Version: 2.0. Effective From: 31/10/2013

Transcription

1 Policy No: OP51 Version: 2.0 Name of Policy: Policy for Bladder, Bowel and Continence Care Effective From: 31/10/2013 Date Ratified 08/03/2013 Ratified Nursing and Midwifery Professional Forum Review Date 01/03/2015 Sponsor Director of Nursing, Midwifery and Quality Expiry Date 07/03/2016 Withdrawn Date This policy supersedes all previous issues. Policy for Bladder, Bowel and Continence Care v2

2 Version Control Version Release Author/Reviewer Ratified by/authorised by /01/2008 SafeCare Council Date January 2008 Changes (Please identify page no.) /10/2013 L Montgomery and J Bowhill N&M Professional Forum 08/03/2013 Policy for Bladder, Bowel and Continence Care v2 2

3 Contents Section Page 1. Introduction Aim of policy Policy scope/access to documentation Duties (Roles and responsibilities) Role of the health care professional Consent Assessment Training Equality and diversity Monitoring compliance with the policy Consultation and review Implementation of policy (including raising awareness) References APPENDICES Appendix 1 Care standards: 26a Constipation b Diarrhoea c Faecal incontinence d Care of patients with probable UTI e Urinary incontinence f Care of urinary catheter Appendix 2 Adult continence assessment tool Appendix 3 Stress incontinence pathway Appendix 4 Urge incontinence pathway Appendix 5 Incomplete bladder emptying Appendix 6 Functional incontinence pathway: Bladder and bowel Policy for Bladder, Bowel and Continence Care v2 3

4 Appendix 7 Urinary retention pathway Appendix 8 Constipation and faecal overflow pathway Appendix 9 Faecal incontinence pathway Appendix 10 Peri anal problems pathway Appendix 11 Irritable bowel pathway Appendix 12 Product assessment pathway continence pads Appendix 13 Assessment and fitting of urinary sheaths Appendix 14 Patient information leaflets 14a Bladder training b Male pelvic floor exercises c Female pelvic floor exercises d Overactive bladder/urge incontinence e Stress incontinence f Functional incontinence: Bladder and bowel g Incomplete bladder emptying h The healthy bladder i Care of your catheter j The healthy bowel k Constipation l Faecal incontinence m Peri anal problems n Irritable bowel Policy for Bladder, Bowel and Continence Care v2 4

5 Policy for Bladder, Bowel and Continence Care 1 Introduction Incontinence is an involuntary loss of urine and/ or bowel motion at an inappropriate time or in an inappropriate place The amount can vary from slight to copious. Incontinence is not a disease but is a symptom of an underlying disorder. (Anderson et al 1988, cited Norton 1992) It has been suggested that currently only 52% of incontinent people seek professional help. The main reason for people not seeking help is that they believe that incontinence is an inevitable part of ageing and that nothing can be done to help them (DOH 2001). The inability to control the function of the bladder or bowel can have a devastating effect upon the physical, social and psychological well being of the person concerned. Incontinence should not be considered a disease but as a symptom, often as the result of multiple aetiology. In order to provide the best solution for the individual concerned it is essential that a focused and comprehensive continence assessment is carried out. High quality bladder, bowel and continence care should be accessible to all individuals presenting with a condition requiring treatment, regardless of age, disability, gender, race, sexual orientation, religion/belief or any other factors which may result in unfair treatment or inequalities in health or employment (Standards for Better Health DOH 2006). Gateshead Health NHS Foundation Trust is committed to the provision of high quality health care in all aspects of its services to patients, visitors, local community and members of staff. This Policy provides a framework for Integrated Continence Care provision which involves all healthcare providers across Gateshead NHS Foundation Trust. This service will link identification, assessment, and treatment of incontinence.. The range of multi disciplinary professionals involved in continence care is diverse, and it is therefore essential that a continence service delivers integrated working practices across organisational and professional boundaries in order to provide effective care and efficient use of resource. 2. Aim of policy Urinary and faecal incontinence can restrict employment, educational and leisure opportunities and lead to social embarrassment and isolation, affecting both physical and mental health (ACA 2000). Gateshead NHS Foundation Trust has a statutory duty to have in place appropriate policies/procedural documents to comply with legislation (The Health and Social Care Act, DOH 2008) This policy aims to aid all professionals in applying best practice for bladder, bowel and continence care. It will provide assessment, treatment and management pathways and guidelines for those patients presenting with bladder and bowel symptoms. A tool has been designed to enable the health professional to identify, assess, treat and help and support people with bowel and bladder incontinence. Policy for Bladder, Bowel and Continence Care v2 5

