RESEARCH ARTICLES

Clean intermittent catheterization in children with neurogenic urinary bladder: home care by relatives

Suzana Antonio^I; Sandra Teixeira de Araújo Pacheco^II ; Márcia Pereira Fernandes Gomes^III; Adriana Teixeira Reis ^IV; Benedita Maria Rêgo Deusdará Rodrigues^V ; Simone Muniz de Souza^VI

^INurse. Specialist in Pediatrics from the Rio de Janeiro State University. Masters Student in Nursing from the Nursing School of the State University of Rio de Janeiro. E-mail: suzananv@hotmail.com
^IIPhD in Nursing from Anna Nery Nursing School. Associate Professor, Department of Maternal and Child Nursing, Nursing School of the State University of Rio de Janeiro. Brazil. E-mail: stapacheco@yahoo.com.br
^IIIMaster in Nursing. Nurse at the Pediatric Outpatient Clinic of Pedro Ernesto University Hospital. Rio de Janeiro, Brazil. E-mail: marciapfg@hotmail.com
^IVPhD in Nursing. Associate Professor, Department of Maternal Child Nursing of the Nursing Faculty of the State University of Rio de Janeiro. Brazil. E-mail: drireis@iff.fiocruz.br
^VPhD in Nursing. Professor of Department of Maternal and Child Nursing, member of the Faculty of Graduate and Post-Graduate Program in Nursing of the Faculty of the State University of Rio de Janeiro. Brazil. E-mail: benedeusdara@gmail.com
^VISpecialist in Pediatric Nursing. Masters Student in Nursing from the Nursing Faculty of the State University of Rio de Janeiro. Brazil. E-mail: simonsms@ig.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.16493

ABSTRACT

This qualitative study to examine care provided by family members to children with neurogenic bladder needing clean intermittent catheterization at home was conducted at a pediatric outpatient department of a university hospital in Rio de Janeiro City. Data was collected by semi-structured interviews of 12 family members, between January and July 2014. Data were examined using Bardin content analysis, resulting in three categories: organizing the environment and the child for the catheterization; preparing hands to perform the catheterization; and the technique performed by the family member. It was concluded that catheterization is performed according to the technique described in the literature, but certain family members perform some steps of the technique inappropriately. We suggest producing guidance protocols for family members to standardize conduct, and holding support groups for them. Keywords: Neurogenic urinary bladder; child care; family; intermittent urethral catheterization.

INTRODUCTION

Neurogenic bladder is a bladder-sphincter dysfunction of neurological origin, which can cause progressive renal injury if clean intermittent catheterization (CIC) is not performed properly and regularly. This neural injury that triggers all dysfunction can be congenital or acquired. Among the causes of congenital injury, we can highlight the myelodysplasia as the most frequent and spinal cord trauma and tumors as causes for acquired njury^1,2.

Myelodysplasia is commonly found in meningocele and myelomeningocele. Children have varying forms of clinical appearance, but usually have urinary incontinence as the predominant symptom. The urinary tract infections are also common and may reach the kidneys, causing pyelonephritis. In addition to physical observations, the investigation of the social and emotional aspect is important, since these children go through many hospital admissions, outpatient and special care that impose on them different living conditions, which may affect their social life and integration in school, possibly generating change throughout routine and family relationships².

This whole context of the children with neurogenic bladder includes them as members of a new emerging children's group in society, internationally known as Children with Special Health Care Needs (CSHCN) and in Brazil as Crianças com Necessidades Especiais de Saúde (CRIANES), which highlight the social vulnerability and the lack of specific public policies for this population³.

Many of their needs are consequences of the reparative therapy process of their health/disease condition. Children with neurogenic bladder are dependent on care that requires the adaptation of the family and the child and the learning of technical care such as: intermittent bladder catheterization, drug administration of continuous use, among others. In addition, they face difficulties in social interaction and relationships, physical and emotional overload, complications that sometimes require ongoing monitoring in outpatient services or even hospitalizations^4,5.

Despite the special health needs of the child, currently, studies that address the care of family members towards children in the home context are scarce in the scientific literature. In health care to the child, usually the nurse is part of the training process of their families to the achievement of home care. Faced with this problem, this study sought to learn about the care provided by the family to the child with neurogenic bladder at home.

LITERATURE REVIEW

Children with neurogenic bladder are included in the CSHCN group, due to their dependency on some technologies and medications. It is emphasized that they have neuromuscular dysfunction and depend on usual care changes.

The bladder catheter is a continuously used technology for this group of children, through the CIC, as a major tool in the treatment⁶. It allows for the periodic emptying of the bladder by introduction of a catheter into the urethra or in a continent stoma. This practice aims to promote the emptying of the bladder, preventing complications from its exaggerated distension and improving the conditions of the urinary tract⁷.

