0 for each incorrect answer

NO HALF SCORES!

H:CONTINENCE-OSTOMY-STOMA/continence assessment-NPH