Download I. Review of literature related to peritoneal catheter care

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BENGALURU, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1
NAME OF CANDIDATE
MR. SELJO SEBASTIAN
2
NAME OF THE
K. R. COLLEGE OF NURSING,
INSTITUTION AND
PROPERTY NO.59, 25/4/ 74, KATHA NO.
ADDRESS
1935, C& M COMPLEX, OMKAR
LAYOUT, UTTARAHALLI- KENGERI
MAIN ROAD, BANGALORE-60.
3
4
COURSE STUDY AND
I YEAR M.SC. NURSING
SUBJECT
MEDICAL SURGICAL NURSING
DATE OF ADMISSION TO
COURSE
5
TITLE OF THE TOPIC
01/06/2011
“A STUDY TO ASSESS THE KNOWLEDGE
AND PRACTICE
OF STAFF NURSES
REGARDING PERITONEAL CATHETER
CARE
AT
BENGALURU
DEVELOP
BOOKLET”
0
SELECTED
WITH
AN
HOSPITALS,
A
VIEW
TO
INFORMATION
6. BRIEF RESUME OF THE INTENDED WORK:
INTRODUCTION
Diagnosis is not the end, but the beginning of practice.
Martin. H. Fisher
The healthy kidney participates in whole-body homeostasis, regulating acid-base
balance, electrolyte concentrations, extra cellular fluid volume, and regulation of blood
pressure. Common clinical conditions involving the kidney include the nephrotic
syndromes, renal cysts, acute kidney injury, chronic kidney disease, urinary tract
infections will diminish kidney function. Renal replacement therapy, in the form of
dialysis or kidney transplantation, is indicated when the glomerular filtration rate has
fallen very low or if the renal dysfunction leads to severe symptoms.1
The kidneys perform a number of tasks, such as concentrating urine, regulating
electrolytes, and maintaining acid-base homeostasis. The kidney excretes and re-absorbs
electrolytes (e.g. sodium, potassium and calcium) under the influence of local and
systemic hormones. pH balance is regulated by the excretion of acids and ammonium
ions. In addition, they remove urea, a nitrogenous waste product from the metabolism of
amino acids. The end point is a hyperosmolar solution carrying waste for storage in the
bladder prior to urination.2
Hemodialysis and peritoneal dialysis are cleansing the blood and removing
excess fluids. In contrast to hemodialysis, peritoneal dialysis works inside the body using
the body’s own natural peritoneal membrane as the semi-permeable membrane through
1
which the blood can be filtered. Continuous ambulatory peritoneal dialysis, automated
peritoneal dialysis, intermittent peritoneal dialysis, continuous automated peritoneal
dialysis, nightly intermittent peritoneal dialysis are the types of peritoneal dialysis. 3 It is
very convenient for the dialysis patient, as they can be done in home settings for long
time, if they care for catheter and catheter site properly.2 Since the 1980s, when
peritoneal dialysis first became a practical and widespread treatment for kidney failure,
much has been studied about how to make peritoneal dialysis more effective and
minimize side effects. Tenckhoff catheter was developed in 1968 and has been widely
used since for chronic peritoneal dialysis patients. Variations of the Tenckhoff catheter
have been designed over the years in a search for the ideal peritoneal dialysis catheter.
The catheters provide an opening through which dialysis solution can be instilled into the
peritoneal cavity and the solution drains after prescribed time. 3
Since the initiation of chronic peritoneal dialysis therapy in India in 1991 both
continuous ambulatory peritoneal dialysis and Continuous cyclic peritoneal dialysis has
emerged as major form of renal replacement therapy. However the dropout rate still
remains high predominately due to negative patient selection and infectious complication.
Exit site infection, tunnel infection and peritonitis are the peritoneal dialysis related
infections and it leads to catheter loss, which when appropriately treated, can reduce
morbidity, mortality and drop out. These infections remain as most common
complication resulting in hospitalization, catheter loss and failure of the peritoneal
membrane. After the catheter is inserted, the insertion site is usually covered with a
sterile gauze dressing, prevent the displacement of the catheter and keep the area clean.
2
The dressing is usually changed at the dialysis home training center seven to 10 days
after catheter placement. If a dressing change is needed before this time, it should be
done by a specially trained peritoneal dialysis nurse.
4
Nurses play a key role in providing care to the patient who have peritoneal
catheter. Major complications related to exit site infections can be avoided if nurses are
provided with adequate information and training on peritoneal catheter care. 3
6.1 NEED FOR STUDY
People with advanced kidney disease may be treated with peritoneal dialysis where a
