H006-21740 - BLADDER RETRAINING ASSESSMENT Resident: Age:...

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Unformatted text preview: BLADDER RETRAINING ASSESSMENT Resident: Age: Admitting Diagnosis: Indwelling Catheter: YES NO Medical Justification: If no justification, obtain order to discontinue and complete the following assessment. Is the resident continent of urine? NO YES If YES, you do not have to complete further assessment. Date: Licensed Staff Signature: If NO, initiate a 3-day urinary pattern assessment, then complete the following within 14 days of admission or from the time a significant COC was identified. Length of incontinence: Cognition Status: Day/s: Month/s: Alert Cooperative Can the resident comprehend simple instructions? Year/s: Oriented x 3 Uncooperative YES Can the resident learn to inhibit or control the urge to void? Confused NO YES NO Can the resident contract the pelvic floor muscle to lessen urgency and/or urinary leakage? YES NO Data Collection Review: Usual voiding pattern: Frequency: Pattern: Upon arising After meals At night only Present Perception of need to void: No pattern Diminished Absent Does the resident require physical assistance for toileting? If yes, indicate type and frequency: What type of assistance needed: Check all that apply Symptoms: Check all that apply Does the resident currently have or has a history of any of the following: Does the resident currently use any assistive devices that may restrict or facilitate toileting? YES Grab bars Raised toilet seat Bedside commode Urinals Pads / Briefs Bed rails Restraints Walker or other assistive device Wheelchair Voids in small amounts Unable to void Difficulty starting / stopping stream Dribbles after voiding Dribbles while sneezing Urgency C/O pain or burning when voiding C/O bladder fullness after voiding Prolapsed uterus Prostate enlargement Urinary catheter / pessary Constipation / fecal impaction Parkinson's or other neurological problems Pressure ulcers Impaired cognition Resistive / uncooperative behavior Impaired mobility Diabetes Mellitus Current or Hx of UTIs Pain Terminal care Visual impairment Bladder / renal dysfunction Abdominal / urologic surgery CHF CVA Trauma to bladder / urethra / kidney Patient Identification Sutter Oaks Midtown Sutter Transitional Care Center A Sutter Health Affiliate Bladder Retraining Assessment 21740 (3/12/08) NO Page 1 of 2 BLADDER RETRAINING ASSESSMENT Resident: Age: Possible drugs that may contribute to Urinary Incontinence/ Retention: Classifications Analgesic (Codeine, Morphine) Antibiotic (Ciprofloxacin, Levofloxacin) Calcium channel blocker (Antianginals) Beta blocker (Atenolol, Metoprolol) Antidepressant / Tricyclic (Elavil, Trofranil) Antidepressant / SSRI (Zoloft, Prozac) Antidepressant / MAO inhibitor (Isocarboxacid) Other: Benzodiazepine (Diazepam, Lorazepam) Estrogen (Premarin) Diuretic (Furosemide) Other: Has the resident had a Post Void Residual (PVR)? If yes, what were the results? Has the resident had a bladder scan post void? If yes, what were the results? Any other pertinent lab work done? If yes, describe What were the results? Based on this comprehensive assessment, the resident has the following type of incontinence: Check one. Urge – can feel the need to void but is unable to inhibit voiding long enough to reach and sit on the commode. The most common cause of urinary incontinence in elderly persons. Stress – leakage of urine when coughing, sneezing, exercising, walking stairs or lifting or other body movements that put pressure on the bladder. Second most common type of incontinence in older women. Mixed (Urge & Stress) – combination; usually with abrupt urgency; (+) nocturia. Overflow – difficulty starting urine stream; leakage of small amounts of urine after urination; incomplete voiding; feeling of fullness after voiding. Functional – urinary tract function is sufficient, but cannot remain continent because of other factors (e.g. altered mentation, altered mobility). Transient – episodic urinary incontinence; usually caused by infections; maybe R/T pharmaceuticals; usually reversible. Based on the above assessment, the following bladder incontinence program will be implemented: Check one. Bladder Rehabilitation / Retraining* – requires resident's cooperation and motivation and ability to resist or inhibit the sensation to urinate. Pelvic Floor Muscle Rehabilitation – requires resident to be able and willing to participate. Prompted Voiding** – cognitively impaired and needs to be able to say their name or reliably point to one of two objects. Resident is checked on a regular basis and prompted, assisted to the bathroom. Habit / Scheduled Training** – cognitively impaired and is provided a planned or scheduled toileting based on the resident's voiding habits. Routine Toileting – cognitively impaired and cannot identify a voiding pattern. Assisted to toilet or provided incontinent care at least every 2 hours. Behavioral Programs – is cognitively aware and positive reinforcement for appropriate elimination is a reasonable approach. Straight Catheter Intermittent*** Utilizes absorbent products, toileting devices or external collection devices **** MDS Coding: • * • ** • *** • **** This program qualifies as "Bladder Retraining Program" – MDS / H3b These programs qualify as "Any scheduled toileting plan" – MDS / H3a If intermittent / straight catheter – check MDS / H3e If resident utilizes any absorbent products, toileting devices or external collection devices – MDS / H3g Incontinent Bladder Program initiated on (date) Care Plan Updated Licensed Nurse Signature: If appropriate, educational information provided Date: BLADDER RETRAINING ASSESSMENT Resident: Age: ...
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