CONTINENCE CARE PATHWAYS
Doc. Ref. No.
Title of Document
Author’s Name
Author’s Job Title
Dept / Service
Doc. Status
Ref no to track policy by
Continence Care Pathways
Mary-Lou Brennan, Continence Service Manager,
Linda Gibney, Continence Advisor
Jenny Tibbs, Continence Advisor
See above
Continence Service
V3
Based on
Guidelines, Evidence-based Practice and BCH
Continence Care Pathways 2008
Signed off by
Publication Date
Next review date
Distribution
Committee responsible for approving the policy
August 2013
August 2015
Bristol Community Health Practitioners
Consultation
Version
V0.1
Date
November 2012
V0.2
April 2013
V3
August 2013
Consultation
Mary-Lou Brennan,
Continence Service
Manager,
Linda Gibney, Continence
Advisor
Jenny Tibbs, Continence
Advisor
Mary-Lou Brennan,
Continence Service
Manager,
Linda Gibney, Continence
Advisor
Post wider BCH review
Checklist for Approving Committee / Board
Has an equality impact assessment
been compiled?
No
Has legal advice been sought
No
Has the policy been assessed for its
impact on Human rights?
No
Have training issues been
considered?
Yes
Have any financial issues been
considered?
Yes
Will implementation be monitored?
Yes
Is there a cascade mechanism in
place to communicate the policy?
-
with staff
with patients
with the public
Yes
Are there linked policies /
procedures?
Yes
Has a review date been set?
yes
Is this related to the core standards
for better health?
Yes
Continence Care Pathways
Welcome to the Bristol Community Health Continence Care Pathways:
We would like to introduce you to the Bristol Community Health (BCH) Continence Care
Pathways. The aim of the pathways is to help in a practical way and to improve the
standard of continence assessment, enabling an evidence based approach to continence
care. The care pathways are available on the public site of the BCH website:
www.briscomhealth.org.uk under Continence Service and also on the Staff side.
The design of the pathways helps avoid duplication of records and is a structured
approach to the assessment and management and review of incontinence. The
statements in the pathways form a standard of care and there is no need to write anything
unless the standard is not met, in which case the variance from the standard should be
recorded.
We wish to acknowledge the excellent work of North Hampshire PCT Continence Care
Pathway Development Group and Barts, The London NHS Trust & Tower Hamlets Primary
Care Trust. These pathways has been adapted in collaboration with NBT South
Gloucestershire Community Services and North Somerset Community Partnership to
enable practitioners to use best practice guidance in a user friendly way.
Further developments of the pathways are anticipated and the care pathways will be
reviewed in two years. We intend to add a Catheter Care Pathway and Bowel Care
Pathway in the future.
Continence Service
Horfield Health Centre
Lockleaze Road
Bristol
BS7 9RR
Tel: 0117 3737 118
Office hours: Mon - Fri 08.30 - 16.30
4
Contents of the Continence Care Pathway
1. Introduction
Introduction to continence assessment in the community
Instruction for using the care pathway
Guidance for completing the continence assessment tool
2. Assessment
Adult Continence Assessment Tool (appendix 1)
Symptom profile (appendix 2)
Bladder record chart (appendix 3)
3. Pelvic floor weakness (stress) pathway (appendix 4)
4 Overactive bladder (urge) pathway (appendix 5)
5. Voiding difficulties pathway (appendix 6)
6. Functional Incontinence/ Cognitive Problems (Appendix 7)
7. Functional Incontinence/ Mobility and/or Dexterity (Appendix 8)
8. Neuropathic (Reflex) Incontinence (Appendix 9)
9. Nocturia (Appendix 10)
10. History Sheet (Appendix 11)
11. Supporting patient information leaflets
Pelvic floor exercises (appendix 12)
Pelvic Floor Exercises for Men (appendix 13)
Urge information sheets (appendix 14)
Caffeine information sheet (appendix 15)
Bristol stool scale (appendix 16)
Bowel habit diary (appendix 17)
Continence in the confused elderly (Appendix 18)
12. Supporting practitioner information forms
Nocturnal Polyuria (appendix 19)
Urinalysis flow chart (appendix 20)
How to collect a urine sample (appendix 21)
Vulval Observation (appendix 22)
Measuring post void residual (appendix 23)
Medication information (appendix 24)
Guidelines for using the Product Requirement Form (appendix 25)
Guide for Patients Receiving Continence Products ( appendix 26)
Skin care Guidance (appendix 27)
13. Useful Addresses (Appendix 28)
14. References
5
Continence Assessment in the Community
Introduction
The “Good Practice Guidelines in Continence Care” (Department of Health 2000) states
that all patients should be asked, as part of an holistic assessment, if they have a bladder
or bowel problem. For the purpose of this document the standard trigger question is “Do
you have any problems with, or concerns about, your bladder or bowel?” If the answer is
“yes” a full continence assessment should be carried out.
This documentation aims to support professionals in undertaking a continence
assessment, and to support clinical decision making rather than replace it. It encourages:
Clear guidance about current best practice
Standardisation of care
Audit of quality and effectiveness, which can be measured
Outcomes, which can be reviewed at regular intervals.
Background
Continence is a “skill gained when a person learns to recognise the need to pass urine
and/or bowel motion, has the ability to reach an acceptable place to void, is able to hold on
until they reach an acceptable place to void, and is able to void/ eliminate effectively on
reaching that place” (Anderson1988, cited Norton 1992). This is the ideal state for
everyone.
Incontinence
Incontinence is “an involuntary loss of urine and/ or bowel motion at an inappropriate time
or in an inappropriate place”. The amount can vary from slight to copious. Incontinence is
not a disease but is a symptom of an underlying disorder (Anderson et al 1988, cited
Norton 1992).
Why undertake a continence assessment?
The World Health Organisation’s Consensus on Continence Conference 1997 drew up the
following explanation of continence management. This looks at incontinence in four ways,
from a person who is truly continent, to one who is totally incontinent. It suggests the
terms “social continence” and “dependant continence” as a means of achieving some
degree of continence in patients.
Social Continence
Continent
Dependant Continence
Incontinent
Social Continence
The client is socially continent. This may involve using pads, appropriate appliance or
internal device (Fonda 1997).
Dependant Continence
This means the client being dependant on others to take them, or remind them to go, to
the toilet (Fonda 1997).
6
Aim
The aim of this continence care assessment tool is that by following care pathways every
patient will achieve their fullest potential. There may be reasons why this may not happen
and the ideal outcomes for a client may be reflected in the social or dependent continence
categories. The research evidence shows that at least 90% of clients under 65 can make
significant health gains if their incontinence is properly diagnosed and managed and 75%
of clients over 65 can make significant health gains (Norton 1992). Therefore each
practitioner should be aiming to improve his or her patient’s continence status.
All clients going through a continence assessment and treatment process will visit each
stage at a different rate. False hope should not be given and realistic goals should be set.
These goals should be reviewed regularly, and progress noted.
Standardisation of Care
This documentation has been designed to slot into community practitioner’s
documentation, but is available on the www.briscomhealth.org.uk to enable adaptation for
different care settings. However to enable continuity of care, a copy of the assessment
form and care pathways used could be given to the client, allowing them ownership of the
document. We will be considering links to GP Practice computer systems in the future.
Audit, Research and Review
Audit of compliance shall be in line with BCH’s audit plan, or as deemed necessary by
either the Quality Directorate or the Continence Service.
Participation and contributions to research by the Continence Service are vital so as to be
involved with national recommendations for policy and practice.
This document will be reviewed and updated every two years or as changes in best
practice standards, guidance or legislation occurs.
Training
A training needs analysis will be carried out when Integrated Care Pathways (ICP) are
implemented to establish areas for future training.
All practitioners undertaking continence assessments and utilising the care pathways
should attend a recognised training course such as the BCH One Day Continence
Promotion and have been assessed as competent.
They must refresh their knowledge and skills five yearly (RCN 2012) by attending the One
Day Continence Promotion Study day which can be accessed through BCH Learning and
Development and personal study should be undertaken. Please see BCH Continence
Policy for further detail on www.briscomhealth.org.uk and for the Core Competency for
Adult Continence Assessment.
7
Instruction for Using the Care Pathway
Background
An audit of the quality of continence assessments, within the Community Directorate of
UBHT, in 1999 showed a wide variation in standards across the directorate. To that end,
an Integrated Care Pathway (ICP) was developed to try and standardise the quality of
assessments. In developing the ICP, the group took into consideration:
Research evidence, where it existed
Best Practice evidence
Department of Health (2000) Good practice in Continence services
Department of Health (2001) NSF for older people
Department of Health (2001) Essence of Care
NICE guidance
RCP audit 2006
About the pathway
The pathway takes the nurse through possible symptoms, enabling identification of appropriate
managements. There are three basic sets of symptoms, pelvic floor weakness, overactive bladder
and voiding dysfunction. However, additional care pathways have been added. Standard
statements are made concerning each behaviour that affects bladder function. Variance from this
behaviour can be resolved with evidence-based patient information leaflets enabling the nurse to
suggest changes at each step of the way. The degree of behaviour change will influence
improvement in symptoms.
A symptom profile: is completed before assessment as progress can be monitored objectively by
improvement of the symptom profile over time.
Pelvic floor weakness: is demonstrated by urinary leakage on coughing, sneezing and exercise
or by any activity that raises abdominal pressure. This puts pressure on the bladder and also on to
the pelvic floor muscles that support the bladder neck keeping it shut tightly to prevent leakage.
Overactive bladder: this can happen when the bladder muscle (the detrusor) starts to contract
before we get to the toilet and frequently leads to an urge leak. A patient information leaflet
advises on lifestyle changes and how to retrain the bladder. Many older women will present with
mixed symptoms of urge and stress leakage and need advice for both.
Voiding dysfunction: can happen to anyone with an outflow obstruction around the bladder neck
or anything that will prevent complete emptying of the bladder. In men it can be due to an enlarged
prostate, in women it can be due to vaginal or uterine prolapse. Acute or chronic constipation can
also impact on emptying as can neurological problems such as stroke, diabetes or multiple
sclerosis.
Prior to assessment: in the community the patient or carer is asked to complete;
a diary of their voiding frequency to enable a clear idea of bladder function and behaviours
affecting symptoms for four days. (bladder diary – Appendix 3)
A symptom profile. (Appendix 2)
A list of current medication
In care homes and care homes with nursing, or hospital setting, it should be possible to ensure
completion of a bladder output/ fluid intake chart or frequency volume chart for four days.
8
Stages of the Care Pathways
1st visit
1. Initial assessment
2. Symptom profile
3. Bladder diary – leave with patient/carer to complete prior to visi
visit to do assessment if appropriate
4. Bothersome rating
5. Agree most relevant pathway and give relevant written
6. Information
7. If unable to commence pathway document reason
1.
2.
3.
4.
1.
2.
3.
4.
2nd visit
Record bothersome rating
Review patient compliance with pathway
If symptoms have improved discharge from pathway
If symptoms have not improved, agree review date as
appropriate
3rd visit
Record bothersome rating
Review patient compliance with pathway