catheter is permanently inserted into the peritoneum through the abdominal wall and
sterile fluid is drained in and out a few times each day. The most common serious
complication is infection of the peritoneum and it is called peritonitis. This may be
caused by bacteria accidentally being transferred from the catheter. 9
Prevention of infections is a prerequisite for successful peritoneal dialysis.
Catheter infections contribute to morbidity, catheter loss, and technique failure. Although
the risk of peritonitis has decreased over the past decade, exit site infections have not
shown a similar consistent downward trend. The four major factors causing catheter
infection are catheter design, insertion technique, patient risk factors, and catheter care.
Catheter problems include displacement, obstruction, perforation of bowel and bladder,
apposition, adherence of the catheter tip to the omentum or infection, fluid leakage due to
incomplete healing of the insertion site or excessive instillation. These catheter-related
3
problems are a cause of permanent transfer to hemodialysis in up to 20 percent the
patients.9
The risk of death from infection in peritoneal dialysis patients is not falling in the
United States. In other parts of the world, infection also continues to be the second most
common cause of death in peritoneal dialysis patients. The incidence of catheter
obstruction varies from 2 to 32 percent in different studies, therefore proper care and
attention to be taken to the peritoneal catheter and exit-site. 11
Today, peritoneal dialysis is a renal replacement therapy performed daily by
thousands of patients or their caregivers in their places of residence. The United States
Renal Data System identified that 26,510 patients were on peritoneal dialysis in 2001. In
a recent multi-center study comparing patient satisfaction, 6.56 patients rated their
dialysis care for peritoneal dialysis and haemodialysis 7 weeks after starting dialysis.
Eighty five percent of patients on peritoneal dialysis reported their overall dialysis care to
be excellent verses a 56 percent rating by patients receiving haemodialysis. The
researchers concluded that clinicians should provide patients information about the option
of peritoneal dialysis. 12
According to Dr. H L Thrivedi Institute of Transplantation Sciences,
Gujarat, the incidence of obstruction causing poor flow of dialysate has been reported to
be 6.0percentage to 20.5 percentages. Omental wrap is a common cause of peritoneal
catheter obstruction with a reported incidence of about 57percentage to 92percentage. 5
4
According to worldwide survey of patients in end stage renal disease, approximately
11percent were receiving peritoneal dialysis, compared to the much more
common hemodialysis. In the United Kingdom, South Korea and Mexico peritoneal
dialysis was more common than the world average, with the latter conducting most of
its dialysis (75percent) through peritoneal dialysis.6
Risk of infection in the presence of peritoneal dialysis catheter includes hernia,
leaking dialysate from exit-site, exit-site pain, stomach pain, perforation of bowel and
bladder. Patient may have an allergic reaction to some catheters. If the patient will not
get appropriate catheter care there it may leads to death of the patient.7 The causes of
bacterial exit site infection include Staphylococcus epidermis’s (20 percent),
Pseudomonas aeruginosa (8 percent), and Escherichia coli (4 percent) Nasal carriage are
common among patients undergoing peritoneal dialysis.8
A successful programme involves a multidisciplinary team and especially nurses
should have adequate knowledge and skills regarding care of catheter, catheter
implantation techniques and its complications. It has been well described that patients
who receive pre-dialysis education are more likely to choose Peritoneal dialysis or other
types of self-care dialysis. Once education by information booklet is provided regarding
catheter and its care to nurses, they can provide quality care and knowledge to the
patients receiving peritoneal dialysis. So the researcher felt the need to assess the
knowledge and practice of nurses regarding peritoneal catheter care and give an
5
information booklet to enhance the knowledge of staff nurses in peritoneal catheter care
and practice.9
6.2 REVIEW OF LITERATURE
Review of literature is a systemic identification, location, scrutiny and summary of
written material that contain information on research problems.
The review of literature related to topic are organized and presented under the following
headings.
I.
II.
Review of literature related to peritoneal catheter care.
Review of literature related to knowledge and practice of staff nurses regarding
