Idea Transcript
Effective Management of Urinary Incontinence in Long-Term Care Facilities
“Train the Trainer” Manual March 2000
Effective Management of Urinary Incontinence in Long-Term Care Facilities
Table of Contents
Introduction......................................................................................................................................1 Learning Objectives .........................................................................................................................2 Licensed Staff ......................................................................................................................2 CNA .....................................................................................................................................3 Presentations ....................................................................................................................................4 Licensed Staff ......................................................................................................................4 CNA .....................................................................................................................................5 Assessment Form .............................................................................................................................6 Medication List ................................................................................................................................7 Algorithm.........................................................................................................................................8 AHCPR Guidelines..........................................................................................................................9 Voiding Diary ................................................................................................................................10 Post Test.........................................................................................................................................11
100 Roscommon Drive Middletown, Connecticut 06457 (860) 632-2008 www.qualidigm.org
Qualidigm
INTRODUCTION
Effective Management of Urinary Incontinence in Long-Term Care Facilities “Train the Trainer” Manual Urinary incontinence remains a major health problem in long term care. The challenges to effectively manage this health problem can often appear daunting. The development of our Urinary Incontinence Project grew from our desire to improve the quality of care related to residents with urinary incontinence, thereby improving their quality of life. Upon completion of our baseline evaluation of your facilities, it was concluded that the comprehensive assessment of urinary incontinence was not addressed completely. Thus, it was difficult to develop effective urinary incontinence diagnoses with subsequent effective management strategies without the appropriate assessment. The following "Train the Trainer" manual was collectively developed based on your suggestions and recommendations to further educate your staff on urinary incontinence assessment and effective management. You will note the common theme of "assessment is key" throughout the manual, since it is the assessment that drives the plan of care. We hope, as you review and use the manual in your staff development activities related to urinary incontinence, that you will find it "user friendly" and an excellent resource for continuing education. Since this manual is intended as an additional intervention during this continuous quality improvement project, we hope you find the tools useful in improving the awareness and knowledge required to deliver the best continence care possible. Sincerely,
Courtney H. Lyder, ND, GNP Clinical Coordinator
Anne Spenard, RN,C, MSN Clinical Consultant
Anne Elwell, RN Project Manager
LEARNING OBJECTIVES
Effective Management of Urinary Incontinence in Long-Term Care Facilities
LEARNING OBJECTIVES Upon completion of this training program, licensed staff will be able to: describe common reversible causes of urinary incontinence differentiate between chronic types of urinary incontinence and describe appropriate treatment options for each diagnosis describe evaluation procedures, which are appropriate for establishing diagnosis of urinary incontinence in the long-term care setting describe the process for completing the Urinary Incontinence Physical Assessment and History Form describe all the components for completing the physical examination for urinary incontinence
Qualidigm
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Effective Management of Urinary Incontinence in Long-Term Care Facilities
LEARNING OBJECTIVES Upon completion of this training program, CNAs will be able to: describe common types of urinary incontinence describe how to complete the 3 day voiding diary describe the techniques in bladder training facilitate pelvic muscle (Kegel) exercises identify the steps to facilitating urinary incontinence
Qualidigm
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STEPS TO CONTINENCE 1. Complete Physical Assessment and History Form 2. Determine the type of Urinary Incontinence 3. Complete Algorithm
PRESENTATION - Licensed Staff (for speaker’s notes please refer to the ppt file)
Overview of Urinary Incontinence (UI) in the Long Term Care Facility Evaluation and Management Ann M. Spenard RN, C, MSN Courtney Lyder ND, GNP
Learning Objectives Describe
common reversible causes of UI Differentiate between chronic types of UI and describe appropriate treatment options for each diagnosis Describe evaluation procedures, which are appropriate for establishing diagnosis of UI in the long-term care setting Describe the process for completing the UI Physical Assessment and History Form Describe all the components for completing the physical examination for urinary incontinence
Steps to Continence 1. Complete Physical Assessment and History form 2. Determine the type of urinary incontinence 3. Complete Algorithm
Evaluation is the Key! Identification of the type of urinary incontinence is the key to effective treatment.
History Obtaining an accurate and comprehensive UI History
Prevalence of Urinary Incontinence Estimated
10% to 35% of adults > 50% of 1.5 million nursing home residents A conservative estimated cost of $5.2 billion per year for urinary incontinence in nursing homes
Fant et.al. Managing Acute and Chronic Urinary Incontinence. Rockville, MD Agency for Health Care Policy and Research. 1996. AHCPR Publication No. 90-06 National Center for Health Statistics. Vital Health Statistics Series. 13(No. 102). 1989e in
Impact on Quality of Life Loss
of self-esteem Decreased ability to maintain independent lifestyle Increased dependence on caregivers for activities of daily life Avoidance of social activity and interaction Restricted sexual activity Grimby et al. Age Aging. 1993; 22:82-89. Harris T. Aging in the Eighties: Prevalence and Impact of Urinary Problems in Individuals Age 65 and Over. Washington DC: Dept. of Health and Human Services, National Center for Health Statistics, No 121, 1988. Noelker L. Gerontologist. 1987; 27:194-200.
Consequences of UI An
increased propensity for falls Most hip fractures in elders can be traced to nocturia especially if combined with urgency Risk of hip fracture increases with )physical decline from reduced activity )cognitive impairments that may accompany a UTI )medications often used to treat incontinence ) loss of sleep related to nocturia
Risk Factors Aging Medication
side effects High impact exercise Menopause Childbirth
Factors Contributing to Urinary Incontinence Medications
Diet
)Diuretics )Caffeine )Antidepressants )Alcohol )Antihypertensives )Hypnotics Bowel Irregularities )Analgesics )Constipation )Narcotics )Fecal Impaction )Sedatives
Age Related Changes in the Genitourinary Tract Majority
of urine production occurs at
rest Bladder capacity is diminished Quantity of residual urine is increased Bladder contractions become uninhibited (detrusor instability) Desire to void is delayed
Types of Urinary Incontinence Stress Urge Mixed Overflow Total
Types of Urinary Incontinence Stress:
Leakage of small amounts of urine as a result of increased pressure on the abdominal muscles (coughing, laughing, sneezing, lifting) Urge: Strong desire to void but the inability to wait long enough to get to a bathroom
Types of Urinary Incontinence (continued) Mixed:
A combination of two types, stress and urge Overflow: Occurs when the bladder overfills and small amounts of urine spill out (bladder never empties completely, so it is constantly filling) Total: Complete loss of bladder control
Remember...
Urinary Incontinence can be treated even if the resident has dementia!!
