Steps to safe swimming for patients on peritoneal dialysis.
Article Type: Report
Subject: Continuous ambulatory peritoneal dialysis (Health aspects)
Continuous ambulatory peritoneal dialysis (Methods)
Peritoneal dialysis (Health aspects)
Peritoneal dialysis (Methods)
Swimming (Training)
Swimming (Methods)
Hemodialysis patients (Health aspects)
Hemodialysis patients (Training)
Author: Cugelman, Arlene
Pub Date: 04/01/2011
Publication: Name: CANNT Journal Publisher: Canadian Association of Nephrology Nurses & Technologists Audience: Trade Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2011 Canadian Association of Nephrology Nurses & Technologists ISSN: 1498-5136
Issue: Date: April-June, 2011 Source Volume: 21 Source Issue: 2
Topic: Event Code: 280 Personnel administration
Geographic: Geographic Scope: Canada Geographic Code: 1CANA Canada
Accession Number: 259157204
Full Text: The regional program of North Simcoe Muskoka opened its peritoneal dialysis program in 1997--since that time there have been few patients for whom swimming was a treasured pastime they wished to continue. Most clients decided not to swim in response to the conventional teaching that swimming posed a risk of infection at the exit site or peritonitis, with removal of the peritoneal dialysis (PD) catheter as a possible outcome.

One patient trialed swimming using the supplies available in 1998 for ostomy care and decided there was more enjoyment standing knee deep in the water without the labour-intensive application of the ostomy ring and bag used at that time. In the early days of our program two patients insisted on swimming without proper precautions resulting in infection and subsequent switch of dialysis modality to hemodialysis.

Recently, we have had several younger patients who spoke repeatedly of wanting to swim, expressing a sincere loss at being unable to participate in what had been a favourite activity before dialysis. Patient-centred care with attention to quality of life, as defined by the patient, became an opportunity to revisit this activity, the historic thinking behind it, and develop new guidelines for its safe adoption.

Table 1. Swimming supplies

1 x Hollister Ostomy Pouch (82335)

1 x Tegaderm[TM]Film (1626W) 10 cm x 12 cm

1 x ConvaTec AllKare[R] Protective Barrier Wipe

1 x ConvaTec AllKare[R] Adhesive Remover Wipe

While attending several conferences, both international and local, I had many opportunities to discuss with nurses instructions they gave to PD patients for swimming, for updates and patient experiences. It appeared the recommendations adopted in 1997 (Prowant & Twardowski, 1996) were still the current model; that being, it is safer to swim in the ocean or a well chlorinated private pool. Swimming was not recommended in lakes, rivers or public pools due to the high bacterial count. Traditionally, swimming was not recommended for patients on PD. An internet search we conducted for articles revealed no recent information.

Researching the new materials used in ostomy care, we elected to trial a Hollister ostomy pouch (see Table 1). The transfer set and PD catheter fit easily into the pouch, which was attached to the skin around the exit site. The edges of the pouch were then secured with Tegaderm[TM] strips to ensure it would be "water tight". The pre-swim procedure steps were:

1. Cleanse the skin with AllKare[R] protective barrier wipes.

2. Apply Hollister ostomy pouch (82335) around the exit site encasing the catheter and transfer set.

3. Cut in half, three 10 cm x 12 cm Tegaderm[TM] films.

4. Apply three half-inch strips of Tegaderm[TM] film around all the edges of the ostomy bag.

5. Allow 20 minutes to adhere before using. The post-swim procedure (see Table

2) steps were:

1. Shower using antibacterial soap.

2. Using the AllKare adhesive remover wipe, begin to loosen the edges of the Tegaderm[TM] film and ostomy pouch and carefully remove/discard.

3. Perform exit site care using chlorexidine swabs, Bactroban[R] cream, as needed, apply a Mepore[R] dressing and secure the catheter/transfer set in their usual fashion.

