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Clinical Consultation: How Do We Teach Clean Intermittent Self-Catherization Using Touch Technique?
Situation: I have been teaching clean intermittent self-catheterization (CIC) to a patient who is nearing discharge. She has had trouble performing self-CIC because she cannot easily visualize her genital area using a mirror when she is lying in bed or sitting in her wheelchair. Are there any techniques that could assist her after discharge so that she can be more independent in the community?
Consultation: Margaret E. “Margi” Williams, MSN CRRN APRN-BC FABDA, staff nurse at Children’s Healthcare of Atlanta, Atlanta, GA, replies:
As rehabilitation nurses, we are all familiar with catheterizing female patients in bed. Many women are taught to do clean intermittent catheterization (CIC) on themselves lying in bed and using a mirror (Crowe, 2003; Intagliata & Allen, 1986; Lapides, Diokno, Silber, & Lowe, 2002; Segal, Deatrick, & Hagelgans, 1995).
A barrier to self-CIC is anatomical variation. Some females who are obese, for example, are not able to use a mirror to visualize themselves well enough to perform self-CIC (March, Romero, & Williams, 2004). Obese women are not the only individuals to have problems with self-CIC, however. To be able to participate fully in life and to accommodate variable schedules, women must be able to accomplish self-CIC in many different settings. In most of these settings, a bed or something to lie on is not available. As one individual has said, “I can’t carry a bed around in my car!” In addition, the design of the typical community toilet stall makes using a mirror almost impossible because there is nowhere to place the mirror to visualize the urethral opening. This is especially problematic for individuals who perform self-CIC while sitting in a wheelchair.
A solution to these problems is to teach the patient how to do self-CIC using the touch technique. Many women eventually figure out on their own how to catheterize themselves using a touch technique. However, they should not have to learn the technique through trial and error when it could be taught in the rehabilitation setting (March, Romero, & Williams, 2004).
Teaching a woman how to do touch-technique self-CIC is easy. Explain to the patient that you are going to teach her how to catheterize herself using touch technique and that using touch technique will facilitate her doing self-CIC while sitting. Explain that this technique will allow her to conduct a more normal life after discharge because she will not have to wait to find a place to lie down to self-catheterize.
To begin the teaching, have the woman lie in bed with the head of the bed raised. Place a mirror between the patient’s legs so she can see her genital area. Then, while she watches in the mirror, point out the clitoris, the vaginal opening, and the urethral opening. Next, help the woman use her fingers to find both the clitoris and the vaginal opening. Have her place one finger over the clitoris and another finger over the vaginal opening (Figure 1). Then, help her to use these two fingers as guides to find the urethral opening. For example, with a finger placed horizontally over the vaginal opening, the urethral opening might be just above that finger, or it might be two fingers’ width above. Finally, help the woman to use her fingers as guides to catheterize herself. This technique involves experimentation, problem solving, and practice because the position of the urethra between the clitoris and the vaginal opening varies greatly (March, Romero, & Williams, 2004).
When the woman is comfortable using touch technique sitting up in bed, teach her to use the touch technique to catheterize herself while sitting in a wheelchair. One way to teach this is to have the woman position her wheelchair in front of a toilet. Have her pull down her pants and flex her hips forward. Then have her place her feet, with the soles of the feet together, on either the back or the front of the toilet. In this position, the knees will be relaxed outward, allowing for access to the genital area. The woman should then be able to perform the self- catheterization using the touch technique (March, Romero, & Williams, 2004).
A modification of the touch technique is the tunnel technique (Figure 2). This modified technique may be useful in several instances, such as when using the touch technique may be difficult because of problems reaching or when self-CIC needs to be performed using one hand.
The principle behind the tunnel technique is simple. When a woman is in a sitting position with the hips flexed forward, the labia minora are close together forming a natural tunnel leading to the urethral opening. While in this position, the woman needs to only slightly separate the labia near the area of the clitoris and insert a catheter at that point. With the labia together, the catheter will be guided naturally toward the urethral opening as it is advanced. The woman also will need to angle the catheter backward as it is guided between the labia to facilitate its insertion into the urethral opening. Some women may need to place a finger over the vaginal opening so that the catheter does not go too far. Others may find that the tunnel technique is easier when the catheter is inserted on one side of the clitoris rather than the other. Using this technique takes practice and problem solving, but it works well (March, Romero, & Williams, 2004).
An advantage of teaching a woman how to perform clean intermittent catherization using the touch technique or the tunnel technique is that minimal supplies are needed. For example, there is no need for a mirror or a transfer board to hold the mirror. Since these catheterization techniques require little equipment, supplies can be placed in a pouch inconspicuously placed on the frame of the wheelchair underneath the seat. Of course, the biggest advantage of teaching your female patients these techniques for self-CIC is that these techniques will facilitate their return to work, to school, or to other activities within the community (March, Romero, & Williams, 2004).
About the Author
Margaret E. “Margi” Williams, MSN CRRN APRN-BC FABDA, is staff nurse at Children’s Healthcare of Atlanta at Scottish Rite, Atlanta, GA. She may be reached at firstname.lastname@example.org.
Crowe, H. (2003). A guide to clean intermittent self-catheterization: Clinical update [Electronic version]. Australian Nursing Journal, April, 2003.
Intagliata S., & Allen, K. (Eds.) (1986). Spinal cord injury: A guide to functional outcomes in occupational therapy. Rockdale, MD: Aspen Publishers, Inc.
Lapides, J., Diokno, A.C., Silber, S.J. & Lowe, B.S. (2002). Clean, intermittent self-catheterization in the treatment of urinary tract disease. Journal of Urology, 167, 1131–1133.
March, K., Romero, T., & Williams, M. (2004). Pediatric approach to bowel and bladder management following spinal cord injury. Paper presented at the annual conference of the Association of Rehabilitation Nurses, Atlanta, GA.
Segal, E.S., Deatrick, J.A., & Hagelgans, N.A. (1995). The determinants of successful self-catheterization programs in children with myelomeningoceles. Journal of Pediatric Nursing, 10(2), 82–88.