The CIC, because it is a simple, safe and inexpensive technique, is generally well accepted by the majority of patients with neurogenic bladder and their families. However, there may be some complications if performed incorrectly, such as trauma to the urethra, urethral stricture, bleeding, urinary tract infections, false paths in the urethra, epididymitis and, more rarely, bladder perforations⁸.

The recommendation for realization of intermittent catheterization is every 4 to 6 hours, according to the water balance of the patient, to prevent hyperextension of the bladder and urinary tract infection. To assess the maximum volume of each emptying, one should know bladder and urodynamic capacity of this patient. Still, it is oriented to the family to prepare the voiding diary and also to record any unusual systemic sense that may occur⁹.

It is observed in practice the abandonment of CIC or inadequate technique and, as justification it is mentioned the poor financial conditions in the purchase of material, the child's resistance and no availability of time of the person responsible for the procedure⁸.

METHODOLOGY

This is a qualitative and descriptive approach research, whose scenario was the pediatric clinic of a university hospital located in the municipality of Rio de Janeiro. The participants were 12 relatives of children with neurogenic bladder who met the inclusion criteria, i.e., being a family member of a child with neurogenic bladder who is assisted in that pediatric clinic and conducting care directly with CIC. The project was approved by the Ethics Research Committee of the aforementioned institution, under opinion number: 517 563. Data collection was held from January to July 2014.

To obtain data we conduct a semi-structured interview. To record participants' speeches we used a Motorola mobile device, model RAZR DI. The anonymity of the participants was guaranteed through the use of a pseudonym with the flower name of their choice, and all were informed about the confidentiality of information collected, as well as the right to withdraw their participation at any stage of the research. A copy of the Informed Consent Form was delivered to each participant after reading it together with the researcher and the necessary clarifications were made; we obtained a written consent of each participant, in that term. So that the objective of the study was achieved, we asked: What precautions do you perform with the child carrier of neurogenic bladder towards the clean intermittent catheterization at home?

The treatment of the information obtained during the interview was grounded in thematic content analysis¹⁰, allowing encoding, development, grouping and summary of testimony, resulting in three analytical categories.

RESULTS AND DISCUSSION

Categories emerging from speeches of family members are described below.

Category 1: Organizing the environment and the child for the CIC

The organization of the environment and materials to be used are needed to successfully performing the catheterization. Some family members have highlighted such zeal as an important item in the care of child with neurogenic bladder:

[...] I lay her in the bed, put the towel properly, I have a medical case [...] that has the products, they are all tidy there. (Tulip)

I prepare everything; I leave everything already prepared on the bed in a cloth. (Rosemary)

The participants mentioned the organization of the site and provision of materials prior to the procedure on the bed or a table. In this respect, it is recommended that before performing the CIC, the necessary materials (sterile or clean the probe, the water-based lubricant, soap, clean towel, water and a container for collecting urine if needed) must be drawn together ¹¹.

It is essential that the procedure follows systematic and rigorous criteria for its implementation, for the organization of the site, preparation of materials and the child's hygiene influence the success of the technique. Moreover, we could observe the concern of family members with child care:

I wash [the children] with mild bar soap and water, then I her properly. (Violet)

[...] I wash with chlorhexidine, and saline solution or water, then there I wash her genitals. (Red Rose)

When children who need intermittent catheterization are in the home environment, it is recommended the clean technique, which is a safe resource for patients with neurogenic bladder, confirmed by national and international research. This technique consists, in addition to strict hand hygiene, the cleaning and preparation of the child, who is participant thereof. It must be carried out carefully and correctly¹².

The direction of movement during cleaning with soap should also be taken into account, according to the following speeches:

[...] first out, then underneath the foreskin. (Pink Daisy)

[..] then I take the water and I wipe with cotton, I always wet in water and remove everything: ointment, feces, urine, from top to bottom. (Magnolia)

In females, hygiene should be performed using the thumb and forefinger of the non-dominant hand to separate small and large lips or skin folds covering the vagina and locate the urethral meatus. With parted lips, the area of the urethra should be cleaned from front to back, carefully, with water and mild soap. For males, one should perform cleaning retracting the foreskin, if the penis does not have phimosis, until the complete exposure of the glans, which should be washed with mild soap and water, using a circular motion, from the ends¹¹.

Thus, it can be seen that family members perform this technique in an organized way and with technical principles, as established in the literature ¹¹, adapting the lay care to almost an expert practice.

Category II: Preparation of the hands in order to perform the catheterization

In this second category, family members showed concern about hand hygiene before performing the CIC.