If symptoms have not improved discuss with or consider
referral to Continence Advisor
Agree review date or discharge as appropriate.
For further help or advice contact the Continence Service.
9
Guidelines for Completing the Continence Assessment Form
The Continence Assessment Form has been designed for healthcare staff to help complete
a comprehensive evidence based assessment. The following is guidance on completing the
form. All patients need to be re-assessed as their needs change.
Patient Details should be completed accurately in capital letter or clear print. Always
record the NHS number; this is a MHRA requirement.
Assessor Details includes the name, designation/title, base and contact number of the
person completing the assessment. Please could you print details or use capital letters
Presenting Problem is the Patient/Carer’s description – document the words used by
the patient/carer and ask how long it has been a problem. Is it getting worse? From
who’s perspective?
Current Management. How does the client currently cope? Specify type and amount
of pads. How often are they changing, and how wet do they get? Specify size and
style of sheath or appliance/receptacle. Is the client happy with current management?
If so, what are they hoping to gain from your assessment?
How does the client feel about their continence problem and how does it affect
them? Bothersome rating describes how much of an impact the bladder problem has
on their quality of life.
Relevant Health History
Weight
Increased body mass index is positively associated with loss of urine. Excess weight
can increase abdominal pressure during physical activity, which may increase bladder
pressure and urethral mobility. This also fits with the governments ‘Healthy Weight,
Healthy Lives’ strategy published in January 2008. The ‘Lose weight, feel Great!’ leaflet
may be helpful and can be obtained from the Librarian at South Plaza.
Obstetric
Risk factors for stress incontinence include weight of baby (over 8lb/ 4kg), trauma
(episiotomy, tear), assisted delivery (forceps, suction), length of labour (long or short),
epidural, number of babies, gaps between them (less than 2 years).
Gynaecological surgery e.g. colposuspension, trans-vaginal tape (TVT), pelvic floor
repair, hysterectomy, sling procedure, injectable urethral bulking agents
Surgical
Previous surgery should be documented. Also document when a catheter may have
been in situ, including reasons.
Particularly relevant: - Urological surgery e.g. Transurethral Resection of
Prostate (TURP), Transurethral Resection of Bladder Tumour (TURBT), bladder
neck surgery, radical prostatectomy, cystoscopy, urethral dilation and stricture
therapy.
10
Medical
Many medical conditions can affect the function of the bladder. For example neurological
conditions:- multiple sclerosis, diabetes, spinal injuries, stroke, dementia, back pain and
also chronic cough, depression, sexually transmitted diseases (particularly Chlamydia
causes urgency), physical and learning disabilities. Also note any history of sexual
abuse, age of menopause and HRT usage. NB hormone replacement therapy is contraindicated following breast cancer; anticholinergic therapy is contraindicated with some
types of glaucoma (discuss with GP). Allergies should be documented.
Constipation
Links have been found between chronic constipation and/ or faecal impaction, and
nocturia, frequency, urgency and stress incontinence (Spence-Jones et al 1994,
Bannister et al 1988). These bowel problems are common in certain groups such as care
homes, care homes with nursing, and hospital clients. Severe constipation and straining
at stool over a prolonged period may cause changes in pelvic neurological function.
Straining at stool has also been shown to be significantly more common in women with
stress incontinence (Spence-Jones et al 1994).
Smoking
There is some evidence that cigarette smoking may be associated with increased risk of
urinary incontinence as a consequence of frequent or violent coughing (Bump et al
1994). Smoking also carries an increased risk of bladder cancer.
Previous treatment/investigations
Ask the client if they are already seeing someone else who is dealing (or has dealt) with
the problem, or who has asked them to request a further appointment should the problem
reoccur.
Medication
Many drugs disturb bladder or bowel function (Appendix 24).
Prompt the client to mention over the counter remedies, particularly laxatives, and herbal
remedies. Some recreational drugs may affect continence.
Urinalysis
Urinalysis is an essential step in a continence assessment. The principle purpose is to
exclude a urinary tract infection which may be a temporary cause of incontinence. Refer
to urinalysis guidance (Appendices 20 and 21).
Dysuria
Dysuria means pain or burning whilst passing urine. It is often caused by a urinary tract
infection. If the patient indicates a history of UTIs, document if specific organisms have
been identified or if not. The frequency and treatment of UTIs should also be noted.
Patients with recurrent UTI's require further investigations (NICE 2012), ask GP if these
have been investigated and request copies of Consultant letters if available.
If the answers are “yes” to the assessment questions, ensure a urinalysis is obtained
and subsequent clean catch specimen or MSU if appropriate. Common causes are poor
hygiene, residual urine, poor fluid intake, atrophic vaginitis and sexually transmitted
diseases
11
Fluids
An accurate record of fluid intake, including type and amount is a vital part of the
assessment. Ask to see the usual size cup or mug. Do they drink a full cup or half?
Caffeine is a diuretic and bladder stimulant, which can exacerbate urgency. Alcohol and
fizzy drinks will have a similar effect. Some people also find it helpful to avoid citric drinks
as well as blackcurrant juice (See Appendices 14 and 15). Many incontinent people use
fluid reduction to manage their incontinence; this is not recommended, as concentrated
urine can irritate the bladder and cause urothelial irritation and will also eventually
diminish bladder capacity, leading to frequency. For suggested fluid intake see
Appendices 14 and 15.
Bowel Habit
Identify the client’s normal bowel habit, including frequency and consistency. If bowels
are known to be a problem prior to assessment, send 14 day bowel habit diary for patient
to complete and use Bristol Stool Scale to document appearance (See Appendices 16
and 17). Identify any recent changes in bowel habit e.g. bleeding, constipation without
cause, diarrhoea, pain and colour of stool and report changes to the GP/ medical
practitioner immediately. The times of faecal incontinence should be documented.
Mobility
Mobility should be noted. The speed of mobility may be an issue when the patient has
urinary or bowel urgency. It may be directly impaired eg due to pain, or indirectly, eg due
to fear of falling. All patients who have fallen in the last year should be considered for a
falls’ assessment. Please see: www.briscomhealth.org.uk/staff/falls-in-older-people
Dexterity
Linked closely to mobility is manual dexterity which may hinder removing clothes to use
the toilet or in the fitting of aids or appliances.
Mental and cognitive function
Confusion and dementia will affect awareness of bladder and bowels and needs careful
assessment and often constant monitoring. A carer’s advice leaflet is available see
Appendix 18.
Toilet Facilities
Identify the toilet position at home, distance, ease of access with aids, use of commode.
A patient’s posture on the toilet is important for successful elimination and they may
require toilet frames, grab rails or steps to rest their feet on and make them feel safe.
Some clients will be dependant upon others for their toileting needs and may only be able
to use the toilet at times of the day when a carer is present.
12
Physical Examination
Consent
Document that the client has given their consent and if anyone else is present, state who. If
the client refuses consent do not proceed with the examination and document in the patient
notes that the examination was refused.
The Mental Capacity Act 2005 provides a statutory framework to empower and protect
vulnerable people age 16 and over who are not able to make their own decisions.
When there is doubt about the mental capacity of a patient to make decisions relating to the
procedure, the BCH guidelines for Assessing Capacity and Determining Best Interests must
be followed. In some cases a Lasting Power of Attorney (LPA) may be been appointed to
make health or welfare decisions on behalf of the person. A written LPA that has been
verified by the Office of the Public Guardian may specify that a named person has the right
to act on behalf of the patient in respect of treatment or welfare decisions specified in the
LPA.
In BCH we realise that for some patients they have personal preferences on the gender of
the health professional who delivers intimate care such as physical examination or
catheterisation. We will ensure that, whenever possible, we will take account of these
preferences. However in certain situations, particularly urgent visits, we may be unable to do
so. In cases such as this the patient is free to withdraw consent for the procedure to take
place and BCH will seek the next available opportunity to provide the care with a member of
staff with the preferred gender. In such situations the risk of delay should be fully explained
and documented.
Skin Condition
Assess for soreness, excoriation, broken areas, skin texture and colour. Atrophic vaginitis
may be present following the menopause or hysterectomy. The vagina and surrounding
tissue may be pale / dry or red and sore and the patient may report feeling itchy. Consider
requesting a local vaginal oestrogen cream, pessaries from GP or ask the GP to consider
inserting an Estriol ring pessary. See Appendix 22 for vulval observation.
When giving advice on general barrier cream, advise only a very thin layer of barrier cream.
If a pad is to be worn, cream may clog pads and reduce absorbency. Seek further advice if
required and see skin care guidance Appendix 27.
Physical Observation
Assess for visible signs of prolapse (shown by external bulging of the vagina) refer to GP as
appropriate. Visible leakage on cough – follow stress incontinence care pathway
Post Void Residual Urine.
Post void residual (PVR) should be measured by intermittent catheterisation, or by bladder
scan. Any PVR predisposes the patient to infection or incontinence. Residual urine may be
due to obstruction or poor bladder contractility (Appendix 23). Less than 50 mls is
considered normal and over 200mls abnormal (Fanti et al 1996). In routine clinical practice a
raised PVR is normally considered to be between 100-150mls. Please note this is in relation
to the volume voided and patient’s symptoms. If found discuss with Continence Service as
further investigation may be necessary. See Voiding Difficulties pathway Appendix 6.
Knowledge of the PVR may have an impact on management e.g. anti-cholinergic therapy
can reduce bladder contractility and is contraindicated when PVR is high.
13
Patient Self Assessment
Symptom profile
Ask / support the patient / carer to complete the symptom profile; this will help to determine
the problem (Appendix 2).
Fluid intake and output Chart
Where possible this should be sent before the assessment to obtain a clear picture of
voiding frequency and incontinence episodes. If the client is in a care home or care home
with nursing, ask the care staff to help fill in the chart. Where possible ask patient /carer to
weigh the wet pads as this objective measurement identifies the level of incontinence. Four
days should be a good example of voiding pattern (Appendix 3). This enables the health
care professional to give advice and plan a treatment programme and review as per the
relevant care pathway.
Bowel Diary
Using the Bristol stool chart as a guide ask the patient to record bowel habit, frequency, stool
type passed and bowel medication taken on the 14 day food and stool diary. This is
essential in management and evidence-based care of bowel dysfunction. (Appendices 16
and 17).
Pathway
Based on the above assessment choose the most relevant pathway for the patients’
presenting symptoms and document which pathway is most relevant. If you are unable to
commence a care pathway or, if deciding not to use a care pathway, the variance/reason
must be documented.
Product Request
Following assessment and review and, if appropriate, the following should be sent to the
Continence Service with the completed product request form ie white, yellow and pink copies
when product samples have been trialled:





copy of the assessment,
symptom profile,
four day fluid intake / output diary
14 day food and stool diary
relevant care pathway
All patients receiving products should be re-assessed two yearly (NICE 2012) or earlier if
their needs change. Please refer to Continence Policy on www.briscomehealth.org.uk
14
Appendix 1
Bristol Community Health Continence Assessment Form
BNSSG Continence Partnership
Title:
Date of Birth:
Name:
Address:
Assessment
Date:
NHS Number:
GP and Address:
Telephone Number:
Post Code:
Assessor’s Name:
Telephone Number:
Assessor’s Base:
Tel:
Presenting Bladder / Bowel Problem
□ Urinary
□ Faecal
□ Double
□ Nocturia / Nocturnal Polyuria (see Care Pathway)
Date of onset of problem: …………………… Who else have they consulted re this problem: ……………………………
…………………………………………………………………………………………………………………………………………
Patient’s and/or Carer’s Aims and Goals for Treatment
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
Current Management

Toileting Regime

ISC


Pads
Indwelling Catheter

Pants

Other

Sheath
……………………………………………………………………………………………………………………………..
How does the client feel about their continence problem? How does it affect them?
Scale 0 – Not bothersome Scale 5 - Extremely bothersome
Relevant Health History (please state or tick)
……………………………………………….…
Number of Pregnancies ………….... Back Problems………………......
Parkinson’s………………………
Difficult Deliveries ………………...… Constipation ……………………..
MS ……………………………..…
Hysterectomy ……………………..… Dementia……………………..…… Spinal Injury .………………….…
Pelvic Surgery ………...…
Depression …………………….…
Psychiatric History………………
Cystoscopy ………………………..... Diabetes ……………………….…
Weight ………………………...…
Prostatectomy …………………….… Learning Disability …………….…
Other…………………………..…
Other/Comments/Previous Investigations ………………………………………………………………………...…
…………………………………………………………………………………………………………………………....
Current Medication
Urinalysis
Fluid Intake
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
………………………………………
Nitrites ………………………………..
Ketone ………………………………..
Blood ……………………………........
Protein ………………………………..
Leucocytes …………………………..
PH .……………………………………
Glucose ……………………………....
Specific Gravity ………………………
Dysuria? ………………………………
If leucocytes/nitrites present or
symptoms of UTI, send clean catch
specimen (CCS). Suspend
assessment until treatment is
completed.
CCS Sent YES/NO Date…………....
Leave four day fluid input and output
chart for completion. If drinking more or
less than 7-8 mugs/glasses, advise to
have 1½ litres of decaffeinated fluid
daily. Drinks containing caffeine, citric
and alcohol (especially at night) may
increase incontinence. (See Urgency
info)
Individual advice given?
YES / NO
Outcome ……………………………..
15
Daily (+) ……
Bowel Habit
Alternate Days …
Consistency of Stool (Bristol Stool Chart)
Less Often …… Faecal incontinence ………..
……
If bowel problems, complete bowel assessment including 14 day food and stool diary
CONTRIBUTORY FACTORS
Mobility
OUTCOME




Independently
Mobile with Carer
Mobile with Aid
Mobile with Aid & Carer
Fall in last year?
Can manage clothes
quickly and easily?
Dexterity
Mental & Cognitive
Ability
Toilet Facilities
YES/NO
YES/NO
Memory unimpaired

Impaired

Upstairs
Downstairs
Commode
Special equipment




PHYSICAL EXAMINATION
YES
Consider Functional
Incontinence/ Mobility
and/or Dexterity
Pathway
If yes, assess for falls
Consider Functional
Incontinence/ Mobility
and/or Dexterity
Pathway
Consider Functional
Incontinence/ Cognitive
Problems Pathway
Information leaflet
given Appendix 18
Consider appropriate
equipment
NO
Outcome
Verbal Consent
Penile Observation
Vulval Observation. Observe for Atrophic Vaginitis
(vulval area can be red and sore, or pale dry and
sore).
Refer to GP for Oestrogen therapy
Skin condition satisfactory?
ADDITIONAL COMMENTS
Patient Assessment
Outcome
YES
NO
YES
NO
Symptom profile completed?
Continence chart completed for 4 days?
Continence charts discussed with patient?
14 day food and stool diary completed (as
appropriate)?
Pathway
Stress Incontinence (SI )/ Pelvic Floor Weakness
Overactive Bladder (OB)
Voiding Difficulties (V.Diff)
Functional Incontinence / Cognitive Problems
Functional Incontinence/Mobility and / or Dexterity
Neuropathic (Reflex) Incontinence
Nocturia / Nocturnal Polyuria
If unable to commence on pathway,
give reason:
Signature of Assessor: ………………………………………
Designation: …………………………...
Assessor’s Name: ……………………………………..... …
Date: …………………………………..
16
Appendix 2
SYMPTOM PROFILE
Name:………………………………. DOB:…………… NHS No.:……………………
Stress Incontinence
I leak when I laugh, cough, sneeze, run or jump

I only ever leak a little urine

At night I only use the toilet once, or not at all

I always know when I have leaked

I leak without feeling the need to empty my bladder

Only my pants get wet when I leak (not outer clothing) or
I sometimes wear a panty liner

Overactive Bladder
I feel a sudden strong urge to pass urine and have to go quickly

I feel a strong uncontrolled need to pass urine prior to leaking

I leak moderate, or large, amounts of urine before I reach the toilet

I feel that I pass urine frequently

I get up at night to pass urine at least twice

I think I had bladder problems as a child

Voiding Difficulties
I find it hard to start to pass urine

I have to push, or strain, to pass urine

My urine flow stops and starts several times

My urine stream is weaker and slower than it used to be

I feel that it takes me a long time to empty my bladder

I feel as if my bladder is not completely empty after I have
been to the toilet

I leak a few drops of urine on to my underwear just after
I have passed urine

17
Appendix 3
FLUID INTAKE AND OUTPUT RECORD
Name: ………………………………………….. dob: ………..
NHS No: …………………………………………………………..
Address/Care Home: …………………………………………..
Please fill in the chart for four days and nights (can be nonconsecutive days). Note what drinks (intake) you have and
the amount in mls, what urine you pass (output) using a
household measuring jug, if you are wet () and the weight
of the pad, if used, in grammes (1gm = 1ml).
For example:
Day/Date: …………………………………
Time
Intake
Time
Output
Wet/Pad
Day/Date: 11th March 2013
Time
Intake
Time
Output
Wet/Pad
Weight
9.00 am
150 mls Coffee
10.00 am
200 mls
350 grammes
10.00 am
150 mls Water
11.30 am
150 mls

