Resources: Continence and Constipation: assessment and management 

The following resource is designed to assist Long-Term Care (LTC) homes with the implementation of the Promoting Continence Using Prompted Voiding and Prevention of Constipation in the Older Adult Population Best Practice Guidelines. Documents found in this resource are evidence-based, but it is not a program plan. Each LTC home is unique and each home is in various stages of guideline implementation. LTC homes are advised to use the resource at their discretion. For those resources that have copyright notations, it is recommended that LTC homes obtain permission from the primary author prior to implementing them within their setting. The Toolkit is a dynamic resource, and is being updated and revised on a regular basis by the LTC Best Practices Initiative team. Visit this site often to see what's new!

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Best Practices/Standards
ResourceLink
RNAO BPG – Promoting Continence Using Prompted Voiding
RNAO Favoriser la continence par le déclenchement de la miction

RNAO Lignes directrices sur les pratiques exemplaires en soins infirmiers (RNAO BPG).

RNAO Promoting Continence Using Prompted Voiding: A PDA Guide

Condensed version of the Continence BPG viewable on Personal Digital Assistants (PDAs) or mobile phones.

RNAO Favoriser la continence par le déclenchement de la miction PDA
RNAO BPG - Prevention of Constipation in the Older Adult Population
RNAO Prévention de la constipation chez les personnes âgées

RNAO Lignes directrices sur les pratiques exemplaires en soins infirmiers (RNAO BPG).

RNAO Prevention of Constipation in the Older Adult Population PDA Guideline

Condensed version of the Constipation BPG viewable on Personal Digital Assistants (PDAs) or mobile phones.
 

RNAO Prévention de la constipation chez les personnes âgées PDA
Continence and Constipation Gap Analysis
Gap Analysis Worksheet: Prevention of Constipation in the Older Adult
Gap Analysis Worksheet: Promoting Continence Using Prompted Voiding
Report Card

A one page summary of an organization’s identified continence issues that incorporate compliance recommendations and continence product monitoring results.

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Assessment Tools
ResourceLink
7-Day Bowel Record

A bowel movement record that captures bowel movements (BMs), incontinence, laxative use, and toileting method over a 7-day period.

Bowel and Bladder Assessment – LTC

A comprehensive assessment of bladder and bowel function for LTC residents developed by the Toronto Best Practice Steering Committee. Back of assessment lists medications that affect continence and treatment options.

Bowel and Bladder Continence Assessment
Dehydration Risk Appraisal Checklist

A one time, single resident risk assessment for dehydration based of the University of Iowa Dehydration BPG.

Indwelling Catheter Insertion Record

A record for catheter monitoring developed by the Toronto Rehabilitation Institute.

Monthly Bowel Record

A record that describes bowel movements, laxative use and effectiveness.

Quarterly Continence Assessment

A brief continence assessment to be used quarterly with LTC residents that is based on RAI-MDS.

RAI-MDS Complementary Resident Assessment

A urinary continence assessment that complements the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) assessments. For use with residents who trigger the Continence Resident Assessment Protocol (RAP) or where a more detailed continence history is required.

RNAO Transdisciplinary Patient/Client Bowel Assessment Tool

A detailed, 5 page assessment of bowel continence issues that can be completed by the patient. A client record sheet is included.

RNAO Transdisciplinary Patient/Client Continence Assessment Tool

A detailed, 5 page assessment of urinary continence issues that can be completed by a patient. Treatment options are suggested and a client record sheet is included.

Signs and Symptoms of Dehydration Checklist

A one-time, single resident assessment for 30 signs and symptoms of dehydration.

Voiding Record – Output

A 24-hour urine output record to monitor toileting and voiding patterns that was developed by the Improving Continence Care in Complex Continuing Care Collaborative (IC-5) Project in Ontario.

Voiding/Fluid Record– Intake and Output

A 3-day, hourly fluid intake and urine output record developed by the Toronto Best Practice Implementation Steering Committee.

Voiding/Intake and Output Record

A 24- hour fluid intake and output recorded with a dehydration scale adopted by the IC-5 project in Ontario.

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Planning & Implementation Tools
ResourceLink
RNAO Toolkit: Implementation of clinical practice guidelines

This Toolkit was designed to assist health care settings in maximizing the potential of Clinical Practice Guidelines through systematic and well-planned implementation. It was also designed to accompany the Nursing Best Practice Guidelines (NBPGs) developed by the Registered Nurses' Association of Ontario (RNAO) in order to facilitate their implementation.

