Successful intermittent self-catheterization teaching: one nurse's strategy of how and what to teach.
Key Words: Bladder management, neurogenic bladder, intermittent self-catheterization, patient teaching, adult learning.
Bladder management is an important aspect of overall health and well-being. Many patients who sustain spinal cord injuries, as well as other neurologic diseases, encounter bladder issues that interfere with the natural emptying of urine from the bladder. Occasionally, overactive symptoms, such as frequency and urgency, can be managed with medication and behavior modification. However, problems encountered with urinary retention or incomplete bladder emptying may require catheterization to empty the bladder.
Intermittent self-catheterization (ISC), instead of long-term indwelling catheterization, is accepted as the preferred method to empty the bladder in patients with retention secondary to neurogenic bladder. ISC involves placing a catheter in the bladder to drain urine then removing the catheter when the bladder is empty. This method of bladder management was introduced by Dr. Lapides in the early 1970s and consists of emptying the bladder at timed intervals, usually every 4 to 6 hours, to keep the bladder volumes at a physiologically normal 400 to 500 ml (Linsenmeyer et al., 2006). ISC has been shown to reduce intravesical bladder pressure, avoid bladder distention, and result in a lower risk of infection than the use of an indwelling catheter (Lapides, Diokno, Silber, & Lowe, 1972).
In addition to the physiologic advantages of ISC, there are quality-of-life benefits for the patient. Patients can enjoy an improved body image without the presence of a drainage bag attached to their leg or wheelchair. This also allows for more unencumbered transfers without the possibility of pulling the catheter or tubes leading to the drainage bag. An additional benefit is the ability to enjoy a more pleasurable sexual intimacy experience without a urinary catheter.
Patients who are able to self-catheterize gain the knowledge and ability to be in control of their bladder function. ISC may be performed in a bathroom or toilet stall, thus maintaining privacy and a semblance of normal bladder function. Catheterization schedules may be arranged so that the catheterization times are convenient to the patient's daily routine.
The Role of Nurses: Setting The Stage for Learning
Patient education is an important nursing function, and in the case of teaching ISC, cannot be understated. Little exists in the literature, and there is a lack of accepted universal standards to guide nurses to teach ISC; therefore, many nurses must rely on their own experience and clinical setting policies. Nurses' experience and knowledge base are varied, allowing for inconsistencies in quality of the instruction. There is evidence in the literature, however, which supports the practice of ISC and describes proper technique of catheterization, which can serve as a basis for nursing instruction (Lapides et al., 1972; Linsenmeyer et al., 2006; Newman, 2008; Newman & Willson, 2011).
As described in Knowles' principles of adult learning, individuals learn best when they are ready and motivated to learn and perceive the need for what they are expected to learn (Knowles, Holton, & Swanson, 2011). The adult learner has a wealth of knowledge and experience that can and should be drawn upon to encourage the participation of the learner. The process of teaching self-catheterization is considered in the context of the nurse/patient relationship as well as the needs of the individual patient. With comprehensive, individualized teaching, a nurse and patient form a partnership that will empower a patient to be more independent in his or her care, and at the same time, help improve self-image and self-esteem.
The catheterization procedure is a routine skill for most nurses. For a patient, it is a new experience, which encompasses many aspects, both physical and psychological, that have not previously been experienced or considered. The nurse's initial assessment includes the patient's overall physical and psychological readiness to learn self-catheterization. Only then can a teaching program be tailored to the patient's needs.
Fear is an important factor for the nurse to consider when a patient has sustained a significant change in his or her body's functional ability and can hinder the learning process (McConville, 2002). The nurse can allay some of this fear by reassuring the patient that he or she will be supported and partnered with the nurse throughout the process of learning bladder self-care. The patient should begin to assist the nurse with the catheterization process as soon as possible. Becoming involved in this process will enable the patient to build confidence and regain control of his or her urinary care.
