Renal: Peritoneal Dialysis Catheter- Chronic Exit Site Care Document No.
Guideline and
Procedure
Renal: Peritoneal Dialysis Catheter – Chronic exit site care
Sites where Guideline and Procedure
applies
Target audience:
Description
All sites where a Peritoneal Dialysis patient receives care.
Nephrology and Non nephrology clinical staff, who provide
care to Peritoneal Dialysis patients.
This document comprises part of the clinical information
package for care for Peritoneal Dialysis patients.
This Guideline and Procedure applies to:
1. Adults
2. Children up to 16 years
3. Neonates – less than 29 days
Keywords
Yes
No
No
Chronic exit site, Exit site, Peritoneal dialysis catheter, Renal,
PD
Replaces Existing Guideline and Procedure Yes
Registration Number(s) and/or name and of
Superseded Documents
Related Legislation, Australian Standards, NSW Health Policy Directive, NSQHS Standard/EQuIP
Criterion and/or other, HNE Health Documents, Professional Guidelines, Codes of Practice or Ethics::



NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
NSW Health Policy Directive PD 2007_036 Infection Control Policy
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf
Prerequisites (if required)
Registered Nurse or Endorsed Enrolled Nurse who have been deemed
competent in the performance of peritoneal dialysis
Guideline and Procedure Note This document reflects what is currently regarded as safe and appropriate
practice. However in any clinical situation there may be many factors that
cannot be covered by a single document and therefore does not replace
the need for the application of clinical judgment in respect to each
individual patient.
If this document needs to be utilized in a Non Nephrology Area please
liaise with the Nephrology Service to ensure the appropriateness of the
information contained within the Guideline and Procedure.
This Guideline and Procedure sets out the steps to be followed when
performing ongoing Peritoneal dialysis catheter exit site care, for a
peritoneal dialysis patient. The procedural components of the document
such as, Preparation of patient, Preparation of equipment, Technique,
Cleaning up and Documentation are considered mandatory.
Position responsible for the
Guideline and Procedure and
authorised by
Contact Person
Kelly Adams, Renal Stream Coordinator, Nurse Manager Community
Dialysis
Contact Details
49 048800
Date authorised
This Guideline and
No
Procedure contains advice
on therapeutics
Date of Issue
Version Number
Month and Year
Renal: Peritoneal Dialysis Catheter- Chronic Exit Site Care Document No.
Review due date
TRIM Number
Version Number
10/26-2-13
Month and Year
OUTCOMES
1
Minimise the risk of exit site infection, peritonitis and potential loss of catheter
2
Patient remains independent with exit site care where appropriate
3
Catheter patency is maintained and trauma to exit site is minimized to ensure long term
patient success with peritoneal dialysis therapy
ABBREVIATIONS & GLOSSARY
Exit site
The site at which the peritoneal catheter exits the abdomen
Tunnel
The subcutaneous track or pathway of the catheter from the exit site to
where the catheter enters the peritoneum
Personal protection equipment
PPE
GUIDELINE
Good exit site care is essential in maintaining good infection outcomes in the patient undergoing
peritoneal dialysis. Excellent hand hygiene is most important before any examination of the
patient’s exit site by the patient, family members, and members of the health care team (Piraino et
al.2011:620). To date, randomised controlled trials on exit site practices have yielded conflicting
results. As such, this clinical protocol is based on clinical experience and level II evidence.
Exit site care includes:
• Use of liquid soaps for showering (i.e. not bar soap)
• Immobilisation of the peritoneal catheter with an anchor tape to prevent trauma to the exit site
• Daily exit site inspection, cleaning and dressing – more frequently if infection is present or the
dressing is soiled / contaminated.
• Patients are trained to inspect their exit site and redress it daily after their shower. Self-care of
the catheter exit site is preferred where appropriate
• When the patient is in hospital, staff should assess the exit site once a day after the patient has
showered and prior to redressing the exit site.
Never use scissors near the exit site/catheter
Exit site appearance
 First 6 to 8 weeks- In the initial post insertion phase, a pink to red exit site is normal.
Localised redness is an inflammatory reaction to the catheter. This develops around Day 3
post operatively and usually resolves within 6 to 8 weeks. Scab formation and crusting are
also fairly common in the new exit site. It is important to record and monitor the exit site
condition, to distinguish this initial inflammatory reaction from infection.
 Chronic exit site - A healthy exit site should be clean, dry, free from scab or crust and
exudate or purulent drainage free from signs of inflammation (redness, swelling) and not
tender to touch (see pic 1).
This Guideline does not replace the need for the application of clinical judgment in respect to each
individual patient.
PROCEDURE
This procedure requires mandatory compliance.
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Patient Preparation
It is mandatory to ensure that the patient has received appropriate information to provide
informed consent and, that patient identification, correct procedure and correct site
process is completed prior to any procedure.
Make the patient comfortable and ensure appropriate privacy.
The dressing is best attended by patient (if able) after showering. Refer to the patient training
manual for patient instructions. If the patient is unwell or unable to perform their own dressing,
attend the dressing as per the procedure below. Whilst patients undergoing peritoneal dialysis are
in hospital, their exit site should be checked by a staff member at least once per day
Staff Preparation
It is mandatory for staff to follow relevant: “Five moments of hand hygiene”, infection
control, moving safely/safe manual handling, and documentation practices.