RNAO Trousse sur la marche à suivre

Mise en place des lignes directrices pour la pratique Clinique.

Toolkit Resources

 Includes:
• Action plan template
• Budget worksheet and template
• Sample budget
• Environment readiness assessment
• Indicator identification
• Stakeholder assessment

RNAO Toolkit: Stakeholder Assessment Worksheet

Worksheet from RNAO Toolkit: Implementation of Clinical Practice Guidelines. Assesses stakeholder influence and support and looks at strategies for engagement (page 32 of Chapter 2).

Best Practice Guideline Implementation: Project Plan

This project plan is intended to be used as an example in organizations wishing to develop an implementation strategy of their own. The project plan demonstrates how and when implementation of the RNAO BPG will occur, by showing the major milestones of the project, and the activities and resources required to meet these goals.

Sustainability of Best Practice Guideline Implementation

Objectives:
• To provide an overview on sustainability of guideline implementation
• To present strategies associated with sustainability
• To provide a framework for sustainability using the Ottawa Model
• To present considerations for evaluating the success of sustainability

RNAO Best Practice Champion Network

RNAO provides free training and networking opportunities to nurture skills in implementing best practice guidelines for individuals and teams.

ABCs for BPGs

A workbook designed to introduce nurses in Long-Term Care to the basics of best practice guideline implementation.

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Quality Improvement Tools
ResourceLink
Health Quality Ontario: Quality Improvement Guide for Long-Term Care (English)

This guide is intended as a jumping off point in the LTC QI journey, and provides foundational knowledge necessary to start improvement projects.

Health Quality Ontario: Quality Improvement Guide for Long-Term Care (French)

 Guide pour l’amélioration de la qualité - des soins de longue durée.

Health Quality Ontario: Tools for QI Teams

This website provides links to downloadable information to help with project accessibility and efficiency through the use of quality improvement tools.

Clinical Model for IC-5 (Improving Continence in Complex Continuing Care Collaborative)

A simple tool for helping organizations identify and prioritize ways to improve continence care that was developed by the IC-5 Project, Ontario.

Continence Project Charter

A detailed plan for implementing continence care improvements across the organization developed by West Park Health Care Centre, Ontario.

Prevention of Constipation Work Plan

A work plan template showing how recommendations from the RNAO Constipation BPG will be addressed. It was developed by West Park Health Care Centre.

Prompted Voiding Work Plan

A work plan template showing how recommendations from the RNAO Continence BPG will be addressed that was developed by West Park Health Care Centre.

Institute for Healthcare Improvement (IHI): Model for Improvement

Developed by Associates in Process Improvement. A simple tool for accelerating improvement. The model does not replace change models currently used in the organizations.

PDSA Worksheet

The Plan-Do-Study-Act (PDSA) or Deming Cycle worksheet is a quality management planning tools.

PDSA Cycle Log Worksheet

The Plan-Do-Study-Act (PDSA) or Deming Cycle worksheet is a quality management planning tools.

Health Quality Ontario: Creating a Mini Survey

Mini-surveys show improvement on a small scale, and provide data for the ‘Study’ part of the Plan-Do-Study-Act cycles. Steps on administering a mini survey and generic sample templates are made available through the website.

Health Quality Ontario: Implementing and Testing Change

Provides descriptions and samples of PDSA cycles, PDSA ramps and run charts, typically used to test and implement change and improvement.

Health Quality Ontario: Analyzing your system

Provides descriptions and samples of tools to analyze your project, including process mapping, pareto charts, and root cause analysis.

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Additional Implementation Resources
ResourceLink
Implementation Strategies from RNAO Prevention of Constipation in the Older Adult Population

Pages 34-35 taken from the RNAO Best Practice Guideline.

Implementation Strategies from RNAO Promoting Continence Using Prompted Voiding

Pages 30-31 taken from the RNAO Best Practice Guideline.

OANHSS Resource Guide for LTC Homes: Skin and Wound Care, Continence Care, Nutrition and Hydration – 2005 (CD-ROM)

Contains a compilation of best practice guidelines, templates, educational materials and references to the related Ministry of Health and Long-Term Care (MOHLTC) draft standards (December 2004) as published and available when this Resource Guide was developed.