To be more effective, the learning process needs to take place over time. Teaching ISC should begin when the nurse performs the first catheterization. The nurse describes and explains the procedure step by step to the patient. Basic anatomy is reviewed, and the reason for ISC is reinforced. The patient who is learning ISC needs to understand the physiologic advantages of self-catheterization, such as decreasing the risk of urinary tract infection and protecting the kidneys by maintaining safe bladder pressures to reduce the risk of reflux.
The nurse observes visual and verbal cues from the patient to determine the level of interest and readiness to take a more active role in the procedure itself. To avoid the patient becoming overwhelmed, the nurse provides information in easy-to-understand, small increments. This allows the patient to retain and build on the information that has been provided. Written pamphlets with diagrams help to explain physical anatomy and reinforce the procedure of catheterization. A catheter similar to what the patient will use is given to the patient so he or she can become familiar with handling the proper equipment. When patients know what to expect, anxiety can be reduced, allowing learning to take place.
Begin with the Basics
After a major injury or illness, some patients with bladder dysfunction are medically and emotionally stable to begin learning self-care while still hospitalized. Procedures in the hospital are often seen as ritualistic, with the donning of sterile gloves, draping, and cleansing the perineal area with antiseptic solutions, such as povodone iodine (Betadine[R]) or benzalkonium chloride. The nurse reassures the patient that the sterility and special cleansing are necessary during hospitalization to protect against acquiring bacteria in the environment that may cause infection.
Occasionally, patients are taught self-catheterization at home. If this is the case, the nurse assesses the patient's ability and readiness to learn ISC and then assists in preparing the home environment. The nurse and patient then work together to determine logistics of where the patient will catheterize and prepares an appropriate space to store supplies.
Patients are instructed that the ISC technique will be different at home. Outside of the hospital environment, the procedure is considered clean, not sterile. Patients in their own environment are at less risk to be exposed to bacteria that may cause a urinary tract infection. Clean technique generally involves washing hands with soap and water prior to catheterization and daily cleansing of the perineum. Perineal cleansing may be required more often when fecal or other wastes are present (Newman, 2008).
Good hand washing by the patient is substituted for sterile gloves. Non-sterile gloves may be used, if the patient prefers. Cleansing the urethral meatus with antiseptic can be exchanged for a baby wipe or soap and water on a clean washcloth (Lapides et el., 1972).
In many cases, it is no longer necessary to explain the process of cleansing and storing catheters between uses because most patients are provided with the appropriate number of catheters to allow a new catheter for each catheterization. The availability of single-use catheters for ISC is largely a result of the recommendation of the United States Department of Veterans' Affairs (2007) stating that catheters labeled and intended as single-use devices should not be reused. Since 2008, the Centers for Medicare and Medicaid Services (CMS) has allowed coverage to support single-use catheters for ISC. Recently, approved supplies were increased up to 200 per month (Muller, 2009). This action greatly simplifies the process of ISC for the patient as well as assists in decreasing the likelihood of urinary tract infection.
When teaching ISC to a female patient, the ability to locate the urinary meatus is essential. Many women learn ISC by initially using a mirror to visualize the urethral opening. Other women prefer to learn ISC by feeling the meatus in relation to the vagina. Women who learn ISC by using the mirror eventually catheterize by feel and eliminate the mirror (Lapides et el., 1972; Newman & Wein, 2009).
Patients initially perform ISC with the nurse's coaching and supervision. Eventually, the coaching becomes unnecessary, and the nurse serves as an observer during the self-catheterization procedure. When successful self-catheterization has been demonstrated, the patient is deemed competent. Since most patients perform ISC 4 to 6 times daily, it generally does not take long for the patient to become proficient. During this time, the nurse remains supportive and accessible, but now in the role of consultant, should questions arise.
As part of the ISC instruction, patients are provided with the instructor's telephone number should problems arise while performing the procedure. Additionally, the nurse working with the patient makes a follow-up call in a week to monitor the patient and offer support.
There are several types of catheters from which the patient may choose depending on one's ability and lifestyle. The nurse educates the patient on catheter options along with advantages and disadvantages to each catheter type. This allows the patient to make an informed decision regarding catheter choice.