6 This tool takes the Health professional through possible symptoms and enables identification of appropriate managements. This policy has been developed in response to: The Good Practice in Continence Service Guidelines (DOH 2000) National Service Framework for Older People (DOH 2001) NICE Guidelines : The Management of Urinary Incontinence in Women Guideline 40 October 2006 NICE Guidelines. Lower urinary tract symptoms: The management of lower urinary tract symptoms in men. Guideline 97 May NICE Guidelines Faecal Incontinence The management of faecal incontinence in adults. Guideline 49.June Essence of care (2010) Benchmarks for Bladder, Bowel and Continence Care. DOH 3 Scope of the policy/access to documentation The Policy aims to aid all health care professionals within Gateshead NHS Foundation Trust in applying best practice for bladder, bowel and continence care.. This also includes any member of staff undergoing training with Gateshead NHS Foundation Trust. The principles of this policy are considered to promote best practice. This policy must be read in conjunction with: Infection prevention control policy hand hygiene Privacy and dignity Infection prevention control policy personal protection equipment Infection control policy waste disposal and recycling Catheterisation policy Royal Marsden Hospital Manual of Clinical Nursing Procedures. Eighth Ed. Online. Chapter 6. Digital Rectal Examination Bowel Care guidelines for patients with a Spinal Cord Lesion. Gateshead Health Foundation Trust Standard of Practice no 50. All care standards, continence assessment tool, and continence pathways are available to download from the Trust intranet site Main page Continence The policy will be promoted at induction to ensure that all members of staff have an understanding of their role with regards to bowel and bladder care and how to access the policy. Policy for Bladder, Bowel and Continence Care v2 6

7 4 Roles and responsibilities DESIGNATION Chief Executive Trust Board Chief Executive Director of Nursing and Midwifery Medical Director Modern Matron Continence leads Ward or department manager All staff Roles and responsibilities The Chief Executive has ultimate responsibility for ensuring effective corporate governance within the organisation and therefore supports the Trust wide implication of this policy. The Trust has a responsibility for providing effective healthcare services to patients. They are responsible for ensuring there is support available to ensure the safety and wellbeing of patients in our care, and therefore supports the full implementation of this policy. The Director of Nursing and Midwifery has delegated responsibility for ensuring that effective systems and processes are in place to provide best evidence based practice to patients within the care of Gateshead NHS foundation trust. The Medical Director has a shared responsibility with the Director of Nursing and Midwifery for ensuring effective clinical governance within the organisation. Support the education and training of staff. The continence lead nurses for the Trust have a responsibility overseeing the development and implementation of the policy, including training provision, information and promotion. They will disseminate information related to the policy using the link nurse system for Essence of care. Must ensure that: Identify those staff who require training in continence assessment and provide the opportunity for those staff to attend necessary training Ensure that continence is addressed appropriately and review the effectiveness of the implementation of the policy and take remedial action when they become aware of any acts or omissions that contravene it. Follows audit process to measure compliance with current standards and guidelines. Managers are also responsible for ensuring that where necessary, local procedures are developed, to support the implementation of this policy. Managers should review the effectiveness of the implementation of this policy, and take appropriate remedial action when they become aware of any acts or omissions that contravene it. All Trust staff have a responsibility to adhere to trust policy and ensure appropriate measures are taken to reduce risks Policy for Bladder, Bowel and Continence Care v2 7

8 5. The Role of the Health Care Professional The healthcare professional is responsible for establishing the patient s needs for a bowel and bladder assessment during their admission to a unit, consultation or treatment. The involvement during a clinical examination, consultation or treatment must be the clearly expressed choice of a patient. Healthcare professionals must: Ensure people and carers have easy access to evidence based information about bowel and bladder care that is adapted to meet their needs and preferences(eoc benchmark) Ensure that people and carers have direct access to staff who can advise them on continence management. Ensure peoples care is planned, implemented continuously evaluated and revised to meet individual bladder and bowel care needs and preferences (EOC benchmark) All opportunities are taken to promote continence and a healthy bladder and bowel among people and the wider community (EOC benchmark) Identify and record any preferences or objections resulting from diverse religious, cultural or ethnic backgrounds as early as possible to avoid the potential for causing offence. Ensure a suitable chaperone is present should the patient choose to have a chaperone. Record the presence of the chaperone and their name in the patient s healthcare record. Seek and record the patient s consent to have relatives or carers present during examinations or procedures. Record whether a patient has declined an assessment/ procedure at any point during the process in the patient s healthcare record. Following initial assessment ask patient/ staff to keep a diary if possible of patient s frequency of incontinence to enable a clear idea of bowel and bladder function and behaviours affecting symptoms for as long as necessary. 6. Consent: Assessment and treatments for continence can cause embarrassment, physical and psychological discomfort and impact on the patients self image. Treatments and assessment may necessitate an invasive procedure. To ensure the patient is fully prepared for the investigations and treatments it is the responsibility of the health care professional to inform the patient of the reason and necessity of the assessment and any treatment. Consent is a patient s agreement for a health professional to provide care. Before a healthcare professional examines, treats or cares for a patient, they must obtain their consent and to inform the patient of the reasons and necessity for the procedure. The health professional must assess the patient s mental health or cognitive status, which may raise questions regarding the patient s ability to give informed consent.. In gaining Policy for Bladder, Bowel and Continence Care v2 8

