Level One Paediatric Continence Assessment Paediatric Continence Assessment Form LEVEL 1. Completed by... Date:... Designation... Contact no... Abbreviations used in this document to be listed here with the full description. GP General Practitioner DOB Date of Birth ADH Antidiuretic hormone Write Patient details Hospital Number: Name Address: Date of Birth: NHS Number: Telephone Contact: GP Name and address Mother s/carer s Name: Father s/carer s Name: Parental responsibility: DOB: DOB: Ethnicity: Mother/Father/Other (please circle) Child protection plan: Current Historical Yes Professional concerns identified: Current Historical Yes Child looked after: Current Main Carer: Consent to text: Historical Yes Page 1 of 6
OTHER PROFESSIONALS INVOLVED/REFERRALS: Name Agency Contact Details Outcome CONCERNS PROBLEM: AIM: Day-time wetting: Night-time wetting: Constipation: When did problem start: Toilet trained: What age toilet trained: DAYTIME WETTING ASSESSMENT How many times urine passed during day: 1-4 5-7 8+ Where passed: Toilet Potty Nappy Other Number of wet episodes each day: Expected bladder capacity (age+1x30): Page 2 of 6
Size of wet patch: Coin Orange Wet pants Wet pant & clothes ++ Wet pants & clothes & puddle +++ Urgency Can child hold on Pain Wet before toilet Wet following toilet Yes Following exercise: Following laughing: Any trigger: Nursery Illness Weaning Other: Request urinalysis at GP: NIGHT TIME WETTING ASSESSMENT Has your child been dry for 3 months or over: Pull up worn at night: Yes Number of wet episodes at night per week: Number of wet episodes each night: Night time routine: Does your child go to toilet before sleeping: Bedtime: Waking time: Lifted at Night: Is child frightened to get up at night: Previous wetting management: Family history of bedwetting: Page 3 of 6
BOWEL ASSESSMENT Stool Type: Size: 1 2 3 4 5 6 7 Frequency: Pain: Straining: Soiling: Smearing: Blood/Mucus: Withholding: Details: Inappropriate behaviour: Currently sitting on the toilet regularly after meals: Behaviour management: Page 4 of 6
RED FLAGS Any constipation in the first few months of life Any delay in passing meconium (>48hrs afterbirth) Any blood/mucus in stools Ribbon Stools Abdominal distension Anecdotal abnormal appearance of anus Weakness of legs or locomotor delay Abnormalities in the lumbosacral and gluteal regions / dimple Red Flags present: IF YES, REFER TO GP THE SAME DAY. HOW DOES IT MAKE THE CHILD FEEL FOOD & FLUID ASSESSMENT Number of drinks per day: 1-5 6-8 other: Type of drinks: Good appetite: Gastrostomy: Present fruit and vegetable intake: under 5 a day 5 a day Details: Appetite: Poor variable good INITIAL ADVICE (tick as appropriate) DAYTIME WETTING ADVICE Attend GP for urinalysis Encourage child to sit on the toilet, relax and not rush, count to ten Timed toileting plan every 1.5-2 hours 6-8 water based drinks a day (at least 3 in school) Fluid chart given Treat constipation if required Review in 2 weeks via phone agreed Page 5 of 6
NOCTURNAL ENURESIS ADVICE Baseline chart given: Reassure the child problem is not their fault 6-8 water based drinks a day (at least 3 in school) Reassure problem is common and treatable Do not tell off Suggest shower/bath in morning Review after 2 weeks CONSTIPATION ADVICE Suggest trial of 2 nights out of pull ups Reduce / Avoid caffeine /tea / coffee / hot chocolate / Coke / blackcurrant cordial Encourage to go to the toilet when getting ready for bed and before sleep Advice given on bedding protection Discuss causes of night time wetting: Lack of ADH Lack of arousability Bladder instability Constipation Small bladder capacity Praise and reward chart for achievable goals e.g. drinking and toilet before bed 6-8 water based drinks a day (at least 3 in school) Promote healthy diet (5 a Day) Good seating position, step, seat reducer Toilet environment, Warm, paper, wet wipes Active, engage exercise Fluid chart given Regular toileting 20 minutes after meals for 5 minutes Praise and reward chart for achievable goals blame culture Attend GP to commence Movicol if stools type 1-3 less than 3 times per week Telephone review after 1-2 Advice Change 4 Life website (fibre swaps) weeks Written information given Website information given www.eric.org.uk www.promocon.co.uk Both on and Please complete as fully as possible and return to:- Paediatric Continence Service, Whitegate Health Centre, 150-158 Whitegate Drive, Room SO61, 2nd floor, Children s services, Blackpool, FY3 9ES or email to Paediatric.continence@bfwhospitals.nhs.uk This Level 1 is available on EMIS Signature: Print name: Designation: Date and Time (use 24hour Clock): Does the patient understand who their health record information may be shared with? Yes / Page 6 of 6