Client details Name(Required)
Firstname
Surname
Date of birth(Required) Care home address(Required)
Referral(Required) Please select... New product request No change to products Change to products
Team(Required) Product Delivery Service
1. Preliminary continence assessment(Required) For all first continence assessments (except for end of life) please complete this section.
For End of Life continence assessments please move on to question four.
2. First urinary continence assessment(Required) 3. First bowel continence assessment(Required) 4. Review for continence products or End of Life assessment(Required) Please note that End of Life clients will receive a four-week supply of products.
5. Does client require continence products?(Required)
1. Preliminary continence assessment Current method of management of issue (including any problems)
Results of bladder diary Volume drunk for 24 hours, types of fluids, frequency of voids, volume of voids smallest/largest and 24 hour output.
Does client have a fluid restricted diet? Difficulty in using toilet Suggest adaptations such as raised toilet seat, rails, commode, urinal etc
Relationships - any issues with sexual function? Do continence problems cause issues with sexual function?
Are any continence products used? For example, continence products (volume and quantity per 24 hrs), sheaths (size and product type)
2. First urinary continence assessment Urinary continence assessment
What has caused urinary symptoms and how long has client had urinary symptoms for? For example, medical condition, medication, surgery.
Any family history of bladder problems? For example, bladder cancer, prostate problems.
What urinary symptoms are present? For example, urine infection, frequency, urge, stress incontinence, dysuria, haematuria, difficulty emptying bladder, no sensation of when to void, post micturition dribble.
Has an MSU been tested and what was the result? Residual by intermittent self-catheterisation
Result of physical examination Skin integrity, pain issues.
3. First bowel continence assessment Bowel continence assessment Dietary intake - regularity of meals, types of foods eaten, issues with swallowing, dental problems, food intolerances.
Issues relating to nausea and vomiting - consider urgent referral
Issues with rectal bleeding/melaena - consider urgent referral
Normal bowel function Please record Bristol stool form for client include normal bowel habit, faecal incontinence and last bowel action.
Frequency, consistency, difficulty in opening/emptying bowels, pain, mucus, colour and odour
History of any bowel obstruction or constipation
History of any faecal incontinence
Frequency, consistency, times of leakage For example, pre/post defecation, pain.
Family history of bowel problems Coeliac, bowel polyps, Crohn's, colitis, bowel cancer. If bowel cancer relationship to client and age at diagnosis.
Information on last bowel movement
Date of last bowel motion, Bristol stool form scale, any bleeding, difficulty, pain
Stool sample sent/ result of stool sample - Document stool sample sent/results Physical examination
Clinical consent obtained Reason why consent not obtained
5. Does client require continence products If fitted products required, enter waist and hip measurement:
Type, quantity per 24 hours Please use fluid intake as a guide to help with product selection.
Is this the first time continence products have been provided? If continence products have been requested for the first time has the client/ carer/parent had a copy of the client agreement form? If continence products have been requested for the first time has the client/care/parent agreed to the following statements If providing continence products for the first time have the following items been discussed:
Agreed by Please select... Client Carer/parent
Is this a client where a carer/parent is supporting the assessment? Consent I accept the following:I understand the named client's personal sensitive data will be shared with a third party supplier to provide/supply products.
Is this for a client? Consent I accept the following:
Please upload completed Bladder and bowel chart
Please upload completed TENA continence patient requirement form
4. Review for continence products or End of Life assessment This section is the same for an End of Life continence assessment OR a review assessment for continence
Review of continence products or End of Life assessment Please select... Review EOL
If change in products or EOL, all sections need to be completed
Bladder and bowel symptoms This includes amount, frequency, urgency and incontinent episodes. If possible include bladder and/or bowel diaries.
Medical condition This includes new or deterioration of health, change in medication, mobility, social, environment, mental health and skin integrity.
Current urinalysis
Further comments on reassessment/assessment of EOL continence needs
Current supply (if applicable)
Order for continence product(s)
Order for continence product(s) to be suspended Details of newly requested continence supply
Please upload supporting documents