9 consent from a patient, the five key principles of the Mental Capacity Act 2005(DOH 2007b) need to be considered. The health professional will: Ensure that the patient is fully informed using verbal and written information, as to the reason for the assessment or treatment and what the process entails. Ensure that verbal consent and agreement is reached and the relevant information is recorded in the medical/ nursing notes. Consent should be seen as a process, not a single event. Patients can change their minds and withdraw their consent at any time (DOH, 2005). A holistic assessment on each patient requiring assessment and treatment must be performed including assessment of manual dexterity and mobility to determine which treatment is most suitable for each individual This will be documented in the appropriate medical/nursing records 7. Assessing continence Assessment and treatment pathways have been devised to map out a process of patient focused care, which specifies key events. Tests and assessments, occurring in a timely fashion, produce the best prescribed outcome, within the resources and activities available for an appropriate episode of care. For patients, use of the pathway will ensure that they receive timely, efficient assessment with promotion of continence as the prime objective. For staff, use of the pathway ensures an effective and appropriate intervention. All patients' admitted to the Gateshead NHS Foundation Trust will be asked whether they experience any problems with their bladder or bowel. This will form part of the initial nursing and medical assessment and will be documented within the nursing and medical notes. Any patient who experiences symptoms or problems will be offered a full assessment, investigation, treatment or referral to specialist services. The continence care standard and continence assessment tool (appendix 2) will be completed and evaluated as part of the patients daily nursing evaluation. Policy for Bladder, Bowel and Continence Care v2 9

10 Continence assessment pathway Admission assessment Patient is identified as having problem with bladder or bowel function Nursing staff complete continence assessment tool available from Trust intranet continence section Assessment will identify type of problem Refer to specific pathway available on trust intranet continence section Follow pathway Review and record bladder/bowel diary. Give relevent patient information leaflets On discharge Provide patient with relevent information booklet The healthy bladder or the healthy bowel. Provide patient with 7 days supply of continence products, and medication as appropriate. Ensure referral to appropriate agency 8. Training Members of staff who undertake a bowel and bladder care should have undergone appropriate training in order to ensure that they develop the competencies required for this role. This will include an understanding of: What is meant by the term bowel and bladder care. What is an intimate examination. Why assessments need to be done. The rights of the patient. Their role and responsibility. Policy and mechanism for raising concerns. Awareness of religious, cultural, interpreting and ethnic issues. Awareness of the normal way in which that particular examination, procedure or treatment is performed to ensure they can identify inappropriate/ untoward behaviour. Awareness of the appropriate treatments for bladder and bowel dysfunction. Awareness of the correct pathways of care including referral to appropriate agencies, hospital departments. Assessment and use of continence products. Appropriate patient information. Policy for Bladder, Bowel and Continence Care v2 10

11 Continence training will be provided by the Continence leads within the Trust in association with outside agencies. Training can be accessed via the OD and Training department. 9. Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we treat members of staff and patients reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic. This policy is therefore intended to offer safeguards to both patients and members of staff during consultation, examination, treatment and care. In this way, the policy promotes equality of opportunity and values diversity. The policy adopts a human rights approach by considering a wide variety of situations, and encourages supportive, reasonable arrangements to promote fairness, respect, equality, dignity and autonomy. 10. Monitoring compliance with the policy Audit Within Gateshead NHS Foundation trust Audit will be carried out on a cyclical basis using Essence of Care Continence Standards as a benchmark to measure best practice. The audit will collect information will include Patient views of continence care received Staff views of continence care provided Documentation of continence care Evidence of correct delivery of continence pathways or documented reason from deviation from pathway The audit will be carried out on an annual basis by the ward/departments continence link nurse plus the wards clinical practice leads, and the results be returned to the Continence Leads /Practice development team for the trust who will collate the collected information to give an overall view of the trusts position re continence care, identify areas of good practice, and any areas of concern. They will report back to the Director and deputy director of nursing. The audit will be used to benchmark practice and guide future developments in provision continence care within the trust. 11. Consultation and review The policy was developed using best practice guidelines, in consultation with members of the Privacy & Dignity Group, The Continence Group, Urology and colorectal services and the practice development team 12. Implementation of policy (Raising awareness) The Bladder and Bowel Continence Leads are responsible for overseeing the development and implementation of the policy, including the development of training, information and health and continence promotion. However individual healthcare professionals have a responsibility to ensure they understand their role in bowel and bladder care, and take appropriate steps to implement this policy effectively, including reporting any concerns as Policy for Bladder, Bowel and Continence Care v2 11

12 appropriate. Managers are responsible for ensuring all members of staff understand how the principles of bowel and bladder care apply to them and their patients. Managers are also responsible for ensuring that where necessary, local procedures are developed, to support the implementation of this policy. Managers should review the effectiveness of the implementation of this policy, and take appropriate remedial action when they become aware of any acts or omissions that contravene it. 13. References ACA (2000) Survey of patients: national care audit. London: Association for Continence Advice. Anderson in Norton C (ed) (1992) The Development of Urinary Continence and Causes of Incontinence. In Wells M (Ed) Nursing for Continence. Beaconsfield, Beaconsfield Publishers. DOH (2007) Faecal Incontinence. NICE Clinical Guidelines DOH (2006) Urinary Incontinence: The Management of Urinary Incontinence in Women. NICE Clinical Guideline 40 DOH (2004) Good Practice Guidelines in Paediatric Continence Benchmarking in Action. DOH (2010) Modernisation Agency, Essence of Care Benchmarks for Continence, Bladder and Bowel Care. DOH (2001) National Service Framework for Older People DOH (2000) Good Practice in Continence Services Norton C (1992) Incontinence in old age. Nursing elder 4(4):17 8 NICE lower urinary tract symptoms, the management of lower urinary tract symptoms in men. Guideline 97 May 2010 Essence of care 2010.EOC benchmarks Policy for Bladder, Bowel and Continence Care v2 12