Cause of Stress Urinary Incontinence Failure
to store secondary to urethral sphincter incompetence
Causes of Urge Urinary Incontinence Failure
to store, secondary to bladder dysfunction )Involuntary bladder contractions )Decreased bladder compliance ) Severe bladder hypersensitivity
Stress Incontinence vs. Urge Incontinence: System Check List Symptoms Urgency accompanies incontinence (strong, sudden desire to void)
Stress Urge Incontinence Incontinence NO YES
Leaking during physical activity (e.g. coughing, sneezing, lifting, etc.)
YES
NO
Ability to reach the toilet in time, following an urge to void
YES
NO
SELDOM
OFTEN
Waking to pass urine at night
Causes of Mixed Urinary Incontinence Combination
of bladder overactivity and stress incontinence One type of symptom (e.g., urge or stress incontinence) often predominates
Symptoms of Overactive Bladder Urgency Frequency Nocturia,
and/or urge incontinence ANY COMBINATION - in the absence of any local pathological or metabolic disorder
Causes of Overflow Urinary Incontinence Loss
of urine associated with over distention of the bladder Failure to empty )Underactive bladder Vitamin B12 deficiency
Outlet
obstruction
)Enlarged Prostate )Urethral Stricture )Fecal Impaction Neurological
Conditions
)Diabetic Neuropathy )Low Spinal Cord Injury )Radical Pelvic Surgery
Neurogenic Bladder What is a neurogenic bladder? A
medical term for overflow incontinence, secondary to a neurologic problem However, this is NOT a type of urinary incontinence
Basic Types and Underlying Causes of Incontinence Type
Definition
Stress
Loss of urine with increase in intra- Weakness and laxity of abdominal pressure (coughing, pelvic floor musculature, laughing, exercise, standing, etc.) bladder outlet or urethral sphincter weakness Leakage of urine because of Detrusor muscle instability, inability to delay voiding after hypersensivity associated sensation of bladder fullness is with local genitourinary perceived conditions or central nervous system disorders Leakage of urine resulting from Anatomic obstruction by mechanical forces on an over prostate, stricture, distended bladder, or from other cystocele, acontractile effects of urinary retention on bladder, detrusor-sphincter bladder and sphincter function dyssynergy Urinary leakage associated with Severe dementia, other inability to toilet because of conditions that cause impairment of cognitive and/or severe immobility, and physical functioning, unwillingness, psychological factors or environmental barriers
Urge
Overflow
Mixed
Causes
Reversible or Transient Conditions That May Contribute to UI “D” “R” “I”
“P”
Delirium Dehydration* Restricted mobility Retention Infection Inflammation Impaction Polyuria Pharmaceuticals
*Dehydration Dehydration
due to decreased fluid intake; increased output from diuretics, diabetes, or caffeinated beverages; or increased fluid volume due to congestive heart failure can concentrate the urine (increased specific gravity) and also lead to fecal impaction The specific gravity of the urine can be tested to determine whether or not the resident is dehydrated
Basic Evaluation Physical
Exam Female genitalia abnormalities )Rectocele )Urethral Prolapse )Cystocele )Atrophic Vaginitis
Basic Evaluation for Differential Diagnosis Patient
History
)Focus on medical, neurological, genitourinary )Review voiding patterns and medications )Voiding diary )Administer mental status exam, if appropriate Physical
Exam
)General, abdominal and rectal exam )Pelvic exam in women, genital exam in men )Observe urine loss by having patient cough vigorously
Basic Evaluation for Differential Diagnosis (continued) Urinalysis
)Detect hematuria, pyuria, bacterimia,
glucosuria, proteinuria )Post void residual volume measurement by catheterization or pelvic ultrasound
Lab Results Lab
results from approximately the last 30 days: )Calcium level normal 8.6 - 10.4 mg/dl )Glucose level normal fasting 65 - 110 mg/dl )BUN normal 10 - 29 mg/100 ml (OR) )Creatinine normal 0.5 - 1.3 mg/dl )B12 level (within the last 3 years) normal 200 - 1100pg/ml
*Normal lab values may vary depending on laboratory used.
Three Day Voiding Diary Three
day voiding diary should be completed on the resident Assessment should be completed 24 hours a day for 3 days Make sure CNA’s are charting when the resident is dry or not, the amount of incontinence, if the voiding was requested or prompted
Basic Continence Evaluation Focused Physical Exam, including: Pelvic
exam to assess pelvic floor & vaginal wall relaxation and anatomic abnormalities including digital palpation of vaginal sphincter Rectal exam to rule out fecal impaction & masses including digital palpation of anal sphincter. Neurological exam focusing on cognition & innervation of sacral roots 2-4 (Perineal Sensation) Post Void Residual to rule out urinary retention Mental Status exam when indicated
Simple Urologic Tests Provocative
Stress Testing Key components )Bladder must be full )Obtain in standing or lithotomy position )Sudden leakage at cough, laughing, sneezing, lifting, or other maneuvers
Female Exam of Urethra and Vagina During a bed side exam the nurse should observe for the following: The presence of pelvic prolapse (urethroceles, cystoceles, rectoceles) )It is more important that you identify the presence of a prolapse than the particular type
Is
the vaginal wall reddened and/or thin? Is the vaginal wall atrophied? Is there abnormal discharge?
Female Exam of Urethra and Vagina (continued) Test
the vaginal pH by taking small piece of litmus paper and dabbing it in the vaginal area )Document the vaginal pH )If the pH is >5 it is a positive finding
Dorsal Lithotomy Position (Normal Vaginal Area)
Male Exam of the Penis Is
the foreskin abnormal? (Is the foreskin difficult to draw back, reddened, phimosis) )Phimosis is a general condition in which the foreskin of the penis can not be retracted
Is
there drainage from the penis? Is the glans penis urethral meatus obstructed?
Male Genitalia
Phimosis
Rectal Exam Nursing
staff should perform a rectal
exam )Document if the resident has a large
amount of stool or the presence of hard stool
Prostate Exam While
completing a rectal exam for constipation, note if you feel the prostate enlarge Please note findings
The Bulbocavernous Reflex Test When
the nurse is inserting a finger into the anus to check for fecal impaction, the anal sphincter should contract When the nurse is applying the litmus paper to check the vaginal pH, the vaginal muscle should contract (When both these muscles contract this indicates intact reflexes)
Post Void Residual A
post void residual should be obtained after voiding via a straight catheterization or via the the bladder scan )If the resident has > 200 cc residual the test is positive (Document the exact results on the assessment form)
Mini Mental Exam (MMSE) Complete
a mini mental exam on the
resident Chart the score on the assessment form Score the resident on the number of questions they answered correctly to the total number of questions reviewed
Basic Evaluation Rectocele
)Anterior and downward bulging of the posterior vaginal wall together with the rectum behind it
Rectocele
Basic Evaluation Urethral
Prolapse
)Entire circumference of urethral mucosa is seen to protrude through meatus
Urethral Prolapse
Basic Evaluation Cystocele
)Anterior wall of the vagina with the bladder bulges into the vagina and sometimes out of the introitus
Distension Cystocele
Basic Evaluation Uterine
Prolapse
)The uterus falls into the vaginal cavity
Uterine Prolapse
Huge Prolapsed Cervix
Basic Evaluation Atrophic
Vaginitis
)Thinning of vaginal and urethral lining causing dryness, urgency, decreased sensation
Advanced Postmenopausal Atrophy
Treatment
Guidelines recommend least invasive evaluation and treatment as baseline!!
