This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the descriptors in the Continence domain to help you assess your or your relative’s “level of need” in this important domain.
Don’t miss parts one, two, three, four and five of this series
Following the 2018 revisions of the DST, Continence moved “up” from number 7 to number 3. As in the 2012 version, it still follows the Nutrition domain and precedes the Skin domain, highlighting the common interaction between these domains: poor nutrition/hydration is likely to affect bladder and bowels; incontinence is likely to impact on skin integrity. Any interrelation between domains (complexity), and its potential impact on the delivery of care (intensity/unpredictability), should be considered in the analysis of the four Key Characteristics.
The assessed levels of need in the Continence domain range from ‘No Needs’ to ‘High’. Unlike most other domains, Continence does not have a descriptor for a ‘Severe’ or ‘Priority’ level of need, indicating that the management of life-threatening needs in this domain is not performed in a community setting (e.g. bowel impaction or urosepsis, which would require urgent admission to hospital). The vast majority of people being assessed for CHC will fall into the descriptors for a ‘Low’ or ‘Moderate’ level of need. The ‘High’ level of need is reserved for those requiring invasive, skilled procedures, such as bladder washouts, frequent re-catheterisation or manual evacuations (removing faeces from the rectum manually).
The following clinical factors are relevant to the assessment of needs in this domain:
- Can the person go to the toilet independently?
- Are they aware of their need to toilet, or do they require prompts and/or assistance?
- Do they have a stoma (colostomy/ileostomy)?
- Do they experience any urinary and/or faecal incontinence?
- Do they use incontinence products (pads, sheaths)?
- Do they suffer from constipation?
- Are they able to communicate symptoms?
- Do they require aperients? Are these administered orally, or rectally?
- Are aperients effective in managing constipation?
- Is there a history of impaction and/or obstruction?
- Is manual evacuation ever required?
- Does the person suffer from urinary tract infections (UTI)?
- Are these acute or chronic?
- Are antibiotics effective in treating UTIs?
- Do UTIs impact on other domains (e.g. Cognition, Behaviour, Psychological & Emotional Needs)?
- Is the person catheterised? Is this intermittent, or in-dwelling?
- Is the catheter problematic, i.e. does it block, by-pass, leak?
- How frequently does this occur?
- Does the person interfere with the catheter? Does this cause trauma?
- How frequently does this occur?
IMPORTANT – The Decision Support Tool provides the following guidance to the MDT when assessing needs in this domain: Where continence problems are identified, a full continence assessment exists or has been undertaken as part of the assessment process, any underlying conditions identified, and the impact and likelihood of any risk factors evaluated.
This underlines the importance of having clear, dated evidence to confirm any problems with continence, their underlying causes and the risks arising from them. This is particularly important for those receiving care at home, where record keeping is often less robust.
Now that we’ve outlined the type of things the MDT will be considering in this domain, let’s take a look at the descriptors for the levels of need. For each descriptor, we provide a case study to give you a better understanding of how the levels of need might be applied at your or your relative’s assessment.
|Continent of urine and faeces.|
Independent with toileting
No problems with constipation or urinary tract infections
CASE STUDY – NO NEEDS
Mrs. X is fully continent of urine and faeces. She takes herself to the toilet independently and does not require any prompts or assistance to meet her continence needs.
There is no evidence that Mrs. X suffers from constipation or urinary tract infections.
Mrs. X presents with ‘No Needs’ as she is continent of urine and faeces.
|Continence care is routine on a day-to-day basis;
Incontinence of urine managed through, for example, medication, regular toileting, use of penile sheaths, etc.
is able to maintain full control over bowel movements or has a stable stoma, or may have occasional faecal incontinence/constipation.
Wears pads and/or uses penile sheath
Requires assistance to use the toilet regularly
No, or very occasional, faecal incontinence
Occasional constipation, effectively managed
Non-problematic stoma (colostomy or ileostomy)
CASE STUDY 1 – LOW
Extract from Care Plan:
Mr. X wears pads day and night. Continent of urine with occasional accidents. Continent of faeces. Mr. x is able to inform staff when he needs the toilet. At night likes to use the commode and a urine bottle in his room.
Mr. X has been diagnosed with Stage 5 kidney disease. He requires Peritoneal Dialysis (PD) via Continuous Ambulatory Peritoneal Dialysis (CAPD) which removes waste products from his blood because his kidneys can no longer do this adequately. Please see Other Significant Needs domain.
Mr. X uses a urinal (bottle) during the day so the staff can measure his urinary output; however, there are frequent accidents when he will spill the contents of the urinal onto his clothes. He requires prompts and assistance to use the urinal at regular intervals throughout the day.
Mr. X will sometimes go to the toilet independently and uses the commode when he needs to open his bowels. He remains continent of faeces throughout the day and night but wears incontinence pads in case of occasional accidents.
