Continence care: Care home assessment form

Your information

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Please make sure you have completed the three day bladder diary before completing the form, as you will need to attach this when prompted.

Bladder diary chart

Training sessions

Continence care home assessment training
Continence care home eligibility criteria training

These training sessions have been produced to assist colleagues, new and old, in completing the continence assessment form. It is suggested that they are completed once and then used as a reference, as and when required, to support you in completing your patients assessment.

Continence Service - care home assessment form

Client details

Name(Required)

Firstname Surname

Date of birth(Required)

Day

Month

Year

NHS number(Required)

Care home address(Required)

Address line 1 Address line 2 Town County Postcode

Referral(Required)

Team(Required)

End of life

The criteria for an end of life continence assessment is when a patient is likely to die in the next four weeks. It is important that products are provided as soon as possible using the nursing home’s buffer stock.

Background

Reason for referral(Required)

Medication summary(Required)

Make a referral to the Continence team if a medication review may improve symptoms - Continence referral form for Health Care Professionals use only.

Past medical history(Required)

Previous surgery(Required)

Weight(Required)

Recommended fluid intake (ml)(Required)

30ml for every kg of body weight.

Client has a fluid restricted diet?(Required)

Yes

If yes, reason and restricted fluid intake (ml)(Required)

Hip measurement (cm)(Required)

Waist measurement (cm)(Required)

Equipment and products

Client has challenges using a toilet(Required)

Yes

If yes, what support has been trailed to date(Required)

Assessment type(Required)

First or review

Background

Reason for referral(Required)

Medication summary(Required)

Make a referral to the Continence team if a medication review may improve symptoms - Continence referral form for Health Care Professionals use only.

Past medical history(Required)

Previous surgery(Required)

Weight(Required)

Recommended fluid intake (ml)(Required)

30ml for every kg of body weight.

Client has a fluid restricted diet?(Required)

Yes

If yes, reason and restricted fluid intake (ml)(Required)

Hip measurement (cm)(Required)

Waist measurement (cm)(Required)

Family history of bladder / bowel disease or symptoms?(Required)

Yes

Please detail family history(Required)

Bladder symptoms(Required)

Yes

If yes, please tick all that apply:(Required)

Frequency

Urgency (with or without incontinence)

Stress incontinence

Post micturition dribble

Difficulty emptying bladder

Lack of void sensation

Poor flow

Dysuria

Haematuria

Nocturia

Nocturnal enuresis

Recurrent urine infection

Pelvic organ prolapse(s)

Any comments

Bowel symptoms(Required)

Yes

If yes, please tick all that apply:(Required)

History of constipation

Faecal incontinence

Incomplete defecation

Pain with defecation

Mucus in the stool

Blood in the stool

History of bowel obstruction

Prolapse(s)

Any comments

Client has regular meals?(Required)

Yes

If yes, type of meals?

Client has swallowing problems?(Required)

Yes

Client has nausea and vomiting?(Required)

Yes

Client has unintentional weight loss?(Required)

Yes

Day of last bowel motion(Required)

DD slash MM slash YYYY

Time (approx) of last bowel motion(Required)

Hours

Minutes

AM/PM

Faecal type(Required)

Use Bristol stool chart and tick all that apply.

Client has had a bladder scan?(Required)

Yes

Pre void (xx)(Required)

Post void (xx)(Required)

Urinalysis indicated(Required)

Yes

Visual inspection highlights the following

Include skin integrity, prolapses, discharge, retraction of penis, scrotum and foreskin, pain issues, haemorrhoids.

Quality data

In the last 12 months, how many incidents has the patient had where poor continence care was a contributary factor

Pressure ulcers

Catheter associated urinary tract infections

Falls / fractures

How often does the patient leak urine?

How much urine do you think the patient leaks?

How much does leaking urine interfere with their everyday life?

When does the patient leak urine?

Bladder and bowel diary

Use the patient’s completed bladder and bowel diary to complete.

Fluid intake in 24 hours (xx)(Required)

Types of fluid

Total bladder voids per day

Total bladder voids per night

Total bladder voids in 24 hours

Total episodes of urinary incontinence in 24 hours

Smallest void (xx)

Largest void (xx)

Total bowel voids in 24 hours

Total episodes of faecal incontinence in 24 hours

Frequency, consistency, difficulty in opening/emptying bowels, pain, mucus, colour and odour

Equipment and products

Client has challenges using a toilet(Required)

Yes

If yes, what support has been trailed to date(Required)

Product prescription changed(Required)

Yes

Main reason for change

Products

Products(Required)

Core

Non-core

Core products

Shaped products

Light to Moderate

TENA Comfort Mini Plus – Working absorbency 150ml - £0.07

TENA Comfort Mini Extra – Working absorbency 250mls - £0.10

TENA Comfort Mini Super – Working absorbency 400mls - £0.12

Shaped products

Moderate to Heavy

TENA Comfort Normal – Working absorbency 450ml - £0.13

TENA Comfort Plus Compact – Working absorbency 650ml - £0.17

TENA Comfort Plus – Working absorbency – 650ml - £0.17

TENA Comfort Extra – Working absorbency – 800ml - £0.19

TENA Comfort Super – Working absorbency – 950ml - £0.24

TENA Comfort Maxi – Working absorbency – 1300ml - £0.29

Non-core products

Non-core products require additional rational as to why core products are not suitable(Required)

TENA Slip Products

Moderate to Heavy

TENA Slip Plus Extra Small, hip size 49-74cm – Working absorbency 700ml

TENA Slip Plus Small, hip size 56-85cm – Working absorbency 700ml - £0.23

TENA Slip Pro Plus Medium, hip size 73-122cm – Working absorbency 900ml - £0.28

TENA Slip Pro Plus Pro Plus Large, hip size 92-144cm – Working absorbency 1000ml - £0.31

TENA Slip Plus Extra Large, hip size 120-160cm – Working absorbency 1000ml - £0.38

TENA Flex

Belted Products

TENA Flex Normal Medium – Working absorbency 400ml - £0.25

TENA Flex Normal Large – Working absorbency 500ml - £0.29

TENA Flex Plus Small – Working absorbency 700ml - £0.30

TENA Flex Plus Medium – Working absorbency 750ml - £0.32

TENA Flex Plus Large – Working absorbency 900ml - £0.35

Details of any other non-core product being requested

Upload bladder diary(Required)

Drop files here or

Accepted file types: docx, pdf, jpg, Max. file size: 10 MB.

Supporting documents

Such as toileting schedule, continence care plan or any other document to support the assessment.

Drop files here or

Accepted file types: docx, pdf, jpg, Max. file size: 10 MB.

Recommended

Services

Pages

Leaflets

Continence care: Care home assessment form

Your information

Training sessions

Continence Service - care home assessment form

Client details

End of life

Background

Equipment and products

First or review

Background

Quality data

Bladder and bowel diary

Equipment and products

Products

Core products

Non-core products