Weight
Day/Date: ………………………………………..
Time
TOTAL
TOTAL
TOTAL
Intake
Time
Output
Wet/Pad
Weight
TOTAL
18
Appendix 3
Name: ………………………………………….. dob: …………………
NHS No: …………………………………………………………………..
Address/ Care Home: ………………………………………………….
Day/Date: ……………………………………..
Day/Date:……………………………………..
Time
Intake
Time
Output
Wet/Pad
Time
Intake
Time
Weight
TOTAL
TOTAL
Output
Wet/Pad
Weight
TOTAL
TOTAL
19
Appendix 4
Stress Incontinence (SI)/Pelvic Floor Weakness Care Pathway
Patient Name………………………………………DOB:…………….NHS No.:………………………
Address/ Care Home:…………………………………………………………………………………….
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
VISIT 1
Presenting problem and
bothersome rating
0 - None 5 – Extremely
Treatment goal
FEMALE PATIENTS:
If patient is dry/sore around
vagina, refer to GP for local
oestrogen therapy consideration
Observe perineal lift and teach
pelvic floor exercises and give
information sheet
MALE PATIENTS:
Teach pelvic floor exercises and
give information sheet
Discuss post micturition dribble
and give ‘A common problem
leaflet’.
ALL PATIENTS:
Discuss bladder diary, voiding
frequency volumes and set
targets
If constipated discuss
treatment options including
correct position, 5 a Day and fluid
advice
Discuss appropriate type and
amount of fluid intake (See
Urgency and caffeine info.
Sheets). You may need to give
bladder training information
Where appropriate give advice on
containment and buying products
Date and time of next visit agreed
with patient (within
8 -12 weeks)
PTO
© Continence Care Pathway Development Group
20
Appendix 4
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
VISIT 2 (8 – 12 weeks)
Presenting problem and
bothersome rating
Record leakage frequency
If symptoms have not improved
reinforce active pelvic floor
exercise programme. Continue
Care Pathway
If symptoms have improved
discharge with maintenance
pelvic floor programme
Date and time of next visit agreed
with patient (within 8-12 weeks)
VISIT 3 (18 – 20 weeks)
Presenting problem and
bothersome rating
Record leakage frequency
If patient’s symptoms have
Improved significantly –
discharge with a maintenance
programme
Patient’s symptoms have not
improved. Refer to Continence
Service, or discuss with GP
further options
SUMMARY COMMENTS:
Specimen signatures for variance:
Visits
Signature
Print Name
Initials
Date
Visit 1
Visit 2
Visit 3
Discharge Date
Signature
© Continence Care Pathway Development Group
Print Name
21
Appendix 5
Overactive Bladder (OB) Care Pathway
Patient Name………………………………………DOB:…………….NHS No.:………………………
Address/ Care Home:…………………………………………………………………………………….
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
VISIT 1
Presenting problem and
bothersome rating
0 - None 5 – Extremely
Treatment goal
FEMALE PATIENTS:
If patient is dry/sore around vagina,
refer to GP for oestrogen therapy
consideration
ALL PATIENTS:
Discuss bladder diary, voiding
frequency volumes and set targets
Discuss appropriate type and
amount of fluid intake, (see Urgency
and caffeine info. sheets). Record
fluid intake
Give caffeine information
Discuss bladder training and give
information sheet
If constipated discuss
treatment options including correct
position, 5 a Day and fluid advice
If diagnosed with neurological
dysfunction e.g. MS, Parkinson’s
disease, Diabetes, CVA, check
for residual urine. If more than
100 -150 mls discuss with
Continence Advisor. If less continue
CP
Check symptoms of pelvic floor
weakness and as appropriate
teach pelvic floor exercises
Where appropriate give advice
on buying products for
containment
Agree date and time of next visit
with patient (within 8 -12 weeks).
Ask patient to complete a bladder
diary for 2 – 3 days before next visit
PTO
© Continence Care Pathway Development Group
22
Appendix 5
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
STANDARD STATEMENT
VISIT 2
DATE
INITIAL
(8 – 12 weeks)
Presenting problem and
bothersome rating
Discuss bladder diary,
voiding frequency volumes
and set targets
If symptoms have improved
discharge with general bladder
health advice
If within 4 – 8 voids per day, less
than 2 voids per night, continue
with bladder training CP
If outside above parameters
for voiding, consider adjuncts
to bladder training options. Anticholinergics, stimulation
(contra-indications e.g. Glaucoma)
Consider setbacks to bladder
training, discuss coping strategies
Date and time of next visit agreed
with patient
VISIT 3 (18 – 20 weeks)
Presenting problem and
bothersome rating
Discuss bladder diary, voiding
frequency volumes and set targets
Patient discharged if they feel
that they no longer have a problem,
or symptoms have improved
significantly
If bothersome rating not improved
refer to Continence Advisor or
consider Urology referral
SUMMARY COMMENTS:
Specimen signatures for variance:
Visits
Signature
Print Name
Initials
Date
Visit 1
Visit 2
Visit 3
Discharge Date
Signature
© Continence Care Pathway Development Group
Print Name
23
Appendix 6
Voiding Difficulties (V.Diff) Care Pathway
Patient Name………………………………………DOB:…………….NHS No.:………………………
Address/ Care Home:…………………………………………………………………………………….
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
VISIT 1
Presenting problem and
bothersome rating
0 - None
5 – Extremely
Agree treatment goals
ALL PATIENTS:
Discuss bladder diary, voiding
frequency volumes and set targets
Discuss appropriate type and
amount of fluid intake (see Urgency
and caffeine info. sheets).
Measure post-void residual urine. If
more than 100-150 mls
refer to Continence Service
If residual less than 100 mls
bladder training information
sheet given to patient
If constipated discuss
treatment options including correct
position, 5 a Day and fluid advice
Review current medication and
refer to list of medication, which
may cause voiding difficulties
Consider treatment with bladder
massager
Where appropriate give advice
on products for containment
MALE PATIENTS:
Consider a prostate assessment
symptom profile
FEMALE PATIENTS:
Give double voiding advice sheet
Consider vaginal examination to
exclude vaginal prolapse and
atrophic vaginitis
ALL PATIENTS:
Date and time of next visit agreed
within 6 – 8 weeks
Patient discharged if they feel
that they no longer have a problem,
or symptoms have improved
significantly
PTO
© Continence Care Pathway Development Group
24
Appendix 6
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
STANDARD STATEMENT
VISIT 2
DATE
INITIAL
Initials
Date
(6 – 8 weeks)
Presenting problem and
Bothersome rating
Agree treatment goals
ALL PATIENTS:
Measure post-void residual
urine. If more than 100-150 mls
refer to Continence Service
If residual less than 100 mls
continue with bladder training
Patient discharged if they feel
that they no longer have a
problem, or symptoms have
improved significantly
Date and time of next visit
agreed. Within 6 – 8 weeks
SUMMARY COMMENTS:
Specimen signatures for variance:
Visits Signature
Print Name
Visit 1
Visit 2
Visit 3
Discharge Date
Signature
© Continence Care Pathway Development Group
Print Name
25
Appendix 7
Functional Incontinence/ Cognitive Problems
Patient Name………………………………………DOB:…………….NHS No.:………………………
Address/ Care Home:…………………………………………………………………………………….
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
Visit 1
Presenting problem
Bothersome rating 0 – 5
Agree treatment goal with
patient/carer
Discuss bladder diary, voiding
frequency volumes and set targets
Discuss appropriate type and
amount of fluid intake (see Urgency
and caffeine info. sheets).
Plan programme of toileting based
on bladder diary encourage toileting
¼ hour before normal voiding
occurs. Consider change of toilet
seat (See Appendix 18)
If undertaking prompted toileting
give praise when toileting is
successful
Review in 4 weeks; agree date and
time of next visit with patient
Visit 2 (4 – 6 weeks)
Bothersome rating at this visit 0 – 5
If dry discharge
maintain successful toileting
programme.
If improvement noted adjust toileting
times up or down accordingly to
achieve continence.
Review in 2 weeks; agree time of
next visit with patient/carer
If no improvement consider advice
on containment e.g. washable
products (which can be purchased)
or pads/ sheaths.
PTO
© Continence Care Pathway Development Group
26
Appendix 7
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
Visit 3 (6 – 8 weeks)
Bothersome rating at this visit 0 – 5
If dry discharge
If problem remains consider advice
on containment options for
containment e.g. washable products
(which can be purchased) or
pads/sheaths
Summary Comments:
Specimen signatures for variance
Visits
Signature
Visit 1
Print Name
Initials
Date
Visit 2
Visit 3
Discharge Date
Signature
© Continence Care Pathway Development Group
Print Name
27
Appendix 8
Functional Incontinence/ Mobility and/or Dexterity
Patient Name………………………………………DOB:…………….NHS No.:………………………
Address/ Care Home:…………………………………………………………………………………….
STANDARD STATEMENT
VARIANCE FROM
STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
Visit 1
Presenting problem
Bothersome rating 0 – 5
Agree treatment goal with patient/carer
Discuss bladder diary, voiding
frequency volumes and set targets
Discuss appropriate type and
amount of fluid intake, (see Urgency
and caffeine info. sheets). Record fluid
intake
If Patient has urgency follow Overactive
Care Pathway
If patient has difficulties mobilising to/ or
using the toilet, where appropriate refer
to OT/ Physio for advice on aids/
mobility
Consider adaptive clothing to aid easier
management of clothing
Consider contacting Continence Service
for advice re specialist toileting aids
Plan programme of toileting based on
patterns identified from bladder diary to
allow for mobility difficulties
Liaise with carers re toileting times if
appropriate
Review in 2- 4 weeks; agree date and
time of next visit with patient
Visit 2 (2 – 4 weeks)
Bothersome rating at this visit 0-5
If dry discharge
maintain successful toileting
programme.
If improvement noted, adjust toileting
times up or down accordingly to achieve
continence.
Review in 2 weeks; agree time of next
visit with patient/carer
If no improvement, consider advice on
containment e.g. washable products
(which can be purchased) or pads/
sheaths
PTO
© Continence Care Pathway Development Group
28
Appendix 8
STANDARD STATEMENT
VARIANCE FROM
STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
Visit 3 (4 – 6 weeks)
Bothersome rating at this visit 0 – 5
If dry discharge
If problem remains consider advice on
containment options for containment
e.g. washable products (which can be
purchased) /pads/sheaths
Summary Comments:
Specimen signatures for variance
Visits
Signature
Visit 1
Print Name
Initials
Date
Visit 2
Visit 3
Discharge Date
Signature
© Continence Care Pathway Development Group
Print Name
29
Appendix 9
Neuropathic (Reflex) Incontinence
Patient Name………………………………………DOB:…………….NHS No.:………………………
Address/ Care Home:…………………………………………………………………………………….
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
Visit 1
Presenting problem
Bothersome rating 0-5
Agree treatment goal with
patient/carer
No evidence of recurrent UTI’s
Discuss bladder diary, voiding
frequency volumes and set targets
Discuss appropriate type and
amount of fluid intake (see Urgency
and caffeine info. sheets).
If evidence of recurrent UTI’s
consider bladder scan / in and out
catheter to rule out residual urine.
If post-void residual over 150 mls or
50% more than average void go to
Visit 1 on Voiding Difficulties Care
Pathway.
Review bladder diary to determine
patient’s normal voiding pattern and
plan toileting programme.
Encourage toileting ¼ hr before
normal voiding would occur
Review in 2 – 4 weeks; agree time
of next visit with patient/carer
Visit 2 (2 – 4 weeks)
Bothersome rating at this visit 0-5
If dry discharge
If problem remains adjust timings up
or down as necessary to achieve
dryness
Review in 2 weeks; agree time of
next visit with patient/carer
PTO
© Continence Care Pathway Development Group
30
Appendix 9
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
Visit 3 (4 – 6 weeks)
Bothersome rating at this visit 0-5
If dry discharge
If problem remains consider advice
on containment options for
containment e.g. washable products
(which can be purchased)
/pads/sheaths
Summary Comments:
Specimen signatures for variance
Visits
Signature
Visit 1
Print Name
Initials
Date
Visit 2
Visit 3
Discharge Date
Signature
© Continence Care Pathway Development Group
Print Name
31
Appendix 10
Nocturia / Nocturnal Polyuria
Patient Name………………………………………DOB:…………….NHS No.:………………………
Address/ Care Home:…………………………………………………………………………………….
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
Visit 1
Presenting problem
Bothersome rating 0-5
Agree treatment goal with
patient/carer
Discuss bladder diary, voiding
frequency volumes and set targets
If urine output overnight is greater
than 1/3 total amount passed,
patient may have reversed diurnal
rhythm consider the following:
1. Give advice regarding no
major drinks after 7pm
2. Avoid caffeine, citric,
chocolate and alcohol based
fluids as last drink (See
Urgency leaflet)
3. Lie on bed for 1 hour after
lunch to aid diuresis in
daytime
4. Give Nocturia / Nocturnal
Polyuria leaflet, appendix 19
Review in 2 – 4 weeks; agree time
of next visit with patient/carer
Visit 2 (2 – 4 weeks)
Bothersome rating at this visit 0-5
If symptoms no longer persist,
discharge
If no change ask GP to consider
diuretics i.e. Furosemide late
afternoon (5-6hrs before bedtime)
Review in 1-2 weeks; agree time of
next visit with patient/carer
PTO
© Continence Care Pathway Development Group
32
Appendix 10
STANDARD STATEMENT
VARIANCE FROM STANDARD
STATEMENT AND
REASON/COMMENTS
DATE
INITIAL
Visit 3 (3 – 6 weeks)
Bothersome rating at this visit 0-5
If symptoms no longer persist,
discharge
If problem remains consider advice
on containment options for
containment e.g. washable products
(which can be purchased)
/pads/sheaths
Summary Comments:
Specimen signatures for variance
Visits
Signature
Print Name
Visit 1
Initials
Date
Visit 2
Visit 3
Discharge Date
Signature