Straight catheters do not have an inflatable balloon that holds the indwelling catheter in the bladder. There are two basic types of straight catheters, uncoated and coated. Uncoated catheters require a separate lubricant. Coated catheters may have hydrophilic, antibacterial, or other coatings. Hydrophilic coated catheters, when exposed to water, become very slippery along the entire length of the catheter and facilitate its passing along the urethra. Recent Centers for Disease Control and Prevention (CDC) guidelines suggest hydrophilic-coated catheters may be preferable over the uncoated straight catheter because they can only be used once and may reduce trauma to the urethra during insertion (Gould et el., 2009).
Catheters are made in different diameters (measured by the French Scale) and vary in length. A French size of 12 or 14 is usual for an adult who performs ISC. Female catheters are 6 inches long, intended for the shorter female urethra. Most women find this catheter easier to handle than the longer standard catheter. A standard catheter is 16 inches long and can be used for either male or female patients.
Sterile catheter systems are available as well. These catheters are also called "no touch" catheters because the catheter is inside of a drainage bag. The bag is designed with an introducer tip that is inserted into the urethra. The catheter is passed through the introducer tip so the catheter is not contaminated by bacteria that may be at the entrance of the urethra (Hudson & Murahata, 2005). Additionally, the catheter inside the drainage bag is pre-lubricated. The patient advances the catheter within the bag and does not actually touch the catheter. This sterile closed catheter system also contains sterile gloves and antiseptic swabs.
Sterile catheter systems may be an effective alternative for patients who experience frequent urinary tract infections. Medicare and Medicaid cover sterile catheter systems for individuals with specific qualifications. These qualifications include either a) documentation of two separate occurrences of urinary tract infection within 12 months, or b) documentation of reflux while on intermittent catheterization. Coverage is also provided for individuals who reside in a nursing facility, are immunosuppressed (such as with long-term steroid use and some patients with multiple sclerosis), or for pregnant patients who are spinal cord injured (National Government Services, n.d.).
Some patients may elect to pay out of pocket for several sterile closed-catheters systems each month as a convenience factor. Since the kit contains all the necessary supplies for catheterization, it is easily portable for the patient and can be used on outings.
During ISC teaching, the nurse addresses areas such as fluid consumption, catheterization schedules, and signs and symptoms of urinary tract infection. Patients are encouraged to drink adequate fluids but may need to limit fluids prior to bedtime so catheterization is not needed during the night. Beverages containing caffeine are discouraged because they are bladder irritants and may stimulate bladder contractions. A bladder diary is advised during the first few weeks of catheterization. Notation of the times and volumes of each catheterization is recorded to track trends. This will assist in developing a catheterization schedule that fits into a patient's lifestyle and maintains urine volumes below 400 to 500 ml (Linsenmeyer et al., 2006).
Signs and symptoms of urinary tract infections are described, and prevention techniques are reinforced with the patient. Additionally, the patient is encouraged to call his or her provider for foul-smelling, cloudy urine (that does not clear with increased fluid intake); blood in the urine; increased spasms; or increased temperature.
If the patient has suffered a spinal cord injury, particularly above the level of T6, autonomic dysreflexia (AD) is discussed. The patient is reminded that the most common cause of AD is a full bladder. The best treatment is to eliminate the cause by catheterizing to empty the bladder as soon as symptoms are experienced (Linsenmeyer et al., 2006). The importance of maintaining a catheterization schedule is reinforced.
As the patient becomes more comfortable with the process of ISC and a relationship is formed with the nurse, questions of a more personal nature regarding bladder management can arise. Practical advice and reassurance are given to the patient regarding situations, such as re-entering the workplace, attending a social function, venturing into a public restroom, or attending an outdoor activity that lacks sanitary facilities. The nurse remains available to answer questions and provide useful suggestions in this adjustment period, as well as refer the patient to other appropriate resources as needed.
