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Clean Intermittent Catheterization in the School SettingElizabeth D. Katrancha, RN, BSN, is an elementary school nurse in Forest Hills School District, Sidman, PA. She is also a master’s degree student in nursing education at Indiana University of Pennsylvania, Indiana, PA
Spina bifida (SB) is a neural tube defect that causes many physical and mental disabilities. Bowel and bladder incontinence is the disability seen most often in these students that requires the school nurse’s attention. Clean intermittent catheterization (CIC) provides the student with SB a vehicle to reach a satisfactory level of continence, helps build self-esteem, and allows the student greater independence. The school nurse assists the student with SB with CIC in the school setting and reinforces the importance of correct technique with the student, family, and other personnel caring for the student. The success of a continence management program at school is dependent on all these individuals working together with the common goal of maintaining normal renal function, gaining urinary continence, and promoting independence of the student.
Key Words: spina bifida • clean intermittent catheterization • school nurse • continence program
Theresa, age 10, registered for school one week prior to the first day. Her mother simply wrote, "spina bifida, wears diapers," on her registration form. The secretary alerted the principal the next day. The principal notified the school nurse (SN) who attempted without success to contact the family prior to the start of school. On the first day of school, a student arrived in the health office at the start of the day, flopped down a package of Depends undergarments and several changes of clothes. She stated, "I’m Theresa and I need to change my pull-up in here." Her Individual Education Plan (IEP) arrived via fax that morning. Theresa was to wear lower extremity orthotics and have a walker to use when ambulating long distances. Theresa arrived at school with neither of these assistive devices.
During a SN’s career, there is a very high probability of encountering a student requiring a continence program that includes clean intermittent catheterization (CIC). CIC is used to protect renal functioning, manage incontinence, or manage a neurogenic bladder; it can successfully reduce incontinence and bacteriuria (Cobussen-Boekhorst, Van Der Weide, Feitz, & De Gier, 2000). The majority of students in the school setting who require CIC are diagnosed with spina bifida (SB), which is a common birth defect. According to the Centers for Disease Control and Prevention, National Centers for Health Statistics, SB affected 19.56 out of 100,000 live births in the United States in 2004. This number was between 25 and 30 per 100,000 live births in the early to mid-1990s; it is these students whom SNs are now caring for in the school setting (Mathews, 2007). "The majority of students in the school setting who require clean intermittent catheterization are diagnosed with spina bifida." Caused by the failure of the fetus’s spine to close properly during the first 28 days of pregnancy, SB is considered a neural tube defect (NTD) (National Institute of Neurological Disorders and Stroke, 2007). Genetic and environmental factors combine to cause SB and other NTDs. Ninety-five percent of children with NTD are born to families with no history of a NTD. Obesity, poorly controlled diabetes, and some seizure medications in the mother have been linked to increased risk of NTD. There has been evidence linking a diet low in the B vitamin folic acid and NTD. The key to increased folic acid in preventing NTD is having enough in the mother’s system before pregnancy and in the very early weeks of pregnancy. Currently, the March of Dimes (2006) recommends that all women of childbearing age take a multivitamin containing 400 milligrams of folic acid every day. According to the March of Dimes Fact Sheet on Spina Bifida (2006), there are three main types of SB. Myleomeningocele is the most common and severe type involving the brain, spinal cord, and its protective covering. There is an opening in the spinal cord through which meninges, cerebrospinal fluid, and neural elements protrude. The opening in the spine is closed surgically shortly after birth; however, some degree of paralysis and bowel and bladder dysfunction remain. In addition, these malformations often result in hydrocephalus, Chiari II malformation, muscle weakness, loss of sensation to lower extremities, cognitive dysfunction, and bowel and bladder incontinence (Schoenmakers, Uiterwaal, Gulmans, Gooskens, & Helders, 2005). The student in the case study was diagnosed with a lumbrosacral level myleomeningocele. She ambulates with a bent-knee gait, has no sensation to inner thighs or buttocks, and is incontinent of bowel and bladder. Meningocele is the least common type of SB and involves a normally developed cord that protrudes through an opening into a cyst or fluid filled sac. If this sac contains meninges and cerebrospinal fluid, it is known as a meningocele. This differs from myleomeningocele in that there are no neural elements protruding (Arts & de Jong, 2004). Surgical closure is used to repair a meningocele and usually results in minimal or no loss of function. Neurological status can deteriorate in an individual with a meningocele because of complications such as tethered cord, Chiari malformation, or hydrocephalus. Surgeons carefully inspect the spinal cord during the closing procedure and transect all adhesions to minimize complications (Arts & de Jong, 2004). The mildest form of SB is occulta; this type of SB involves a malformation of the vertebra and rarely causes symptoms. Often called hidden spina bifida, it is estimated that 15% of these cases go undetected (March of Dimes, 2006).