A loaded bowel can affect the drainage of the dialysis fluid and it is important that Mr. X does not become constipated. Staff are required to monitor the frequency of bowel movements as Mr. X may not remember to inform them due to impaired cognition and short-term memory loss. Laxatives are prescribed and administered daily with good effect.
Mr. X presents with a ‘Low’ level of need as his Continence care is routine on a day-to-day basis; incontinence of urine managed through … regular toileting …. and he is able to maintain full control over bowel movements.
CASE STUDY 2 – LOW
According to the care staff and his family, Mr. X is ‘fiercely independent’ with his continence needs. His Care Plan indicates that he has occasional urinary accidents, usually during the night, although he will robustly deny this if questioned.
Mr. X is, understandably, very embarrassed by incidents of incontinence and will attempt to hide them from staff; his bed sheets have been found, on occasion, in the bin in his bathroom and stuffed under his mattress. Staff need to be vigilant to ensure his room is kept clean and to handle any incidents of incontinence sensitively and discreetly. Staff check Mr. X’s room every morning while he has his breakfast in the dining room to avoid upsetting or embarrassing him.
Mr. X is currently trialling a Convene (penile sheath) at night due to nocturnal incontinence. Discussions should be had with Mr. X about a range of continence products specifically for men that would maintain his dignity. A referral to the Continence Service has been made by his GP.
Mr X is usually continent of faeces, although has had a couple of accidents when he has been unwell.
Mr. X has a history of constipation and is prescribed a daily laxative with good effect. Mr. X has not suffered from constipation since his admission to the home, likely because he is now taking a regular laxative.
Mr. X presents with a ‘Low’ level of need as his continence care is routine on a day-to-day basis. Incontinence of urine managed through … use of penile sheaths. And may have occasional faecal incontinence/constipation.
CASE STUDY 3 – LOW
Mrs. X is fully continent and takes herself to the toilet independently. She does not require prompts or assistance to meet her continence needs.
Mrs. X has a colostomy following surgery on her bowel five years ago. The stoma is stable and non-problematic. Mrs. X is usually able to care for the stoma and empty the colostomy bag herself, although she may need some assistance if she is feeling unwell or particularly tired.
Mrs. X presents with a ‘Low’ level of need as her continence care is routine on a day-to-day basis; … has a stable stoma.
|Continence care is routine but requires monitoring to minimise risks, for example those associated with urinary catheters, double incontinence, chronic urinary tract infections and/or the management of constipation or other bowel problems.|
Incontinence of urine and faeces (double incontinence)
In-dwelling catheter, managed routinely
Chronic (i.e., persisting) urinary tract infection
Recurrent constipation, managed with medications – e.g., laxatives and/or enemas
CASE STUDY 1 – MODERATE
Doubly incontinent. Wears pads day and night.
Completely unaware of toileting needs. Does not indicate needs.
No bowel problems but is prescribed regular Lactulose once daily.
Nurse Assessor’s comments:
Mrs. X is doubly incontinent and completely unaware of her toileting needs. Staff utilise pads in order to manage her incontinence and provide regular checks and changes of her pads to ensure her comfort and to reduce the risk of irritation to her skin.
She is prescribed regular laxatives once daily which are reported to be effective in maintaining a healthy bowel habit. She does not suffer with recurrent urinary tract infections and there is no evidence to indicate that Mrs X’s continence needs are complex or difficult to manage.
Mrs. X presents with a ‘Moderate’ level of need as she continence care is routine but requires monitoring to minimise risks, for example those associated with … double incontinence […].
CASE STUDY 2 – MODERATE
Incontinent of urine.
Suffers with constipation.
Incontinent of urine day and night.
Continent of faeces.
Refuses to wear continence pads – will remove and shred pads.
Staff have a toileting regime in place to promote continence which helps somewhat; however, accidents still occur.
History of recurrent UTI, now chronic (E-coli), managed with prophylactic antibiotics.
Treated with Senna for constipation but no chronic history/history of severe symptoms.
No history of bowel problems.
Nurse Assessor’s comments:
Since admission to the care home, Mrs. X’s continence is noted to have declined and she is now incontinent of urine day and night. She requires full assistance from staff to meet her continence needs with the use of pads and regular toileting. She remains largely continent of faeces providing staff take her to the toilet regularly.
Mrs. X dislikes wearing pads and has a tendency to remove and shred them. She requires regular checks to ensure she is clean and dry.