13 Gateshead Health NHS Foundation Trust APPENDIX 1 CARE STANDARDS Gateshead Health NHS Foundation Trust Care Standard 26A CONSTIPATION Constipation is confirmed when normal bowel pattern is not maintained and the patient is feeling uncomfortable. Assess normal bowel pattern i.e.: daily, alternate days etc. Is pain experienced on defecation? Are laxatives used at home, and if so what? Assess appetite and encourage high fibre foods from the menu. Encourage good intake of oral fluids 2 3 litres of fluid daily. Encourage mobility and refer to physiotherapist if appropriate. Ensure privacy at all times and always provide hand washing facilities. Ensure patients privacy and dignity is maintained throughout their hospital stay. Ensure infection control standards are adhered to at all times, especially before and after patient contact. Involve the patient and their relatives / carers in the decision making process around their care needs. Ensure patient is aware of their condition / disease process in order to promote independence and self management. Ensure that you have considered making reasonable adjustments to meet the needs of patients with disabilities. Stimulant laxatives; (senna, sodium docusate, bisocodyl) Stimulate nerve endings in the gut wall causing irritation resulting in peristalsis in both the small and large bowel. NB: Abdominal cramp can be experienced if stool is hard. It is recommended that a stool softener be added if this is the case. Osmotic agents: can be divided into two groups i.e.: lactulose causes osmotic effect on the small bowel, causing small bowel distension resulting in defecation, can take anywhere from 3 to 48 hours to work. Magnesium preparations/magrols i.e.: movicol exert osmotic pressure on the gut. Rapid effect usually within 2 6 hours. Bulking agents: i.e.: Fybogel works by retaining water and promoting microbial growth in the colon which increase faecal mass resulting in an increased peristalsis. NB: for these to be effective 2 3 litres of fluid needs to be drunk every day. NOT suitable in acute constipation due to abdominal distension, feeling of fullness causing a reduction in appetite. Suppositories: Melt at body temperature after being inserted directly into the rectum. Enemas: Must be prescribed after full assessment of the patient has been made for suitability prior to administration. Evacuant enemas i.e. phosphate are solutions administered directly into the rectum with the sole purpose of being expelled along with faecal matter. Retention enemas i.e.: arachis oil, olive oil are inserted into the rectum and retained for a specific length of time to soften and lubricate the faeces. Digital rectal examination should be performed after discussion with medical staff and full patient assessment. (Refer to digital rectal examination manual for guidance) Follow Trust guidelines for appropriate constipation laxatives. References: Barrett, J, A. (1992) Faecal incontinence in Clinical Nursing Practice. The Promotion and Management of Continence. Prentice Hall. New York. Gateshead NHS Trust (2006) Prescribing Treatment of Constipation in Adults. Nathan, A. (1196) Laxatives, Pharmacy Journal. The Royal Marsden Hospital Manual of Clinical Nursing Practice. The Promotion and Management of Continence. Prentice Hall. New York. Gateshead Health NHS Foundation Trust Standards of Practice No16, 18, 20, 21, 50 & 51 Policy for Bladder, Bowel and Continence Care v2 13

14 Care Standard 26B DIARRHOEA Definition Diarrhoea results when the balance between absorption, secretion and intestinal motility is disturbed. It has been defined as an 'abnormal increase in the quantity, frequency and fluid content of stool and associated with urgency, perianal discomfort and incontinence. The cause of diarrhoea needs to be identified before effective treatment can be instigated. 1. Determine normal bowel elimination pattern; the use of any regular laxatives/enemas and the incidence of any previous diarrhoea. 2. Diarrhoea of sudden onset with no obvious cause (e.g. laxative medication) must be assumed to be of infective origin until proven otherwise and the following actions taken: Stool specimens to be sent as soon as possible. Specimens to be sent for Culture and Sensitivity within 72 hours of admission and Clostridium difficile / please highlight if recent foreign travel. Document the collection of specimens in daily care record. Strict standard precautions to be undertaken (wearing gloves and aprons, hand washing, disposal of waste). Movement into single room and commence barrier nursing methods, ensure STOP sign on the door of cubicle. Remove alcohol gel until cause established. Patient to have dedicated toilet/commode. Check KIC chart in patient notes for any previous Clostridium difficile carriage. If two or more cases on ward with suspected infective diarrhoea inform the Infection Prevention Control Team (bleep 2057) for outbreak management and support who will advise when to submit samples for Norovirus 3. Provide assistance to and from the toilet as required. Ensure privacy and dignity is maintained at all times. Encourage good hand hygiene and provide washing facilities. 4. Record the frequency of all episodes of diarrhoea, and document its appearance using the Bristol Stool chart (noting the presence of any blood/mucus etc.). 5. Encourage a good fluid intake and a bland diet. 6. If unable to tolerate adequate oral fluid intake it may be necessary to supplement with intravenous therapy. 7. Monitor and document fluid intake and output as, depending on the degree of diarrhoea, the risk of dehydration is high. 8. Advise about protecting skin integrity around the perineal area by careful washing and drying after each episode of diarrhoea, providing assistance as necessary. Policy for Bladder, Bowel and Continence Care v2 14