SB causes varying degrees of paralysis, orthopedic issues, learning disabilities, and bowel and bladder control issues. Bowel and bladder control issues are usually present in the child with SB. The nerves of the spinal cord in the sacral spine levels three, four and five (S3, S4, S5) control sensation to the perineal area. Because these nerves are near the base of the spine, any lesions above the level of S3 will result in bowel and bladder dysfunction (Apparelyzed, n.d.). Goals of urologic care for students with SB revolve around maintaining normal renal function and gaining urinary continence (Joseph, 2001). CIC improves continence, decreases infections related to incomplete bladder emptying, provides the student with control over continence, and can improve body image, self-esteem, and peer relationships (Cobussen-Boekhorst et al., 2000). Management of urinary continence depends on the level of the spinal lesion, bladder control, and individual preference (Segal, Deatrick, & Hagelgans, 1995). Some individuals choose to use overflow voiding into incontinence products, whereas others seek out surgical augmentation of the bladder. Successful treatment of bowel and bladder incontinence requires an individualized approach and has evolved during the past 10 years. There are several new thoughts and techniques in augmentation. Each technique is tailored to the individual with great success (Thakur, Bangar, Kumar, & Karmarkar, 2007). The lack of innervation to the bladder necessitates the student with SB have some type of continence program. The most common nonsurgical program is CIC.
According to Kari (2006), CIC has had a positive impact on managing all types of neurogenic bladder conditions. CIC is the best way to preserve renal functioning by keeping the bladder empty and free of infection. As the name implies, CIC is a clean, not sterile procedure. Catheters are cleaned and reused, sterile gloving is not needed, and the urethral opening is cleaned with soap and water or some other nonalcohol-containing wipe. Done every 4 to 6 hr while awake, this procedure may result in periods of urinary continence for the student with SB. CIC is necessary for complete bladder emptying in students with SB. Incomplete emptying or overflow voiding can result in undesirable outcomes such as hydronephrosis, urinary tract infection, pyleonephritis, or renal failure. Overflow voiding into incontinence products can produce unwanted odor and the need to use bulky incontinence products that may cause the student embarrassment and shame. According to Verhoef and colleagues (2007), students with SB reported poorer perceived health than a reference group. This study showed a large deficit in perceived health related to walking and self-care ability. Self-care ability includes toileting issues. Equipment necessary for CIC is listed in Table 1. In addition to a private place to perform the procedure, it is necessary to have a sink for hand washing and a toilet or container to collect urine. Using a mirror will help the student visualize the urethral opening, especially in females. As the student becomes more comfortable with his or her anatomy, remove the mirror to allow the student to learn the location of the urethral opening by touch. The ability to catheterize by touch increases the student’s ability to self-catheterize in any setting. Also important is teaching the student the proper procedure to clean and store the catheter between uses. CIC, when performed independently by the student, can be done in any restroom with little interruption to the student’s daily routine.
Family Role Families play a key role in CIC. Ideally, a student with SB requiring CIC should come into the school setting with a strong knowledge of CIC and maximum independence appropriate for age. Many students arrive in the school setting requiring only minimal support from the SN. However, other students with SB arrive in the school setting having never begun a continence program or having been completely cared for by a well-meaning parent, not allowing the student to participate in self-catheterization. The reasons why a continence program is not in place are varied; it may not be medically necessary, parental fear or neglect, student fear, or noncompliance. Cultural and religious beliefs may also contribute to parental and student attitudes about CIC. Regardless of the reason, the SN needs to obtain family support to move forward or continue with a continence program. The SN should seize opportunities to discuss the benefits of CIC, including expense, convenience, and independence. The SN should also consider how CIC is handled in the home setting, including time of day and how CIC is handled on family outings.
