Adult Bladder and Bowel Dysfunction Protocol Urinary Dysfunction: assessment, diagnosis, treatment and management Page 1 of 9
Adult Bladder and Bowel Dysfunction Protocol Urinary Dysfunction: assessment, diagnosis, treatment and management Policy reference: Continence Introduction The protocol covers the identification, assessment, diagnosis, treatment and management of urinary dysfunction, in accordance with current guidelines. 1. Clinical condition/situation Clinical condition/situation Eligibility criteria Exclusion criteria Consent process Actions following refusal/ non adherence All patients with urinary symptoms in all areas in NHS Lothian. Adults with urinary dysfunction. Children under 16 years of age. Refer to Children and Young People Continence Protocol Manual (NHS Lothian 2012). Informed consent must be obtained and formally documented in nursing notes before undertaking assessment and management of care (NHS Lothian 2014). Refusal to accept recommended treatment plans should be clearly documented in the health records and discussed with clinical team. Consider the consequences of non adherence. Page 2 of 9
2. Criteria for staff participation in the protocol Required professional qualifications Knowledge and skills All registered nurses. A registered nurse can delegate aspects of care to non registered staff as appropriate (NHS Lothian 2012). Non registered staff will demonstrate competence to their employing authority before participating in care of named patients. Registered nurses must at all times act within The Code: Professional standards of practice and behaviour for nurses and midwives (NMC 2015). Standards for medicine management (NMC 2015) and Safe use of medicines policy and procedures (NHS Lothian 2016). Registered nurses will have knowledge of: normal bladder function factors that may cause urinary dysfunction assessment and care planning specific to urinary dysfunction types of urinary dysfunction, treatment and management options drugs affecting bladder function bladder retraining toileting schedules when to refer to Bladder and Bowel Nurse Specialist or secondary care Training in all aspects of urinary dysfunction (including assessment, diagnosis, treatment and management) is available in NHS Lothian. Page 3 of 9
Core competencies Core competencies should include: assessment and diagnosis of urinary dysfunction bladder scanning and interpretation of results clinical significance of urinary test results evaluating urinary dysfunction treatment and/or management As in all nursing activities, registered nurses who have difficulty maintaining their competence should contact their line manager. 3. Description of treatment/practice under the protocol Patient assessment Patient assessment must be carried out by a registered nurse using appropriate assessment tool and must include: urinalysis 3 day frequency/volume chart physical examination (vaginal/rectal/ abdominal) by medical staff or other competent practitioner post void residual bladder scan Consideration should also be given to: medical, surgical and obstetric history current medication and its affect on bladder/bowel relevant lifestyle issues for example obesity, smoking mobility/dexterity environment/toilet access/carer availability cognitive/emotional factors ability to communicate skin condition Page 4 of 9
Assessment of urinary dysfunction and care planning Hospital inpatients Complete the bladder and bowel dysfunction assessment in the Nursing Risk Bundle on TRAK within 24 hours of admission. All patients with an identified problem should be fully assessed by nursing and medical staff using assessment tool. Type of urinary dysfunction must be diagnosed and appropriate care plan initiated. Nurses should arrange regular review dates with the patient and should also be reviewed regularly as part of Multidisciplinary Team meetings. It is recognised that not all patients are suitable for a treatment plan. If this is the case, reasons why must be clearly documented and a suitable management plan commenced and documented. All patients who require support after discharge from hospital must be referred to community nurses and care providers. Detailed information on type of urinary dysfunction and care plan should be fully discussed and given. Community patients For patients referred directly with bladder dysfunction or when problem identified on district nurse care rounding tool. Commence full assessment using community urinary dysfunction assessment tool. Establish type of dysfunction and contributing factors. Follow nursing management plan according to type of dysfunction diagnosed. Refer to GP if any red flag symptoms, significant post void residual or further assessment is required. Document on TRAK findings, treatment plan and advice given. Page 5 of 9
