Client Information

Continence Assessment

Date of assessment: *

Name of assessor:

Email or Assessor: *

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Client Information

Client full name: *

Date of birth:

Age:

Gender:

Email:

Phone Number:

Preferred contact method:EmailPhone

Is the client eligible for CAPS funding

YesNoNot sure

Allergies:

Reaction:

Medications:

Presenting problem:

Onset:

Previous management strategies:

Is the condition improving?

What other health professionals are involved?

Medical & Surgical History & Bristol Stool Chart

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Medical and Surgical History

Cognition Impairment

Neurological Conditions

Mental Health

Heart Issues

Is the client on

Fluid restrictionsOn any diuretics, any swelling on lower legsOther

Provider further details

Hypertension

Other

Renal Disease

Diabetic

Pelvic Organ Prolapse

Enlarged Prostate

Urethral Structure

Constipation

IBS

History of UTI's

Drug and Alcohol Issues

Autonomic Dysreflexia

Smoker

Chronic Cough

Surgical

Other

Bristol Stool Chart

Describe the type of movement?

Any medication client is currently using for constipation?

Last bowel movement?

Function

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Obstetrics/Gynaecological History

Pregnancies

Vaginal CaesareanTearsEpisiotomyGynaecological ProcedureN/A

Provider further details

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Sensory

Behaviour indicating toileting

WonderingRestlessPulling on clothesOther

Provider further details

Communication

VisionHearingSimple InstructionsSign LanguageOther

Provider further details

Sleep disorders

Physical exercise

Toilet access

Obstetrics/ Gynaecological History & Sensory

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Function

Does the client know where the toilet is?

Is the client independent with the toilet?

Does the client need to be prompted to use the toilet?

YesNoOther

Provide further details

Does the client need to be assisted on the toilet?

YesNoOther

Provide further details

Is the client unwilling to use the toilet?

YesNoN/AOther

Provide further details

Is the client restless prior to using the toilet?

YesNoN/AOther

Provide further details

Does the client require assistance to wipe self post usage?

YesNoOther

Provide further details

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Mobility

Is the client mobile?

YesNo

Provide further details

Does the client use a mobility aid?

YesNo

Function & Mobility

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Assistive Devices

Does the client use any of the following?

WheelchairWedgesStanding hoistFull hoistDaily living equipmentBed panNon-spill bottleCommodeHandrailToilet frameBottom wiperModified clothingNight lightPing pong ball in toilet4 wheeled walker2 wheeled walkerWheelchairBed boundOther

Provide further details

Level of assistance required

DependentPromptSupervisionNeeds full assistanceIndependentOther

Provide further details

Assistive Devices

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Incontinence Aids

Does the client use any of the following continence aids?

CatheterIMCWaterproof beddingKyliesSPCOther

Provide further details

Does the pad keep dry and comfortable?

YesNo

How many times a day is the continence aid used?

How many continence aids are used at night?

Current use of incontinence aids used to keep client dry and comfortable?Day Type: Size: Night Type: Size:

Previous management strategies?

Is the condition improving?

Incontinence Aids

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Nutrition

Breakfast

Lunch

Dinner

Supper

Bladder function

Urine Colour

Urine Output

Urine Analysis Performed

YesNoOtherUnable to Perform

Provider further details

Last Urine voided

Bladder diary in use for continence and incontinence?

YesNo

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Frequency of Toilet Use

How many times a day?

How many times a night?

Does the client notify a carer/family member when they have been incontinent?

Nutrition & Frequency of Toilet Use

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Details:  

Provide a detailed description of the client’s current status, including relevant health factors such as diagnosis, prognosis, co-existing conditions, disabilities, and their impact on the client's daily functioning. 

Include information on personal and instrumental activities of daily living (ADLs and IADLs), formal and informal support systems, and any significant life transitions. 

Consider any health concerns or related aspects that may influence the client’s need for continence support, ensuring a comprehensive understanding of their overall situation.

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Bladder Problems

Is the client currently experiencing a bladder problem?

YesNoN/AOther

Provider further details

Does the person have a history of bladder problems?

YesNoN/AOther

Provider further details

What kind of support does the client prefer?

Wear a continence aid/pad during the dayTo be assisted to go to the toilet at specific time. To wear an incontinence pad/aid during the nightN/AOther

Provide further details

Does the client use or wear a product to help maintain their social continence?

YesNoN/A

Provide further details

Aid used/worn for maintain social incontinence

UrinalCondom drainageAn incontinence pad/aid (brand and size)A commodeA Bed panN/AOther

Provide further details

Does the client have a catheter?

YesNoN/A

Catheter type

An indwelling urethral catheterSelf-intermittent catheterisation

Catheter size and type

Frequency of catheter changes

Date of last IDC/SPS change

Bladder Problems

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Client Goals

Goal 1

Goal 2

Goal 3

Goal 4

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Management Plan

 

Patient education - double voiding techniqueCarer educationTreat UTIPelvic floor exercisesBladder retrainingTreatment of enlarged prostateCatheterisationDiuretic use in PMImprove medical therapy for CHF/Diabetes/OtherRegular toiletingImproving toileting habits/positioningAddress constipationReduce caffeine intakeIncrease fibreAlter fluid intakeExerciseBedwetting alarm programOther

Provider further details

Medication (consider GP)

UrgencyFrequencyPoor streamNocturiaOther

Provider further details

Continence Aids

PadsIDCUridomeSMCSPCOther

Provider further details

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Identify the Various Types of Loss Experienced

Recommendations

Final Draft of the Assessment

Yes

Care Managers Email:Care Managers email address is their first name @sensiblecare.com.au (eg. mary@sensiblecare.com.au)

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