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Policies and Procedures
ResourceLink
Policy and Procedure for Bladder and Bowel Management Toronto Best Practice in LTC Initiative

A detailed policy and procedure for improving both bladder and bowel continence in LTC residents with sample policies and nursing care plans. It can also be used as a reference guide.

Policy and Procedure: Hydration Management Toronto Best Practice in LTC Initiative

A detailed policy and procedure for preventing dehydration in LTC residents. It was developed by the Toronto Best Practice Implementation Steering Committee.

Intermittent Catheterization Protocol

A protocol for adjusting intermittent catheterization times developed by the IC-5 project in Ontario.

Guideline: Discontinuing an Indwelling Urinary Catheter

A guideline developed by the IC-5 project in Ontario.

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Care Planning
ResourceLink
Constipation

Nursing care plans to assess a resident’s readiness for prompted voiding, initiate a prompted voiding trial contained in the Toronto Best Practice Initiative’s Bowel and Bladder Management Policy.

Diarrhea

A nursing care plan for residents with diarrhea.

Hydration

Hydration nursing care plans for risk reduction, sick days and end of life for LTC residents developed by the Toronto Best Practice Initiative.

Urinary Tract Infection

A nursing care plan on the prevention of urinary tract infections in LTC residents

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Education Resources
ResourceLink
Self Learning and PowerPoint Presentations
A Model for Excellence in Continence Care PowerPoint

A well illustrated presentation on improving continence care developed by the IC-5 project.

Continence and Stroke PowerPoint

A presentation on the impacts of stroke on urinary continence with interventions and a case study. Developed by the Ontario Central South Regional Stroke Program.

Continence/Constipation Workshop for RNs in Long-Term Care PowerPoint

A presentation on hydration, prompted voiding, constipation and hygiene based on the RNAO Continence and Constipation BPGs with case studies, facilitator and participants’ guides.

Dealing with Urinary Incontinence Using Prompted Voiding – An Overview PowerPoint

A succinct presentation on incontinence and prompted voiding based on the work done in the IC-5 and IC-3 Improving Continence Care Projects. Developed by the Northwestern Ontario BPG in LTC Initiative.

Drugs and Urinary Incontinence PowerPoint

A presentation on medications that effect incontinence and drugs that treat incontinence developed by a pharmacist.

Prevention of Constipation PowerPoint

A succinct presentation on constipation based on RNAO and other BPGs developed by the Northwestern Ontario BPG in LTC initiative.

Promoting Hydration in Older Adults: Fluid for Thought

A presentation on causes, risk factors and interventions for dehydration developed by the Committee for the Enhancement of Elder Friendly Environments (CEEFE) Central South Geriatric Program (Ontario).

RNAO: Self-Learning Package - Continence Care Education

A self-directed learning package for health care professionals caring for adult patients experiencing urinary incontinence developed by RNAO.

Ultrasound Bladder Scan Self Learning Package

An in-depth learning package on how to use a bladder scanner developed by IC-5 Project. Contains a catheterization decision tree and a self-assessment test.

Charts
Bladder Control Muscles

An illustration showing the muscles that control the bladder emptying from the RNAO Self Learning Package for Continence (pg. 39)

Bristol Stool Chart

A chart showing the different types of stools taken from the RNAO Continence /Constipation Workshop for RNs in Long-Term Care - Participant’s Package.

Catheterization

A side view diagram showing the placement of a catheter in female bladder from the RNAO Self Learning Package for Continence (pg. 46)

Diagram of Urinary Tract

An illustration of the urinary system from the front and side, useful for one to one education with staff, families and residents from the RNAO Self Learning Package for Continence (pg. 15)

Female and Male Urinary Tract

An illustration of the structure of the lower male and female urinary tracts from the RNAO Self Learning Package for Continence (pg. 16).

Innervations of Urinary Tract

An illustration showing how the urinary tract nerves come from the brain and spinal cord from the RNAO Self Learning Package for Continence (pg. 17).

Normal Micturation Cycle

A diagram showing the bladder filling and emptying cycles and the muscles involved in this process from the RNAO Self Learning Package for Continence (pg. 18)

Pelvic Floor/Descent

Illustrations showing the pelvic floor and a descended pelvic floor from the RNAO Self Learning Package for Continence (pg. 41).