© Continence Care Pathway Development Group
Print Name
33
Appendix 11
S- Situation
B- Background
A- Assessment
R- Recommendation
Surname:
First Name:
NHS
Number:
Date
© Continence Care Pathway Development Group
DOB:
Sex:
GP:
Clinical Notes
34
Appendix 11
S- Situation
B- Background
A- Assessment
R- Recommendation
Surname:
First Name:
NHS
Number:
Date
© Continence Care Pathway Development Group
DOB:
Sex:
GP:
Clinical Notes
35
Appendix 12
STRESS INCONTINENCE INFORMATION SHEET
Leakage when you cough, run, jump laugh or sneeze may be called “stress incontinence”.
It can be caused or aggravated by childbirth, being overweight, constipation and chronic
coughing. It is due to a weakness in the pelvic floor muscle. It is very important that you
do not reduce your fluid intake as this may actually make your
problem worse, and can cause constipation.
Physiotherapists, doctors and nurses know that pelvic floor exercises
can help you to improve your bladder control. When done correctly,
pelvic floor exercises can build up and strengthen the muscles to help
you hold urine.
Do not feel embarrassed – studies show that as many as one woman in three have this
symptom.
PELVIC FLOOR EXERCISES
THE PELVIC FLOOR
Layers of muscle stretch like a hammock from the pubic bone in front to the bottom of the
backbone. These firm supportive muscles are called the pelvic floor. They help to hold
the bladder, womb and bowel in place and to close the bladder outlet and back passage.
HOW THE PELVIC FLOOR WORKS
The muscles of the pelvic floor are kept firm and slightly tense to stop leakage
of urine from the bladder or faeces from the bowel. When you pass water or
have a bowel motion the pelvic floor muscles relax. Afterwards, they tighten
again to restore control.
Pelvic floor muscles can become weak and sag because of childbirth, lack of
exercise, the change of life or just getting older. Weak muscles give you less
control and you may leak urine, especially with exercise or when you cough,
sneeze or laugh.
HOW PELVIC FLOOR EXERCISES CAN HELP
Pelvic floor exercises can strengthen these muscles so that
they once again give support. This will improve your bladder
control and improve or stop leakage of urine. Like any other
muscles in the body, the more you use and exercise them, the
stronger the pelvic floor will be.
© Continence Care Pathway Development Group
36
Appendix 12
HOW TO DO YOUR PELVIC FLOOR EXERCISES
1. Sit comfortably with knees/ legs slightly apart. Without moving your tummy muscle or
bottom, try to squeeze the muscle around the back passage. Pretend you are trying to
stop wind from escaping!
2. Now try the same with front part of the muscle. Again without moving the tummy or
bottom, squeeze and lift the muscle into the vagina. Moving this front part of the muscle
is harder and takes time to practice.
3. Once you can tighten and lift the muscles (lifting is as though you are taking the muscle
up steps one at a time), pull as hard as you can and hold for as long as you can (e.g. 5
seconds), then relax. Repeat this 5-10 times with a good ‘rest’ for 10 seconds between
each contraction. Do the group of 5-10 slow pull up exercises three times a day without
making your muscle ache.
4. Now try to squeeze your muscle quickly like a one-second ‘flick’, then relax. Repeat this
quick pull up exercise five times. Only do this once before your group of slow
contractions.
5. These two actions of moving your muscle – i.e. slowly and then fast – will strengthen
the pelvic floor muscle so that you will be able to do more repetitions and hold the
squeeze longer. This will make the muscles strong and powerful.
You may find pelvic floor exercises difficult at first, but you will need patience and
perseverance in order to improve. All exercise needs to be repeated regularly in order to
get a good result and the pelvic floor is no exception. Try doing them sitting, standing and
lying down. You may notice an improvement in 6 – 8 weeks if you perform the exercises
as above. The pelvic floor exercises will become much easier to perform as the muscle
gets stronger and will become a habit.
Your personal Pelvic floor exercise programme
Number of slow pull up
exercises…… and hold for ……..
Rest for 5 -10 seconds
Number of fast pull up exercises:
© Continence Care Pathway Development Group
37
Appendix 13
PELVIC FLOOR EXERCISES FOR MEN
Practice each section separately.
The aim is not only to strenghthen the pelvic floor muscle but also to give it ‘bulk’ so that it can help
prevent the escape of urine from the urethra.
1. Locate Bladder Muscle Group
2. Locate Rectal Muscles
Contract the same muscles used to
stop the flow of urine.
Pull up as if trying to draw the penis
inside the body.
Pretend you have wind.
Tighten the rectal muscles around the
anus as if trying to prevent wind
escaping.
Hold tight for 3 normal breaths relax slowly
Hold tight for 3 normal breaths –
relax slowly.
Practice 5 contractions at a time
throughout the day
Practice 5 contractions at a time
3. Raise entire pelvic floor
throughout the day
4. After dribble
Find 4 opportunities in a day to tighten
these muscles 5 times.
To eliminate this problem ‘milk’ the last
few drops from the urethra.
Pull up – hold tight – breathe normally
– relax slowly.
Place a finger behind the scrotum and
gently massage forward prior to giving
a shake
Practice while sitting, standing or lying.
Little and often, anywhere anytime.
Gradually increase the period you hold
tight for from 3 breaths.
© Continence Care Pathway Development Group
38
Appendix 13
AFTER DRIBBLE – A COMMON PROBLEM
Few men admit to having this problem but a great many suffer and are embarrassed by it.
It affects all ages.
After dribble means the loss of a few drops of urine after the main stream when the bladder
appears empty. The medical term for this is post micturition dribble.
It usually happens just as the penis is being replaced and clothing rearranged and results in underwear and
trousers getting wet and stained. Some men find that even though they wait a while and shake carefully it
remains a problem.
What is happening is that the urethra (the tube leading from the bladder to the tip of the penis) is not being
completely emptied by the muscles that surround it.
A ‘sump’ of urine pools in the urethra
(See the diagram on the right.)
The best way to deal with this is to push the
last few drops of urine from the urethra with
your fingers before the final shake.
The technique is as follows:
After passing urine wait for a few
seconds to allow the bladder to
empty;
Place the fingertips of the left hand
three finger-breadths behind the
scrotum and apply gentle pressure
(see A on the diagram);
Keeping pressure in the midline gently
but positively draw the fingers towards
the base of the penis under the
scrotum;
This pushes the urine forward into the
urethra where it can then be emptied
by shaking or squeezing in the usual
way;
Before leaveing the toilet repeat the
technique twice more to make sure that the urethra is completely empty.
This technique can be practised at home.
When in public toilets it can be done discreetly with a hand inside a a trouser pocket and will avoid the
problem of stained trousers.
If after-dribble is associated with other urinary problems, for example delay or difficulty in emptying
the bladder, or frquency or urgency, please consult your doctor.
© Continence Care Pathway Development Group
39
Appendix 14
URGENCY INFORMATION SHEET
What is a normal bladder habit?
It is normal for an adult with a reasonable fluid intake to pass
one to two cups full of urine each time the bladder is emptied
(between 250-400ml) during the day and maybe once at night.
This may increase slightly with age. As we get older our bladder
capacity may get a little smaller, so we need to pass urine a little more often, including
once or twice a night.
Urgency is the symptom of having to hurry to pass urine.
Frequency is when you need to go to the toilet a lot, eight or more times in 24 hours, but
only pass small amounts of urine.
What you can do about it?
Whatever the cause there are certain rules to follow to help control your symptoms:
Do not reduce your fluid intake. Far from helping this may make your problem much
worse, and can also cause constipation. Have approximately
1½ litres of decaffeinated fluid per day.
Try to avoid drinks containing caffeine, which is found in tea, green tea, coffee,
chocolate and cola - reduce gradually to avoid headaches, moods
etc.
Fizzy drinks may also exacerbate your symptoms
Some people also find it helpful to avoid citric drinks such as
orange, lemon, lime, grapefruit and tangerine as they can irritate the
bladder. Blackcurrant is a natural diuretic.
Alcohol can also increase urgency
Avoid passing urine “just in case”
Try to increase the amount of time between visits to the toilet
Do not try to hold on at night - it will only keep you awake. Practising holding on in the
daytime will gradually help night time problems
If you have been given water tablets you must take them no matter how often they
make you want to go. Discuss this problem with your nurse or doctor
© Continence Care Pathway Development Group
40
Appendix 14
If you are overweight try to lose a few pounds, this relieves stress on
the pelvic floor. You may be able to obtain help via your GP regarding
accessing dietary and exercise options e.g. Weight Watchers
programmes and vouchers for Sports Centres.
Be careful with your diet – too much or too little fibre is not good for
you. Try changing your diet to see what works best for you
You may need to take tablets to help relax your bladder muscle.
When is a bladder training programme used?
Bladder training is a treatment for people who suffer from an urgent need to pass small
amounts of urine more frequently than normal, who may also experience leakage with
urgency.
Sometimes people with no urgency learn to pass urine frequently to avoid accidents.
These people may also benefit from bladder training.
What is bladder training?
The aim of bladder training is to improve bladder control and increase the amount of urine
the bladder can comfortably hold without urgency or leakage of urine.
The programme teaches people to suppress the urgent desire to pass urine until a socially
acceptable time and place is found. When the bladder is sensitive or over-active learning
to ‘hold on’ can initially be difficult but usually becomes easier with practice.
The bladder training programme. Keep a bladder chart or diary to
measure progress. If you haven’t been given a chart by your doctor or
continence advisor, simply record when and how much urine you pass
and write down any accidental loss of urine. Fill in the bladder chart for
2-4 days (including overnight).
Try to gradually increase the time between visits to the toilet
Each time you get the urge to go to the toilet, try to hold on for a
few minutes longer
If you wake up during the night with a strong desire to go to the
toilet, it is reasonable to go and empty the bladder right away
(unless advised otherwise). As you improve by day you will gain
confidence to practice the programme at night.
© Continence Care Pathway Development Group
41
Appendix 14
Some helpful hints
When you have the urgent need to pass urine, you may find it helpful to sit down
and try to take your mind off wanting to get to the toilet
When you do go to the toilet, walk, don't run
Avoid going to the toilet 'just in case'
Drink 6-8 cups of fluid over the day unless told otherwise by your doctor
Minimise the intake of fluids which may irritate the bladder, for example, coffee, tea,
cola and alcohol see advice above
Maintain a good bowel habit by keeping your bowel regular and avoiding
constipation as this can increase bladder sensitivity
Do your pelvic floor exercises - this gives you confidence to hold on. See Pelvic
floor Training for Women and Pelvic Floor Training for Men.
Will there be setbacks?
Do not be concerned with small day to day variations in your bladder pattern - these are
normal for everyone. However, any person who starts a bladder training programme may
experience set backs when the symptoms seem worse again. These may occur:
When you are tired or run down
During a urinary tract (bladder) infection (see the doctor immediately if you suspect
this)
At times of anxiety or emotional stress
When the weather is wet, windy or cold
During times of illness e.g. cold or flu
If this does happen, do not be discouraged. Think positively and keep trying. Further
information and support can be obtained from your health care professional.
How to contact the Continence Service: Tel: 0117 3737 118
&RQWLQHQFH6HUYLFH
+RUILHOG+HDOWK&HQWUH
/RFNOHD]H5RDG
%ULVWRO
%655
© Continence Care Pathway Development Group
42
Appendix 15
CAFFEINE
Caffeine is a natural drug that stimulates the body. It can act upon the central nervous
system, heart muscle and lungs. It is a diuretic (it makes you produce more urine).
Caffeine tightens the blood vessels and can worsen the effects of migraine type
headaches. Caffeine may affect fertility and osteoporosis. For some people caffeine is
also an irritant to the bladder.
It has been considered that the average person should not take more than 300mgs of
caffeine per day. The following table shows the amounts per serving in various foods and
drinks.
Food/drink
Fresh Coffee
Instant Coffee
Tea
Instant Tea
Coke Cola
Diet Coke
Pepsi Cola
Diet Pepsi
Dr Pepper
Red Bull
Chocolate bar (1oz)
Some Cold Relief Tablets
Drinking chocolate (3 heaped
teaspoons)
Caffeine per Serving
80 -150 mgs
65 -100mgs
30 -70 mgs
30mgs
45.6mgs
45.6mgs
37.2mgs
37.2mgs
39.6mgs
80mg per 250mls
15mgs
30mgs
8mgs
Ref. Website: Frequently asked questions about caffeine.
Caffeine can be addictive in nature and people can experience withdrawal effects when
reducing their caffeine intake. It is therefore vital that someone wishing to reduce their
caffeine intake does so by cutting down gradually, ie by reducing 1 cup per day.
Alternatives to caffeine drinks:



Herbal tea, eg peppermint, camomile
Fruit juices such as apple, cranberry, elderflower, peach and raspberry
Please note that hot chocolate, alcohol, lemonade and other fizzy drinks may also
cause bladder irritation and blackcurrant is a natural diuretic
© Continence Care Pathway Development Group
43
Appendix 16
BRISTOL STOOL SCALE
© Continence Care Pathway Development Group
44
Appendix 17
14 Day Food, Stool and Medication Diary
Patient’s Name: …………………………………………………
DOB: …………………
NHS No: …………………………..………
Address/Care Home:……………………………………………………………………………………………………………………………………………
DATE
FOOD AND DRINK
(Please record everything you eat and drink e.g. Lunch: meat, boiled potatoes,
peas, carrots, gravy, apple and yoghurt + 150mls water – please do not write
‘normal diet’)
STOOL TYPE, FAECAL
INCONTINENCE/SOILING
IF APPROPRIATE AND
TIME OCCURRED
BOWEL MEDICATION
Name, amount and times
(See Bristol Stool Chart)
© Continence Care Pathway Development Group
45
Appendix 17
14 Day Food, Stool and Medication Diary
Patient’s Name: …………………………………………………
DOB: …………………
NHS No: …………………………..………
Address/Care Home:……………………………………………………………………………………………………………………………………………
DATE
FOOD AND DRINK
(Please record everything you eat and drink e.g. Lunch: meat, boiled potatoes,
peas, carrots, gravy, apple and yoghurt + 150mls water – please do not write
‘normal diet’)
STOOL TYPE, FAECAL
INCONTINENCE/SOILING
IF APPROPRIATE AND
TIME OCCURRED
BOWEL MEDICATION
Name, amount and times
(See Bristol Stool Chart)
© Continence Care Pathway Development Group
46
Appendix 18
CONTINENCE IN THE CONFUSED ELDERLY
The way we stay continent is a very complex function that allows us to voluntarily
postpone passing urine or having our bowels opened until we are at the appropriate place.
This skill can be affected by a condition such as dementia. It may happen just
occasionally or, as the illness progresses, more frequently. It is very important to
understand that it may be due to a treatable condition so the first thing to do is discuss it
with a Health Care Professional.
Treatable conditions may include:
Urinary tract infection – someone may complain of pain or burning when passing
water or may show an expression of pain if they have difficulty talking. You or the
person may notice that their urine looks cloudy or smells. Sometimes an infection can
be present without specific symptoms so it is always worthwhile asking your nurse or
doctor to check that all is well
Prostate gland trouble (in men) – your GP will be able to assess if this is a problem
and advise you about treatment and help in managing leakage
The side effects of some medication – unfortunately some medications do affect
how your bladder and bowel work. It is always advisable to discuss this with your
doctor if this could be the case and he or she may be able to change them or alter the
dose. Please take advice before stopping or changing the time of taking any
medicines.
Constipation may cause urinary incontinence through pressure on the bladder or
bowel leakage where loose, smelly motions leak around the hard stool blocking the
bowel. It is important that you discuss this with a health care professional to advise
how to improve this problem.
Lack of recall – sadly when people become forgetful this may also mean they
gradually lose the memory of what to do in a toilet or even where the toilet is. Advice
can be given to help you manage in these circumstances.
It is very important to try to help this person keep their own continence skills for as long as
possible.
© Continence Care Pathway Development Group
47
Appendix 18
How you can help:
Get to know the person’s habits. This may seems a strange and very personal thing to
suggest but usually our bladder and bowel actions have some pattern to them. It may
be worthwhile noting when the person is most likely to use the toilet. As their memory
starts to play tricks upon them, you can help by reminding them to go to the toilet at the
times when you know they are most likely to go. Keep this as a regular routine.
It may be that the person finds it difficult to verbally let you know they need to use a
toilet. If this is the case you will need to become aware of other signs such as
fidgeting, wandering or pulling at clothing and suggest they use the toilet.
Make sure they drink enough during the day to keep the bladder and bowels healthy.
People can forget to drink, or be reluctant to. Your nurse or GP can advise you.
When you think about it, using the toilet is a very complicated thing to do involving lots
of different steps to be successful. Try to keep using the toilet to a few, regular, easy
steps. Always use the same language to ask or describe what is happening and keep
to the same routine inside the toilet. Consider changing the toilet seat to a red colour
as this is the last colour to go on the colour spectrum. This may help with toilet
recognition.
Decide the toilet routine, keep to it and tell others. This is important so that if the
person spends time apart from you, the routine to use the toilet is the same and the
skill is encouraged to remain.
Keep in contact with the health care professional that is helping you. Discussing and
monitoring changes as they occur can help prevent them from becoming larger
problems.
How others can help:
With aids and adaptations to make using the toilet easier
Advice about clothing so that the person can get quick access to themselves in the
toilet – e.g. velcro rather than zips or buttons
Advice about diet to keep bowels healthy
Advice about hygiene
Advice about mobility
Advice about special problems to help manage any wetness and to keep the person
dignified, comfortable and dry
To provide the time to listen to your worries, suggest other ideas and to work with you.
© Continence Care Pathway Development Group
48
Appendix 19
Nocturia / Nocturnal Polyuria
Some people who have to get out of bed to pass water (urine) during the night have
nocturnal polyuria. Nocturnal polyuria means that you pass too much urine at night,
compared to the daytime.
Nocturnal polyuria is commoner in older people and there are a number of causes.
Some causes are simple
Doing most of your drinking in the evenings. This means any fluid from water to
beer!
Eating a lot of water containing foods in the evening. These foods include salads,
vegetables and fruit but also rice and pasta.
Other causes are a little more complicated
If your ankles are swollen in the evening, they will often be slim by the morning. In
this case the water in your ankles is brought back into the body and changed into
the urine you produce at night. Occasionally swollen ankles may mean that your
heart is not working as efficiently as it could.
If you sit a lot then you can get fluid lying in the legs, which is similar to swollen
ankles.
Snoring can be a symptom of sleep apnoea, a condition where the throat is
temporarily blocked in sleep. This can cause nocturnal polyuria because it leads to
the heart releasing a substance that causes urine to be produced.
There are other rare causes.
What can you do about it?
Look at the way you eat and drink and spread it out evenly throughout the day.
Have drier foods in the evening.
If you have swollen ankles go and see your doctor and show her/him this sheet.
Exercise regularly. Walking is good, but if you have heart problems go to your
doctor first.
If you are overweight you are more likely to snore, so try to lose weight.
If you snore and feel exhausted in the day, you might have sleep apnoea, so see
your doctor.
49
Appendix 19
Other things that can be done
If you have swollen ankles then:
- Putting your feet up after lunch and when you watch television often helps. But
your feet need to be as high as your heart. That means lying on a bed or sofa.
- Wearing elastic stockings can help.
- You doctor may prescribe a tablet, Frusemide (40mg), at teatime (4.00pm to
6.00pm) to make you pass extra urine in the evening.
50
Appendix 20
Bristol HPA Urine Algorithm and Guidance
51
Appendix 21
How to collect a urine sample
Urine samples are an effective way of testing for certain problems, especially Urinary Tract
Infections (UTI). Therefore it is important to collect a sample so that things such as UTI’s
can be diagnosed and treated, or ruled out. However this can be a challenge if you need to
get a sample of urine from a child or client who is unable to co operate, and they wear
nappies or pads you may find the following instructions useful.
When should I collect the sample?
It is usually best to collect the sample after they have been bathed. This is because the
pad area needs to be clean. However, you can just wash and dry the pad area with soap
and water. It is also important that you do not put any creams, lotions or talc on, as this will
contaminate the sample.
Equipment you will need
1.
2.
3.
Specimen pot
Syringe
Small insert pad with no super absorbent gel
How should I collect the sample?
Place the insert pad that you have been provided with inside clients pad, and
secure as usual.
Check at intervals of about 60 minutes, and when it is wet remove the pad. (If the
pad is soiled, the process needs to begin again, as this will also contaminate the
sample.)
Place the pad on a surface and wash your hands.
Using the syringe in which you have been provided, place the tip on the pad and
then gently pull up the plunger and you should see urine appearing in the syringe.
Then dispense the urine into the sterile bottle provided.
You will need 30 mls of urine for a good sample, you may need to repeat the whole
process until you have 30mls in one go.
References
Alam et al. (2005) Comparison of urine contamination rates using three different methods of
collection: clean-catch, cotton wool pad, and urine bag. The Liverpool School of Tropical Medicine,
Liverpool, UK.
Feasey, S. (1999) Are Newcastle urine collection pads suitable as a means of collecting