School Nurse Role Most students with SB receive care from a spina bifida clinic (SBC). SBCs are found throughout the United States. They bring together health care specialists from neurology, neurosurgery, nursing, ophthalmology, orthopedics, pediatrics, physical and occupational medicine, and urology. The goal is to use a team approach for the management of the student with SB to achieve maximum independence and self-care. The SN should find out which clinic the student uses and ask the parent to have a copy of the most recent clinic visit notes forwarded to the school. Some families may have a copy in their possession that they can share immediately. The SN may also request that parents sign a consent-to-share-information form that can be faxed or mailed to the clinic so that future clinic notes will be shared with the SN automatically. Theresa received care from a clinic approximately 2 hr away. Her clinic notes from a visit during the summer arrived during the second week of school. When the SN first meets with the family and student, a complete health history should be obtained to provide the student with the best care during the school day. Obtain a past medical history, including orthopedic surgeries, latex allergy, and presence of hydrocephalus, shunt, and last shunt revision. The SN should ensure a private location for this interview and maintain a nonjudgmental attitude. If SBC notes are available, they will serve as a guide during the history-taking process. Ask the student to describe where he or she does not have sensation on his or her body. Review with the student and family all assistive devices the child may use, such as wheelchair, walker, crutches, or orthotics. Theresa was to have bilateral lower extremity orthotics and a walker. However, she arrived at school with neither of these. Her mother did have prescriptions for these; therefore, the SN assisted the family in locating a medical supply company and obtaining the necessary assistive devices. The interview should next focus on toileting issues by asking the parent and child to detail the current bowel and bladder regimen. The bowel regimen may consist of increased fiber, laxatives, or enemas, and needs to be managed in the home. The urinary continence management program specifics should be gathered at this time by asking if the student uses CIC for bladder emptying or has some other type of continence care. If there is no program in place, determine the reason why by asking the family and student and reviewing the SBC notes. This line of questioning needs to be nonjudgmental and nonthreatening to the student and family. It is important to make the student and family feel comfortable with the care level provided by the SN. A judgmental attitude by the SN may hinder cooperation. Personal, religious, and cultural beliefs concerning CIC and incontinence vary among students and their families. Probing these feelings and beliefs assists the SN in understanding of the position taken on self-catheterization. If a CIC program is used, the SN should ask about the current regime, including frequency of catheterization, and type of catheter, its reuse, cleaning, and storage between uses. Explore the position most comfortable for CIC (i.e. prone, squatting, sitting on the toilet seat, or sitting on the edge of the wheelchair). The mobility of the student will usually influence the position the student best tolerates. Talk with the family about the procedure used to cleanse the labia or penis and type of cleansing agent used; disposable alcohol-free wipes are generally used in the school setting. Tactfully ask about the level of student participation in the procedure and the family’s wishes for the student’s independence. Some parents do not wish to have their child participate at all in the CIC procedure, and the SN must be respectful of their decision. However, the SN should encourage independence without being forceful. Students who are participating in a CIC procedure can verbalize what their level of participation is and how they feel about it. Reassure the student that the SN will offer support, privacy, and confidentiality at all times. Students who claim independence with CIC may still have days when assistance is required. Students must be confident that the SN will be available to help as needed. This may be difficult for the SN with the multiple demands or schools. If the SN cannot be physically available, it may be necessary to delegate the task to unlicensed assistive personnel (UAP). This need to delegate must follow individual state nurse practice act guidelines and school policy. If the procedure is to be delegated to a UAP, this should be discussed with the family. The SN and the UAP need to be aware of what time the independent student catheterizes and ensure that the SN or UAP will be available at that time. The UAP needs to be adequately trained and supervised by the SN in CIC techniques and signs and symptoms of complications (Gursky & Ryser, 2007). The SN may wish to provide the UAP and family with the decision tree in Figure 1. This decision tree will guide the actions of the SN, UAP, or family if complications arise.