peritoneal catheter care.
III.
Review of literature related to information booklet.
I. Review of literature related to peritoneal catheter care
A study was conducted with an aim to determine whether specific preventive
measures reduce the rate of peritoneal catheter related infection due to staphylococcus
aureus. 10 subjects were chosen for the study with 3 months follow-up. The literature
concludes that strong evidence that staphylococcal carriage prophylaxis using either oral
rifampin or mupirocin ointment in exit-site significantly reduces infection. 14
According to Department of Medicine & Associated LN Hospital, New Delhi
survey report, peritonitis is one of the most frequent complications of peritoneal dialysis
catheter related infection. In 2005 incidence and the mortality rate of fungal peritonitis
6
varies from 5percent to 53percent. Peritonitis occurred more frequently in the summer
months. At the end of 2005, 70 percent patients continued on continuous ambulatory
peritoneal dialysis, with 3 deaths. This indicates the need and importance of proper care
in catheter care.10
A retrospective study was conducted with an aim to find causes for loosening of
catheter following continuous ambulatory peritoneal dialysis and peritonitis. The study
reviewed 579 episodes of continuous ambulatory peritoneal dialysis from 1999 to 2006 in
a tertiary care referral hospital. The study concluded that peritonitis associated with exitsite infection and abdominal catastrophes were more likely to proceed to loosening of
peritoneal dialysis catheter. 15
A survey was developed to determine the prevalence of specific components of post
operative and chronic peritoneal catheter exit-site care procedures. 585 surveys were
analyzed. The most frequent components of post operative exit-site care were the use of
prophylactic antibiotics, daily dressing changes, procedures limited to trained staff with
sterile technique, povidone iodine and hydrogen peroxide as cleansing agents and gauze
dressings. The most frequent component of chronic exit-site care procedures were daily
care done with shower or bathing, anti bacterial or pure soap for cleansing, hydrogen
peroxide only as needed. Catheter stabilization and dressing to the infected site given.
The result of the survey was there were significant difference between the United States
and other location. 16
7
A retrospective study was conducted with an aim to assess higher incidence of
catheter related infections in a tropical climate; data from adult patients treated for at least
12 months were analyzed to determine if climate conditions could account for the
findings. Total of 139 catheter related infections episodes were recorded with a rate of 1
patient per 8 months. The study concluded that higher incidence of catheter related
infections was found during the hot seasons in comparison to the cold seasons. 17
2. Review of literature related to knowledge and practice of staff nurses
regarding peritoneal catheter care
A study was conducted about response of nurses towards management and
teaching of patients on continuous ambulatory peritoneal dialysis with an aim to shed
light on the way trained nurses responded to the challenge of teaching patients to manage
life on continuous ambulatory peritoneal dialysis. The data was collected by means of
participant observation over a period of nine months. Supplementary data was collected
from out-patient clinic and at continuous ambulatory peritoneal dialysis multidisciplinary
meetings. In the light of these observations the study concluded that a specialist nurse
liberated from the responsibilities of ‘the ward’ may be able to provide a better service
for these patients. 18
A study was carried on 82 nurses, who were working in dialyses stations in Lodz
province with an aim of to find the answers for questions: How is nursing independence
formed
by
taking
care
of
patients
in peritoneal
dialysis?
What
is
level
of nurse’s preparation for independent work in dialyses stations? Has education
of nurses really influence on quality of professional care? The study result was of
8
uplifting the professional qualifications which had 78percentage
nurses. Respondents
thought that nursing group only partially 42percentage should take independent
operations. Only 50percentage of nurses have conceded that they have possibility to
obtain the full information about health status of patients from doctors. The Study
concluded that systematic training and longest professional practice in dialysis station
should help farthest development of nursing independence. 19
An evaluative study was conducted to examine the effects of peritoneal dialysis
