The management of indwelling catheters for people with multiple sclerosis using bladder irrigation
Pauline Howard, continence advisor, Friarage Hospital, Northallerton
Way Ahead 2003;7(1):8-9
Report of a study undertaken by the author and Lindy Turnbull DN, RGN, BSc.
It is well documented that many people with multiple sclerosis (PWMS) experience bladder dysfunction. There are two distinct types of bladder disorders in MS: over-activity and incomplete emptying. Typical symptoms of an overactive bladder are frequency of micturition, an urgency to void with associated urge incontinence and nocturia. Alternatively, incomplete emptying causes hesitancy when trying to void, a poor stream or dribbling and a sensation that the bladder is not empty. This can lead to recurrent urinary tract infections due to residual urine left in the bladder.
Some patients' urinary symptoms can only be managed with an indwelling catheter, something that poses many questions. For professionals, providing quality care while minimising risk with indwelling catheters can be a difficult balance. For some patients, maintaining good quality of life with a catheter can prove almost impossible.
With the aim of improving quality of life for patients, mostly PWMS, experiencing severe complications from long-term urinary catheterisation, bladder irrigation in the community as a care intervention was developed using the principles of clinical governance. Through close collaboration between primary and secondary care, traditional boundaries were overcome, and patients and carers became involved in a procedure that meets patients' needs, supervised and supported by community staff.
Long-term urethral catheters
Long-term indwelling urinary catheters should be seen as a last resort in bladder management; however, when non-invasive measures have failed, they may be the only practical solution for managing urinary dysfunction in the community or nursing home environment.
Unfortunately, problems are associated with indwelling urethral catheters such as the failure of urinary drainage due to catheter blockage by encrustation. Traumatic for patients and carers (1), symptoms and complications include urinary tract infection, leakage and discomfort from both the catheter and the drainage system.
In 1996 Getliffe (2) outlined best catheter management as that which identifies a "pattern of catheter life" and plans catheter changes that "respond to the needs of the individual". The particular needs of immobile people with catheters have been identified. Norton (3) discusses "inveterate blockers" and Getliffe's 1994 study (4) outlined two groups of patients: 'blockers' who are less mobile and suffer recurrent catheter blockage, and 'non-blockers' who never experience blockage.
In a rural area of North Yorkshire community nurses identified patients who could be classed as 'blockers'. These patients had a history of frequent catheter blockage which required a community nurse visit. The nursing team covers a large geographical area, leading to long waits for patients when a callout response is delayed. Pain and discomfort, stress on caring relationships and increased dependency on professionals resulted. The district nursing team found themselves in a professional dilemma over acting to safeguard the interests of the patient. (5) Only reacting to catheter blockage problems could cause pain and distress for patients, while preventing a blockage meant frequently changing a catheter which appeared to be draining well. Frequent catheter changes are associated with increased infection risks.
A proactive approach was taken to care planning and all aspects of catheter management were reassessed (6). The patient's general health, diet and fluid intake, urine Ph, hygiene, bowel management, type of catheter and drainage system and medication were all addressed. Catheter life cycles and early warning symptoms of impending blockage (4) were identified by maintaining good documentation. Yet a number of highly dependent patients, mostly PWMS, continued to have problems and were being re-catheterised two or three times a week.
Catheter valves were tried with the aim of flushing debris down the catheter (7) but found to be unacceptable or unsuitable for these patients. Bladder installations were tried, even though evidence for their use from previous studies has been inconclusive. The installations made little or no impact on the cycle of persistent blocking and may have contributed to the problem (8). One patient tried supra-pubic catheterisation but even with anticholinergic medication experienced urethral leakage of urine on movement. Another patient declined this type of catheterisation.
All care interventions available in the community seemed to have been exhausted. These patients needed admission to hospital to flush out the debris and stone formation from their bladders using cystoscopy. Admission to acute hospital wards was unsettling for the patients and an extra demand on hospital resources, since these totally dependent patients required special mattresses and hoist equipment as well as intensive nursing time.
Collaboration with the consultant urologist identified bladder irrigation as a way of flushing debris from the bladder thereby preventing catheter blockage. Usually an inpatient procedure, bladder irrigation needed to be undertaken in the patient's home to maximise potential benefits. The following describes the procedure of bladder irrigation.
Definition of bladder irrigation
Bladder irrigation is the continuous washing out of the bladder with sterile fluid (9).
Aim
To remove heavily contaminated material from the urinary bladder.
Objectives
- Prevent the formation of urinary calculi
- Reduce the level of infection in the bladder
- Keep the indwelling catheter patent for an optimum length of time
- Reduce the number of admissions to hospital
- Improve time management of community nurses by reducing crisis and/or out-of hours visits
- Improve quality of life for the patient and their carer
Outcomes
Bladder irrigation works well in the home setting and has resulted in catheters remaining patent for longer periods, in some cases three months. Episodes of symptomatic infection have reduced for one patient and all patients have experienced fewer unplanned catheter changes.
Patients and carers find the procedure appropriate to their routines at home and perform irrigation when suitable for them. Some carers work in partnership with nurses to perform the procedure, while others require minimal support from professionals and enjoy the freedom and autonomy to fit the procedure into their day without waiting for a nurse to visit.
Conclusion
Bladder irrigation in the community was developed to overcome problems for a specific group of patients. It provides a way of managing the risks involved with long term catheters and reduces build up of debris within the bladder thereby increasing the life of the catheter, reducing recatheterisation rates. Quality of life for this group of patients and their carers has improved enormously. Efficiency of care has improved and catheter management can be planned to meet the needs of patients.
Further study may evaluate the potential benefits in a larger group of patients and assess the effect of bladder irrigation in preventing the complications such as bladder stone formation.
Further reading
- Capewell A, Morris SL. Audit of catheter management provided by district nurses and continence advisors. Br J Urology 1993; 71(3):259 -264.
- Department of Health. A first class service - quality in the new NHS. London: Department of Health. 1998.
- Department of Health. Clinical Governance - quality in the new NHS. London: Department of Health.1999.
- Department of Health. Reference guide to consent for examination or treatment. London: Department of Health. 2001.
- Kelson M. Patient defined outcomes. London: College of Health. 1999.
- Roe BH. Catheters in the community. Nursing Times 1989;85 (36): 43.
References
- Pomfret I. Continence: catheter care - trouble shooting. J Comm Nurs 1999; 13(6):
- Getcliffe K. Bladder installations and bladder washouts in the management of catheterised patients. J Adv Nurs 1996; 23(3): 548-554
- Norton C. Nursing for continence. 2nd ed. Beaconsfield: Beaconsfield publishers; 1996.
- 4. Getcliffe K. The characteristics and management of patients with recurrent blockage of long-term urinary catheters. J Adv Nurs 1994; 20(1): 140-149.
- UKCC. Guidelines for professional practice. London: United Kingdom Central Council for nursing, midwifery and health visiting. 1996.
- 6. Simpson L. Indwelling urethral catheters. Nurs Stand 2001;15(46):47-53.
- 7. Addison R. Catheter valves: a special focus on the Bard Flip-Flo catheter valve. Brit J Nurs.1999;8(9):576-580.
- Getcliffe K. Care of urinary catheters. Nurs Stand 1993; 7(44): 31-34.
- Mallett J, Dougherty L, editors. Manual of Clinical Nursing Procedures 5th ed. Oxford: Blackwell Science. 2000.
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