Nurses should arrange review dates as required throughout the treatment plan and at 12 weeks. If no improvement after 12 weeks then GP should be informed to consider referral into secondary care. It is recognised that not all patients are suitable for a treatment plan. If this is the case, reasons why must be clearly documented and a suitable management plan commenced. Care Home residents For Care Homes with registered nurses: Commence full assessment using care home urinary dysfunction assessment tool. Establish type of urinary dysfunction and contributing factors. Follow nursing management plan according to type of dysfunction diagnosed. If post void bladder scan is required refer to Bladder and Bowel Nursing Team Refer to GP if any red flag symptoms, significant post void residual or further assessment is required. Document findings, treatment plan and advice given. Nurses should arrange review dates as required throughout the treatment plan. If no improvement then GP should be informed to consider referral into secondary care. For Care Homes without registered nurses For new residents with urinary dysfunction or when existing residents develop a problem: Complete assessment tool and refer to Bladder and Bowel Nursing Team if prompted to on form after reversible causes ruled out. Page 6 of 9
Referral pathway for specialist advice Documentation Information given to patient and/or carer Transfer of patients If there is no improvement after 15-20 weeks or following treatment, discuss with Bladder and Bowel Nurse Specialist or medical staff (with patient s consent). Consider a specialist referral (RefHelp, NHS Lothian). During all stages of the assessment and treatment process the nurse must comply with the following documents: The Code: Professional standards of practice and behaviour for nurses and midwives (NMC 2015) Data Protection Act 1998 (Home Office 1998) Clinical Documentation Standards (NHS Lothian 2010) Documentation will include: appropriate urinary dysfunction assessment tool which should be summarised on TRAK holistic patient assessment by a registered nurse outcomes of the assessment process decisions made and actions taken evaluation of all care given and effectiveness of treatment At all stages of assessment and care planning the patient and/or carer: will be informed of any outcomes of the assessment and treatment process will be involved in decision making and care management, when possible will be provided with written information where appropriate When patients are transferred between care settings, all relevant information must be communicated to the appropriate healthcare staff to provide continuity of care (NHS Lothian Discharge Policy 2011). A current care plan detailing current bladder management should be available. Page 7 of 9
Identifying and managing possible adverse reactions Supplies of products for containment of incontinence or urology items Defective products Nurses must be aware of side effects of prescribed medication and discuss them with patients (and/or carers) where appropriate. Document and refer to medical staff. Nurses must be aware of adverse effects of products used for management of incontinence. Products should only be offered following complete assessment as a temporary management strategy while treatment plan is ongoing or as long term only if treatment has failed. Refer to Products section from the Adult Bladder and Bowel Dysfunction Protocol for more information. Hospital Nurses working in hospital settings should be aware of local arrangements for ordering and supply of products. Discharge planning When the discharge date is known: inform the district nursing team that patient will need reviewed and products ordered provide the patient on the day of discharge from hospital with at least one week s supply of products as it can take 7-14 days for product delivery in the community Community Products to manage bladder and bowel dysfunction are available in the community via Continence Care Service and can be ordered by community nurses. Refer to Products section from the Adult Bladder and Bowel Dysfunction Protocol. Inform staff of a product fault by telephoning 0131 537 4572 and provide the following information: product code and batch number a brief summary of the fault Staff will arrange an uplift of unused faulty product. Page 8 of 9
4. Management and monitoring Professionals involved in drawing up of protocol Manager authorising protocol Audit All members of the Bladder and Bowel Nursing Team in NHS Lothian with acknowledgement to the original members of this protocol group. Dawn Arundel, Clinical Nurse Manager. Audits of the protocol will be conducted periodically in conjunction with the Bladder and Bowel Nursing Team. Protocol date 2014 Review date 2017 5. References Home Office (1998) Data Protection Act 1998 NHS Lothian (2014) Policy for Obtaining Consent NHS Lothian (2016) Safe Use of Medicines Policy and Procedures NHS Lothian (2013) Promoting dignity: Policy and procedural guidance on the use of chaperones during intermittent examination and care of patients NHS Lothian (2012) Children and Young People Continence Assessment and Management Guidelines NHS Lothian (2012) Delegation of Care Policy for Nurses, Midwives and Allied Health Professionals NHS Lothian (2011) Discharge Policy NHS Lothian (2010) Clinical Documentation Standards NHS Quality Improvement Scotland (2005) Best Practice Statement Continence - adults with urinary dysfunction Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives Nursing and Midwifery Council (2015) Standards for medicines management Page 9 of 9