Students catheterized by a caregiver with little or no self-participation require more of the SN’s attention. Taking into consideration parental wishes, make each CIC session into a learning opportunity. The SN should take the time to describe each step of the procedure to the student each time it is done. Use correct anatomical terminology and deliver the information in a concise, matter-of-fact manner. As the student matures emotionally and physically, gradually increase responsibility over months or years until the student self-catheterizes with minimal assistance. Again, the SN should take into consideration the necessity of using a UAP to provide this assistance to the student with SB. "Theresa’s mother was not willing to begin a clean intermittent catheterization program. She stated that the spina bifida clinic had wanted her to do this but that she thought it was ‘gross.’" Students who present to the SN who have not been introduced to a continence program present the biggest challenge for the SN. When facing this situation, the SN must prepare for small advances, large setbacks, and high levels of frustration. The nurse must deal positively with his or her own frustration, the frustration of the student, and family. Remember, what is being taught today will allow the SB student greater independence in the future. Theresa fits into this category. Never introduced to a continence program, she overflow voids into an adult diaper. Teaching her CIC reduces odor, urinary tract infections, decreases costs, and allows her a greater amount of independence (Cobussen-Boekhorst et al., 2000). So, where does the SN start when faced with this challenging problem? The SN must first develop a relationship with the student and family. Inform them of your willingness and desire to increase the SB student’s independence. When the family or student begins to verbalize the desire to begin a continence program, the process of supporting and assisting the student and family in obtaining instruction in CIC begins. During the third week of school, Theresa’s mother came to meet with the SN, guidance counselor, classroom teacher and special education supervisor. The reason for the meeting was to update Theresa’s IEP and obtain more information about her health status. The SN had spoken on the phone with Theresa’s mother several times and had begun a therapeutic relationship. Theresa was falling frequently and was unwilling to change her pull-up during the school day. The other students were avoiding contact with Theresa because of the odor of urine. Through reading the SBC notes, the SN was aware that the urology department had recommended a CIC program for Theresa. Catheterization was discussed during this meeting. Theresa’s mother was not willing to begin a CIC program. She stated that the SBC had wanted her to do this but that she thought it was "gross." The SN spoke with her about Theresa’s development and the need for independence. The financial burden of using incontinence products was discussed. White and Williams (1992) state that "incontinence is unhealthy, socially unacceptable and expensive, and it is a problem that can usually be successfully dealt with" (p. 476). All of these issues were discussed in a nonthreatening manner. Theresa’s mother needed to know that the SN had Theresa’s best interests in mind. Several days after the meeting, Theresa’s mother came to the school and stated she reconsidered and would like to start a continence program, if the SN would help. The SN helped Theresa and her mother devise a plan. "As the student matures emotionally and physically, gradually increase responsibility over months or years until the student self-catheterizes with minimal assistance." The first step is to advise the parent to contact their SBC for instruction in CIC. The SBC will also be able to arrange for a medical supplier to ship the needed supplies to the student’s home. SBCs are experts in teaching CIC and are in the best position to provide initial instruction to a student with SB in the technique of CIC. The SBC will also provide the SN with a physician order for CIC in the school setting. The SN can help the family arrange appointments with the SBC for CIC instruction. The SN must be prepared to support and reinforce the CIC procedure with the student and family. The SN will need to devote time to provide reinforcement and support despite other time constraints. During the immediate postlearning period, the SN can reinforce the teaching with the parent and student along with any UAP that may be assisting the SN. A strong relationship with the SN may be the catalyst to independence for the student. After the teaching session at the SBC, a physician order is obtained, supplies are ordered, and a schedule for catheterization-in-school needs is developed. Get input from the teacher and student about time considerations related to the procedure. Generally, CIC needs to be performed at least four times daily, twice during the school day. The first procedure should be mid-morning and the second midafternoon. The specific time should be coordinated with the classroom teacher to minimize the loss of instructional time. Discuss with the teacher the reasons for CIC and the positive affects it can have on a student’s independence. Having a supportive, cooperative classroom teacher can enhance the student’s success at CIC. Another consideration in the schedule is proximity. Students with SB expend a good deal of energy moving about, whether ambulatory, in a wheelchair, or using a walker or crutches. If the student must travel a great distance to the health office, he or she may be too exhausted to participate in CIC, so try to choose a time when the student is close to the health office. Elementary school students are in one classroom the majority of the school day. They generally only travel to other parts of the building for lunch and special classes such as art, music, library, and physical education. If those special classes are nearer the health office, suggest that the student leave class a few minutes early for catheterization instead of making an extra trip. If the school health office does not have adequate privacy or space, the SN should discuss this need with school administrators and locate an area that would be appropriate to complete the catheterization procedure. The SN may need to be creative in locating an appropriate area if the health office is not adequate. Is there a handicap-accessible restroom that is not frequented by other students during the school day, and if so, could it be closed when the student with SB needs to use it? After the supplies have arrived and the initial instruction has been provided, invite the caregiver who will be assisting with the CIC at home into the health office to reinforce the program. The SN may want to review key teaching points of the procedure found in Table 2 with the student and caregiver.
