TIPS on assessing Continence when completing your Decision Support Tool

This is the next blog in our ‘TIPS’ series giving our tips on key areas of the Decision Support Tool.

There are 12 areas of care need that are considered when a Decision Support Tool (DST) is completed, these are referred to as ‘care domains’:

1. Breathing
2. Nutrition
3. Continence
4. Skin (including tissue viability)
5. Mobility
6. Communication
7. Psychological and Emotional Needs
8. Cognition
9. Behaviour
10. Drug Therapies and Medication
11. Altered States of Consciousness
12. Other significant care needs

The third care domain is Continence. This domain considers the needs of a person relating to their bladder and bowel function, and toileting.

Get Help Breaking Down the Decision Support Tool: Continence

The DST notes:

‘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;

1. Describe the actual needs of the individual, providing the evidence that informs the decision on which level is appropriate, including the frequency and intensity of need, unpredictability, deterioration and any instability.
2. Take into account any aspect of continence care associated with behaviour in the Behaviour domain’.

The levels of need that can be selected are; ‘No Needs’, ‘Low’, ‘Moderate’ and ‘High’. Each level of need has a description on the DST, we call these the ‘Descriptors’. They are as follows:

As seen above, person with ‘No Needs’ will be fully continent, with no other continence problems that require managing.

Low Needs

A person with ‘Low’ needs may have incontinence of urine, but can control their bowel movements. A carer will need to manage their bladder output for them because they are not able to self-care. Management may include things such as administering medication for an overactive bladder; helping the person to the toilet; using a toileting regime (i.e. where a person is taken to the toilet on, for example, a 2-3 hourly basis, to try to keep the bowel and bladder functioning at set times). This helps to regulate the bowel and/or bladder and also helps to prevent them from soiling themselves. Toileting regimes are often used together with continence products/pads in case of ‘accidents’.

Moderate Needs

If a person has double incontinence, they will fall into the ‘Moderate’ level of need. ‘Double incontinence’ means that the person cannot control the output of urine or faeces. They will need to be toileted on a regime and/or with continence pads/products. Many people with dementia type illnesses will have double incontinence because they have no awareness of their toileting needs. People can also lose control of their bowel or bladder due for various reasons, e.g. poor function, perhaps due to weak, damaged or overactive muscles, an obstruction or blockage.

Top Tip 1 – Make sure that incontinence is noted in the ‘Cognition’ domain as it can help the assessor to identify the level of cognitive awareness.

Assessors often miss cross-referencing other domains to help them to identify the level of cognition. (Whether a person can feed themselves or not should also be considered in Cognition too, as this can also indicate the persons level of awareness/ability).

Top Tip 2 – Ensure that the assessor records in the Continence and/or Mobility domain, the mobility needs of the person. For example, it is important to consider can the person get to the toilet without support? Do they need to be assisted by one or two people? What do carers need to do to assist? Is a hoist needed? Does the person have the ability to sit on the toilet or commode without support? Are there any other challenges to toileting the person? Do they have challenging behaviour around toileting (this should be recorded in the ‘Behaviour’ domain), for example, do they co-operate or resist? Are they aggressive?

Top Tip 3 – Check if the person has compromised skin – pressure sores, wounds, red/sore areas in the area covered by continence products. If so, and they have incontinence of faeces, it is often necessary to dress these areas, or at least to apply barrier creams and to change continence products quickly after soiling. The greater the skin compromise, the greater the need to attend to continence care promptly – this needs to be taken into account in the ‘Continence’ domain (and/or in the ‘Skin’ domain), otherwise it may get missed when the 4 Key Characteristics are considered.

Moderate or High Needs

Management of faeces and Constipation

‘Moderate’ also covers people suffering with constipation which need this to be managed for them if they are unable to cope by themselves. It might include carers administering medication, such as senna or lactulose (which help to soften the stool to relieve constipation).

Generally, fluid intake will also be monitored as a greater intake of fluid will help to prevent constipation (as 75% of stools are made up of water).

It might include monitoring the output of faeces to avoid the bowel becoming impacted (i.e. where stool is not passed and accumulates, causing a hard mass of stool that gets stuck in the colon or rectum). This problem can be very severe. It can cause faecal overflow (liquid that looks like diarrhoea, which passes by the impacted faeces and mislead carers to think the person has diarrhoea when they are in fact severely constipated), abdominal pain, loss of appetite and nausea, distress and increased agitation/confusion. It needs to be treated quickly.

Monitoring the stool output ensures that carers record on a chart when stools have been passed and helps identify how long it has been since the person last passed a motion. Most people pass stools every 1-3 days. A person that has not had a bowel movement within this period will need to be checked for constipation. This will involve the GP, District Nurse or General Nurse examining the person for signs of impaction. It might need additional medication to soften the stool, or enemas to remove the stool. If the blockage cannot be shifted, the person will need to be assisted in hospital. If impacted stools are a frequent problem, it is likely that the care needs will be ‘High’ as manual evacuations may be necessary. A specialist is likely to be involved in this care, such as a specialist bowel and bladder nurse.

