VOL: 98, ISSUE: 48, PAGE NO: 51
Ann Winder, RGN, continence adviser, Park Drive Clinic, BalldockIntermittent self-catheterisation (ISC) is an extremely intimate technique and those teaching it must be aware of both verbal and non-verbal behaviour by patients throughout the procedure. The instructor needs to be empathetic, supportive and skilled in the technique, as the patient faces a change in both lifestyle and body image. Psychosexual awareness means being alert to any sexual anxieties the patient may have.
Intermittent self-catheterisation (ISC) is an extremely intimate technique and those teaching it must be aware of both verbal and non-verbal behaviour by patients throughout the procedure. The instructor needs to be empathetic, supportive and skilled in the technique, as the patient faces a change in both lifestyle and body image. Psychosexual awareness means being alert to any sexual anxieties the patient may have.
The frequency of ISC depends on the individual needs of the patient. A useful guide is based on the measurement of voided volumes and residual urine at each episode of catheterisation:
- When planning the number of times a patient needs to catheterise the urinary volumes plus residual should not be greater that 500ml at each catheterisation;
- If a patient does not void at all the total bladder capacity should not exceed 500ml between catheterisations;
- In some high-risk patients or those with a history of urinary tract infection (who void but leave a residual) it is not advisable to exceed a residual of 100ml between catheterisations, as this potentially leads to recurring urine infections.
- If patients are wet between catheterisations they may require catheterisation more frequently. If they also have some detrusor instability they may require ISC plus anticholonergic medication.
It is vital that a comprehensive fluid chart is maintained for at least two weeks to ensure that a correct and safe management plan can be implemented. The aim is to help patients to understand how the technique and their lifestyle (fluids, diet, exercise, daily living) influences their bladder function and patterns. The aim is to ensure that their bladder problem and its management should not dominate their lives.
A urinary diary can be used to collect simple, standard and detailed data and is an essential integral part of establishing safe bladder care for the patient performing ISC (Abrams et al, 1998).
Before introducing the technique to the patient it is important to consider how the patient will manage at home, in residential care or in hospital. It is very important to consider practicalities in the patient's home/living environment. A programme for teaching ISC is illustrated in Box 1.
It is essential that patients can choose their own brand of catheters. The differences between catheters may seem small, but this can be a determining factor for the user regarding comfort and compliance. Nurses need to consider what influences their choice and their patient's choice of product and be able to justify their decisions (Addison, 2000). There are now large ranges of self-lubricating hydrophilic catheters. These are for single use, as the lubrication reduces with subsequent use. It is important to follow the standards set by the Medical Devices Agency (2000).
There is evidence that there is a reduction in urinary tract infections associated with ISC. It has been found that in those who have bacteriuria, 50% is due to Escherichia coli (Bakke and Digranes, 1991). In the majority of cases the bacteriuria is asymptomatic and treatment with antibiotics is not recommended.
Cranberry juice has been reported to reduce bacterial colonisation of the bladder (Avorn, 1994). It is suggested that patients performing ISC can benefit from drinking two to three glasses a day.
During the period of learning this technique, and especially with patients who have a history of UTI and other medical conditions, it may be prudent to give a course of trimethoprim. However, this should not be regarded as routine practice, but based on individual patient assessment (Gruneberg, 1996).
ISC is often abandoned due to poor patient compliance. This is generally related to either the patient finding the technique unacceptable or by a patient's low tolerance to change in lifestyle.
Ideally, this should have been discussed during the original consultation. It is vital that the patient is committed and, although the instructor can use firm persuasion, the patient should never feel bullied into performing ISC.
ISC has been shown to be very beneficial to patients, not only medically but also in respect of quality of life. However, it remains essential that health care providers are conversant with the complex needs and skills required when teaching ISC, thus ensuring safety in the care and management required for these patients.