Treat Transient Causes First Such as: Atrophic vaginitis Symptomatic urinary tract infections (UTI)
Hypoestrogenation Causes (Loss of Estrogen) Decreased
glycogen Decreased lactic acid Increased vaginal pH Increased risk of UTI’s
Urinary Tract Infections (UTI) The vaginas of postmenopausal women not being treated with estrogen have been found to be predominately colonized by E. coli
Circulating Estrogen Inhibits Uropathogen Growth by: Colonization
of the vagina with
lactobacilli Maintenance of acidic pH ( 50% of 1.5 million nursing home residents A conservative estimated cost of $5.2 billion per year for urinary incontinence in nursing homes
Impact on Quality of Life Loss
of self-esteem Decreased ability to maintain independent lifestyle Increased dependence on caregivers for activities of daily life Avoidance of social activity and interaction Restricted sexual activity
Consequences of UI An
increased risk of falls Most hip fractures in elders can be traced to nocturia (night time voiding) especially if combined with urgency Risk of hip fracture increases with )physical decline from reduced activity )cognitive impairments that may accompany
a UTI )medications often used to treat incontinence )loss of sleep related to nocturia
Risk Factors Aging Medication
side effects High impact exercise Menopause Childbirth
Factors Contributing to Urinary Incontinence Medications Bowel
Irregularities )Constipation )Fecal Impaction
Diet
)Caffeine )Alcohol )Chocolate )Acidic fruit or juices (OJ,pineapple) )Spicy foods )Nutrasweet products )Tomatoes, spaghetti
Age Related Changes in the Urinary Tract Majority
of urine production occurs at
rest Bladder capacity is decreased Quantity of urine left in the bladder after urinating is increased Bladder contractions without warning Desire to void is delayed
Several Types of Urinary Incontinence Stress: Leakage of small amounts of
urine as a result of increased pressure on the abdominal muscles (coughing, laughing, sneezing, lifting)
Urge: The strong desire to void but the
inability to wait long enough to get to a bathroom
Several Types of Urinary Incontinence (continued) Mixed: A combination of two types,
stress and urge
Overflow: Occurs when the bladder
overfills and small amounts of urine spill out (The bladder never empties, so it is constantly filling)
Total: Complete loss of bladder control
Remember... Urinary incontinence can be treated even if the resident has dementia!!
Stress Incontinence vs. Urge Incontinence: System Check List Symptoms Urgency accompanies incontinence (strong, sudden desire to void)
Stress Urge Incontinence Incontinence NO YES
Leaking during physical activity (e.g. coughing, sneezing, lifting, etc.)
YES
NO
Ability to reach the toilet in time, following an urge to void
YES
NO
SELDOM
OFTEN
Waking to pass urine at night
Symptoms of Overactive Bladder Urgency
to void Frequency in voiding Nocturia (getting up two or more times at night to void) and/or urge incontinence ANY COMBINATION
Causes of Mixed Urinary Incontinence Combination
of bladder spasms and stress incontinence One type of symptom (e.g., urge or stress incontinence) often predominant
Reversible or Transient Conditions that may Contribute to UI “D” “R” “I”
“P”
Delirium (Sudden or increased confusion) Dehydration Restricted mobility Retention Infection Inflammation Impaction Pharmaceuticals (Drugs)
Continence Treatment Behavioral
)Pelvic Muscle Rehabilitation (PMR) - for
strengthening or relaxation )Urge Inhibition Training - reduce or control urgency )Bladder and/or Bowel Training - reduce frequency )Treatment of Bowel Dysfunction Medications Surgery
Behavioral Treatments Fluid
management Voiding frequency Toileting assistance )Scheduled toileting )Prompted voiding Bladder training Pelvic floor muscle exercises
Bladder Training & Urgency Inhibition Training Bladder
Training - Techniques for postponing voiding Urge Inhibition Training - Techniques for resisting or stopping the feeling of urgency Bladder Training & Urge Inhibition training - Strongly recommended for urge and mixed incontinence and is recommended for management of stress incontinence
Behavioral Treatments Pelvic
Muscle (Kegel) exercises Goal: To strengthen the muscle that controls the release of urine )Proper identification of muscle (if able to
stop urine in mid stream) )Planned active exercise (hold for 10 seconds then relax do this 30 - 80 times per day for a minimum of 8 weeks)
Biofeedback Very
helpful in assisting residents in identifying and strengthening pelvic muscles )Give positive feedback for bladder training, habit training and/or Kegels
Summary With
correct diagnosis of UI, expect more than 80% improvement or cure rate without surgery!!
Case Study 1 Mrs.
Martin: )She was admitted to a skilled nursing facility following a hospitalization for surgical repair of a fractured hip which occurred when she fell on the way to the bathroom.
Prior to Admission: She
was living at home with her daughter. Her medical history included high blood pressure and thinning of the bones. Mrs. Martin’s daughter reported that her mother frequently rushed to get to the bathroom on time and often got out of bed 4 to 5 times per night to urinate.
Upon Admission to the Nursing Home: Mrs.
Martin’s transfer status was assist of one with a walker. Nursing staff implemented an every 2 hour toileting schedule. This resident was frequently incontinent.
Upon Admission to the Nursing Home: (continued) Mrs.
Martin stated that she knew when she needed to void but could not wait until the staff could take her to the bathroom. She could feel the urine coming out but could not stop her bladder from emptying. Mrs. Martin felt embarrassed about wearing a brief but felt it was better than getting her clothing wet. Her incontinence was sudden, in large volumes and accompanied by a strong sense of urgency.
Problem Identification The
problems identified by the staff during the first case conference included urge incontinence and impaired mobility.
What can we do to help Mrs. Martin? Help
her get stronger in walking. Help her resist the urge to urinate frequently. Check her at night frequently and offer to take her to the bathroom as needed. Respond as quickly as possible. Give positive feedback when she is able to get to the bathroom in time. The doctor may order medication.
Voiding Diary, Why Use Them? People
are not born with bladder control, it is a learned behavior. As people involuntarily lose urine they sometimes retrain their bladder by going to the bathroom too frequently. A voiding diary helps us to see if a new toileting pattern will help keep a person dry or if a simple reminder at a certain time will help that person get to the bathroom on time.
Voiding Diary, Why Use Them? (continued) Your
help in completing these diaries is as important as many of the medications or treatments that the nurse may give !!! The information that you collect (including your comments) is vital for the development of an individualized plan of care for the resident.