Our patient followed precisely the guidelines as recommended and was instructed to contact the home dialysis unit immediately for any concerns regarding the exit site or PD catheter. Supplies were given to the patient to trial--every swim was enjoyed problem free. It was found to be more economical for the patient to purchase supplies from the hospital versus retail. The pharmacies varied greatly in both the items held as stock and the cost of supplies. Ordering through our facility, at a special rate set for patients, the cost for supplies was approximately $5.00 per swim.

Table 2. Exit-site care supplies

1 x Chlorexidine Swabs

1 x Mepore[R] Dressing

Bactroban[R] Cream

PD belt

The patient reports swimming more than 30 times during the summer of 2010. She would often be in the lake for an hour at a time "just floating and enjoying". Each swim had multiple entries over several hours and she would often spend the entire day at the beach. Most recently, with the arrival of the cold weather, she has enjoyed swimming at the local YMCA problem free. The following is our patient's experience of swimming and its importance to her:

Being able to swim has made all the difference to me this summer. Swimming is one of my favourite things to do, so it would have been disappointing to sit on the sidelines while everyone else was having fun enjoying one of Muskoka's most basic pleasures--summer days spent at the beach.

I am a patient at the Soldier's Memorial Hospital in Orillia, Ontario. I chose to use the PD method using the overnight cycler. This method has given me daytime freedom including the freedom to swim.

The swimming pouch gave me the freedom to belly flop into Lake Vernon in Huntsville, just two minutes down the road from where I live. I was so excited at the prospect of being able to swim again that I used my Facebook "news feed" so that my friends knew when I would be heading to the beach to enjoy the soothing delights of that lake on a hot summer's day. I have enjoyed swimming from a very young age.

Over the course of the 30 swims I enjoyed, the device completely waterproofed my PD catheter and, more importantly, the exit site. I was careful to take a shower after swimming using, as always, antiseptic soap. Proper exit site care afterwards was also important.

I was happy to discover that the device was fairly incognito under my black suit.

I'm so glad that I had this wonderful opportunity and that others may be able to have the chance to try it as well.

This patient, highly motivated and attentive to instructions, was an excellent candidate to trial the newly created Steps to Safe Swimming Guideline (Soldiers' Memorial Hospital, 2011) for peritoneal dialysis clients.

Patients are trained in the Steps to Safe Swimming Guideline and application of the equipment. This guideline was expanded in 2011 to include a client signature to the listed risks and possible outcomes if the guideline is not followed as outlined. We advise against hot tubs, Jacuzzis and soaking tubs. Patients using the Steps to Safe Swimming Guideline are being tracked for peritonitis and exit site infection rates and, to date, there have been no adverse events or outcomes.

As a PD nurse, witness to patients' many trials, it was a pleasure to witness the utter joy this patient expressed first at the thought of being able to swim again, and her exuberance as she shared her many experiences "just floating and enjoying".

References

Plante, B., Amadai, M., Herbert, E., & O'Regan, S. (1990). Tegaderm dressings for peritoneal dialysis and gastrojejunostomy catheters in children. Advances in Peritoneal Dialysis, 6, 279-280.

Prowant, B.F., & Twardowski, Z.J. (1996). Recommendations for exit care. Peritoneal Dialysis International, 16(Suppl. 3), S94-S99.

Sandahl, L.L., & Owens, E.L. (1989). Use of an ostomy pouch for pediatric CAPD swimmers. American Nephrology Nurses Association (ANNA) Journal, 16(4), 274-277.

Soldiers' Memorial Hospital. (2011). Steps to Safe Swimming Guideline. Orillia, ON: Author.

Copyright [c] 2011 Canadian Association of Nephrology Nurses and Technologists

Department Editor: Eleanor Ravenscroft, RN, PhD, CNeph(C)

Arlene Cugelman, RN, CNeph(C), Charge Nurse/Clinical Educator, Orillia Soldier's Memorial Hospital, Orillia, ON

Address correspondence to: Arlene Cugelman, RN, CNeph(C), Charge Nurse/Clinical Educator, Orillia Soldier's Memorial Hospital, 170 Colborne Street West, Orillia, ON L3V 2Z3; Email: ACugelman@osmh.on.ca
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