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Under 65 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

EmailPostCallText

Is the client eligible for CAPS funding?

YesNoUnsure

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Guardian/ Representative/ Carer Information

Full name

Relationship

Gender

Email

Phone Number

Preferred Contact Method

EmailPostCallText

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Presenting Problem

Onset

Previously dry during the dayPreviously dry during the nightNever have a period of drynessContinuous incontinence/ dribblingOther

Provide further details

Impact in day-to-day life

Previous Management Strategies

Is a healthcare professional currently involved in the care?

YesNoUnsure

Do you need someone to be involved?

YesNo Unsure

Provide further details

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Obstetrics / Gynaecological History

Has the client ever been pregnant?

YesNo

Has the client ever given birth?

YesNo

What type of birth was it?

Vaginal CaesareanTearsEpisiotomyGynaecological procedureOther

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Medical & Surgical History

Choose one of the below

Cognition Impairment Neurological Conditions Mental Health Heart Issues Hypertension Renal Disease Diabetic Urethral Structure ConstipationIBS History of UTI’s Drug and Alcohol Use (age dependent, privately asked question) Smoker (age dependent, privately asked question) 2 client information genderChronic cough (age dependent) Surgical Prostate enlargement Prostate cancer – Management PlanOthers

Provide further details

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Bristol Stool Chart

Clear drawing

Describe the type of movementBased on the bristol stool chart

Is there any medication being used to manage constipation?

YesNoUnsure

Provide further details

When was the last bowel movement? Describe the last movement

Frequency of bowel movementsDescribe an average bowel movement

Symptoms of bowel difficulties

Change in bowel habits/frequencyStraining to empty bowelsDifficulty in emptying bowelsSmearing in underwearBlood in stool/ from anusNeed to use hand to help empty bowelsIncomplete emptying feelingPain/ discomfort with bowel actionOther

Provide further details

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Urinary

Are you taking any diuretic medications?Prescribed? Over the counter or in a chemist off the shelf? Name of medication? How much is taken and how often?

How often do you void your bladder?Frequency and how it is voided

Incontinence frequency

UrgencyNocturiaPolyuriaStrainingWeak StreamIntermittencyDysuriaPost micturition dribblesUrinary retentionSpraying of urinary streamOther

Provide further details

Does the client demonstrate an awareness of a full bladder?

YesNoUnsure

Does the client notify their carer/ parent/ representative when they have been incontinent?

YesNo

Provide further detailsHow do they notify them? If no, why not?

Circumstances when leaking

Change in medicationOnly occurs in unfamiliar surroundingsCircumstances unknownLeak when getting in bed/sit down in chairLeak getting out of bed/standing up off the chair Leak when putting the key in the front doorLeak when hearing water running or in cold weatherLeak without knowing/insensible lossLeak when sneezing, coughing, laughingLeak when walking or liftingUrgency – little warning of need to pass urinePast history of leakageUnable to get to the toilet in timeOther, specify

Provide further details

Sympoms of voiding difficulty

Hesitancy to start voidingSlow streamDouble voidPost-mic dribbleStrain to empty Need to push on the bladder to empty (Manual expression)Incomplete emptying bladder/bowelHaematuria (blood in urine)Urine has an offensive odour/dark colourLeak when walking or liftingNocturnal enuresisOther

Provide further details

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Sensory

Behaviour indicating toileting

Wondering Restless Pulling on clothes Standing on tip toes Crossing of legs Squatting w/ heel pressed into perineum Uses speech Other

Provide further details

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Communication

Communication

VisionHearingSimple InstructionsSign LanguageToileting clock/alarmOther

Provide further detailsHow else do they communicate? What type of alarm/clock is used?

Are there any sleep disorders?

YesNoUnsure

Provide further detailsWhat type of sleep disorder?

Is there any automatic lighting in the room during the night?

YesNo

Provide further detailsIf no, why not? If yes, where? What type? Is it motion or timer, etc.?

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Mobility

Is the client mobile?

YesNo

Does the client use a mobility aid?

YesNo

Provide further detailsPlease describe the type of mobility aid and why they are using it

Does the client walk with a gait?

YesNo

Provide further detailsDescribe the type of gait the client has

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Function

Is the client using a catheter or SPC?

YesNo

Provide further detailsSpecify what is being used

Is the client independent with catheter bag empties?

YesNo

Provide further detailsWhy or why not?

Does the client need to be prompted to empty their catheter bag?

YesNo

Provide further detailsHow are they prompted? Or how do they remember?

Does the client want to partake in catheter care?

YesNo

Provide further detailsWhy or why not?

Is a healthcare professional currently involved in the care?

YesNo

Provide further detailsWho? Do they need someone to be involved?