What Information Do We Need? Time
a person toileted (did the resident request or was it offered). Did the resident void in the bathroom or were they wet? Small or large incontinent episode. Reason for the incontinent episode.
How Long Do You Complete A Voiding Diary? The
voiding diary is completed for 3 days across all three shifts.
What Effect Will This Program Have For the Resident & Staff? Improved
quality of life for the resident Reduce the number of residents needing Q2 hour toileting. )All residents will have an individualized
plan for scheduled toileting or prompted voiding that meets their needs. )Less briefs and clothing to change because of incontinence. )Overall, less time spent toileting and providing incontinence care, leaving more quality time to be spent with your residents.
ASSESSMENT FORM
Name _____________________________________
Date ________________
Urinary Incontinence Assessment and Evaluation Please complete both sides of the form. *Key
History
U
Do you frequently have a strong urge to go to the bathroom?
Yes
No
U
Do you have trouble making it to the bathroom without losing control of your urine?
Yes
No
U
Do you get up to urinate 2 or more times a night?
Yes
No
U
Do you urinate more than 8 times in 24 hours?
Yes
No
U
Do liquids (especially coffee, colas, and alcoholic beverages) Αgo right through you≅?
Yes
No
O
Do you urinate with a weak, dribbling, soft stream with no force?
Yes
No
O
Do you feel like you have to urinate again after going to the bathroom?
Yes
No
T
Do you have pain when you urinate?
Yes
No
T
Do you have any problems with moving your bowels?
Yes
No
T
Have you had any illness or injury of the back?
Yes
No
T
If yes, was the illness or injury treated with surgery?
Yes
No
T
Have you ever had a stroke?
Yes
No
T
Do you smoke?
Yes
No
S
Do you wet yourself when you cough, sneeze, laugh, or exercise?
Yes
No
S
Do you lose control of your urine when you move from the bed to a chair or wheelchair to the toilet?
Yes
No
S
Have you had prostate surgery? (males only)
Yes
No
S
How many children have you delivered? (females only) (>4 at risk)
# ________
Have you had a hysterectomy? (females only)
Yes
No
Medications O
Is resident on an antipsychotic (except atypical antipsychotic i.e. Clozaril, Risperidol)?
Yes
No
O
Is resident on an antidepressant (except SSRIs i.e. Prozac, Zoloft, Paxil; or Pamelor)?
Yes
No
O
Is resident on disopyramide?
Yes
No
T
Is resident on a diuretic?
Yes
No
O
Is resident on an antihistamine?
Yes
No
T
Is resident on a sedative/hypnotic?
Yes
No
O
Is resident on an alpha-stimulant?
Yes
No
T
Is resident on a narcotic?
Yes
No
O
Is resident on an antispasmotic?
Yes
No
S
Is resident on an alpha-blocker?
Yes
No
O
Is resident on a calcium channel blocker?
Yes
No
S
Is resident on an antiparkinsonian (except Sinement and Deprenyl)?
Yes
No
O
Is resident on an anticholinergic?
Yes
No
*Definition Key: 8 Qualidigm7, 3/2000
U = Urge
O = Overflow
T= Transient
S= Stress Page 1 of 2
*Key
S
Physical Examination (licensed physician or licensed nurse) Was Provocative Stress Test completed?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Mini mental exam completed? Score_____________
Yes
No
Three day voiding diary completed?
Yes
No
Results S
Was bulbocavernosus reflex conducted? Results
O
Obtained post void residual (PVR)? (> 200cc is significant) Results
T
Obtained urinalysis? (Dipstick with results) Please list positive findings
T
Performed rectal exam for constipation? Results
Female Examination of urethra and vagina S
Is there the presence of pelvic prolapse (urethroceles, cystoceles, rectoceles)?
Yes
No
T
Is the vaginal wall reddened and/or thin?
Yes
No
T
Is the vaginal wall atrophied?
Yes
No
T
Is there abnormal discharge?
Yes
No
T
Vaginal pH (> 5 is positive finding)
Yes
No
Results Male Examination of Penis T
Is foreskin abnormal (e.g. is foreskin difficult to draw back, reddened, phimosis)?
Yes
No
T
Is there drainage from penis?
Yes
No
O
Is glans penis urethral meatus obstructed?
Yes
No
O
Prostate exam completed?
Yes
No
Calcium level baseline [ 8.6 - 10.4 mg/dl ] Results_________________________
Yes
No
Glucose level [ Fasting 65 - 110 mg/dl ] Results_________________________
Yes
No
BUN [10 - 29 mg/100 ml ] or Creatinine [ 0.5 - 1.3 mg/dl ] (circle one) Results _________________
Yes
No
B12 level (within the last 3 years) [ 200 - 1100 pg/ml ] Results_______________________
Yes
No
**Lab Results: Within the last 30 days of assessment (most recent results)
If ΑYes≅ to any questions on either side of form, patient may need to be further evaluated by specialist. ** Normal lab values may vary depending on laboratory used.