Equipment Requirements
• Gauze squares, 1 to 2 packets (extra packet required when using 0.9% sodium chloride)
• Tape (NOTE: use same type of tape patient uses at home to avoid possible irritation)
• 0.9% Sodium Chloride or 2% Chloehexidine swab (if requried)
• Mupirocin ointment or medicated honey (if prescribed)
• Non sterile gloves
• Personal protective equipment (PPE)
• Patients’ Medical Records
• Alcohol hand gel
Procedure Steps
Daily assessment and dressing when attended by staff
1. Wash hands
2. Open gauze. Use sterile packaging as dressing surface.
3. Ensure catheter is securely taped to the body (anchor tape 3-4cm from the exit site) and
catheter is in correct alignment without any tension on exit site
4. Remove old dressing, leaving anchor tape in place (don PPE if needed)
5. Gel hands, allow to dry. Don gloves if any crusting or exudate is present
6. Inspect exit site – note any tenderness, inflammation or discharge
7. Wash hands for one minute
8. Don non sterile gloves
9. Remove old anchor tape and ensure catheter is not pulled or twisted whilst attending exit site
dressing
10. Swab around exit site with Saline soaked gauze or 2% Chloehexidine swabs (if infection is
suspected), starting at one fixed point and coming around catheter to meet that point. Allow to
dry.
11. If applying any ointment to exit site and around exit site using a gauze square
12. If patient uses a pillow dressing under catheter to retain catheter’s natural position, fold one
piece of dry gauze in half and carefully place under catheter
13. Replace anchor tape 4 cm away from exit site ensuring catheter is in correct alignment without
any tension on exit site
14. Apply clean gauze dressing, over exit site and tape all four edges of the gauze (like a window
frame)
15. Secure catheter to abdomen where comfortable
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Pic 1: Healthy exit site, 4 years post insertion
Alert: If signs of infection, redness, bleeding or discharge is present during exit site
inspection - medical officer intervention should be sought as a swab of the exit site may
need to be taken and topical or oral antibiotic treatment commenced. More frequent
dressings are often indicated in the presence of an infection – Refer to: Peritoneal Dialysis
Catheter – Management of an Infected Exit Site
APPENDICES
Appendix 1 - Hand Hygiene Australia
Appendix 2- Twardowski Z.J., Prowant B.F. 1996. Classification of normal and diseased exit sites;
Peritoneal Dialysis International, Vol 16 Supp 3
REFERENCES
• Greaves, S., 2005. CAPD patient training manual. Wansey Community Dialysis Centre.
• Hand Hygiene Australia 2013: Five Moments for Hand Hygiene
• JHH Nephrology SWP: P13 (rescinded)
Routine Exit Site Care: A reference protocol for clinical staff. Baxter
• Mujais, S., Crabtree, J.H., Firanek, C.A., Piraino, B., Abu-Alfa, A.K. (2006).
Access care and complications management, Care of the adult patient on
peritoneal dialysis. Baxter
• Piraino, B., Bernardini, J., Brown, E., Figueiredo, A.E., Johnson, D.W., Lye, W-C., Price, V.,
Ramalakshimi, S., Szeto, C-C. (2011)
ISPD Position statement on reducing the risks of peritoneal dialysis-related infections. Peritoneal
Dialysis International, Vol 31, pp. 614-630
FEEDBACK
Any feedback on this document should be sent to the Contact Officer listed on the front page.
Appendix 1
Adopted from the World Health Organization and Hand Hygiene Australia
Appendix 2 Twardowski Z.J., Prowant B.F. 1996. Classification of normal and diseased exit sites
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Appendix 2 Twardowski Z.J., Prowant B.F. 1996. Classification of normal and diseased exit sites; Peritoneal Dialysis International, Vol
16 Supp 3
Catheter Exit Site Classification
Chronically Infected (Grad 4)
Inflammation > 4 weeks duration.
- Drainage: Purulent or bloody external drainage spontaneous
or after pressure. Wet exudate on dressing.
- Swelling, erythema and or pain.
- Epithelium: absent or partly covers the sinus.
- Granulation tissue: exuberant around the exit or in the sinus.
-
Crust or scab around the exit or in the sinus
Acutely Infected (Grad 3)
- Inflammation < 4 weeks duration.
- Drainage: Purulent or bloody external drainage,.
spontaneous or after pressure. Wet exudate on dressing.
Pain, swelling or tenderness.
Exit colour: bright pink or red with ≥13mm diameter.
Epithelium: absent or partly covers the sinus.
- Granulation tissue: exuberant around the exit or in the sinus.
Crust or scab around the exit or in the sinus.
Equivocal (Grad2)
- Drainage: Purulent or bloody only in the sinus cannot be
expressed. Dried exudate on dressing.
- Exit colour: bright pink or red with <13mm diameter.
- Epithelium: absent or partly covers the sinus.
- Granulation tissue: plain or slightly exuberant around the
exit or in the sinus.
- Crust or scab around the exit may be large, difficult to
detach.
Good (Grad1)
- Drainage: sinus is dry, or barely visible, clear or thick
exudate.
- Exit colour: natural, pale pink, purplish or dark or bright pink
discolouration <13mm diameter.
- Epithelium: strong and partly covering the visible sinus.
Fragile mucosal deeper in the sinus.
- Granulation tissue: plain.
- Crust may be small or specks on the dressing.
Perfect (Grad 0)
- Exit is at least 6 months old.
- Drainage: sinus is dry, or barely visible, clear or thick
exudate.
- Exit colour: natural, pale pink or dark.
- Epidermis: strong and mature covering the whole visible
sinus.
- Crust: none or specks on the dressing, easy to detach.
- Absence of pain, swelling, granulation tissue, and external
secretion
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