Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 1. Wilma J Phipps, Barbara C Long, Nancy Fugate Woods. Shefers medical surgical nursing. Seventh edition. B.I publication (p) Ltd: New Delhi. p. 630-631. 2. Bobbee Terrill. Renal Nursing- A Practical Approach. Ausmed Publications March 2002, Australian Health Education (P) Ltd, Australia. p.237-270. 3. Joyce .M. Black, Jane Hokanson Hawks. Mastering Medical-Surgical Nursing. Medical Surgical Nursing. Clinical Management of Positive Outcomes.7th Edition. Volume-1. p: 956-957. 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. Available from URL: http://www.uptodate.com/contents/tunnel-and-peritonealcatheter-exit-site-infections-in-continuous-peritoneal-dialysis. 9. B.T Basavanthappa. Medical Surgical Nursing. Jaypee Brother’s Medical Publishers (P) Ltd, New Delhi. P.749-751 18 10. Singh NP, Gupta S, Chandra J, Anuradha S, Kohli R, Rizvi SN. Continuous ambulatory peritoneal dialysis-an initial Indian experience. J Indian Med Assoc. 2005 Jan;103(1):22,24,26passim. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed/16008326 11. 35th annual coference of Indian society of nephrology. Indian J Nephrol2004; 14:99-156. Availabe from URL:http://medind.nic.in/iav/t04/i3/iavt04i3p99.pdf 12. Troubleshooting non-infectious peritoneal dialysis issues by Donna E. Maaz findarticles / health / nephrology nursing journal / sept-oct,2004.available from URL:http://findarticles.com/p/articles/mi_m0ICF/is_5_31/ai_n17207522/ 13. Prasad N, Gupta A, Mathew M, Abraham G. Access-related complications in peritoneal dialysis in developing countries. adv ren replace ther. 2002 apr;9(2):1448.available from URL: http://www.ncbi.nlm.nih.Gov/Pubmed/12085391 14. Ritzau J, Hoffman Rm, Tzamaloukas Ah, Effect of preventing staphylococcus aureus carriage on rates of peritoneal catheter-related staphylococcal infections literature synthesis. perit dial int. 2001 sep-oct; 21(5):471-9. Available From URL: Http://Www.Ncbi.Nlm.Nih.Gov/Pubmed/11757831 15. Yang Cy, Chen Tw, Lin Yp, Lin Cc, Ng Yy, Yang Wc, Chen Jy, Determinants of catheter loss following continuous ambulatory peritoneal dialysis peritonitis. Peri dial int. 2008 jul-aug; 28(4):361-70. available from URL:http://www.ncbi.nlm.nih.gov/pubmed/18556378 16. Barbara F. Prowant, Bradley A. Warady, Karl D. Nolph, Peritoneal dialysis catheter exit-site care: results of an international survey. Peritoneal dialysis international, vol. 13, pp. 149-154. 19 17. Alves Fr, Dantas Rc, Lugon Jr, Higher incidence of catheter-related infections in a tropical climate. adv perit dial. 1993; 9:244-7. Available From URL:Http://Www.Ncbi.Nlm.Nih.Gov/Pubmed/8105935 18. Luker Ka, Box D, The Response 0f nurses towards the management and teaching of patients on continuous ambulatory peritoneal dialysis (Caperitoneal dialysis).Int.J.Nurs Stud. 1986;23(1):519.AvailableFromURL:Http://Www.Ncbi.Nlm.Nih.Gov/Pubmed /3632951 19. Babska K, Nowicki M, Tkaczyk M, Independence of nurses in the therapeutic team based on dialysis units in region of lódź. pol merkur lekarski. 2009 apr;26(154):306-10. Available From : Http://Www.Ncbi.Nlm.Nih.Gov/Pubmed/19580194 20. Kai Ming Chow,Cheuk, Chun Szeto,Man Ching Law,Janny Suk Fun Fung, Influence of peritoneal dialysis training nurses experience on peritonitis rates. Clin j am soc nephrol. 2007 jul; 2 vol4.p. 647-52. Available From URL: Http://Www.Ncbi.Nlm.Nih.Gov/Pubmed/17699477 21. S L Lewis; B F Prowant; C Douglas; C L Cooper. Nursing practice related to peritoneal catheter exit site care and infections. ANNA journal / American Nephrology Nurses' Association 1996;23(6):609-15; discussion 616-7.avilable from URL: http://www.ncbi.nlm.nih.gov/pubmed/9069790 22. Dryden Ms, Ludlam Ha, Wing Aj, Phillips I, Active intervention dramatically reduces caperitoneal dialysis -associated infection. Adv perit dial. 1991 (7):125-8. Available From URL: Http://Www.Ncbi.Nlm.Nih.Gov/Pubmed/1680407 20 23. Dukkers Van Emden Dm. Initial experiences with home care for peritoneal dialysis rendered by district nurses. ned tijdschr geneeskd. 1995 apr 1; 139(13):664-9. Available From URL: Http://Www.Ncbi.Nlm.Nih.Gov/Pubmed/7723867 24. Ghafari A, Sepehrvand N, Hatami S, Ahmadnejad E, Ayubian B, Maghsudi R, Kargar C.Effect of an educational program on awareness about peritoneal dialysis among patients on hemodialysis. Saudi J Kidney Dis Transpl. 2010 Jul;21(4):636-40. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed/20587865 25. Piccoli GB, Mezza E, Iadarola AM, Bechis F, et al., Education as a clinical tool for self-dialysis. [Journal Article] Adv Perit Dial 200.186-90. Available from URL: http://www.unboundmedicine.com/medline/ebm/record/11045290/abstract/Educati on_as_a_clinical_tool_for_self_dialysis_ 26. Bordin G, Casati M, Sicolo N, Zuccherato N, Eduati V, Patient education in peritoneal dialysis: an observational study in Italy. J ren care. 2007 octdec;33(4):165-71.Available from URL: Http://Www.Ncbi.Nlm.Nih.Gov/Pubmed/18298034 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