Continence Assessment Form And Care Plan Page 6
ADVERTISEMENT
1
2
3
4
5
6
7SECTION E: Medical
(This section may need to be completed by an RN, Continence Nurse or GP)
24. Please indicate whether or not the resident has any of the following potentially reversible causes of incontinence
■
■
■
■
■
Delirium
Bladder infection
Constipation
Irritable bowel syndrome
Medication
■
■
■
■
■
Atrophic vaginitis
Unstable diabetes
Depression
Enlarged prostate
Restraint use
25. If yes to any of the conditions, could this condition be causing the residents incontinence?
■
No
■
Yes (please list) ________________________________________________________________________________________________
26. Is there any potential to treat or improve the residents’ condition with any of the following options
■
■
■
■
Medication
Bladder training
Electrical stimulation
Pelvic floor muscle training program
■
■
■
■
■
■
■
Referral to:
GP
Continence Nurse
Urologist
Geriatrician
Gynaecologist
Physiotherapist
SECTION F: Resident Perspectives
(This section should be completed in conjunction with residents and/or their family members)
Best practice recommendations
Ensure residents and families are given information about healthy bladder and bowel habits
■
If the resident has a low affect and/or is bothered by their symptoms discuss this with an RN or the GP
■
If a continence product is used, ensure that it fits the resident, absorbs any incontinence,
■
and protects the resident’s underwear and outer clothing
Bladder Function
Bowel Function
27. If you are experiencing a bladder problem, what kind of assistance
28. If you are experiencing a bowel problem, what kind of assistance
would you prefer? (may tick more than one)
would you prefer? (may tick more than one)
■
■
No assistance
No assistance
■
■
To be assisted to go to the toilet at _____________________
To be assisted to go to the toilet at _____________________
■
■
To wear pads during the day
To wear pads during the day
■
■
To wear pads during the night
To wear pads during the night
■
■
To be seen by a specialist for further investigation
To have a laxative
■
■
To be seen by a specialist for further investigation
Other ____________________________________________
■
Other ____________________________________________
____________________________________________________
____________________________________________________
29. If you are experiencing a bladder problem, how much of a problem
30. If you are experiencing a bowel problem, how much of a problem
is this for you?
is this for you?
■
■
■
■
No problem
A bit of a problem
No problem
A bit of a problem
■
■
■
■
Quite a problem
Severe problem
Quite a problem
Severe problem
■
■
■
31. If you are wearing a continence product, does it keep you dry and comfortable?
N/A
Yes
No
■
■
If no, would you like to consider other options?
Yes
No
Further comments and/or observations ____________________________________________________________________________________
____________________________________________________________________________________________________________________
Staff member completing assessment
Staff member endorsing this assessment
Care plan discussed with and agreed to by
■
■
■
family
Yes
No
N/A
Name _____________________________________
Name _____________________________________
Family/Other–Name __________________________
Signature __________________________________
Signature __________________________________
Signature __________________________________
Designation ________________ Date ___________
Designation ________________ Date ___________
Relationship ________________ Date ___________
Developed by Deakin University and funded under the National Continence Management Strategy
6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dma 3051 - Request For Independent Assessment For Personal Care Services (pcs) Attestation Of Medical Need - North Carolina Department Of Health And Human Services
Legal
Related Categories
Parent category: Medical