Urinary Incontinence Assessment Policy

Urinary Incontinence Assessment Policy

Effective Date: [Original NPP Date]
Revised Date: [Current Date]

Resident Name: _____________________________________________

1. Current Incontinence Status

• Is the resident currently incontinent of bladder?

  • NO – Monitor resident for RISK FACTORS for incontinence & proceed to care plan.
    • None
    • History of UTIs
    • Impaired Mobility
    • History of urinary retention
    • Dependent transfer (2-person assist)
    • Severe cognitive impairment
    • Neuro disorders (e.g., multiple sclerosis, diabetes)
    • Other: _________________________________

• YES – Check all that apply and complete the rest of the form:

2. Incontinence Symptom Profile (Observed and/or History of)

Stress Urinary Incontinence

• Leakage with cough/sneeze/physical activity
• Urinates in small amounts – drops/spurts
• Weak to intermittent stream (dribbles)
• No nocturia or incontinence at night
• Incontinence without sensation of urine loss

Urge Urinary Incontinence

• Strong uncontrolled urgency prior to incontinence
• Frequency in urination – 8 times during waking hours
• Nocturia > 2 times per night
• Enuresis
• Urine loss on way to toilet room
• Moderate to large amount of urine leakage

Overflow Urinary Incontinence

• Difficulty starting urine stream
• Weak to intermittent stream (dribbles)
• Post void dribbling
• Prolonged dribbling
• Feeling of fullness after voiding
• Voiding in small amounts often
• PVR 200 cc’s on 2 separate measurements

Functional Urinary Incontinence

• Mobility/manual dexterity impairments
• Lack of immediate access to a toilet or substitute
• Use of restraints
• Medications
• Pain with movement
• Cognitive impairment

3. Type of Incontinence

• ____ Urge Incontinence: abrupt loss of urine/sudden desire to void/frequency/nocturia
• ____ Stress Incontinence: small loss of urine during physical activity
• ____ Mixed Incontinence: abrupt urgency or desire/frequency/nocturia AND loss of small amount of urine with physical activity
• ____ Overflow Incontinence (PVR must exceed 200ml): weak stream, hesitancy, or intermittency/dysuria/nocturia/frequency/urgency/incomplete voiding/frequent or constant dribbling
• ____ Functional Incontinence: physical weakness/poor mobility or dexterity/cognitive problems/medications/environmental impediments
• ____ Transient/Reversible Incontinence: delirium/infection/atrophic urethritis or vaginitis/medications/increased urine production/restricted mobility/fecal impaction/pain/elevated blood sugar

4. Assessment for Bladder Retraining

• Can the resident comprehend and follow through on education and instructions?
  ____ Yes ____ No

• Can the resident identify urinary urge sensation?
  ____ Yes ____ No

• Can the resident learn to inhibit or control the urge to void until reaching a toilet?
  ____ Yes ____ No

• Can the resident contract the pelvic floor muscle to lessen urgency and/or urinary leakage?
  ____ Yes ____ No

If the answers to the above questions are “No” and the conditions are not reversible, it is not likely that the resident has the essential skills needed to be successfully retrained and may be a candidate instead for scheduled toileting and/or incontinence care.

Comments

Nurse’s Signature: _____________________________________________
Date: __________________________

References:

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]