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Principles of patient assessment

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Urology continence nurse specialist Frances Roberts discusses things to keep in mind when deciding whether a patient is suitable for intermittent self catheterisation.

Intermittent self catheterisation (ISC) can give personal control over bladder function and promote independence. It is the preferred method of bladder emptying for motivated patients with good dexterity (Association for Continence Advice, 2007) and can be taught to anyone from the age of 4-5 years (with parental consent and support). Health professionals should be aware of the Convention on the Rights of the Child (UNICEF, 1989).

Patient selection

Patient criteria for successful ISC are listed in Box 1. Patients must have their post micturition residual urine measured; a volume of 100ml or more indicates the bladder is not emptying adequately. The Royal College of Nursing (2008) suggests the decision to use ISC should not be based solely on the residual urine volume and it is essential the cause is identified. Some urologists recommend urodynamic studies for patients with suspected bladder emptying problems who may require ISC (Chapple and Christmas, 1990). A decision to start ISC must be made in consultation with the patient’s GP or consultant.

Box 1. Criteria for successful intermittent self catheterisation

Patients must:

  • Be well motivated
  • Have good cognitive skills
  • Have good manual dexterity - the ability to hold the catheter with enough strength to insert it
  • Have good physical ability
  • Have the ability to visualise the urinary meatus
  • Be able to follow verbal instructions
  • Be able to read/understand written instructions
  • Be aware of the problems associated with ISC
  • Understand how to avoid associated problems such as urinary tract infections

Assessment

The success of ISC depends on the patient’s understanding of, and willingness to be responsible for, regular bladder emptying. Physical and psychological effects of learning the procedure must also be considered. Any patient concerns as well as the psychological impact of treatment must be explored and addressed in an initial assessment.

Many patients are uncomfortable with the idea of touching an intimate part of their body and women are often embarrassed by their lack of knowledge of their anatomy. Patients often worry that ISC will be painful and they might injure themselves while inserting the catheter. Assessment for suitability must therefore be approached with sensitivity, understanding and compassion to reduce feelings of embarrassment and discomfort.

Adequate time must be allocated in a safe, private environment so a trusting professional relationship can be established. A good understanding of patients’ specific needs is vital and these must be addressed to achieve a successful, positive outcome. This will help ensure patients are motivated and improve adherence to treatment (RCN, 2008; Skills for Health, 2007).

Dexterity

Fowler (1998) suggests that people who can write and feed themselves usually have adequate dexterity to self catheterise. Blindness, tremour, reduced perineal sensation, learning disability and paraplegia do not automatically exclude patients from using ISC. Other considerations are outlined in Box 2.

Box 2. Main considerations

  • Cultural sensitivities
  • Religious needs
  • Female genital mutilation - this occurs mainly in Africa, the Middle East and parts of Asia
  • Patients’ past experiences
  • Sexual dysfunction
  • Practicalities of carrying out intermittent self catheterisation at home - some patients may need extra equipment while, for those unable to self catheterise, it may be worth exploring whether an appropriate carer could be taught the procedure

Source: ACA (2007)

Nurses’ skills

Patients who undertake ISC must be committed and should never agree to the procedure because they feel bullied into it. Some may give up ISC because they find it unacceptable, have a low tolerance to change or because of a deterioration in their general health status. It is vital nurses have the right skills to assess patients and teach ISC to ensure complete safety of the patient, and achieve a positive outcome and improved quality of life (Robinson, 2007).

Frances Roberts, DNCert, DPSN, RGN, is urology continence nurse specialist, University Hospitals Birmingham Foundation Trust

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