Clean intermittent catheterization in patients with spinal cord injury: knowledge of nurses HOW TO CITE

Introduction: Spinal cord injury results in failure to empty the bladder, leaving the individual exposed to the risk of recurrent urinary tract infection, vesicoureteral reflux and even loss of renal function. Clean intermittent catheterization (CIC) is the method of choice for emptying the bladder in these cases. Although it has a simple technique, its performance should be well oriented in order to avoid complications such as infections or traumas. Guidance for the technique should be performed during the hospitalization period due to the injury and the nurse is responsible for this action. Objective: To evaluate the knowledge of nurses working in a trauma care hospital in relation to clean intermittent catheterization. Methods: Questionnaire constructed based on the guidelines of the European Association of Urological Nurses, applied to 18 nurses from a university hospital, a reference in the treatment of spinal trauma, regarding neurological dysfunction of the lower urinary tract and clean intermittent catheterization. Results: The participants presented expressive knowledge about lower urinary tract neurological dysfunction and CIC. There were errors regarding the CIC technique in the indication of the use of procedure gloves, in the lubrication of the catheter, collection of periodic urine cultures, use of antibiotics and in the need for instructions before discharge from hospital. Conclusion : Although the sample demonstrated knowledge on several issues related to the subject, the errors indicate the need for training and especially awareness of the responsibility of guidance before discharge from hospital. simple, su rendimiento debe estar bien orientado para evitar complicaciones como infecciones o traumatismos. La guía para la técnica debe realizarse durante el período de hospitalización debido a la lesión y la enfermera es responsable de esta acción. Objetivo: Evaluar el conocimiento de las enfermeras que trabajan en un hospital de atención de traumas en relación con la cateterización intermitente limpia. Métodos: Cuestionario construido sobre la base de las directrices de la Asociación Europea de Enfermeras Urológicas, aplicado a 18 enfermeras de un Hospital Universitario, una referencia en el tratamiento del trauma espinal, con respecto a la disfunción neurológica del tracto urinario inferior y el cateterismo intermitente limpio. Resultados: Los participantes presentaron conocimiento expresivo sobre la disfunción neurológica del tracto urinario inferior y el cateterismo intermitente limpio. Hubo errores con respecto a la técnica CIL en términos de indicar el uso de guantes de procedimiento, en la lubricación del catéter, la recolección de urocultivos periódicos, el uso de antibióticos y la necesidad de orientación antes del alta hospitalaria. Conclusión: Aunque la muestra demuestra conocimiento sobre varios temas relacionados con el tema, los errores indican la necesidad de capacitación y especialmente la conciencia de la responsabilidad de la orientación antes del alta hospitalaria.


INTRODUCTION
Nurses feel every day the need to develop their scientific knowledge in search of answers to health problems in order to achieve excellence in care 1  The steps to be followed are hygiene of the genital area and hands and lubrication and introduction of the catheter 8 . The independence in performing the procedure may not be achieved by patients with high injuries, but the possibility of improved motor function, i.e., improved hand mobility, arises after the first year diretrizes da Associação Europeia de Enfermeiros Urológicos, aplicado a 18 enfermeiros de um hospital universitário, referência no atendimento do trauma raquimedular, a respeito de disfunção neurológica de trato urinário inferior e cateterismo intermitente limpo. Resultados: Os participantes apresentaram conhecimento expressivo a respeito da disfunção neurológica de trato urinário inferior e CIL. Houve erros quanto à técnica do CIL nos quesitos de indicação do uso luvas de procedimento, na lubrificação do cateter, coleta de culturas periódicas de urina, uso antibióticos e na necessidade de orientação antes da alta hospitalar. Conclusão: Apesar de a amostra demonstrar conhecimento em várias questões relacionadas ao tema, os erros indicam necessidade de capacitação e principalmente de conscientização quanto à responsabilidade de orientação antes da alta hospitalar. DESCRITORES: Cateterismo urinário; Educação em saúde; Enfermeiro; Estomaterapia.
Although it is the method of choice for bladder emptying and prevention of complications of NLUTD, CIC is not free of complications. Even with a relatively simple technique, it needs to be performed in a systematic way; for this, the patient must be trained by the nurse still in the period of hospitalization 10 . According to the Ministry of Health's guidelines for attention to the person with spinal cord injury, every patient with spinal cord injury needs to be directed to the CIC before discharge from hospital independently of the urodynamic study.
Therefore, it is essential that the nurses who assist these patients are able to give such guidance 3 .
The educational process regarding the CIC is of

RESULTS
Eighteen nurses participated in the study. Table 1 shows the sample profile data. It is noted that the sample was composed predominantly of women, with an average age of 37.6 years, with a post-graduation course, and an average of 11 years working in the field. Table 2 shows the frequency and percentage of correct responses signaled by nurses for each content approached regarding clean intermittent catheterization.
It is observed that most nurses are aware that spinal cord injury results in an underactive or overactive bladder, and that both can lead to chronic urinary retention.
Despite this result, a small percentage of the sample indicated that the CIC should be guided before discharge and more than half of the participants cited that it should be taught only after the result of the urodynamic study.
Most nurses agreed that the CIC can be performed by a caregiver committed to maintaining the recommended   In the cases of patients without manual agility, due to loss of movement and lack of adaptation to auxiliary devices or due to learning difficulty, the presence of a caregiver to be trained to perform the technique is essential 14 . An applied research in a hospital in the countryside of São Paulo with 141 users of CIC showed in its result that half of these patients need help from relatives, caregivers or primary care health professionals to perform the procedure 15 .
The majority of the sample agreed that the CIC should be performed even without infrastructure, to maintain its optimal regularity and no storage of urine above 500 ml.
Users of CIC should be attentive to the question of infrastructure, however they should not refrain from doing the CIC due to lack of a clean location, being away from home or on a travel; because regular catheterization acts in the prevention of infections and other consequences related to stagnant diuresis 16 .
Regarding hand hygiene with soap and water, no substitution by alcohol gel and no need for sterile gloves, most of them responded correctly and showed to know the subject, but on the topic of using procedure gloves, the majority responded that it is necessary, which can burden and hinder the procedure. The recommendation for hand hygiene with water and soap, preferably liquid soap, is cited by several authors 6,8,14 . In the absence of infrastructure such as sinks, they guide to carry water in a bottle or other utensil to wash hands and the urethral meatus 8   It is not advisable to reduce the water intake so that there is no change in the color and odor of the urine. All participants assertively agreed with this statement. Water intake is considered one of the best practices for prevention of urinary tract infection 16  The response with a large number of errors that proved more worrying was regarding the patient's orientation to CIC before discharge. The majority of the sample did not mark this statement as true, with the location of the sample being a reference in the care of the spinal cord injury and every nurse should be aware and safe for orientation during the period of hospitalization.
It is necessary to discuss the topic among services that provide such services in order to shed light on the need for training programs and implementation of assistance protocols.