The SN should be prepared to offer a great deal of guidance during the first attempt at CIC in the school. The SN should applaud the student and caregiver for their efforts and encourage continued practice. Invite the caregiver back to practice at school until comfortable to begin the procedure at home. At this point, the SN should begin the CIC schedule on a routine basis. The student should continue to wear incontinence products until a pattern of dryness is established. The CIC schedule should be adjusted to allow for maximum periods of dryness. If the student is incontinent prior to catheterization, then the time between CIC needs to be shortened by 10 min each time. If the student is remaining dry between CIC, then the time between catheterizations can be lengthened by 10 min each time until the length of time that provides the optimum continence is reached. Some students with SB will have greater success than others depending on bladder size and amount of bladder spasticity. It may be many weeks, months, or even years until the student is independent with CIC at school. The SN must be patient, consistent, and positive with the student and family. The SN should reinforce the positive aspects of CIC and support the student and family as they learn this procedure. Many students with SB will wish to continue to use the health office and the assistance of the SN or UAP. The student may eventually be independent enough to use the regular restroom. However, because of the desire for privacy, most students choose to continue to use the health office throughout their school careers. Another area of concern for the student with SB is school trips. The school district must provide a nurse or UAP to accompany the student with SB to assist with CIC unless a parent is available and desires to accompany the student on the trip. The school cannot require the parent to accompany the child or deny the child access to the trip. Address school trips in the student’s IEP. The SN should contact the facility where the student will be going and discuss the accessibility to a handicap-accessible restroom. If the student with SB is wheelchair bound, special transportation will also be needed. The SN can request that the parent pack travel supplies including an extra catheter and changes of clothing to accompany the student on the trip, but the SN should be prepared to provide these items if the parent does not do so.
Students with SB and their families come into the school setting in many different ways, with many different backgrounds, and a multitude of needs. The common need for the majority of these students is CIC on a daily basis. Regardless of dependency level, these students rely on the SN to assist and support them on the road to independence. The SN must be knowledgeable, nonjudgmental, and supportive of these students and their families. Reinforcing and participating in CIC takes time and commitment from the SN, student, and family. Development of a strong therapeutic relationship increases the likelihood of success. The family, student, teacher, SN, and UAP must work together to make the CIC program successful. Theresa began the CIC program at school and at home. Several months into the program, she has had some success at self-catheterization but continues to need the SN and her mother to assist her. There are times when her mother becomes frustrated and gives up. Reinforcement, praise, and encouragement needs to be communicated to Theresa and her mother on a regular basis. Theresa now remains dry between catheterizations and reports feeling that CIC has given her freedom and normalcy. The classroom teacher reports that Theresa is developing positive peer relationships and has increased self-esteem. Theresa appears to have a new sense of pride in her appearance and shows a higher sense of self-worth.
Apparelyzed, What is a spinal cord? n.d.Arts, M, & de Jong, T. (2004). Thoracic meningocele, meningomyelocele or myelocyctocele? Diagnostic difficulties, consequent implications and treatment. Pediatric Neurosurgery, 40, 75-79[CrossRef][Medline] [Order article via Infotrieve]Cobussen-Boekhorst, J, Van Der Weide, M, Feitz, W, & De Gier, R. (2000). Using an instructional model to teach clean intermittent catheterization to children. British Journal of Urology International, 85, 551-553Gursky, B, & Ryser, B. (2007). A training program for unlicensed assistive personnel. Journal of School Nursing, 23(2), 92-97[CrossRef][Medline] [Order article via Infotrieve]Joseph, DB. (2001, June). SBA fact sheet: Urologic care and management 2001. Retrieved November 9, 2007, from the Spina Bifida Association Web site: http://www.sbaa.org/site/c.gpILKXOEJqG/b.2021229/k.238B/UROLOGIC_CARE_AND_MAN-AGEMENT_2001.htm.Kari, J. (2006). Neuropathic bladder as a cause of chronic renal failure in children in developing countries. Pediatric Nephrology, 21, 517-520[CrossRef][Medline] [Order article via Infotrieve]March of Dimes. (2006, April). Quick references and fact sheets (spina bifida). Retrieved November 6, 2007, from the March of Dimes Web site: http://www.marchofdimes.com/printableArticles/4439_1224.asp.Mathews, TJ. (2007, January 11). Trends in spina bifida and anencephalus in the United States, 1991–2004. Retrieved November 18, 2007, from Centers for Disease Control, National Center for Health Statistics Web site: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/spine_anen.htm.National Institute of Neurological Disorders and Stroke. (2007, November 13). NINDS spina bifida information page (What is spina bifida?). Retrieved November 18, 2007, from the National Institute of Neurological Disorders and Stroke Web site: http://www.ninds.nih.gov/disorders/spina_bifida/spina_bifida.htm.Schoenmakers, M, Uiterwaal, C, Gulmans, V, Gooskens, R, & Helders, P. (2005). Determinants of functional independence and quality of life in children with spina bifida. Clinical Rehabilitation, 19, 677-685
The Journal of School Nursing, Vol. 24, No. 4,
197-204 (2008)
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Abstract
CASE STUDY