Transient Causes of Urinary Incontinence

A one page list of the major causes of incontinence.

Fact Sheets / Pamplets / Pocket Cards / Logos
RNAO Fact Sheet: Incontinence: Breaking the Silence

A fact sheet on urinary continence for patients and families with recommendations for action based on the RNAO Continence BPG. Available in French.

RNAO L’incontinence : Rompre le silence

RNAO Fiche de renseignements pour la sensibilisation en matière de santé.

RNAO Fact Sheet: Constipation: Prevention is the Key

A fact sheet on preventing constipation for patients and families with recommendations for action based on the RNAO Constipation BPG. Available in French.

RNAO La constipation : La prévention est maître

RNAO Fiche de renseignements pour la sensibilisation en matière de santé.

Medications That Can Affect Bladder and Bowel Function

A list of commonly used medications that impact on incontinence by brand and generic name.

Pelvic Muscle Exercises for Men

An information sheet to teach kegel exercises to men with a diagram.

Pelvic Muscle Exercises for Women

This is an information sheet to teach kegal exercises to women. It includes a diagram.

Preventing dehydration in older adults - Patient Education Pamphlet

A 2-page pamphlet written in plain language using large print on how people can prevent dehydration in themselves.

Prevention of Constipation in the Older Adult Population – Snapshot

This is a plain language, one page summary of the recommendations from the RNAO Constipation BPG for staff, families and residents.

Promoting Continence Using Prompted Voiding – Snapshot

A plain language, one page summary of the recommendations from the RNAO Continence BPG for staff, families and residents.

The Bladder Issue BP Blogger Newsletter December 2006

A succinct, 2-page newsletter that covers myths and facts about urinary continence and toileting issues. Developed by the BPG in LTC Initiative Central South and The Long Term Care Resource Centre, Hamilton, Ontario

The Bowel Issue BP Blogger Newsletter – February/March 2008

A succinct 2-page newsletter with myths and facts about constipation, fecal incontinence and bowel programs. Developed by Regional Geriatric Program Central and The Long Term Care Resource Centre Hamilton, Ontario

The Fluids Issue BP Blogger Newsletter - June 2007

A succinct, 2-page newsletter that covers myths and facts about dehydration in LTC residents. Developed by the Best Practice in LTC Initiative Central South and The Long Term Care Resource Centre Hamilton

Videos
Websites
Anna and Harry Borun Center for Gerontological Research. Incontinence Management Training Module

The definitive guide to implementing prompted voiding in LTC. A clearly written, self-learning package that breaks the process into steps-assessment, responsiveness, maintenance and audits. Includes voiding records, monitoring forms, MDS subscales, etc. Highly recommended.

Canadian Nursing Continence Advisor Association (CNCA)

A National Association mandated to enhance the specialty of Nurse Continence Advisors (NCA) in Canada by promoting education, research, and clinical practice. The Nurse Continence Advisor (NCA) role is an independent practice model focusing on conservative methods of managing incontinence.

Improving Continence Care in Complex Continuing Care (IC-5)

A collaborative project between five Ontario hospitals that improved continence care. This website has the resources developed during the project with many practical ideas for implementation.

The Canadian Continence Foundation

A national non-profit organization for people with incontinence that has a detailed best practice guideline on urinary incontinence including diagnostic tests, treatments and flow charts on incontinence management in men, women and the frail elderly. Several consumer education resources are on the website.

The Hartford Institute for Geriatric Nursing

This Institute out of the New York University College of Nursing has developed ConsultGeriRN.org as an evidence-based online resource for nurses in clinical and educational settings. Urinary Continence Nursing Standard of Practice Protocol: Urinary Incontinence (UI) in Older Adults Admitted to Acute Care is one of 22 BPGs developed by this organization on geriatric topics.

Wound, Ostomy and Continence Nurses Society (WOCN)

Founded in 1968, the Wound, Ostomy and Continence Nurses Society (WOCN) is a professional, international nursing society of more than 4,200 healthcare professionals who are experts in the care of patients with wound, ostomy and incontinence.

Education Resources
RGP's On-line Teaching Resources

A collection of online teaching resources for specialized geriatric services developed by academic centers and national, provincial and state associations in Canada and the USA compiled by the Regional Geriatric Program of Toronto.  Topics include:  3Ds (Dementia, Dilirium, Depression), incontinence, constipation, pressure ulcers, wound care, sleep disorders, falls, elder abuse, nutrition, and much more!