nurse trainers on the clinical outcome of gram positive peritonitis. This study included
200 consecutive peritoneal dialysis patients. The study concluded that there is a negative
association between the trainers length of time in practice and peritonitis incidence which
reminds the use of principles of adult learning to teach patients by the nurses. 20
A descriptive study conducted on 54 nurses regarding nursing practice related to
peritoneal catheter exit-site care and infections. The study result was hydrogen peroxide
and povidine iodine are frequently used in the nursing care of chronic exit-sites. The
study concluded that by using cleansing agents are necessary to determine the most
effective procedure to promote healthy exit-sites. 21
A study was conducted to address the problem of high hospital and community
acquired continuous ambulatory peritoneal dialysis infection. It concentrated on reducing
Staphylococcus aureus carriage, improving aseptic operative technique like intensive
training for nursing staff and patients in aseptic care of the exit site, and avoidance of
contact of the exit site with unsterile water. This was associated with an overall 10-fold
9
reduction in exit site infection, a twofold reduction in peritonitis, and a 4.5-fold reduction
in catheter loss from infection. These reductions have been sustained. The study
concluded that preventing infection in continuous ambulatory peritoneal dialysis patients
requires persistence and commitment but improves the patient's quality of life. 22
A descriptive study was conducted to investigate the feasibility of home care for
continuous ambulatory peritoneal dialysis by district nurses on Patients with end-stage
renal disease who were not able to carry out the continuous ambulatory peritoneal
dialysis treatment themselves were given assistance by district nurses. During the study
period questionnaires were sent to both the district and the hospital nurses and the study
period was 58 months of continuous ambulatory peritoneal dialysis home care.
Community nurses had received a preliminary training by the staff of the dialysis
department and they were supported by consultation. The study concluded that
continuous ambulatory peritoneal dialysis home care by district nurses is feasible on the
conditions like extra financing, preliminary training and support for the district nurses
from the hospital staff by consultation. 23
3. Review of literature related to information booklet
A study was conducted to evaluate the effect of an educational program on awareness
about peritoneal dialysis among patients on hemodialysis. This study attempt to define
the impact of an educational program for improving the use of continuous ambulatory
peritoneal dialysis. This is a quasi-experimental study conducted with educational
materials including workshop, teaching by booklet and showing educational films,
performed in Urmia, Iran. A questionnaire was designed for data collection and enrolled
10
160 patients with an aim-based sampling method. The overall patients' information about
continuous ambulatory peritoneal dialysis scoring was as follows: 75% had
little information; 19% had moderate information and 6% of patients were well informed.
All the information levels increased after intervention.24
An education program was designed for patients with chronic renal failure.
Lessons involved two hours of informal discussion on the main aspects of end stage renal
disease and renal replacement therapy; booklets were created from tape recordings of the
lessons. With regard to books, 500 copies of the book what does dialysis mean? Were
given out in the region; this book was validated in 22 patients on peritoneal dialysis and
18 on hemodialysis. It helped patients to accept dialysis in 65% of cases and to
comprehend it in 90%. Of 56 patients, 53 asked for further material; 19 changed their
initial opinion.25
An observational study was conducted to describe the characteristics of the
education programmes used in Italian Peritoneal dialysis-centers, evaluating a possible
relationship between programmes and peritonitis rates. The survey involved 150
public dialysis centers in Italy. Training occurs in all the centers, while predialysis education, home visits and re-training take place in 38.3 percent, 50 percent and
44.2 percent respectively. The study concluded that lower peritonitis rates prove to be
correlated to these activities rather than to presence of specialized personnel, or training
time. 26
11
STATEMENT OF THE PROBLEM
“A STUDY TO ASSESS THE KNOWLEDGE AND PRACTICE OF STAFF
NURSES REGARDING PERITONEAL CATHETER CARE AT SELECTED
HOSPITALS, BENGALURU CITY WITH A VIEW TO DEVELOP AN
INFORMATION BOOKLET.”
6.3 OBJECTIVES OF THE STUDY