specimens from infants? Northampton General Hospital NHS Trust. Patient Advice Leaflets:
Collecting Urine Samples. http://www.gp-training.net/pal/gyngu/uticoll.htm
Rao et al. (2004) An Improved urine collection pad method: a randomised clinical trial. Department
of Child Health, Rotherham General Hospital, Rotherham, Yorkshire, UK.
52
Appendix 22
Vulval Observation
Introduction
A female patient presenting with bladder problems, or pelvic pain, may require a vulval
observation to determine the nature and extent of their symptoms. Observe for signs of
infection, vaginal atrophy and prolapse all of which can be treated and improve continence
problems. It is important to consider consent (see Physical Examination Pg 13 in this
document), chaperone and relevant infection control procedures. See Skills for Health –
National Occupational Standards (SfH, NOS) Continence Competencies –
www.skillsforhealth.org.uk Ref CC01 and CC12.
Guidance on performing assessment
With the woman lying in supine position, hips flexed and abducted.
Observation
1. Perineal skin should be examined for scar tissue, lesions, excoriation, soreness or
evidence of any irritation. Any cause for concern should be referred appropriately.
2. Any unpleasant odour or discharge should be noted as should any signs of gaping
of the introitus. Any concerns should be referred back to the GP or consultant as
appropriate.
3. The vaginal mucosa should be exposed and examined for colour, presence of
rugae and hydration. Healthy vaginal mucosa should be moist, rugated and a deep
pink/red colour. Dry, sore, thinned epithelium indicates atrophic vaginitis and may
require topical medication.
4. Further observation may detect signs of prolapse.
5. Asking the patient to cough may demonstrate perineal descent, urine loss and
provoke or increase the degree of any prolapse present.
6. Perineal observation of a voluntary pelvic floor muscle (PFM) contraction can
indicate strength and endurance. Elevation of the perineum suggests a moderate
to strong contraction.
7. Breath holding or co-contraction of any other muscle group should also be noted,
and the patient instructed regarding any inappropriate activity. Co-contraction of
the transversus abdomini and/or the glutei is not contraindicated but should not
replace a correct PFM contraction.
Adapted from : ACA Good Practice Guidance (2008) Vaginal Examination and
Assessment of the Pelvic Floor. ACA
53
Appendix 23
Measurement of Post void residual urine
Residual urine is retained in the bladder after micturition due to incomplete bladder
emptying. The stagnant urine can provide a focus for infection and the formation of
bladder stones or calculi. The actual amount can be measured in two ways:1. Passing by a single-use hydrophyllic coated intermittent catheter to withdraw the urine
2. Ultrasound scan
For speed, passing an intermittent catheter will give an immediate answer. If the amount
retained is 150 or more, please discuss what further action may be required with the
relevant health care professional/Continence Service to ensure a safe and consistent
approach is achieved.
Possible cause of incomplete emptying:
 History of neurological or neuropathic disease (MS, Parkinson’s, diabetes)
 Enlarged prostate
 Uterine prolapse
 Constipation
Obstructive symptoms include:
 Hesitancy
 Poor stream
 Straining to pass urine
 Stop start micturition
 Terminal dribbling
 Feeling of incomplete bladder emptying
Prior to doing a post void residual with an intermittent (in/out) catheter please carry
out:
1. Abdominal palpation
2. Prostate assessment in men
3. Urine test
4. FVC / intake and output chart
Rationale
The patient should be encouraged to empty their bladder prior to the procedure to ensure
a true post void residual is measured.
The procedure should be aseptic to reduce the risk of infection
The catheter should be non-retainable single-use hydrophyllic coated e.g. Lofric, Easicath
Procedure
1. Explain and discuss the procedure with the patient and gain consent
2. Ensure the patient has attempted to empty their bladder
3. Screen the bed
4. Bring equipment – appropriate size single use intermittent hydrophyllic (nelaton)
catheter: Catheterisation pack
Lubrication gel - if appropriate
*not with soaked catheters
Clean container
5. Wash hands using six-step technique, apply (sterile) gloves
6. Perform intermittent catheterisation as per Royal Marsden Hospital Manual (2007)
7. Measure residual volume and record in patients’ notes.
54
Appendix 24
Medication Likely To Effect Continence
DRUG
USE
Alcohol
Anticholinesterase
Neostigmine
Benhexol, Procylidine
Hyoscine, Propantheline
Anti histamines
Pizotifen
Promethazine
Antidepressants
Amitriptyline, Lofepramide
Imipramine
Calcium channel blockers
Nifedapine
Cytotoxics
Cyclophosphamide
Ifosfamide
Loop diuretics
Frusemide
Bumetanide
Metazolone
Thiazides
Bendroflurazide
Cyclopenthiazide
Amiloride, Triamterene
Spironolactone
Antipsychotics
Chlorpromazine
Thioridozine, Droperidol,
Halperidol, Pimozide
Benzodiazepines
Nitrazepam Temazepam
Lorazepam
Barbiturates
Amylobarbitone,
henobarbitone
Chloral derivatives
Phenothiazines
Chlorpromazine,
Thioridazine
Diamorphine, Morphine
Theophylline,
Caffeine
EFFECT
Impairs mobility, reduces sensation, increases
urinary frequency and urgency, induces diuresis
Myasthenia gravis
Bladder sphincter muscle relaxation causing
Irritable bowel spasm
involuntary micturition
Control of smooth muscle, increased peristalsis
Antimuscarinic drugs also known as anticholinergics
Parkinson’s Disease
Drug induced
Voiding difficulties
Parkinsonism
Drugs with antimuscarinic side effects
Allergies, Hay fever,
Voiding difficulties
Rashes,
Migraine, Travel sickness
Reduced awareness of desire to void
Social
Depression
Voiding difficulties
Angina, arrhythmia,
hypertension
Malignancies
Nocturia, increased frequency
Haemorrhagic cystitis
Diuretics
Management of
hypertension
Urinary urgency
Pulmonary oedema
Urge incontinence
Heart failure, oedema
Diabetes insipidus
Urinary urgency
Oliguria due to renal
Frequency
failure
Ascites, Nephrotic
Urge incontinence
syndrome
Hypnotics/sedatives
Schizophrenia and
related psychotic illness
Nausea, vomiting,
Voiding difficulties, decreased awareness
agitation
Anxiety
Sedation
Decreased awareness, impaired mobility
Sedation
As above
Sedation
As above
Sedation
Decreased awareness of desire to void
Opiate analgesics
Pain control, Drug abuse
Bladder sphincter spasm causing difficulty in
micturition and urge incontinence
Xanthines
Asthma
Increased diuresis, aggravates detrusor instability
causing urge incontinence
55
Appendix 25
Guidelines for using Product Requirement Form
1.
Always print and use black ink.
2.
Please fill in all the relevant boxes - not doing so will result in a delay in the products reaching the
patient as the form will be sent back to you. The products cannot be sent out if the form is
incomplete. Please always order samples for patients to try prior to ordering.
3.
The FULL postcode is vital as the carrier cannot make a delivery without it i.e. BS11 is not enough.
4.
Tick only one type and one category of incontinence. Abbreviations are as follows for category.
EMI
LD T
-
Elderly Mentally Infirm
Learning Difficulty
Terminal
Neuro
PD
- Neurological
- Physical Disability
5.
Use the other notes section to highlight special instructions i.e. takes time to answer the door,
deliver Wednesday etc. See Guide for patients receiving products on BCH staff website.
6.
Alternative delivery address - needs to be within walking distance for the driver i.e. next
door/upstairs flat. Please use main address box if delivery is to go to another family member/carer.
7.
Delivery cycles at present:
1 pad per day (Couche, Midi, Maxi)
1 pad per day (Normal, Plus, MoliCare) 2 pads per day (All Products)
3 pads per day (All Products)
Children 4 – 18 years:
Adults:
Care Homes:
Care Homes with Nursing:
Terminal Patients:
48 week delivery cycle
24 week delivery cycle
16 week delivery cycle
12 week delivery cycle
A maximum of 4 products per 24 hours -12 week delivery cycle
A maximum of 3 products per 24 hours - 12 week delivery cycle
16 week delivery cycle
4 weekly
12, 8 week or 4 week one-off delivery, appropriate to diagnosis
8.
Use the form to help you. The working capacities are shown for all the pads.
9.
Shaded areas are at the discretion of the Continence Service and will have to be authorised.
10.
This is a product request form - all clinical details should appear on your assessment.
Please do not write any confidential clinical details on the form.
11.
Paul Hartmann Ltd are there to help in matters regarding delivery - for clinical issues please
contact your Continence Service.
12.
Post all copies (white, yellow, pink) along with your continence assessment form and relevant care
pathway to the Continence Service. The continence assessment form and the yellow copy will be
returned for your files.
13.
All patients must be re-assessed two yearly (NICE 2012) or earlier if their needs change.
14.
For re-assessments - if no change complete the product form on line. If there is a change of
product, increase in size or quantity, add evidence of why increase is needed to your reassessment and send both assessment and product form to the Continence Service.
Continence Service, Horfield Health Centre, Lockleaze road, BS7 9RR
Tel: 0117 3737118
56
Appendix 26
Guide for Patients Receiving Continence Products
This guide is designed to help you understand how the home delivery service for continence
pads works and what you need to do in order to alter, stop or recommence your deliveries.
Please note that Paul Hartmann Ltd who manufacture the products, and CityLink - the carrier
who deliver them, will only action alterations if they have authorisation from Bristol Community
Health. If your pad supply is no longer appropriate please contact your assessing nurse.
Your Contact Nurse details