Signature_____________________________________ 8 Qualidigm7,3/2000
Completion Date:_______________________
Page 2 of 2
MEDICATION LIST
Urinary Incontinence Medication List 8-MOP
Antispasmodic
Acetophenazine maleate
Antipsychotic
Adalat CC
Calcium Channel Blocker
Adalat
Calcium Channel Blocker
AK-Dilate (eye solution)
Apha-Stimulant (Alpha Agonist)
AK-Nefrin (eye solution)
Apha-Stimulant (Alpha Agonist)
Aldactazide
Diuretic
Aldactone
Diuretic
Alfenta Injection
Narcotic
Allegra
Antihistamine
Aller-Chlor
Antihistamine
Allerest Nasal
Apha-Stimulant (Alpha Agonist)
Alurate
Sedatives/Hypnotics
Amantadine HCL
Antiparkinsonism Agent
Ambien
Sedatives/Hypnotics
Amiloride HCL
Diuretic
Amiloride HCL/HCTZ
Diuretic
Amiloride
Diuretic
Amlodipine besylate
Calcium Channel Blocker
Amobarbital sodium
Sedatives/Hypnotics
Amylobarbitone
Sedatives/Hypnotics
Amytal sodium
Sedatives/Hypnotics
Anergan
Antihistamine, Sedatives/Hypnotics
Anexsia 5/500
Narcotic
Anexsia 7.5/650
Narcotic
Antirizine
Antihistamine
Antispas
Anticholinergics, Antispasmodic 1
Urinary Incontinence Medication List Antivert
Anticholinergics, Antihistamine
Antrizine
Anticholinergics
Anxanil
Antihistamine
Apo-Benztropine
Antiparkinsonism Agent
Apo-fluphenazine
Antipsychotic
Apo-haloperidol
Antipsychotic
Apo-Lorazepam
Sedatives/Hypnotics
Apo-Perphenazine
Antipsychotic
Apo-Thioridazine
Antipsychotic
Apo-Trifluperazine
Antipsychotic
Apo-Trihex
Antiparkinsonism Agent
Apresazide
Vasodilator with Diuretic
Aprobarbital
Sedatives/Hypnotics
Aquachloral supprettes
Sedatives/Hypnotics
Aramine
Apha-Stimulant (Alpha Agonist)
Artane
Antiparkinsonism Agent
Astemizole
Antihistamine
Astramorph/PF
Narcotic
Atarax
Antihistamine
Atenolol/Chlorthalidone
Beta Adrenergic Blocker with Diuretic
Ativan
Sedatives/Hypnotics
Atropine Sulfate S.O.P. (Eye drops)
Anticholinergics, Antiparkinsonism Agent
Atropine sulfate
Anticholinergics, Antiparkinsonism Agent
Atropisol (Eye drops)
Anticholinergics, Antiparkinsonism Agent
Atrovent
Anticholinergics
Azatadine maleate
Antihistamine
Benadryl
Antihistamine, Antiparkinsonism Agent, Sedatives/Hypnotics 2
Urinary Incontinence Medication List Bendroflumethiazide
Diuretic
Benylin cough
Antiparkinsonism Agent, Antihistamine, Sedatives/Hypnotics
Bentyl
Anticholinergics, Antispasmodic
Bentylol
Anticholinergics, Antispasmodic
Benzthiazide
Diuretic
Benztropine Mesylate
Antiparkinsonism Agent
Bepridil HCL
Calcium Channel Blocker
Biperiden hydrochloride
Antiparkinsonism Agent
Bisoprolol Fumarate/HCTZ
Beta Adrenergic Blocker with Diuretic
Bonamine
Anticholinergics, Antihistamine
Bonine
Anticholinergics, Antihistamine
Bromocriptine Mesylate
Antiparkinsonism Agent
Bromphen
Antihistamine
Brompheniramine maleate
Antihistamine
Bucladin-S softabs
Anticholinergics, Antihistamine
Buclizine hydrochloride
Anticholinergics, Antihistamine
Bumetanide
Diuretic
Bumex
Diuretic
Buprenex
Narcotic
Bupropion HCL
Antidepressant
Butabarbital sodium
Sedatives/Hypnotics
Butisol sodium
Sedatives/Hypnotics
Byclomine
Anticholinergics, Antispasmodic
Bydramine
Antihistamine, Antiparkinsonism Agent, Sedatives/Hypnotics
Calan SR
Calcium Channel Blocker
Calan
Calcium Channel Blocker 3
Urinary Incontinence Medication List Calm-X
Anticholinergics, Antihistamine
Capozide
ACEI with Diuretic
Cardene SR
Calcium Channel Blocker
Cardene
Calcium Channel Blocker
Cardizem CD
Calcium Channel Blocker
Cardizem SR
Calcium Channel Blocker
Cardizem
Calcium Channel Blocker
Carvedilol
Alpha Blockers
Cetirizine
Antihistamine
Chlor-Tripolan
Antihistamine
Chloral hydrate
Sedatives/Hypnotics
Chlorothiazide
Diuretic
Chlorpromazine hydrochloride
Antipsychotic
Chlorthalidone
Diuretic
Chorpheniramine maleate
Antihistamine
Claritin
Antihistamine
Claritin Reditabs
Antihistamine
Clemastine fumarate
Antihistamine
Cloazpine
Antipsychotic
Clonidine HCL/Chlorthalidone
Adrenergic Stimulant with Diuretic
Clozaril
Antipsychotic
Cogentin
Antiparkinsonism Agent
Compazine
Antipsychotic
Compoz
Antihistamine, Antiparkinsonism Agent, Sedatives/Hypnotics
Cophene-B
Antihistamine
Coreg
Alpha Blockers
Coricidin
Apha-Stimulant (Alpha Agonist) 4
Urinary Incontinence Medication List Covera-HS
Calcium Channel Blocker
Cyclizine hydrochloride
Anticholinergics, Antihistamine
Cyproheptadine hydrochloride
Antihistamine
Dalgan
Narcotic
Dalmane
Sedatives/Hypnotics
Daricon
Anticholinergics, Antispasmodic
Darvocet-N 50
Narcotic
Darvocet-N 100
Narcotic
Darvon Compound-65
Narcotic
Darvon
Narcotic
Darvon-N
Narcotic
Demadex
Diuretic
Demerol Hydrochloride
Narcotic
Desyrel
Antidepressant
Dexchlor
Antihistamine
Dexchlorpheniramine maleate
Antihistamine
DHC plus
Narcotic
Diamine T.D.
Antihistamine
Dibent
Anticholinergics, Antispasmodic
Dicyclomine hydrochloride
Anticholinergics, Antispasmodic
Dilacor XR
Calcium Channel Blocker
Dilasyn
Antihistamine
Dilaudid-HP
Narcotic
Diltiazem HCL
Calcium Channel Blocker
Diluadid
Narcotic
Dimenabs
Antihistamine, Anticholinergics
Dimenhydrinate
Anticholinergics, Antihistamine 5
Urinary Incontinence Medication List Dimetane
Antihistamine
Dioptic=s Atropine (Eye drops)
Anticholinergics, Antiparkinsonism Agent
Diphen Cough
Antihistamine, Antiparkinsonism Agent, Sedatives/Hypnotics
Diphenhydramine hydrochloride
Antihistamine, Antiparkinsonism Agent, Sedatives/Hypnotics
Disopyramide phosphate
Disopyramide phosphate
Diucardin
Diuretic
Diuril
Diuretic
Dizmiss
Anticholinergics, Antihistamine
Dopamine
Apha-Stimulant (Alpha Agonist)
Dopar
Antiparkinsonism Agent
Doral
Sedatives/Hypnotics
Dormarex 2
Antihistamine, Antiparkinsonism Agent, Sedatives/Hypnotics