To assess the knowledge of staff nurses regarding peritoneal catheter care.

To assess the practice of staff nurses regarding peritoneal catheter care.

To determine the association between the knowledge scores of staff nurses
regarding peritoneal catheter care with the selected demographic variables.

To determine the association between the practice scores of staff nurses regarding
peritoneal catheter care with the selected demographic variables.

To provide information booklet to the staff nurses regarding peritoneal catheter
care.
6.4 OPERATIONAL DEFINITIONS
 Assess: Refers to exploring the information on knowledge of staff nurses regarding
peritoneal catheter care.

Knowledge: Refers to awareness of staff nurses regarding peritoneal catheter
care.
12

Practice: Staff nurses using their knowledge in performing peritoneal catheter
care.
 Staff nurses: Refers to nursing personnel who have completed general nursing
and midwifery, B.Sc.nursing, PBB.Sc.nursing and are working at selected
hospitals.

Peritoneal catheter: It is a soft thin tube inserted in to the peritoneal cavity
through the anterior abdominal wall to perform peritoneal dialysis.

Peritoneal catheter care: The care provided by staff nurses to patients having
peritoneal catheter.
 Selected hospitals: study will be conducted in N.U hospital and Bangalore
hospital.

Information booklet: It refers to small booklet containing information and
pictures showing the peritoneal catheter and its care.
6.5 ASSUMPTIONS
 The staff nurses may have inadequate knowledge regarding peritoneal catheter
care.
 The knowledge and skills acquired by staff nurses helps in providing better care
for patients having peritoneal catheter.
6.6 DELIMITATIONS
The study is delimited to staff nurses who are working at selected hospitals, Bengaluru.
13
6.7 RESEARCH HYPOTHESIS
Ho- There will be no significant association between the knowledge and practice of staff
nurses regarding peritoneal catheter care with the selected demographic variables.
6.8 VARIABLES UNDER STUDY
Study variables
: Knowledge of staff nurses regarding peritoneal catheter care.
Attribute variables: Age, sex, educational qualification, years of experience, religion,
socio economic status, source of information.
7. MATERIALS AND METHODS
7.1 SOURCES OF DATA:
Data will be collected from staff nurses working at selected hospitals, Bengaluru.
7.2 METHODS OF DATA COLLECTION:
7.2.1Research approach:
Descriptive research approach will be used in my study.
7.2.2 Research design:
Descriptive research design is adopted for this study.
7.2.3 Research setting:
The study will be conducted at selected hospitals, Bengaluru.
14
7.2.4 Population:
Staff nurses working at selected hospitals, Bengaluru.
7.2.5Sample:
Staff nurses working at selected hospitals, Bengaluru.
7.2.6 Sampling technique:
Non probability- Purposive sampling technique will be used in this study.
7.2.7 Sample size:
50 staff nurses working at selected hospitals, Bengaluru.
7.2.8 Sampling criteria
Inclusion criteria:

Staff nurses who are available at the time of data collection.

Staff nurses who are willing to participate in the study.
Exclusion criteria.