15 Gateshead Health NHS Foundation Trust Care Standard 26C Faecal Incontinence 1. The Healthcare Professional will ensure that the patient has been given a full explanation of the need for continence assessment, and the necessary physical examinations. 2. The Healthcare Professional will identify any preferences or objections resulting from diverse cultural or ethnic backgrounds as early as possible to avoid the potential for causing offence. This information will then be disseminated throughout the healthcare team. 3. The Healthcare Professional will seek and record the patients consent for the assessment, examination or procedure in accordance with the Trust guidelines and policy on patient consent. 4. The Healthcare Professional will record the event of a patient withholding consent for an assessment, examination or procedure in the nursing and medical records. 5. Nursing staff will complete the Adult Continence Assessment Tool to establish type and details of continence problems. Prompt referral to medical staff and appropriate services will be instigated if the assessment indicates RED FLAG symptoms in accordance with the guidelines in the tool. 6. Nursing staff will identify the appropriate treatment path for the type of continence problem. The guidance on the path will then be followed with any deviation explained and documented. Pathway for faecal incontinence is available on the Trust Intranet within the Trust policy for bowel, bladder and continence care. 7. Nursing staff will ensure that the skin integrity is maintained by keeping it clean and dry. The patient may require assistance to wash the affected areas with soap and water when necessary. Appropriate care must be taken to prevent excoriation of the skin using Cavilon cream to intact skin or Cavilon spray to broken areas. 8. Nursing staff will assess the need for incontinence pads in accordance with the Trust formulary. Patients, relatives and carers may require education about the application and use of these products including when to change them and the correct method of disposal. Patients will be given an adequate supply of these products. 9. Health care staff will ensure that the privacy and dignity of the patient is maintained at all times. 10. Appropriate infection control standards must be adhered to before and after patient contact in accordance with Trust policies and procedures. 11. Health care professionals will ensure that the patient and relatives and carers are fully involved in the decision making process regarding the care needs of the patient. They must also have access to or be provided with evidence based information around bowel care which has been adapted to meet their individual requirements and preferences. 12. The nursing and medical staff will ensure that the patient is kept fully informed with progress on their condition or disease in order to promote independence and self management. 13. Prior to discharge, the nursing staff will ensure that the patient is fully informed in the treatment process and of referrals to other agencies, with an estimated time scale for contact to these agencies. A copy of the patient information leaflet 13, Faecal Incontinence, will also be given. Any referrals to outside services or agencies will be faxed, phoned or posted promptly, prior to the patient being discharged. 14. Nursing staff will ensure that the patient is given a one week supply of the necessary equipment prior to discharge. 15. The patient will be supplied with contact numbers for community nursing or community continence services if appropriate. 16. Nursing staff will have considered making reasonable adjustments to help to meet the needs of patients with learning disabilities. References: DOH Good Practices in Continence Services (April 2000) NICE Guidelines: Faecal Incontinence (June 2007) DOH Modernisation Agency. Essence of Care Benchmarks for Continence (2010) The Royal Marsden Manual of Clinical Nursing Practice (2011) Policy for Bladder, Bowel and Continence Care v2 15

16 Gateshead Health NHS Foundation Trust Care Standard 26D CARE OF PATIENTS WITH PROBABLE URINARY TRACT INFECTION (UTI) 1. If the patient is demonstrating signs and symptoms of sepsis, review the monitored observations including, temperature, BP, oxygen saturations, respiratory rate, pulse and urine frequency / volumes recording them on a labelled EWS chart with EWS score. 2. If a full septic screen is required please send blood cultures, urine specimen, MRSA screen, swab of any wounds and document screen has been performed. 3. Urinalysis is an important part of patient assessment and should routinely be performed and documented on admission. If a patient is presenting with symptoms of a UTI perform and document the urinalysis in the nursing and/or medical notes. 4. Provide urine bottle to obtain sample for urine analysis ensuring patients consent is gained before obtaining sample, and patients privacy and dignity is maintained at all times. 5. Ensure samples obtained are labelled with patients details i.e. name, date of birth, hospital unit number, time, date, location and address. 6. Collected urine sample should be requested via ICE, inputting the clinical details of any antibiotics proposed or current. The specimen should then be sent to the laboratory immediately for microscopy, culture and sensitivity screening to identify the presence of infection and the most effective treatment. 7. Liaise with medical staff and microbiology regarding best treatment. Discuss if any investigations are required e.g. ultra sound scans and refer to specialists if necessary i.e. urology. 8. Administer prescribed medication i.e. antibiotics at correct times and any stat medications with 1 hour of prescribing, as advised by doctors and ensure patients take prescribed medication. 9. Communicate effectively with the MDT, patients and relatives to inform them of current treatment and progress on a regular basis. 10. Ensure the patient is aware of any investigations or procedures they may have and are prepared physically for planned investigations. 11. Ensure infection prevention and control standard precautions are adhered to at all times; hand hygiene is performed before and after patient contact, in line with trust policies and procedures. 12. Patients with a catheter insitu are at high risk of developing a UTI, infection control measures should be adhered to at all times. The catheter record and plan of care should be completed daily. Patient education and information should be given with regards to catheter care and the rational for the need of the catheter. 13. Monitor fluid and dietary intake and output, on a daily basis whilst advising patients to increase fluid intake, keeping a record. 14. The patient should be monitored to assess the effectiveness of treatment. If the patient does not demonstrate signs of improvement liaise with medical staff and the microbiologist if required regarding the treatment plan. 15. From developing a UTI patients may present with some degree of confusion, it is important to monitor confusion levels, orientate patients to ward, identify any risks. 16. Ensure relatives / carers and patients are involved in any long term treatment and decision making regarding long term care and support is provided. 17. Ensure that the patient is aware of their condition / disease process in order to promote independence and selfmanagement. 18. Ensure you have considered making reasonable adjustments to meet the needs of patients with disabilities. References Nursing Standard (2007) urinary tract infection: diagnosis and management for nurses. 21, 23, NHS Direct (2008) Urinary tract infection, adults, Available [online]: Accessed: 29/02/08 Policy for Bladder, Bowel and Continence Care v2 16

