CHRONIC PD CATHETER EXIT SITE CARE
SHOWER TECHNIQUE (for the Healthy Exit Site)

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PURPOSE:

2. To ensure standardization of technique between all of the Toronto Home Peritoneal Dialysis (PD) Units and Home Care Agencies.
3. To reduce the risk of infection at the peritoneal dialysis catheter exit site. This may also reduce the risk of peritonitis.

POLICY:

11. To be performed by a registered nurse (or registered practical nurse) trained in PD for a patient following suture/clip/steri strip removal usually two weeks post PD catheter implantation. Prior to suture/clip removal, refer to the Procedure for Post-Operative Dressing Technique.
12. Frequency for exit site care by shower technique is based on the following:
    • routinely done every two days (minimum)
    • post showering
    • daily or more frequently during infection episode
    • daily if crust is present
13. Inspection of the exit site and documentation of the exit site condition on the Patient Care Record is essential. If the exit site becomes inflamed or infected, call the Home PD Unit immediately. Refer to the Procedure for Care of the Infected PD Catheter Exit Site. Also notify the unit if there is any trauma (eg. catheter has been forcibly pulled; there has been aggressive crust removal resulting in redness or bleeding) to the exit site.
14. The standard cleaning solution for catheter care is 2% chlorhexidine gluconate aqueous solution with a 4% isopropyl alcohol as a stabilizer. Trade name for this solution is Stanhexidine.
    If the patient is sensitive to chlorhexidine gluconate, check his/her records or ask the Home PD Unit for a substitute antiseptic solution order.
15. Tub baths are not recommended for patients with peritoneal catheters.
16. Dressing should be air-permeable. Tape may be substituted by Burnnet or Flexnet or catheter immobilizer based on patient allergies or patient preference.
17. If mupirocin ointment is ordered, ensure that the PD catheter is the silastic type, and the mupirocin is applied sparingly. Mupirocin cream may be used with polyurethane catheters.
18. Refilling liquid soap/transferring liquid soap between containers must be avoided. If liquid soap is unavailable, antibacterial liquid soap may be substituted (eg. Dial).
19. Wash cloths should be white or light coloured. With dark colours, the dye can come out. If unable to provide clean wash cloths and towels daily, may substitute with clean gauze.

PROCEDURE:

17. Assess the patient's ability to perform modified shower technique independently. If not, it should be done by the nurse. (see Guideline #1)
18. Wash hands for two minutes.
19. Gather the equipment: (see Guideline #2)
    • antibacterial liquid soap (eg. Dial, Jergens)
    • clean wash cloth
    • clean towel
    • chlorhexidine gluconate 2% aqueous solution
    • 3 packages of 5x5 cm gauze
    • 1 dressing (i.e. mepore or gauze) (see Guideline #8)
    • tape
    • mupirocin if ordered + Q tip or 3rd package of gauze
20. Have patient undress and remove the old dressing. (see Guideline #4)
21. Examine the old dressing and inspect the exit site for signs of infection (redness, crusting, swelling, sanguinous or purulent discharge).
22. Wash hands.
23. Leave the PD catheter and transfer set or extension taped to the abdomen.
24. Shower and shampoo as usual. Avoid scrubbing the exit site.
25. Apply antibacterial liquid soap to a clean wet wash cloth and very gently clean around the exit site. Wash the exit site and surrounding skin in a circular motion starting from the exit site and working outwards. (see Guidelines #4 + #5)
26. Rinse well. (see Guideline #6)
27. Gently pat dry the exit site first with a clean towel. Then dry the rest of the body.
28. Open the gauze packages. Saturate one with chlorhexidine gluconate 2%.
29. Paint a small circle of chlorhexidine gluconate 2% around the exit site in the same circular motion. Ensure that chlorhexidine gluconate 2% is not "probed" into the sinus. Allow to air dry for 30 seconds.
30. Apply the mupirocin sparingly around the exit site as ordered by the physician, using a Q tip or a gauze. (see Policy #7, Guideline #7)
31. Place one 5x5 cm gauze under the PD catheter at the exit site so that the catheter is resting on the gauze (optional). Apply the final dressing -- sterile gauze with hypofix or mepore. (see Guidelines #8+9)
32. Tape the transfer set to the patient's skin in a comfortable position, minimizing excessive tension on the exit site. The PD catheter and transfer set may be looped and anchored at all times. Some patients may use an immobilizer. (see Guideline #3)
33. Document the condition of the exit site.

NURSING GUIDELINES:

12. Ensure the procedure is done in a clean environment (eg. no pets in the room).
13. Gloves and masks are not necessary for chronic exit site care. Technique is clean. However, masks may be used at the nurse's discretion (eg. if he/she has a cold; if referring unit has specified). Gloves (procedural, not sterile) may be used in the event of discharge at the exit site as part of the BSP practices. For dry, intact exit sites, gloves are not required.
14. Immobilization of the PD catheter AT ALL TIMES is critical in preventing trauma by mechanical action during handling and normal body movements.
15. Minimal and gentle movements of the catheter should be used when performing exit site care.
16. Never forcibly remove crust from the PD catheter exit site. Hydrogen peroxide or Shur-Clens may be recommended according to doctor's order.
17. Flow of the water should be in a gentle downward position.
18. Mupirocin cream is more expensive than mupirocin ointment.
19. The size of gauze used is optional according to patient/unit preference. Some units may offer the patient the option of not using a dressing six months post PD catheter implantation if the exit site is well-healed.
20. When securing the PD catheter, ensure that the catheter follows its natural direction to avoid trauma to the exit site. Also, ensure that the catheter does not bend at its connection to the adapter, as the catheter can crack over time. This puts the patient at risk for getting peritonitis.

References

5. Gokal R, Alexander S, Ash S, Chen J, Danielson A, Holmes C, Joffe P, Moncrief J, Nichols K, Piraino B, Prowant B, Slingeneyer A, Stegmayr B, Twardowski Z and Vas S: Peritoneal catheters and exit-site practices toward optimum peritoneal access. 1998 (official report from the International Society for Peritoneal Dialysis). Peritoneal Dialysis International vol. 18, pp 11-33, 1998.
6. Lancaster, L: Peritoneal Dialysis; Exit Site Care from Core Curriculum for Nephrology Nursing, 3rd edition, American Nephrology Nurses' Association, 1995.
7. Thodis E, Bhaskaran S, Pasadakis P, Bargman J, Vas S and Oreopoulos D: Decrease in the staphylococcus aureus exit-site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site. Peritoneal Dialysis International, vol. 18, pp 261-270, 1998.

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