Staff nurses who are not available at the time of data collection

Staff nurses who are not willing to participate in the study.
Duration of the study: This study will be conducted for the period of 2 months.
7.2.9 Tools for data collection
The tool for the present study consists of 3 parts.
Part A: Items on demographic variables.
15
Part B: Knowledge items on various aspects of peritoneal catheter care.
Part C: Checklist for assessing practice of peritoneal catheter care.
7.2.10 Data collection procedure
Formal permission will be obtained from the administrative heads (director) and nursing
superintend of selected hospitals to conduct the study. The researcher introduces himself
to the in charge sisters of various departments of Selected hospitals, Bengaluru. The staff
nurses selected for the study will be approached and consent will be taken to participate
in the study. Questionnaire will be distributed to the staff nurses and the time allotted to
fill each questionnaire will be approximately 30 – 45 minutes.
7.2.11 Data analysis method
Descriptive statistics: data will be analyzed by means of percentage, mean, mode,
median and standard deviation.
Inferential statistics:
Chi-square test will be used to determine the association between knowledge and practice
scores of staff nurses regarding peritoneal catheter care with the selected demographic
variables.
7.3 Does the study require any investigation or intervention to be conducted on
patients or other human or animal?
No.
16
7.4 Has the ethical clearance been obtained from your institution?

Ethical clearance will be obtained from the research committee of K.R College of
nursing, Bengaluru.

Permission will be obtained from nursing superintendent of selected hospitals,
Bengaluru.

The informed consent will be taken from the samples for their willingness to
participate in the study.
17
8. REFERENCES
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3. Joyce .M. Black, Jane Hokanson Hawks. Mastering Medical-Surgical Nursing.
Medical Surgical Nursing. Clinical Management of Positive Outcomes.7th Edition.
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4. Jeremy Levy, Julie Morgan, Edwina Brown. Oxford Hand Book Of Dialysis. 2nd
Edition. Oxford University Press Publication, Newyork. p. 371-374, 390-400.
5. Sainaresh VV, Jain SH, Engineer DP, Patel HV, Shah PR, Trivedi HL
Laparoscopic salvage of omental wrapping of the continuous ambulatory peritoneal
dialysis catheter. Available from
URL: http://www.indianjnephrol.org/preprintarticle.asp?id=83031
6. Wikipedia.Thefree encyclopedia available from
http://en.wikipedia.org/wiki/Peritoneal_dialysis
7. Sharon Manthhik Lewis, Margret Mc Lean, Heitkemper ,Shannon Ruff Dirksen.
Medical Surgical Nursing. 6th Edition, 2004, Mosby Publications. P.573-580.
8. Tunnel and peritoneal catheter exit site infections in continuous peritoneal dialysis.
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9. B.T Basavanthappa. Medical Surgical Nursing. Jaypee Brother’s Medical
Publishers (P) Ltd, New Delhi. P.749-751
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10. Singh NP, Gupta S, Chandra J, Anuradha S, Kohli R, Rizvi SN.
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Med Assoc. 2005 Jan;103(1):22,24,26passim. Available from URL:
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19
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21
9
SIGNATURE OF THE CANDIDATE
PERITONEAL DIALYSIS IS DIALYSIS OF CHOICE
10
REMARK OF THE GUIDE
TODAY,
NURSE
SHOULD
UPDATED THEIR
KNOWLEDGE ON PREVENTION OF PERITONEAL
CATHETER RELATED PROBLEMS.THE STUDY IS
RELEVANT TO THE PRESENT SENARIO MAY BE
APPROVED.
11
NAME AND THE DESIGNATION OF
MRS.ROOPA SARITHA REDDY.
GUIDE.
ASSOCIATE
DEPARTMENT
PROFESSOR,
OF
MEDICAL
SURGICAL NURSING,
K R COLLEGE OF NURSING,
BANGALORE.
A. SIGNATURE
B. CO-GUIDE
C. SIGNATURE
D. HEAD
OF
THE
MRS. ROOPA SARITHA REDDY
DEPARTMENT
E. SIGNATURE
12
REMARKS OF THE PRINCIPAL
SIGNATURE
22
23