Dramamine
Anticholinergics, Antihistamine
Duragesic
Narcotic
Duramorph
Narcotic
Duration Mild
Apha-Stimulant (Alpha Agonist)
Dyazide
Diuretic
DynaCirc
Calcium Channel Blocker
DynaCirc CR
Calcium Channel Blocker
Dyrenium
Diuretic
Edecrin
Diuretic
Effexor
Antidepressant
Eldepryl
Antiparkinsonism Agent
Empirin with Codeine
Narcotic
Enalapril Maleate HCTZ
ACEI with Diuretic
Enduron
Diuretic 6
Urinary Incontinence Medication List Esidrix
Diuretic
Estazolam
Sedatives/Hypnotics
Ethacrynic acid
Diuretic
Ethchlorvynol
Sedatives/Hypnotics
Extentabs
Antihistamine
Felodipine
Calcium Channel Blocker
Fentanyl Citrate and droperidol
Narcotic
Fexafenadine hydrochloride
Antihistamine
Fioricet with Codeine
Narcotic
Fiorinal with Codeine
Narcotic
Fluoxetine hydrochloride
Antidepressant
Fluphenazine hydrochloride
Antipsychotic
Fluphenazine deconate
Antipsychotic
Fluphenazine enanthate
Antipsychotic
Fluphenazine
Antipsychotic
Flurazepam hydrochloride
Sedatives/Hypnotics
Fluvoxamine maleate
Antidepressant
Formulex
Anticholinergics, Antispasmodic
Furosemide
Diuretic
Gardenal
Sedatives/Hypnotics
Glutethimide
Sedatives/Hypnotics
Glycopyrralate
Anticholinergics, Antispasmodic
Gravol
Anticholinergics, Antihistamine
Guanethedine Monosulfate/Hydrochlorothiazide
Adrenergic blocker with Diuretic
Halcion
Sedatives/Hypnotics
Haldol LA
Antipsychotic
7
Urinary Incontinence Medication List Haldol deconoate
Antipsychotic
Haldol
Antipsychotic
Haloperidol decanoate
Antipsychotic
Hismanal
Antihistamine
Histanil
Antihistamine, Sedatives/Hypnotics
Hydralazine Hydrochloride
Vasodilator with Diuretic
Hydralazine HCL
Vasodilator with Diuretic
Hydrazide
Vasodilator with Diuretic
Hydrocet
Narcotic
Hydrochlorothiazide (HCTZ)
Diuretic
HydroDiuril
Diuretic
Hydroflumethiazide
Diuretic
Hydroxyzine hydrochloride
Antihistamine
Hygroton
Diuretic
Hyoscine HBr
Anticholinergics
Hyzaar
Angiotensin II receptor antagonist with Diuretic
Indapamide
Diuretic
Inderide LA
Beta Adrenergic Blocker with Diuretic
Inderide
Beta Adrenergic Blocker with Diuretic
Infumorph
Narcotic
Intropin
Apha-Stimulant (Alpha Agonist)
Ipratropium bromide
Anticholinergics
Isoptin SR
Calcium Channel Blocker
Isoptin
Calcium Channel Blocker
Isopto hyoscine Ophthalmic (eye drops)
Anticholinergics
Isopto-Atropine ophthalmic (Eye drops)
Antiparkinsonism Agent, Anticholinergics
Isradipine
Calcium Channel Blocker 8
Urinary Incontinence Medication List Kemadrin
Antiparkinsonism Agent
L-Deprenyl
Antiparkinsonism Agent
Labetalol hydrochloride
Alpha Blockers
Labetolol
Alpha Blockers
Largactil
Antipsychotic
Larodopa
Antiparkinsonism Agent
Lasix
Diuretic
Levo-Dromoran
Narcotic
Levodopa
Antiparkinsonism Agent
Lisinopril HCTZ
ACEI with Diuretic
Lopressor HCT
Beta Adrenergic Blocker with Diuretic
Lopressor HCT 50/25
Beta Adrenergic Blocker with Diuretic
Lopressor HCT 100/25
Beta Adrenergic Blocker with Diuretic
Lopressor HCT 100/50
Beta Adrenergic Blocker with Diuretic
Loratidine
Antihistamine
Lorazepam
Sedatives/Hypnotics
Lorcet
Narcotic
Lortab
Narcotic
Losarten Potassium HCTZ
Angiotensin II receptor antagonist with Diuretic
Lotensin HCT
ACEI with Diuretic
Loxapac
Antipsychotic
Loxapine hydrochloride
Antipsychotic
Loxapine Succinate
Antipsychotic
Loxitane
Antipsychotic
Loxitane-C
Antipsychotic
Lozol
Diuretic
9
Urinary Incontinence Medication List Ludiomil
Antidepressant
Luvox
Antidepressant
Maprotiline hydrochloride
Antidepressant
Marezine
Anticholinergics, Antihistamine
Maxide
Diuretic
Mebaral
Sedatives/Hypnotics
Meclizine hydrochloride
Anticholinergics, Antihistamine
Mellaril
Antipsychotic
Mepergan
Narcotic
Mephobarbital
Sedatives/Hypnotics
Mesoridazine besylate
Antipsychotic
Metaraminol
Apha-Stimulant (Alpha Agonist)
Methadone hydrochloride
Narcotic
Methdilazine hydrochloride
Antihistamine
Methoxsalen
Antispasmodic
Methscopolamine bromide
Anticholinergics
Methyclothiazide
Diuretic
Methyldopa-Chlorothiazide
Adrenergic Stimulant with Diuretic
Methyldopa-Hydrochlorothiazide
Adrenergic Stimulant with Diuretic
Metolazone
Diuretic
Metoprolol Tartate/HCTZ
Beta Adrenergic Blocker with Diuretic
Midamor
Diuretic
Minims
Anticholinergics, Antiparkinsonism Agent
Mirtazapine
Antidepressant
Moban
Antipsychotic
Moditen enanthate
Antipsychotic
Moditen hydrochloride
Antipsychotic
10
Urinary Incontinence Medication List Moduretic
Diuretic
Molindone hydrochloride
Antipsychotic
MS Contin
Narcotic
MSIR
Narcotic
Mydfrin (eye solution)
Apha-Stimulant (Alpha Agonist)
Mykrox
Diuretic
Nardil
Antidepressant
Nasahist BND-Stat
Antihistamine
Nauseatol
Anticholinergics, Antihistamine
Nefazodone hydrochloride
Antidepressant
Nembutal SodiumNovopentobarb
Sedatives/Hypnotics
Neo-Synephrine
Apha-Stimulant (Alpha Agonist)
Nicardipine HCL
Calcium Channel Blocker
Nifedipine
Calcium Channel Blocker
Nimodipine
Calcium Channel Blocker
Nimotop
Calcium Channel Blocker
Nisoldipine
Calcium Channel Blocker
Normadyne
Alpha Blockers
Norpace CR
Disopyramide phosphate
Norpace
Disopyramide phosphate
Norvasc
Calcium Channel Blocker
Nostril
Apha-Stimulant (Alpha Agonist)
Novamobarb
Sedatives/Hypnotics
Novolorazepam
Sedatives/Hypnotics
Novoperidol
Antipsychotic
Novopheniram
Antihistamine
Novosecobarb
Sedatives/Hypnotics
11
Urinary Incontinence Medication List Nubain
Narcotic
Numorphan
Narcotic
Nytol
Antihistamine, Antiparkinsonism Agent, Sedatives/Hypnotics
Olanzapine
Antipsychotic
Optimine
Antihistamine
Oramorph SR
Narcotic
Orap
Antipsychotic
Oretic
Diuretic
Orlamm
Narcotic
Ormazine
Antipsychotic
Oxsoralen
Antispasmodic
Oxyphencyclimine hydrochloride
Anticholinergics, Antispasmodic