Many ISC teaching aids/ resources may be in the form of written or visual materials produced by catheter manufacturers or professional organizations, such as from the Society of Urologic Nurses and Associates (SUNA) (2006). These resources can include pamphlets, charts, or DVDs. Additionally, some continence product companies have services that assist a patient with ordering supplies. Select companies even have applications ("apps") for smart phones that show accessible public restrooms within a geographic area and provide a rating system with regards to cleanliness. Health care facilities and organizations dedicated to a particular group (for example, the Multiple Sclerosis Society [www.nationalmssociety. org] and Spinal Cord Injury [www.spinalcord.org]) offer support groups where an individual can meet with others who have been in the same situation, share advice, and offer suggestions to make their transition smoother.
Learning ISC can be a daunting task for a newly diagnosed patient with a voiding dysfunction. Guidance and instruction from a knowledgeable nurse can make this learning process a positive experience as the patient gains the skill and confidence to successfully perform ISC. A comprehensive teaching strategy, with the optimal goal of the individual regaining bladder independence, can be empowering for both the nurse and the patient.
1. Define intermittent self-catheterization (ISC).
2. Explain the benefits to patients when using ISC rather than long-term indwelling catheterization.
3. Discuss the role of urologic nurses when their patients choose ISC as a means of treatment.
4. Identify key strategies urologic nurses can employ when teaching patients about managing their ISC.
5. List resources for ISC that urologic nurses can share with their patients.
Gould, C., Umscheid, C, Agarwal, R., Kuntz, G., Pegues, D., & the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2009). Guideline for the prevention of catheter-associated urinary tract infections. Retrieved from http://www.cdc.gov/ hicpac/pdf/CAUTI/CAUTIguideline 2009final.pdf
Hudson, E., & Murahata, R.I. (2005). The "no-touch" method of intermittent urinary catheter inertion. Can it reduce the risk of bacteria entering the bladder? Spinal Cord, 43(10), 611-614.
Knowles, M.S., Holton, E.F., & Swanson, R.A. (2011). The adult learner (7th ed.). Oxford, UK: Elsevier.
Lapides, J., Diokno, A.C., Silber, S., & Lowe, B.S. (1972). Clean intermittent catheterization in the treatment of urinary tract disease. Journal of Urology, 107(3), 458-461.
Linsenmeyer, T.A., Bodner, D.R., Creaseu, G.J., Green., B.B., Groah. S.O. & Joseph A. for the Consortium for Spinal Cord Medicine (2006) Bladder management for adults with spinal cord injury: A clinical practice guideline for healthcare providers. Journal of Spinal Cord Medicine, 29, 527-573.
McConville, A. (2002). Patients' experiences of clean intermittent catheterization. Nursing Times Plus, 98(4), 55-56.
Muller, N. (2009). Medicare coverage of catheters. Ostomy Wound Management, 55(3), 10.
National Government Services. (n.d.). LCD for urological supplies (L27219). Retrieved May 24, 2012, from http:// apps.ngsmedicare.com/applications/ Content.aspx?DOCID=21680&CatID& ContentID=34371
Newman, D.K. (2008). Internal and external urinary catheters: A primer for clinical practice. Ostomy Wound Management, 54(12), 18-35.
Newman, D.K., & Wein, A.J. (2009). Managing and treating urinary incontinence (2nd ed). Baltimore: Health Professions Press.
Newman, D.K., & Willson, M.M. (2011). Review of intermittent catheterization and current best practices. Urologic Nursing, 31(1), 12-29.
Society of Urologic Nurses and Associates (SUNA). (2006). Clinical practice guidelines: Adult clean intermittent catheterization. Retrieved from http://www, suna. org/resources/ adultCICGuide.pdf
United States Department of Veterans Affairs. (2007). Letter on intermittent catheterization and the use of sterile catheters [IL 10-2007-018]. Washington, DC: Veterans Administration.
Phyllis Sheldon, MS, RN-BC, CNS-BC, CUCNS, is a Clinical Coordinator, Out-Patient/Procedure Suite, Helen Hayes Hospital, West Haverstraw, NY.
Statement of Disclosure: The author reported no actual or potential conflict of interest relating to this continuing nursing education activity.
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|Title Annotation:||CNE SERIES|
|Date:||May 1, 2013|
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