Mrs. X has a history of recurrent UTI prior to admission which, unfortunately, went undiagnosed and untreated for some weeks. She became very unwell and was admitted to hospital with urosepsis having collapsed at home. Investigations while she was in hospital confirmed chronic infection and inflammation of her bladder lining. Mrs. X is prescribed prophylactic Nitrofurantoin to manage symptoms and prevent worsening infection. Staff are required to monitor for symptoms of exacerbation, such as: confusion, disorientation, agitation, poor sleep, frequent urination, discomfort – e.g. holding her lower abdomen, fever, loss of appetite. Mrs. X is sometimes able to communicate her symptoms to staff, but due to increasing cognitive impairment this is not always reliable and she relies on skilled monitoring and anticipation of symptoms by staff who know her well.
Mrs. X presents with a ‘Moderate’ level of need as her continence care is routine but requires monitoring to minimise risks, for example those associated with … chronic urinary tract infections […].
CASE STUDY 3 – MODERATE
Mrs. X has an in-dwelling catheter which was inserted during a recent stay in hospital when she was unable to pass urine for a number of days, leading to her bladder becoming distended. Upon her return home, a trial without catheter was attempted, but had to be abandoned after Mrs. X did not pass urine for over 48-hours and was experiencing abdominal pain.
The catheter is managed by the District Nursing team, who change the tubing every three months.
The catheter has not been problematic to date and Mrs. X has not required any bladder washouts or catheter changes outside routine care, which is provided by the District Nursing team.
Mrs. X is fully continent of faeces and takes herself to the toilet independently.
Mrs X presents with a ‘Moderate’ level of need as her continence care is routine but requires monitoring to minimise risks, for example those associated with urinary catheters […].
|Continence care is problematic and requires timely and skilled intervention, beyond routine care (for example frequent bladder wash outs/irrigation, manual evacuations, frequent re-catheterisation).|
Problematic indwelling catheter, requiring frequent intervention
Severe constipation leading to risk of impaction, faeces removed manually
CASE STUDY 1 – HIGH
|18/06/2020||Catheter not draining well and complained of pain Re-catheterised.|
|13/08/2020||Catheter blocked. Bladder washout given – no effect Re-catheterised.|
|04/09/2020||Catheter blocked, failed bladder washout. Re-catheterised.|
|24/09/2020||Bladder washout failed. Catheter blocked. Re-catheterised.|
|07/10/2020||Catheter blocked. Bladder washout given – no effect. Re-catheterised.|
|26/10/2020||Catheter blocked Bladder washout given – no effect. Re-catheterised.|
|07/11/2020||Catheter blocked. Bladder washout given – no effect. Re-catheterised.|
|11/12/2020||Catheter bypassing. Unable to give bladder washout. Re-catheterised.|
|11/12/2020 – 16.44||Bypassing – positional. Catheter position altered – resolved issue.|
|11/12/2020 – 18.52||Re-catheterised|
Care plan – 17/12/2020:
Occasional continence difficulties during the day and night.
Occasional pain with bowel movement.
Nurse Assessor’s comments:
Mrs. X is diagnosed with chronic renal failure and suffers with urinary retention for which she has a permanent urethral catheter in situ. She also suffers with constipation and is prescribed aperients which are effective in managing her symptoms.
Mrs. X’s catheter has been chronically and frequently problematic having required 20 bladder washouts and 9 re-catheterisations in 3 months. She requires close monitoring of her urine output to identify when her catheter is blocked and requires prompt and skilled intervention in order to troubleshoot and provide appropriate care to reduce the risk of pain, discomfort and infection.
Mrs. X presents with a ‘High’ level of need as her continence care is problematic and requires timely and skilled intervention, beyond routine care (for example frequent bladder wash outs/irrigation … frequent re-catheterisation).
CASE STUDY 2 – HIGH
Mr. X is doubly incontinent and wears pads throughout the day and night. He is unable to alert staff to episodes of incontinence and is unaware of the need to void. He struggles to open his bowels now that he is unable to sit on the toilet.
Mr. X has a history of chronic constipation and faecal impaction leading to bowel obstruction. A stent has been inserted into his bowel. Mr. X requires careful management of this bowel to prevent reoccurrence, taking into account the fact that his bowel is now weakened.
Mr. X is prescribed oral laxatives twice daily, as well as a stool softener, which is usually effective in maintaining regular bowel movements. Staff monitor bowel movements closely and administer phosphate enemas if Mr. X has not opened his bowel for more than 48-hours.
If Mr. X has not opened his bowel after two enemas have been administered, staff perform manual evacuation to ensure he does not become impacted. Care records confirm this is required 1-2 times a month.
Mr. X presents with a ‘High’ level of need as his continence care is problematic and requires timely and skilled intervention, beyond routine care (for example … manual evacuations).
We hope this has helped you to understand the descriptors in the Continence domain. Don’t miss the Skin domain, coming very soon!
If you need help assessing your relative’s level of need in any domain on the DST, don’t hesitate to contact one of our specialist Advice Lines to discuss your case today. Or, if you need expert advocacy support with any stage of your assessment or appeal, visit our 1-2-1 support page.
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