I wash hands with mild liquid soap before it. (Pink Daisy)

I wash hands before everything. And if I use the changing table, I try to wash hands and I clean it with alcohol, then I do things and in the last step I wash hands to take the probe and do it, but sometimes I have already washed hands and forgot the diaper, so I wash hands again. (Magnolia)

First of all, washing hands, I wash hands, then I wash my hands again, then I clean hands with alcohol, 70% alcohol. (Lotus)

The family members' hands play the main role in performing the catheterization. They are essential and must be prepared and sanitized properly. Whereas it is not a sterile technique, clean intermittent catheterization requires that family members perform it with care and attention to hand hygiene. The simple use of water and mild soap can reduce the microbial population and often break the chain of disease transmission, thus preventing urinary infections. Hands should be washed after touching any contaminated material before and after performing any procedure¹³.

However, it is verified that in some situations they mention the use of gloves during the procedure with children:

[...] sometimes, when it is possible, I put the gloves. I put the gloves without dirtying. I don't always use them. Here they taught me to do without the gloves, but they were causing much infection, so when it is possible, I do it with the gloves. (Daisy)

I have worn gloves for a while, then I stopped because the doctor asked to stop because it cause allergy. (Pink Daisy)

Non-sterile gloves. I wore sterile gloves only when I had to do a test or something like that. (Jasmine)

The literature does not support the practice of wearing gloves in CIC. The hand hygiene avoids the use thereof, of any antiseptic or other sterile materials ¹². However, these family members may have received guidance on this requirement, in the hospital, what may come to justify its use. Thus, they seem to transfer what was learned during hospitalization for the care of children at home.

Category III: The performance of catheterization technique by the family member

The respondents' statements pointed to the lubricant use before the introduction of the probe in children.

I use the ointment X, I take a little from the tube, spill a little, then I put a bit directly on the probe, without touching it. (Tulip)

I put the ointment. Every time. I put it on the rubber. I leave it on the paper, the piece of paper of the gauze and I put the rubber. (Violet)

[...] and take the probe and then wrap the probe in my hand, like this, and I put it, before putting the ointment, I throw a little bit away, and then I put in probe. (Azalea)

The speeches indicate the use of the same type of lubricant ointment, which also has anesthetic effect in its constitution. These statements reflect the concern of the family member about not causing any adverse reaction inherent in the procedure, such as trauma to the mucosa and pain in children.

Most water soluble lubricating gel, with anesthetic, promote rapid and profound anesthesia of mucous and lubrication, which reduces friction. They are characterized by high viscosity and low surface tension, providing intimate and prolonged contact of the anesthetic with the tissue, producing long term efficient anesthesia (20-30 minutes) and fast onset of action (within 5 minutes, depending on the application area)¹⁴.

However, it is observed between the lines that one of the family members sometimes does not use the lubricant in the procedure:

[...] I lubricate the probe with ointment X. I use just a little, on the tip, a little bit and ointment on the hand, and I put in the probe. And sometimes I do without it. (Lotus)

The guidance to family members on the use of lubricant prevents injuries in urethral mucosa. One should put a proper quantity of lubricant at the tip and in the first centimeters of the catheter before introducing it¹¹.

The family member must still be guided on the possible adverse effects of excessive use of lubricant with anesthetic. As with any local anesthetic, reactions and complications are avoided by using the lowest effective dose and in children under the 12 years of age. The adverse effects of these lubricants with anesthetics may be acute systemic toxicity and allergic reactions¹⁴.

To enter the probe, it is also needed the full view of the urinary meatus by the family member. For this, there are necessary maneuvers with peculiarities for each sex. The following statements indicate how the family member reported the completion of this procedure:

Then introduce (the probe), I open the genital region and introduce it. (Tulip)

[...] I open the vagina and introduce the probe. (Daisy)

I roll up the penis and introduce the probe. (Sunflower)

The literature recommends that in boys the exteriorization of the glans (if there is no phimosis) is held, exposing the foreskin and urinary meatus. It is necessary to maintain the penis erect with one hand and with the other (preferably the dominant one) slowly insert the lubricated catheter, through the urethra. In girls, it should be used the thumb and hand indicator of the non-dominant hand to separate large and small lips or folds of skin that covers the vagina and locate the urinary meatus. With the dominant hand, one should insert the lubricated catheter, delicately through the urethra¹¹.

It is noteworthy that the genital anatomy of the child as well as small features and delicate structures can be confusing, especially in females. It is not uncommon, during the technique performed by a professional, that difficulties arise in guiding the catheter to the urinary meatus. Thus, the technique can be repeated a few times until one succeeds in the catheterization. This data can contribute to greater exposure of children to occurrence of infections and traumas.