17 Gateshead Health NHS Foundation Trust Care Standard 26E Adult Urinary Continence 1. The Healthcare Professional will ensure that the patient has been given a full explanation of the need for continence assessment, and the necessary physical examinations. 2. The Healthcare Professional will identify any preferences or objections resulting from diverse cultural or ethnic backgrounds as early as possible to avoid the potential for causing offence. This information will then be disseminated throughout the healthcare team. 3. The Healthcare Professional will seek and record the patients consent for the assessment, examination or procedure in accordance with the Trust guidelines and policy on patient consent. 4. The Healthcare Professional will record the event of a patient withholding consent for an assessment, examination or procedure in the nursing and medical records. 5. Nursing staff will complete the Adult Continence Assessment Tool to establish type and details of continence problems. Prompt referral to medical staff and appropriate services will be instigated if the assessment indicates RED FLAG symptoms in accordance with the guidelines in the tool. 6. Nursing staff will identify the appropriate treatment path for the type of continence problem. The guidance on the path will then be followed with any deviation explained and documented. Pathways are available for stress incontinence, urge incontinence, functional incontinence and urinary retention. 7. A midstream or catheter specimen of urine will be taken as part of the assessment. This will identify or rule out the presence of a urinary tract infection. If an infection is present, this must be treated with the appropriate antibiotics and, after treatment, urinary symptoms must be re assessed. If an infection is not present, commence the recording of fluid intake and output (including leaks and frequency) on an integrated care chart for three days. This will establish a pattern of incontinence and will identify whether the fluid intake is adequate. If the fluid intake is not adequate, this must be corrected and the urinary symptoms must be reassessed. 8. Nursing staff will ensure that the skin integrity is maintained by keeping it clean and dry. The patient may require assistance to wash the affected areas with soap and water when necessary. Appropriate care must be taken to prevent excoriation of the skin using Cavilon cream to intact skin or Cavilon spray to broken areas. 9. Nursing staff will assess the need for urinary incontinence pads or sheaths in accordance with the Trust formulary. Patients, relatives and carers may require education about the application and use of these products including when to change them and the correct method of disposal. Patients will be given an adequate supply of these products. 10. Health care staff will ensure that the privacy and dignity of the patient is maintained at all times. 11. Appropriate infection control standards must be adhered to before and after patient contact in accordance with Trust policies and procedures. 12. Health care professionals will ensure that the patient and relatives and carers are fully involved in the decision making process regarding the care needs of the patient. They must also have access to or be provided with evidence based information around bladder care which has been adapted to meet their individual requirements and preferences. 13. The nursing and medical staff will ensure that the patient is kept fully informed with progress on their condition or disease in order to promote independence and self management. 14. Prior to discharge, the nursing staff will ensure that the patient is fully informed in the treatment process and of referrals to other agencies, with an estimated time scale for contact to these agencies. A copy of the patient information leaflet 15, Bladder Problems, will also be given. Any referrals to outside services or agencies will be faxed, phoned or posted promptly, prior to the patient being discharged. 15. Nursing staff will ensure that the patient is given a one week supply of the necessary equipment prior to discharge. 16. The patient will be supplied with contact numbers for community nursing or community continence services if appropriate. 17. Nursing staff will have considered making reasonable adjustments to help to meet the needs of patients with learning disabilities. References: DOH Good Practices in Continence Services (April 2000) NICE Guidelines; Urinary Incontinence in Women (April 2006) NICE Guidelines; Treatment of Lower Urinary Tract Symptoms in Men (2010) DOH Modernisation Agency. Essence of Care Benchmarks for Continence (2010) Policy for Bladder, Bowel and Continence Care v2 17