RNAO: Continence/Constipation Workshop for RNs in Long-Term Care – Facilitator’s Guide

A workshop on continence and constipation.

RNAO: Continence/Constipation Workshop for RNs in Long-Term Care – Participant’s Package

A workshop on continence and constipation for the participants.

Other Resources
Joanna Briggs Institute: Management of Short Term Indwelling Urethral Catheters to Prevent Urinary Tract Infections

An evidence-based practice information sheet for Health Professionals on catheterization that discusses the technique, care, etc. One of the series developed by the Joanna Briggs Institute in Australia, a leader in evidence-based practice resources.

Promoting Hydration in Older Adults – Food for Thought Poster

This is a coloured poster that shows the risk factors for dehydration and uses the mnemonic (H2O) to help staff and families. Developed by the Elder Friendly Environments Coalition.

Rehabilitation Nursing Foundation

Part of the Association of Rehabilitative Nurses (ARN), an American organization whose mission is to promote and advance professional rehabilitation nursing practice through education, advocacy, collaboration, and research to enhance the quality of life for those affected by disability and chronic illness.  Have an excellent BPG on constipation. For more information, visit http://www.rehabnurse.org/about/researchfoundation.html.

Scottish Intercollegiate Guidelines Network

A comprehensive guideline on urinary incontinence management in the general population. Includes assessment, physical and medical therapies. Also included are: audit tools; flow charts; and resource implications. The use of containment products is discouraged until a full incontinence assessment is completed. A quick reference version of the guideline is available. For more information, visit www.sign.ac.uk.

Tips and Tools for Everyday Living: A Guide on Stroke Caregivers – Section 10 Managing Continence

A quick synopsis of the issues of urinary incontinence in stroke survivors, written in plain language with tips on helping with incontinence. Developed by the Heart and Stroke Foundation.

Urinary Catheterization

A BPG that covers various types of catheterization with strong emphasis on prevention of infection developed by the National Health Service in Britain.

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Evaluation
ResourceLink
Evaluating Your Success

From RNAO’s Toolkit: Implementation of Clinical Practice Guidelines, Chapter 5, pages 57-64.

Bladder Scan Quality Assurance Form

An audit form to record regular tests on bladder scanners to ensure that they are functioning properly.

Bladder Scanner Authorization/Validation Tool

An audit form that allows an observer to evaluate and record the step by step use of a bladder scanner.

Evaluation of IC-5: Improving Continence Care in Complex Continuing Care

An evaluation that shows the parameters used and gives examples of charts and tables used to demonstrate the effectiveness of this approach.

IC-5: Audit Indwelling Urinary Catheter

An audit tool for monitoring catheter use on a unit or in a LTC home.

IC-5: Knowledge, Attitudes and Beliefs Survey of Continence Care in Complex Continuing Care

A survey on continence care.

Myths and Truths about Incontinence

A one-page questionnaire on incontinence that can be used to measure success of an incontinence educational campaign. It includes answers.

St. Lawrence Lodge: Prompted Voiding Best Practice Guideline Quiz

A one-page quiz on the RNAO Prompted Voiding BPG.

Toileting Schedule Audit

An audit tool on resident level of continence, use of continent products and frequency of toileting.

Program Evaluation: The basics

The Public Health Agency of Canada – Agence de la Santé Publique du Canada toolkit for evaluation of programs particularly as it considers constraints in human resources and finances.  En haut de la page principale il y a un hyperlien pour la version française de ce document.  The whole toolkit can be accessed at: http://www.phac-aspc.gc.ca/php-psp/toolkit-eng.php.
 

The Evaluation Center – Western Michigan University

This contains checklists and tools for planning your evaluation.

Ontario Injury Prevention Resource Centre. There is a link to the stages of evaluation.

This website provides access to a toolkit of evaluation methods and measures.  
 

Public Health Agency of Canada - A Guide to Project Evaluation: A participatory approach

This evaluation guide provides an easy-to-use comprehensive framework for project evaluation.
 

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Recommended Readings/References
ResourceLink
Learnings from the IC-5 Collaborative Experience

This article describes what to consider when planning a Continence Care Quality Improvement Collaborative Project and lessons learned from the IC-5 Project in Ontario.

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