Another potential risk is the catheter knotting in the bladder, due to excess of catheter introduced. Family members recall that this aspect of the technique is fundamental:

I introduce the probe until urine comes out. Then I stop . (Violet)

[...] and I introduce into the urethra. Until about 5cm, then I remove it a little bit, do a back and forth, sometimes I remove it and put again, the same probe. (Lotus)

I put the probe, I count until the number 7, then I stop to put the probe, then I put it until when I stop counting at number 7. (Azalea)

It was observed that there is no single guidance on when to stop inserting the probe, demonstrating the need for standardization of the procedure. The literature shows that in both sexes, the probe should be introduced until the urine starts to flow, after it, the probe must be held in this place. It is warned that one should not move the probe into and out when it meets resistance; one must press it lightly, but firmly, until the probe advances ¹¹. One of the procedures used by the families for the facilitation of the urine drainage probe has been the use of the syringe in order to aspirate the contents:

Right at the very beginning I was doing (the withdrawal of urine) with the syringe, but then the nurse said it could cause damage to her. Then I stopped doing it. (Violet)

[...] I pull the urine with a syringe, I one let it trickle, but it takes too long, I was afraid of something remains, then I'd rather pull the syringe, the 20ml syringe, I pull with the syringe, throw it out; if the syringe is making resistance, I know there is not anything else, sometimes you also have to move a little bit the probe to see if there's more. (Rosemary)

By aspirating the urine via syringe in order to expedite the CIC, the family member may cause minor injury to the inner wall of the bladder. This is caused because the bladder wall touches the catheter orifice causing injuries that facilitate the penetration of bacteria. Lack of sensitivity of some children diagnosed with myelomeningocele further increases the risk of non-perceived injury¹⁵.

After removing the probe, on must decide on its destiny, which must be discarded or prepared for reuse. About this, some family members reported the care they perform to reuse the probe:

We received a paper from the hospital and it was told there that we should get filtered water and boil it, take coconut soap or a mild soap; there was also a solution, it was 1 liter of water and 1 tablespoon of bleach. I would wash my hands properly, I melt the soap, let the solution with water ready, then I would wash under running water, then with soap and water solution, then I would remove with filtered and boiled water and then I would remove all the soap; then I would immerse in the solution with bleach and left there for an hour and then I've washed with filtered water, and then used the syringe to dry it. We did this for about two weeks. Then we stopped to reuse. (Magnolia)

[...] and I put the probe into a butter pot. Then I wash the probe. I use the probe 2 or 3 times. I wash it with detergent in the syringe, I inject the syringe inside the probe, and then I inject mineral water several times, and then I inject air to dry inside and then I put it in a clean container with alcohol. Later, I use it again. (Lotus)

It can be seen in the speeches, different ways to reuse the probe. In this sense, it is recommended to start by washing the catheter, externally and internally, with mild soap and water, and internal cleaning with a 10 or 20 ml syringe; rinsing and drying it with a clean cloth¹⁶. Some authors recommend performing the external washing with soap and water and then rinsing the inside with water, drying with clean towel and keeping in a dry place, inside a clean container^17,18. Other authors recommend washing catheters with soap and water and simmering for 10 minutes ^19,20.

Keeping the catheter immersed in sterile solution is unnecessary and is an attitude that should be discouraged to the family members as it can cause irritation of the urethral mucosa and affect the normal flora, contributing to secondary colonization²¹.

The catheter should be washed with soap and water, rinsed, dried and stored in a suitable bag or even stored on paper towels for the next use²². However, some of the relatives reported not reusing catheters by fear of infection:

No, I tried to do it (reuse) but it didn't work out. (Jasmine)

But in another meeting I learned that I could boil it. But I don't do it! (Rosemary)

The decision to reuse or not the probe is more related to economic than technical purposes, given the current evidence that allow the reuse of catheter in a clean manner. Therefore, it should be evaluated the cost-benefit with families in order to develop strategies to better meet their social needs.

CONCLUSION

Children with neurogenic bladder have demands for specific health care that require family and child adaptation. It has been found through this study that most families have been performing the technique properly. The concern of the family members with essential features to perform the technique was highlighted in the statements, such as the gathering of the necessary materials, the organization of the site, the sanitation of the child and hands, lubricant use, visualization of the urinary meatus, the introduction of the probe, care in drainage of urine and reuse of the probe. However, inadequacies were found in the performance of the technique among certain participants, with respect to the use of abdominal massage and use of syringe to aid the drainage of urine, the use of non-sterile and sterile gloves, introduction of the probe in a little precise way and no use of lubricant.

Limitations of the study included the small number of participants and a unique setting, which prevent the generalization of findings.

It is suggested the production of a guide and/or manual for the family members, with all the guidelines in clear and easy way to understand, for standardizing procedures.

As an educational strategy we also suggest the realization of groups with professionals and family members, to approach them and to perform the guidance in a practical way in order to dispel doubts and fears. We also emphasize the need for more frequent monitoring of these children, to evaluate the procedure and its adequacy to the age and stage of child development.

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