18 Gateshead Health NHS Foundation Trust Care Standard 26F Insertion and Care of Indwelling Urinary Catheter In conjunction with this care standard, all staff must comply with Hand Hygiene Policy IPC no 4; Personal Protective equipment IPC no 2. Antimicrobial guidelines for catheterisation, Nursing procedure for urethral catheterisation, and procedure for taking a specimen of urine and removal of urethral catheter. All staff must complete catheter record and file in patients notes. Before and during catheterisation, the patient and carers can expect that: 1. All alternatives to catheterisation have been considered and the need for catheterisation in this patient outweighs possible complications 2. The staff will involve the patient and relatives/carers in the decision making process around their care needs. 3. A full assessment of the patient will have been performed, considering the reason for catheter and determined whether there are any contra indications 4. Staff will fully explain the need and procedure for inserting a catheter, any possible complications that could occur and provide information to enable the patient/carer to make an informed decision. 5. Staff will ensure that patients privacy and dignity is maintained throughout the procedure and hospital stay. 6. The patient will be given antibiotics if required according the antimicrobial guidelines for catheterisation 7. The catheter will be inserted by a practitioner who has undergone training in catheterisation and is competent in performing the procedure 8. Staff will ensure infection prevention and control standard precautions are adhered to at all times, performing hand hygiene before and after patient contact or their environment, in line with Trust policies. 9. The procedure will be performed using aseptic non touch technique as per Trust policy OP A urinalysis should be performed following catheterisation. If this is positive and infection suspected a CSU should be completed on ICE and sent to the laboratory for culture and sensitivity. 11. Staff will ensure procedure is documented in nursing/medical notes ensuring safe continuation of care and the catheter record is commenced. 12. Ensure you have considered making reasonable adjustments to meet the needs of patients with disabilities. Following catheterisation the patient/carers can expect that: 13. The staff will ensure that the patient is aware of their condition in order to promote independence and self management. They will provide the patient/carer with written information to help the patient care required. 14. The staff will explain/ teach the patient /carers the daily care needed to minimise risks associated with an indwelling urethral catheter and will carry out/ assist with daily care needed to optimise patient s recovery. 15. The staff will assess the continuing need for the catheter on a daily basis ensuring catheter is removed when safe to do so. The ongoing need for the short term catheter will be documented daily in the catheter record. 16. If the patient requires the catheter to be in place following discharge from hospital the nursing staff will ensure the patient/carers are fully aware/able to continue care. Staff will ensure the appropriate catheter is in place. 17. Staff will ensure patient/carer is informed of the follow up and plans for change or removal of the catheter. 18. Staff will ensure patients are discharged with all necessary equipment should district nurses need to change catheter prior to patient obtaining continuing supplies on prescription. They will also provide written information on catheter care and discuss this with the patient/carer. ` 19. Staff will ensure that the district nursing service is aware of patients discharge and will provide contact numbers for the district nursing service should there be problems/concerns prior to district nurse s first visit. When removing the catheter 20. If done in hospital, staff will explain procedure to patient ensuring privacy & dignity is maintained at all times. 21. If the catheter has been insitu for 7 days or longer then refer to antimicrobial guidelines prior to removal. 22. Staff will explain the routine to follow the removal of the catheter and will make sure the patient has drinks available following the removal and that suitable toilet facilities are available for each patient. 23. Staff will ensure that the patient is able to pass urine correctly and does not have high post residual urine. 24. If the patient is unable to void naturally staff will discuss the care necessary with the patient/carer. 25. The nursing/medical staff will ensure that the patient is referred to the urology nursing team if further investigation and treatment is needed. References: Urethral Catheterisation. Royal Marsden Manual of Clinical Nursing; Chapter 24. Procedures; Mallet and Bailey Catheter Care; RCN guidance for nurses: National Occupational Standards Department of Health (1999) Saving Lives: our healthier nation. London DH Department of Health (2003) Winning ways: working together to reduce health care associated infection in England. London DH. Institute for Healthcare Improvement (2010) Royal College of nursing (2008) Guidelines for indwelling urethral catheters and catheterisation. London NICE: Infection Control; Prevention of health care associated infection in primary and secondary care. (2003) Clinical reference CG2. Policy for Bladder, Bowel and Continence Care v2 18

19 APPENDIX 2 ADULT CONTINENCE ASSESSMENT TOOL Patient Details/ addressograph label here Ward/ Department Date. Reason for Admission.. Urinary Incontinence Day/ Night Faecal Incontinence Day/ Night Medical Factors Surgical Factors Obstetric/ Gynaecological Factors Drug/ Alcohol Factors General Assessment Physical Examination Mental Health Status Cognitive Impairment Patients Understanding of Incontinence Continence Aids Used/ Level of Management Catheter in situ on admission Yes/ No Date of Catheter renewal Catheter Inserted on admission Yes/ No Date of Insertion. Date of CSU/ MSU Sample sent Date of Stool Sample sent... Fluid intake/ Output (including leaks) recorded on Integrated Care chart from. Bowel and Bladder Diary implemented for days from.. DATE OF CARE STANDARDS IMPLEMENTED Constipation 26A Faecal Incontinence 26C. Urinary Incontinence 26E Diarrhoea 26B... Probable UTI 26D.. Care of Catheter 26F.. RED FLAG IDENTIFIED ON. REFERRED TO PATIENTS WITH ESTABLISHED OR NEW SPINAL CORD INJURY SHOULD BE IMMEDIATELY REFERRED TO COLORECTAL NURSE SPECIALIST COMPLETE APPROPRIATE SYMPTOM PROFILE THEN REFER TO PATHWAY IN POLICY Referred to Urology Nurse Specialist on.. Referrer.. Referred to Colorectal Nurse Specialist on... Referrer. Referred to Community Continence Services on.. Referrer. Completed by Sig Designation.. Policy for Bladder, Bowel and Continence Care v2 19