Pamine
Anticholinergics
Parabromclylamine maleate
Antihistamine
Paral
Sedatives/Hypnotics
Paraldehyde
Sedatives/Hypnotics
Parlodel
Antiparkinsonism Agent
Parnate
Antidepressant
Paroxetine
Antidepressant
Paxil
Antidepressant
Pentazine
Antihistamine, Sedatives/Hypnotics
Pentobarbital sodium
Sedatives/Hypnotics
Percocet
Narcotic
Percodan
Narcotic
Percodan-Demi
Narcotic
Pergolide mesylate
Antiparkinsonism Agent
Periactin
Antihistamine 12
Urinary Incontinence Medication List Peridol
Antipsychotic
Permax
Antiparkinsonism Agent
Permitil
Antipsychotic
Perphenazine
Antipsychotic
Phenazine
Antihistamine, Antipsychotic, Sedatives/Hypnotics
Phenelzine sulfate
Antidepressant
Phenergan
Antihistamine, Sedatives/Hypnotics
Phenetron
Antihistamine
Phenobarbital
Sedatives/Hypnotics
Phenoject-50
Antihistamine, Sedatives/Hypnotics
Phenylephrine
Apha-Stimulant (Alpha Agonist)
Pimozide
Antipsychotic
Placidyl
Sedatives/Hypnotics
Plendil
Calcium Channel Blocker
PMS Procyclidine
Antiparkinsonism Agent
PMS Benztrpoine
Antiparkinsonism Agent
PMS-Cyproheptadine
Antihistamine
PMS-Prochlorperazine
Antipsychotic
PMS-Promethazine
Antihistamine, Sedatives/Hypnotics
Poladex
Antihistamine
Polaramine
Antihistamine
Polythiazide
Diuretic
Posicor
Calcium Channel Blocker
Prazosin HCL/Polythiazide
Adrenergic blocker with Diuretic
Prinizide
ACEI with Diuretic
Pro-50
Antihistamine, Sedatives/Hypnotics
13
Urinary Incontinence Medication List Pro-Banthine
Anticholinergics, Antispasmodic
Procardia XL
Calcium Channel Blocker
Procardia
Calcium Channel Blocker
Prochlorperazine
Antipsychotic
Procyclid
Antiparkinsonism Agent
Procyclidine
Antiparkinsonism Agent
Prolixin deconate
Antipsychotic
Prolixin
Antipsychotic
Prolixin enanthate
Antipsychotic
Promazine hydrochloride
Antipsychotic
Promethazine hydrochloride
Antihistamine, Sedatives/Hypnotics
Propantheline bromide
Anticholinergics, Antispasmodic
Prorex
Antihistamine, Sedatives/Hypnotics
ProSom
Sedatives/Hypnotics
Prozac
Antidepressant
Prozine-50
Antipsychotic
Quazepam
Sedatives/Hypnotics
Quinethazone
Diuretic
R.O. Atropine (Eye drops)
Anticholinergics, Antiparkinsonism Agent
Reactine
Antihistamine
Restoril
Sedatives/Hypnotics
Revimine
Apha-Stimulant (Alpha Agonist)
Rhinall
Apha-Stimulant (Alpha Agonist)
Risperdal
Antipsychotic
Risperidone
Antipsychotic
RMS
Narcotic
Robinul
Anticholinergics, Antispasmodic
14
Urinary Incontinence Medication List Roxanol 100
Narcotic
Roxicodone
Narcotic
Ru-Vent M
Anticholinergics, Antihistamine
Rythmodan
Disopyramide phosphate
Scopolamine hydrochloride
Anticholinergics
Secbutabarbital
Sedatives/Hypnotics
Secbutobarbitone
Sedatives/Hypnotics
Secobarbital sodium
Sedatives/Hypnotics
Seconal sodium
Sedatives/Hypnotics
Seldane
Antihistamine
Selegiline hydrochloride
Antiparkinsonism Agent
Serentil
Antipsychotic
Sertraline hydrochloride
Antidepressant
Serzone
Antidepressant
Sinarest Nasal
Apha-Stimulant (Alpha Agonist)
Sleep-Eze 3
Antihistamine, Antiparkinsonism Agent
Solfoton
Sedatives/Hypnotics
Sominex 2
Antihistamine, Antiparkinsonism Agent, Sedatives/Hypnotics
Somnal
Sedatives/Hypnotics
Sparine
Antipsychotic
Spironolactone/HCTZ
Diuretic
Spironolactone
Diuretic
Stelazine
Antipsychotic
Stemetil
Antipsychotic
Sublimaze
Narcotic
Sufenta
Narcotic
Sular
Calcium Channel Blocker 15
Urinary Incontinence Medication List Symmetrel
Antiparkinsonism Agent
Tacaryl
Antihistamine
Talacen
Narcotic
Talwin
Narcotic
Talwin NX
Narcotic
Tavist
Antihistamine
Tavist-1
Antihistamine
Telechlor
Antihistamine
Temazepam
Sedatives/Hypnotics
Tenoretic
Beta Adrenergic Blocker with Diuretic
Terfenadine
Antihistamine
Thalitone
Diuretic
Thioridazine hydrochloride
Antipsychotic
Thorazine
Antipsychotic
Tiazac
Calcium Channel Blocker
Timolide
Beta Adrenergic Blocker with Diuretic
Timolol Maleate/HCTZ
Beta Adrenergic Blocker with Diuretic
Tizanidine
Antispasmodic
Torsemide
Diuretic
Trandate
Alpha Blockers
Transderm-Scop
Anticholinergics
Tranylcypromine sulfate
Antidepressant
Travel Aid
Anticholinergics, Antihistamine
Travel Eze
Anticholinergics, Antihistamine
Travel tabs
Anticholinergics, Antihistamine
Trazodone hydrochoride
Antidepressant
Triamterene/HCTZ
Diuretic 16
Urinary Incontinence Medication List Triamterene
Diuretic
Triazolam
Sedatives/Hypnotics
Trichlormethiazide
Diuretic
Trifluoperazine hydrochloride
Antipsychotic
Triflupromazine hydrochloride
Antipsychotic
Trihexy
Antiparkinsonism Agent
Trihexyphenidyl hydrochloride
Antiparkinsonism Agent
Trilafon
Antipsychotic
Tripelennamine hydrochloride
Antihistamine
Triprolidine hydrochloride
Antihistamine
Triptone
Anticholinergics
Tylenol with Codeine
Narcotic
Tylox
Narcotic
Uvadex
Antispasmodic
Vascor
Calcium Channel Blocker
Vaseretic
Calcium Channel Blocker, ACEI with Diuretic
Venlafaxine
Antidepressant
Verapamil SR
Calcium Channel Blocker
Verapamil HCL
Calcium Channel Blocker
Verelan
Calcium Channel Blocker
Vesprin
Antipsychotic
Vicodin ES
Narcotic
Vicodin
Narcotic
Viscerol
Anticholinergics, Antispasmodic
Vistaril
Antihistamine
Wellbutrin
Antidepressant
Wellbutrin SR
Antidepressant 17
Urinary Incontinence Medication List Wygesic
Narcotic
Zanaflex
Antispasmodic
Zaroxolyn
Diuretic
Zestoretic
ACEI with Diuretic
Ziac
Beta Adrenergic Blocker with Diuretic
Zoloft
Antidepressant
Zolpidem tartrate
Sedatives/Hypnotics
Zydone
Narcotic
Zyprexa
Antipsychotic
18
ALGORITHMS
Stress Incontinence Assessment Indicates Stress Incontinence No
Date/Initials
Transient Cause Identified Yes Date/Initials
Treat Transient Cause
No
Incontinence Continues Yes Evidence of Vaginal Prolapse?