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Examination

Weight

Temperature

Blood Pressure

Vomitting

YesNoUnsure

Provide further details

Poor Feeding

YesNoUnsure

Provide further details

Pain at Present

YesNoUnsure

Provide further details

Pain when Voiding

YesNoUnsure

Provide further details

Pain when Opening Bowels

YesNoUnsure

Provide further details

Growth faultering

YesNoUnsure

Provide further details

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Abdomen

Bladder distention

YesNoUnsure

Provide further details

Palapte bladder, renale mass, faecal mass

YesNoUnsure

Provide further details

Discomfort/pain on palpation

YesNoUnsure

Provide further details

Auscultation of bowel sounds

YesNoUnsure

Provide further details

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Lower Back / Spine

Function

YesNoUnsure

Provide further details

Strength

YesNoUnsure

Provide further details

Sensation

YesNoUnsure

Provide further details

Perfusion

YesNoUnsure

Provide further details

Fluid retention

YesNoUnsure

Provide further details

Does the client consent to physical examination perineum, extrernal genitals and perianal area?

YesNo

Abnormalities to perinum

Abnormalities to external genitals

Abnormalities to perianal area

How does the skin appear on the above areas?

IntactThinRednessPaleExcoriateFlakyDischargeOther

Other (please specify)

Which Pain Scale/s will be used

Face Pain ScaleFLACC Pain ScaleAbbey Pain Scale

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Face Pain Scale

Clear drawing

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FLACC Pain Scale

Face

0 - No particular expression or smile1 - Occiassional grimace or frown; withdrawn, or disinterested2 - Frequent - constant quivering chin, clenched jaw

Legs

0 - Normal position, relaxed1 - Uneasy, restless, tense2 - Kicking or legs drawn up

Activity

0 - Lying quietly, normal position, moves easily1 - Squirming, shifting back and forth, tense2 - Arched, rigid, or jerking

Cry

0 - No crying (awake or asleep), occasional complaint1 - Moans or whimpers; sobs; frequent complaint2 - Crying steadily, screams

Consolability

0 - Content, relaxed1 - Reassured by occasional touching, hugging, or being talked to, distractable2 - Difficult to console or comfort

FLACC Pain Scale Score

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Abbey Pain Scale

VOCALISATION
(e.g. whimpering, groaning, crying)

0123456789101112131415

FACIAL EXPRESSION
(e.g. looking tesne, frowning, grimacing, looking frightened)

0123456789101112131415

CHANGE IN BODY LANGUAGE

0123456789101112131415

BEHAVIOURAL CHANGE

0123456789101112131415

PHYSIOLOGICAL CHANGE

0123456789101112131415

PHYSICAL CHANGES

0123456789101112131415

Abbey Pain Scale Score

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Catheterisation

Is a catheter present/used?

YesNo

Is a trial required?

Are there any bladder problems?

What type of catheterisation?

Location of catheterisation

Clear drawing

Insertion date

Size of catheter

Surrounding skin

Output amount

Output colour

Sediment present?

Frequency of bag empties

Frequency of changes (bladder problems)

Independent of with cares

Urine colour - Nutrition

Urine output - Nutrition

Urine analysis performed (nutrition)

YesNo OtherUnable to perform

Provide further details

Bladder scan performed

YesNoNot applicable

Provide further details

Bladder diary in use for continence and incontinence

YesNoNot applicable

Provide further details

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Assistive Devices

Does the client use any of the following?

WheelchairWedgesStanding hoistFull hoistDaily living equipmentBed panNon-spill bottle Commode Handrail Toilet Frame Bottom wiper Modified clothing Night lightPing pong ball in toilet Walker Wheelchair Bed bound Other

Provide further details

Level of assistance required

Dependent Prompt SupervisionNeeds full assistanceIndependent Other

Provide further details

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Incontinence Aids

Does the client use any of the following incontinence aids?

Waterproof beddingKyliesStomaPantsPadsOther

Provide further details

How many times a day is a continence aid used?

How many contincence aids are used during the day?

Do the current use of continence aids help to keep the client dry and comfortable?

What previous management strategies have been used/trialled?

Is the condition deteriorating?

When did the deterioration begin?

Sleeping Arrangements

How often do you wake up at night?

How many continence aids are used at night?

How often are continence aids changed during the night?

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Nutrition

Breakfast

Lunch

Dinner

Snacks

Dietary modifications

Fluid intakeType, amount, times of the day and night, any restrictions?

NGT or alternative feeding device

YesNoUnsure

Provide further details

Does the client see a dietitian?

YesNoUnsure

Provide further details

Rate, amount, type

Site Inspection

Is a healthcare professional currently involved in the care?

YesNoUnsure

Provide further details

Adequate latching to breast?

YesNoUnsure

Provide further details

Frequency of feeds/meals?

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Bladder Problems

Is the client currently experiencing bladder problems?

YesNoUnsureOther

Provide further details

What kind of support does the client prefer?

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

Provide further details

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

YesNoN/AOther

Provide further details

What aid is worn/used for continence maintaining social incontinence?

UrinalIDCPad/PantCommodeBed panN/AOther

Provide further details

Does the client have a stoma?

YesNoN/A

Provide further detailsColostomy/ ileostomy/ urostomy, etc.

Is a Healthcare Professional involved in the care?

YesNoUnsure

Provide further details (including contact information)

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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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