Name: ..…………………………………………………………………..
Base: ……………………………………………………………………..
Telephone number: ……………………………………………………
Continence products’ manufacturer details
Name: Paul Hartmann Ltd
Telephone number: 01706 694755
57
Appendix 26
Starting the Home Delivery Service
1. Your Nurse has assessed your continence needs and decided that you require pads and / or
treatment. The pads are provided for your use only. The nurse completes a requisition form
which is sent to the Continence Service and then onto Paul Hartmann Ltd. You will then
receive ….. weeks’ worth of products within approximately 10 working days from the date
Paul Hartmann Ltd receive the form.
2. If you are out, or unable to answer the door, your pads can be left at an alternative delivery
point close by, e.g. a garage, in a porch, with a neighbour with the same post code, or with
family or a friend at a different address nearby. Please let your nurse know where you would
like your alternative address to be. This is very important as you may be unable to answer
the door or to wait in all day to receive your products.
Deliveries
1. Your products will be delivered by a company called CityLink. The drivers have all been
trained to understand the nature of the products. All drivers carry identification. If you are
out the driver will post a CityLink card through the door, which will inform you when another
delivery will be attempted. Please note that if you are not in the second time the goods will
be returned to the depot.
2. You will be asked to sign for your products if you are able to do so. On the side of the box
you will find a plastic wallet containing a delivery note, this tells you what products are
enclosed and your next delivery date.
3. The next delivery date will always be as stated on the delivery note, unless that date falls on
a Bank Holiday. In this instance your delivery will normally occur before the date due.
58
Appendix 26
Running out of Stock
1. You have been allocated a specific amount of products per day. Please be careful not to
exceed this amount or you will run out before your next delivery is due. If the pads are
insufficient you may need re-assessing and will need to purchase in the interim. Please
contact your assessing nurse.
2. Your delivery should last until the next is due. It is important to use the products as
discussed with your assessing nurse. If you find you are running out please contact your
nurse as soon as possible so that a re-assessment can take place.
3. Please note there is a maximum allowance which cannot be exceeded. The NHS cannot
guarantee to provide you with additional products. You may need to make arrangements
to buy extra pads to ‘top up’ your supply.
4. We would like to recommend that you purchase an extra packet of your products to cover
any unforeseen delivery problems that may arise such as inclement weather or strike
actions.
Too many pads
If you have too many pads and need a delivery/deliveries to be stopped, please telephone Paul
Hartmann Ltd and your assessing nurse (phone numbers on front page).
You will need to do this at least 5 days before your expected delivery date. This does not mean
that your deliveries will be stopped forever and you will be required to be re-assessed if the
pads are stopped for six months or more.
If you no longer need the pads it is your responsibility to inform your assessing nurse and/or the
Continence Service.
Please Help Us to Help You
Be at home on your delivery date, OR
Have advised us of an alternative delivery point
Inform your assessing nurse if your condition alters.
Please inform us if you are admitted to hospital or are going to be away from home when a
delivery is due.
5. Please inform either Paul Hartmann Ltd or your assessing nurse if you change address.
1.
2.
3.
4.
59
Appendix 26
Please DO NOT:
1. Ask the driver to remove stock you have already accepted and signed for
2. Tip the driver
3. Ask the driver to alter your order in any way
Your Pad Details
Name of Pad/s
Allocation
You may wish to make a note of your next delivery dates below.
Please keep this leaflet in a safe place. You or your family may wish to contact us
regarding deliveries or products, our contact details are on the front page.
This leaflet was adapted from a leaflet produced by North Somerset Community Partnership
with the assistance of Paul Hartmann Ltd.
60
Appendix 27
SKIN INTEGRITY AND CONTINENCE CARE
Protecting the integrity of the skin and providing effective treatment if skin breakdown occurs is
an essential part of effective nursing care. When absorbent continence products are used to
manage incontinence, extra care needs to be taken to prevent damage to the skin from contact
with urine and faeces.
General principles
Encourage the client or carer to check the skin regularly to ensure healthy skin is
maintained.(1)
Ensure carers report and document any changes to the skin condition without delay.
Soap products can lead to drying of the skin, and may affect the pH balance of the skin.
Un-perfumed soap or soap-free cleansers are gentler on the skin.(1)
Creams should not be used unless prescribed.
Prescribed creams should be thinly applied only in the area affected, as thick application is
unnecessary and may adversely affect the absorbency of continence care products.
Thick, greasy preparations such as zinc and castor oil nappy rash creams and lotions(3)
which contain a higher level of mineral oil or silicone may adversely affect the absorbency
of continence care products.
Avoid the use of talcum powder in conjunction with body worn continence products.
Talcum powder forms a paste when wet, which clings to skin, maintaining urine contact.
This paste can also clog absorbent products, limiting absorption.(2)
In your area, you may have a skin care formulary which should be followed
You should always refer to your local guidelines / policy with regard to tissue viability
Emollient bath additives may be added to bath water to protect, soften and smooth the skin. In
this instance, as the skin is gently dried before a product is applied, these will not have a
detrimental effect on the absorbency of products.
These preparations make skin and surfaces slippery – particular care is needed when
bathing
Adapted, by kind permission, from Skin Integrity and Continence Care (2012) Wendy
Colley, Clinical Resource Manager, Paul Hartmann Ltd. These guidance notes have been
prepared taking into account current evidence, where available.
(1) Penzer R, Finch M (2001) ‘Promoting healthy skin in older people’, Nursing Older People.
13, 8.
(2) O’Brien M. (2005) ‘Clinical Procedure Guidance’, GOSH.
(3) Source: British National Formulary 62 (2012)
(4) Source: J Junkin, J L Selkof. J Wound, Ostomy, Continence. Nurs. 2007: 34 (3): 260-269
Disclaimer: This information is provided to assist patient care and is offered with the best of
intentions. By deciding to use or refer to the information contained on the Skin Integrity leaflet,
the organisation providing healthcare, clinical staff and patient accepts that under no
circumstances may PAUL HARTMANN Ltd or its staff be held responsible for incorrect
diagnosis, inappropriate treatment or any other negative or harmful outcome as a result of the
information in this leaflet.
August 2012
61
Bristol Community Health
Appendix 28
USEFUL ADDRESSES
Association for Continence Advice (ACA)
Drumcross Hall
Bathgate
Scotland
EH48 4JT
Tel: 01506 811077
www.fitwise.co.uk
www.aca.uk.com
Association of Chartered Physiotherapists in Women’s Health (ACPWH)
14 Bedford Row, London, WC1R 4ED
Tel: 020 7306 6666
www.csp.org.uk
Bladder and Bowel Foundation
SATRA Innovation Park
Rockingham Road, Kettering, Northants, NN16 9JH
Tel: 01536 533255
www.bladderandbowelfoundation.org
e.mail: info.bladderandbowelfoundation.org
Continence Care Forum (for nurses)
Royal College of Nursing
20 Cavendish Square, London, W1G ORN
Tel: 020 7409 3333 or 0345 772 6100 (RCN Direct)
www.rcn.org.uk
ERIC : Education & Resources for improving Childhood Continence
36 Old School House, Brittania Road,
Kingswood, Bristol, BS15 8DB
Tel: 0845 370 8008
www.eric.org.uk
PromoCon
(Promoting Continence and Product Awareness)
Burrows House, 10 Priestley Way, Wardley Industrial Estate, Worsley, Manchester, M28
2LY
Telephone: 0161 607 8219
www.promocon.co.uk
e mail: [email protected]
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Bristol Community Health
Appendix 28
RADAR Key Royal Association for Disability and Rehabilitation. Keys are available for
anyone with bladder or bowel problems. Most major towns have a list of local facilities.
Keys are £2.25 + £1.75 postage and packing
Radar, 12 City Forum, 250 City Road, London, EC1V 8AF
Tel: 020 7250 3222
www.radar.org.uk
e mail: [email protected]
Living DLC (Mobility and Driving Centre)
The Vassall Centre, Gill Avenue, Fishponds, Bristol, BS16 2QQ
Tel: 0117 9653651
www.thisisliving.org.uk
The Disabled Living Foundation (DLF)
Address - Disabled Living Foundation, Ground Floor, Landmark House, Hammersmith
Bridge Road, London W6 9EJ
Reception/Switchboard: 0207 289 6111 times are 9.00 am - 5.00 pm Monday to Friday.
Helpline: 0300 999 0004 (charge at Local Call Rate). Opening times are
10.00 am - 4.00 pm Monday to Friday.
Equipment centre – 0207 289 6111 Ext. 247/204. Opening times are
10.00 am - 4.00 pm Monday Friday. Visits are strictly by appointment only.
www.livingmadeeasy.org.uk
e mail: [email protected]
The PILATES Foundation UK LTD
PO Box 51186, London, SE13 9DA
Tel: 020 7033 0078
www.pilatesfoundation.com
Waterloo Home Design Centre (part of WE Care and Repair)
Waterloo Road, St Philips, Bristol BS2 0BH
Tel: 0117 954 2222
Open Monday – Friday 0900 – 17.00 hrs. No appointment necessary.
www.wecr.org.uk or e-mail: [email protected]
July 2013
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Bristol Community Health
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