20 ADULT CONTINENCE ASSESSMENT GUIDELINES MEDICAL FACTORS; Urinary History: To include storage symptoms such as frequency, nocturia, urgency, stress incontinence and leakage. Also voiding symptoms such as hesitancy, straining to void and poor or intermittent urinary stream. Any post micturition symptoms such as dribbling or a feeling of incompletely emptying of the bladder. Bowel History: To include symptoms of storage such as diarrhoea, urgency to defecate, frequency and soiling. Also voiding symptoms such as constipation, flatulence, straining and feeling of incompletely emptying the bowel. Also consider rectal bleeding, change in bowel habit, painful evacuation, how many unsuccessful attempts at defecation, and whether the patient digitally assists their evacuation. Relevant Medical Conditions: To include condition which may exacerbate or co exist with urinary or faecal incontinence such as disorders of the neurological system (e.g. multiple sclerosis, spinal cord injury, Parkinson s disease, cerebral vascular accident or pelvic deformities or injury. Also consider metabolic disorders such as diabetes, and disorders of the cardio respiratory and renal system. SURGICAL FACTORS: To include previous surgery for spinal conditions, low rectal surgery, sympathectomy or complex pelvic surgery. Consider any other treatment which may interfere with the normal support mechanisms of the vagina or urethra such as the application of a full leg plaster or a hernia support. OBSTETRIC/ GYNAECOLOGICAL FACTORS: To include the number and type of deliveries and their outcome; the menstrual history, and the menopausal status. An enquiry to be made into the symptoms of uterovaginal prolapse. The woman s sexual function, her expectations for this and for future childbearing will need to be discussed. DRUG/ ALCOHOL FACTORS: Some medications may be associated with urinary incontinence and may need to be reviewed. These include sedatives, hypnotics and smooth muscle relaxants. Drugs which affect fluid balance such as diuretics or alcohol need to be documented. Some drugs which affect the autonomic nervous system may affect bowel or bladder tone or function. Drug history will need to include any allergies which may affect treatment options. Also record any laxatives used and whether the patient is compliant with their drug prescription. GENERAL ASSESSMENT: The social and functional impact of urinary or faecal incontinence. Environmental factors, dexterity, personal relationships, occupation, lifestyle factors such as smoking or obesity. PHYSICAL FACTORS: Examination may reveal an enlarged bladder or pelvic mass. Uterine, ovarian or prostate enlargement, rectal prolapse or anal sphincter dysfunction. Are haemorrhoids present or is there an anal fissure or tear. Also obvious discomfort may indicate a pelvic infection or atrophic changes. Loss of sacral sensation may indicate neurological disease. Bladder scan may be indicated at this stage. MENTAL HEALTH/ COGNITIVE IMPAIRMENT: This section is to include level of understanding or memory function. Underlying psychological problems or known psychiatric conditions. Levels of anxiety and depression may need to be considered. If the patient has carers, examine the availability and frequency of support available. PATIENTS UNDERSTANDING OF CONDITION: To include how the patient manages their incontinence such as route planning. Look at the impact of the problem on the patient s lifestyle and how their social life is affected. CONTINENCE AIDS USED/ LEVEL OF MANAGEMENT: In this section the availability and cost of aids may be addressed, how aids are used and the level of success in managing the incontinence. It may be relevant, at this stage, to determine the patient s expectations of the continence service Policy for Bladder, Bowel and Continence Care v2 20

21 ADULT CONTINENCE ASSESSMENT SYMPTOM PROFILE When a patient answers yes to several key questions, treat as mixed incontinence. STRESS INCONTINENCE Do you leak urine when you cough, sneeze, run or jump? Do you only leak a little urine? At night, do you use the toilet once or not at all? Do you leak without feeling the need to empty your bladder? Do only your pants get wet when you leak (no outer clothing)? Do you sometimes need to wear a pad or panty liner? URGE INCONTINENCE/OVERACTIVE BLADDER Do you feel a strong urge to pass urine or have to go quickly? Do you feel a sudden uncontrolled urge to pass urine prior to leaking? Do you leak moderate or large amounts of urine before reaching the toilet? Do you pass urine frequently (more than seven times a day)? Do you get up more than twice during the night to pass urine? Did you have bladder problems as a child? INCOMPLETE BLADDER EMPTYING Do you find it hard to start to pass urine? Do you have to push or strain to pass urine? Does your urine flow stop and start several times? Is your stream weaker and slower than it used to be? Does it take a long time to empty your bladder? Do you feel as if your bladder is not empty after passing urine? Do you leak a few drops of urine onto your underwear after passing urine? FUNCTIONAL INCONTINENCE Is your toilet upstairs, downstairs or both? Do you have any equipment at home to help you with toileting? Are you able to access the toilet at home? Are you able to access the toilet in hospital? Do you have a problem adjusting your clothing in order to use the toilet? Are you able to do your own laundry? URINARY RETENTION (chronic/ acute) Is the patient able to pass urine Yes/ no Is abdominal pain present Yes/ no (if yes, bladder scan indicated) Policy for Bladder, Bowel and Continence Care v2 21