Caring for a Peritoneal Dialysis Catheter

Skill 12-13

Caring for a Peritoneal Dialysis Catheter

Peritoneal dialysis is a method of removing fluid and wastes from the body of a patient with kidney failure, using blood vessels in the abdominal lining (peritoneum) to fill in for the kidneys, with the help of a special fluid (dialysate) washed in and out of the peritoneal space. A catheter (a thin, soft silicone rubber tube) inserted through the abdominal wall into the peritoneal cavity allows dialysate to be infused and then drained from the body (Figure 1). The exit site should be protected and kept clean and dry to allow for healing, which may take up to 6 weeks (Bridger, 2019). Daily exit-site dressing changes are not started for 2 weeks, with dressings only reinforced if needed to minimize catheter manipulation (George, 2019a). Once the exit site has healed, routine exit-site care is provided daily (George, 2019a). The catheter insertion site is a site for potential infection, possibly leading to catheter tunnel infection and peritonitis ; therefore, meticulous care is needed. The incidence of exit-site infections can be reduced through a cleansing regimen by the patient or caregiver. Until the site is healed care is performed using aseptic technique, to reduce the risk for a health care-acquired infection. Once healed, clean technique can be used by the patient and caregivers.

Delegation Considerations

The care of a peritoneal dialysis catheter is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, care of a peritoneal dialysis catheter may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Face masks (2)
Sterile gloves
Nonsterile gloves
Additional PPE, as indicated
Antimicrobial cleansing agent, per facility policy
Sterile gauze squares (4)
Sterile basin
Sterile drain sponge
Transparent, occlusive site dressing
Topical antimicrobial, such as mupirocin or gentamicin, depending on prescribed interventions and facility policy
Sterile applicator
Plastic trash bag
Bath blanket

Assessment

Inspect the peritoneal dialysis catheter exit site for any erythema, drainage, bleeding, tenderness, swelling, skin irritation or breakdown, or leakage. These signs could indicate exit-site or tunnel infection. Assess the abdomen for tenderness, pain, and guarding. Assess the patient for nausea, vomiting, and fever, which could indicate peritonitis. Assess the patient's knowledge about measures used to care for the exit site.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Altered skin integrity risk
Knowledge deficiency
Infection risk

Outcome Identification and Planning

The expected outcomes to achieve when performing care for a peritoneal dialysis catheter are that the peritoneal dialysis catheter dressing change is completed using aseptic technique without trauma to the site or patient; the site is clean, dry, intact, and without evidence of inflammation or infection; and the patient participates in self-care, as appropriate.