Stop/Resolved
Yes Pessary Placed
Date/Initials
No
No Prolapse Corrected?
Surgical Consult
Date/Initials
Yes Incontinence Continues
No
Stop/Resolved
Yes Management and Treatment
Date/Initials
Kegel Exercise
Behavior Management
Vaginal Weight Cones
No
Incontinence Continues
Date/Initials
Stop/Resolved
Yes Date/Initials
Pharmacological Interventions
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
Incontinence Continues
No
Stop/Resolved
Yes Check and Change Schedule
Date/Initials © Qualidigm®, 3/2000
Urge Incontinence Assessment Indicates Urge Incontinence No
Date/Initials
Transient Cause Identified Yes Treat Transient Cause
Date/Initials
No
Incontinence Continues Yes Evidence of Vaginal Prolapse?
Stop/Resolved
Yes Pessary Placed
Date/Initials
No
No Prolapse Corrected?
Surgical Consult
Date/Initials
Yes Incontinence Continues
No
Stop/Resolved
Yes Management and Treatment
Date/Initials
Kegel Exercise
Behavior Management
Fluid/Dietary Management*
No
Incontinence Continues
Date/Initials
Stop/Resolved
Yes Date/Initials
Pharmacological Interventions
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
No
Stop/Resolved
Yes Check and Change Schedule
Date/Initials
Signature
_____ ________________ Initial
Incontinence Continues
Signature
* Eliminate dietary caffeine such as in coffee, tea, colas, and chocolate
© Qualidigm®, 3/2000
Mixed Incontinence Urge & Stress Assessment Indicates Mixed Incontinence No
Date/Initials
Transient Cause Identified Yes Treat Transient Cause
Date/Initials
Incontinence Continues Yes Evidence of Vaginal Prolapse?
No
Stop/Resolved
Yes Pessary Placed
Date/Initials
No
No Prolapse Corrected?
Surgical Consult
Date/Initials
Yes Incontinence Continues
No
Yes
Stop/Resolved
Management and Treatment
Date/Initials
Kegel Exercise
Date/Initials
Vaginal Weight Cones
Fluid/Dietary Management*
Behavior Management
No
Incontinence Continues
Date/Initials
Stop/Resolved
Yes _____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
Date/Initials
Signature
_____ ________________ Initial
Pharmacological Interventions
Signature
Incontinence Continues Yes Check and Change Schedule
No
Stop/Resolved
Date/Initials
* Eliminate dietary caffeine such as in coffee, tea, colas, and chocolate
© Qualidigm®, 3/2000
Overflow Incontinence
Assessment Indicates Overflow Incontinence
Indwelling Catheter Discontinued within past 72 hours
Date/Initials
No
Yes Date/Initials
Monitor PVR Q2 - 4o prn For 72 hrs Post Indwelling Catheter Removal PVR 200cc or greater
No
Stop/Resolved
Yes No
Transient Cause Identified
Date/Initials
Yes Treat Transient Cause
Incontinence Continues
No
Stop/Resolved
Yes Refer to Specialist
Date/Initials
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
_____ ________________ Initial
Signature
© Qualidigm®, 3/2000
ATTACHMENTS A = Voiding Diary B = Bladder Diary C = Incontinence Monitoring Record D = Bladder Diary
Attachment A
RESIDENT ______________________________________________________ Date ______________________ Time Toileted/ Urinated (Y/N)
Did Resident Request Toileting (Y/N)
PAD Changed? Type of Wet/Dry PAD Used
Type/Amt of Fluids Drank
Comments/ Initials
Attachment B. Sample Bladder Record Name: ___________________________________
Date: ______________________
INSTRUCTIONS: Place a check in the appropriate column next to the time you urinated in the toilet or when an incontinence episode occurred. Note the reason for the incontinence and describe your liquid intake (for example, coffee, water) and estimate the amount (for example, one cup). Time interval
Urinated in toilet
Had a small incontinence episode
Had a large incontinence episode
Reason for incontinence episode
Type/amount of liquid intake
6–8 a.m. 8–10 a.m. 10–noon Noon–2 p.m. 2-4 p.m. 4-6 p.m. 6-8 p.m. 8-10 p.m. 10-midnight Overnight No. of pads used today: _______________
No. of episodes: __________________
Comments: ____________________________________________________________
Attachment C. Sample Incontinence Monitoring Record for Hospital and Nursing Home Patients
INSTRUCTIONS: EACH TIME THE PATIENT IS CHECKED: 1) Mark one of the circles in the BLADDER section at the hour closest to the time the patient is checked. 2) Make an X in the BOWEL section if the patient has had an incontinent or normal bowel movement.
y = Incontinent, small amount z = Incontinent, large amount
ο = Dry ∆ = Voided correctly
X = Incontinence BOWEL X = Normal BOWEL
Patient Name: _______________________________ Room #: _________ Date: ______________ Time 12 am 1 2 3 4 5 6 7 8 9 10 11 12 pm 1 2 3 4 5 6 7 8 9 10 11
BLADDER Incontinence Dry Voided of urine correctly y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____ y z ο ∆cc_____
BOWEL Incontinence Normal Initials Comments
TOTALS: Copyright 1984, the Regents of the University of California. Used with permission.
BLADDER DIARY Resident Name: ___________________________ Room #: ___________
Date: ___________________
INSTRUCTIONS: Check the resident every 2 hours to see if they are wet. If the resident asks for the bedpan or to go to the bathroom please toilet the resident and record if he/she voids. Record the amount of fluid intake. Day: 1 ______ 2 ________ 3 _________
Time
Incontinent of urine S M L
Dry (✓)
Voided bed pan/toilet (✓)
Aware of urge to void Y N
Fluid intake (cc’s)
Initials
Comment
12:00 MN 1:00 am 2:00 am 3:00 am 4:00 am 5:00 am 6:00 am 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm 8:00 pm 9:00 pm 10:00 pm 11:00 pm Additional Comments: _____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________