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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
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
Pads / Briefs Bed rails
Walker or other assistive
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
C/O bladder fullness after
voiding Prolapsed uterus
Urinary catheter / pessary
Constipation / fecal impaction
Parkinson's or other
Pressure ulcers Impaired cognition
Resistive / uncooperative
Current or Hx of UTIs
Terminal care Visual impairment
Bladder / renal dysfunction
Abdominal / urologic surgery
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/
Calcium channel blocker
(Atenolol, Metoprolol) Antidepressant / Tricyclic
Antidepressant / SSRI
Antidepressant / MAO inhibitor
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
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
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
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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- Spring '09