Implementation

Action	Rationale
1. Review the patient's health record for prescribed interventions related to catheter site care. Gather equipment.	This ensures appropriate interventions for the patient. Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Encourage the patient to observe or participate, if possible.	This ensures the patient's privacy. Discussion promotes engagement and helps to minimize anxiety. Having the patient observe or assist encourages self-acceptance.
5. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and prevents unnecessary stretching and twisting of muscles on the part of the nurse.
6. Adjust the bed to a comfortable working height (VHACEOSH, 2016). Assist the patient to a supine position. Expose the abdomen, draping the patient's chest with the bath blanket, exposing only the catheter site.	Having the bed at the proper height prevents back and muscle strain. The supine position is usually the best way to gain access to the peritoneal dialysis catheter. Use of a bath blanket provides patient warmth and prevents unnecessary exposure.
7. Put on nonsterile gloves. Put on one of the facemasks; have the patient put on the other mask.	Gloves protect the nurse from contact with blood and bodily fluids. Use of facemasks deters the spread of microorganisms.
8. Gently remove old dressing, noting odor, amount, and color of drainage; leakage; and condition of the skin around the catheter. Discard the dressing in an appropriate container.	Drainage, leakage, and skin condition can indicate problems with the catheter, such as infection.
9. Remove gloves and discard. Perform hand hygiene. Set up a sterile field. Open the packages. Using aseptic technique, place two sterile gauze squares in the basin with an antimicrobial agent. Leave two sterile gauze squares opened on the sterile field. Alternatively (based on facility's policy), place sterile antimicrobial swabs on the sterile field. Place the sterile applicator on the field. Squeeze a small amount of the topical antimicrobial on one of the gauze squares on the sterile field.	Hand hygiene prevents the spread of microorganisms. Until the catheter site has healed, aseptic technique is necessary for site care to prevent infection.
10. Put on sterile gloves. Pick up the dialysis catheter with your nondominant hand. With the antimicrobial- or sterile normal saline-soaked gauze/swab, cleanse the skin around the exit site using a circular motion, starting at the exit site and then slowly going outward 2 inches (Bridger, 2019). Scabs or crusts should never be removed forcibly to avoid creating open areas susceptible to infection (George, 2019a).	Aseptic technique is necessary to prevent infection. The antimicrobial agent cleanses the skin and removes any drainage or crust from the wound, reducing the risk for infection.
11. Continue to hold the catheter with your nondominant hand. After the skin has dried, clean the catheter with an antimicrobial-soaked gauze, beginning at the exit site, going around the catheter, and then moving up to end of the catheter. Gently remove crusted secretions on the tube, if necessary.	Movement of the catheter should be minimal in the immediate postoperative period (Bridger, 2019). Antimicrobial agents cleanse the catheter and remove any drainage or crust from the tube, reducing the risk for infection.
12. Using the sterile applicator, apply the prescribed topical antimicrobial to the catheter exit site.	Application of topical antimicrobial at the catheter exit site prevents exit-site infection and peritonitis (Bridger, 2019; George, 2019b; National Kidney Foundation, 2019; Szeto et al., 2017).
13. Place a sterile drain sponge around the exit site. Then place a 4 × 4 gauze over the exit site. Cover it with a dressing. Remove gloves and then masks. Perform hand hygiene.	The drain sponge and 4 × 4 gauze are used to absorb any drainage from the exit site. Occlusion of the site with a dressing deters site contamination. Once the site is covered, masks and gloves are no longer necessary. Hand hygiene prevents the spread of microorganisms.
14. Label the dressing with the date, time of change, and your initials.	Other personnel working with the catheter will know information related to site care.
15. Coil the exposed length of tubing and anchor the catheter to the patient's abdomen with tape or a commercial device (Bridger, 2019; George, 2019b).	Anchoring the catheter absorbs any tugging, preventing tension on, and irritation to, the skin or abdomen.
16. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.	Positioning and covering provide warmth and promote comfort. A bed in the low position promotes patient safety.
17. Put on gloves. Remove or discard equipment and assess the patient's response to the procedure.	These actions deter the spread of microorganisms. The patient's response may indicate acceptance of the catheter or the need for health teaching.
18. Remove gloves and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the peritoneal dialysis catheter dressing change has been completed using aseptic technique without trauma to the site or to the patient; the site has remained clean, dry, intact, and without evidence of redness, irritation, or excoriation; the patient's fluid balance has been maintained; and the patient has verbalized appropriate measures to care for the site.

Documentation

Guidelines

Document the dressing change, including the condition of the skin surrounding the exit site, drainage, or odor; the patient's reaction to the procedure; and any patient teaching provided.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient reports pain when you palpate the abdomen; purulent or cloudy drainage is present, site is red or swollen, or foul odor is noted when old dressing is removed: Notify the health care team immediately (George, 2019b). Any of these signs could indicate a site infection or peritonitis.
You note that the old dressing is saturated with clear fluid: Replace the dressing to prevent skin breakdown. Notify the health care team. A frequent complication is leakage from the exit site. Frequently check the dressing, especially after the patient has had solution placed in the abdominal cavity.

Special Considerations

General Considerations

Instruct patients to avoid showering for 2 to 3 weeks, until the site has healed; site care should be performed after every shower (Bridger, 2019; George, 2019b; National Kidney Foundation, 2019).
Remind patients performing their own site care of the importance of good handwashing before self-care (George, 2019a; National Kidney Foundation, 2019; NIDDK, 2018a).
Discourage patients from wearing tight clothes and belts around the exit site.

Community-Based Care Considerations

Once the catheter site is healed, clean technique can be used by the patient and caregivers.
Teach patients the signs of exit-site infection and encourage them to contact their health care team for prompt intervention.

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Skill 12-13