Ee494c7bcaebc61df9a5 …



AMPH – PGN -04

Appendix 1

Nursing Assessment for Continence

Name: ………………………………………………………………

Date of Assessment: ………………………………………………………………

Assessed by: ………………………………………………………………

Hospital Rio Number: ………………………………………………………………

Referred by: ………………………………………………………………

Consultant ………………………………………………………………

Has patient given consent to share information with other professionals Yes/No

What does the patient feel is their main problem?..................................................

How long have they had the problem?...................................................................

How this impacts upon the patient’s quality of life (QAL)

Not at all (0) ( Minor problem (1) ( Problematic (2) ( A real problem (3) (

A major impact (4) ( Score (Reassess after commencing treatment)

MEDICAL HISTORY

• Diabetes

• Neurological (multiple Sclerosis, epilepsy, C.V.A, Parkinson’s, spinal Injury)

• Learning Difficulties

• Physical difficulties

• Gender dysphoria

• Other please specify……………………………………………………………...

Previous or current Bladder/Bowel Specialist

• Name……………………………………………………………………………….

• Date seen………………………………………………………………………….

• Were seen…………………………………………………………………………

• Recommendations……………………………………………………………….

Previous or current Continence Nurse/District Nurse

• Name……………………………………………………………………………….

• Date seen………………………………………………………………………….

• Were seen…………………………………………………………………………

• Recommendations……………………………………………………………….

SURGICAL HISTORY

• Cystoscopy

• Urethral dilation

• Bladder neck surgery

• Prostatectomy

• Abdominal hysterectomy

• Vaginal hysterectomy

• Pelvic floor repair

• Bowel investigations/operations

• Feminising genital reconstructive surgery

• Masculinising genital reconstructive surgery

• Other please specify……………………………………………………………...

OBSTETRIC HISTORY

• Number of pregnancies

• Large babies (4kgs/8.5 lb)

• Difficult deliveries

• Smears

• Menstrual cycles / menopause

Current drug Therapy/List drug therapy

( Analgesic

• Diuretic

• Anti - depressants

• Hypnotics

• Oestrogen

• Major tranquillisers

• Aperients

• Previous/present anti-cholinergic therapy

• Others please list………………………………………………..........................

………………………………………………………………………………………

Cognitive Assessment

Communication……………………………………………………………………………

Is patient aware of the need to pass urine/faeces?.................................................

Is patient aware there is a problem?.......................................................................

Patients/Carers expectations…………………………………………………….........

Impact of mood relating to bladder and bowel problem

________________

0. 10

No impact Maximum impact

Social History Who Lives at home, availability of carers, affect upon social life

……………………………………………………………………………………………..

Home Environment Type of house……………………………………………

Mobility

• Full mobility

• Walks with aids

• Needs help

• Chair bound

• Bed fast

• Manual dexterity

• Transfer problems

Toileting Facilities

• Accessible to patient

• Commode

• Urinal

• Bedpan

• Specific aid

• Raised toilet seat

• Able to use toilet unaided

• Needs help

Bowel Pattern

• Normal bowel pattern

• Comment…………………………………………………………………………

…………………………………………………………………………………….

Bowel assessment required Yes ( No (

Present Continence Aids

• Conveen System Yes ( No (

Details

• Pads Yes ( No (

Details

• Indwelling /Supra pubic catheter Yes ( No (

Details

• Catheter assessment required Yes ( No (

Details

• I.S.C. Yes ( No (

Details

• I.S.C. assessment required Yes ( No (

Urinalysis

MSU

• Yes ( No (

• On (Date)

• Results

• Treatment

• History of past/present U.T.I.

• Current antibiotic therapy

Fluid Chart Information

• Fluid intake. No. of cups in 24 hours ………………

• Type of fluid. Please comment…………………………………………..

• How many times P.U. per day ………………

• How many times P.U. per night ………………

• Max volume passed (approx) ………………

• Min volume passed (approx)

Types of Incontinence

These questions will help determine types of incontinence.

Symptoms of Stress

• Do you leak a little when you cough/sneeze?

Yes ( No (

• Do you leak a little when you walk upstairs or downhill?

Yes ( No (

• How long can you hold after you feel the desire to pass urine?

Symptoms of Urge

• How long can you hold after you feel the desire to pass urine?

Up to 2 minutes ………………

Up to 5 minutes ………………

Longer than 5 minutes ……………...

• Is the desire so great that you would be wet if you did not go to the toilet

Immediately?

Yes ( No (

Symptoms of Incomplete Bladder Emptying

• Do you know when the urine is leaking?

Yes ( No (

• Are you wet all the time?

Yes ( No (

• Do you have hesitancy?

Yes ( No (

• Do you have to strain to pass urine?

Yes ( No (

• Do you leak immediately after you think you have finished?

Yes ( No (

• Any past history of urine infections?

Yes ( No (

Symptoms of Reflux

• Does your bladder empty without warning?

Yes ( No (

Nocturnal Incontinence

• Are you ever incontinent during the night?

Yes ( No (

Nocturia

• Do you wake up to void urine?

Yes ( No (

• Is this due to pain or disturbance?

Yes ( No (

Clinical Assessment

• Prostrate examination ………………

• Vaginal examination ………………

• Bloods} U’s and E’

Glucose

Full blood count

• Residual bladder scan

• Sex and Relationship Clinic Assessment

(Inform of Service and discuss with patient)

Referral YES ( NO (

Summary

Action plan

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