Colostomy Care

A colostomy is an operation to divert one end of the colon (part of the bowel) through an opening in the stomach. The opening is called a stoma. A pouch can be placed over the stoma to collect the stools/faeces. A colostomy can be permanent or temporary. People with a colostomy bag will be considered as ‘Moderate’ on the DST, unless there are frequent and significant problems with the colostomy bag, in which case this may increase the level of need to ‘High’. Some common problems involve not passing many stools, or passing watery stools, bloating and swelling of the abdomen/stomach, stomach cramps, a swollen stoma and/or nausea or vomiting. The site of the stoma insertion can become infected and this needs to be managed by carers. Severe infections may increase the level of need in ‘Continence’ to ‘High’.  The care needed of the skin around the stoma should be recorded on the DST in ‘Continence’ and in ‘Skin’. The DST assessors will need to consider all the evidence to decide whether the care is ‘Moderate’ or ‘High’ based on the history of the colostomy  care.

Other bowel problems could include irritable bowel syndrome or chronic diarrhoea. The key consideration should be ‘what care is needed to manage the problem?’

Management of urine and Catheter Care

A person who is unable to empty their bladder fully or has other problems urinating, may need to have a catheter. A urinary catheter is a flexible tube that is inserted to empty the bladder into a drainage bag. Catheters need to be managed, and if a person is unable to manage the catheter themselves, carers need to do this for them. This care is measured as ‘Moderate’ as long as it not problematic. Catheter care will involve a carer emptying the bag and maintaining hygiene of the catheter site, as well as monitoring for urinary tract infections (UTIs) – as infection is more likely with a catheter in situ. The carer will need to clean the catheter, change the drainage bags, check the catheter is draining properly and that the tube is not kinked or damaged, wash the drainage bags every day, and ensure that sufficient fluids are drunk.

A catheter that is problematic is likely to fall into the ‘High’ level of need. The history of the catheter management is important here: the records need to be checked to see if the catheter has had to be changed more often than usual. A catheter is normally changed every 12 weeks. It might need changing more often because of infections, encrustation, or blockages. Encrustation is where crystals deposited from the urine become trapped in the organic matrix and can eventually clog or block the catheter. In severe cases, the catheter may need changing after several days rather than the usual 12 weeks. Catheters should be changed by a nurse or other qualified clinician.  The GP or care home will hold records of any problems with the catheter care.

Top Tip – A person’s poor cognition may be a factor to note on the DST in relation to catheter care, as it may be that they pull the catheter out, requiring more frequent re-catheterisation; infections caused by the catheter may increase confusion, challenging behaviour or falls risks. Also, it might be more difficult to change the catheter because the person may be uncooperative, resistive, or aggressive. These matters should be recorded on the DST, as they will impact on the 4 Key Characteristics.

Chronic Urinary Tract Infections

Also, within the ‘Moderate’ level of need is the management of UTIs if they are recurring. The term ‘chronic’ is used in this descriptor in relation to UTI’s to indicate where the infection is persistent or long-lasting. A person may need to have repeat courses of antibiotics, but even then UTI may not resolve. A one-off UTI without other continence needs would not be considered ‘Moderate’.  UTIs might create other problems, particularly in the elderly, such as confusion or increased confusion, or increased falls risk. This, too, should be recorded on the DST.  The frequency of UTIs, what care is needed to manage them and the severity of the infections should all be recorded on the DST and considered in the overall assessment.

Top Tip – If a person is not able to communicate their continence needs, this creates greater care needs, because carers will need to monitor and record bowel movements and be responsible for ensuring that the person remains well hydrated (and given the correct amount of fluid/drinks throughout the day). They will need to monitor input and output of urine and faeces, and manage constipation or loose stools. If a person has no ability to communicate their needs around continence, this should be recorded in the ‘Continence’ and/or ‘Communication’ domain so that it is not missed when the 4 Key Characteristics are considered.

Although not an exhaustive list, the above information covers some of the most common issues that are considered when assessing ‘Continence’.

PART 1- Looking At The 4 Key Indicators: Unlocking the basics

PART 2 – Looking At The 4 Key Indicators: Gathering pieces of evidence

PART 3 – Looking At The Four Key Indicators: Completing the Jigsaw

PART 4 – Looking At The Four Key Indicators: Drafting Your Conclusions

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Summary

You must ensure that whatever the continence problem, the care needed to meet the needs are properly recorded and considered in conjunction with the other domains of care.

For further reading in our ‘TIPS on assessing…’ series:

TIPS on assessing ‘Communication’ in your Decision Support Tool

TIPS on assessing ‘Altered State of Consciousness’ in your Decision Support Tool

TIPS on assessing ‘Behaviour’ when completing the Decision Support Tool for CHC Funding

If you need help with an MDT assessment, appeal or advocacy support don’t hesitate to contact us or get help from one of our specialist Advice Lines to discuss your case today.

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