For both home hemodialysis and home peritoneal dialysis, home dialysis training represents an important tool for improving the quality of performance of the respective procedure, which should subsequently contribute to an improvement in the success of therapy. In addition, performing hemodialysis or peritoneal dialysis in the patient’s own home should considerably improve the quality of life of the patient concerned by significantly reducing the amount of time spent traveling to the dialysis center in question, which is no longer necessary. Furthermore, the patient should be enabled to lead his or her own life as normally as possible. The support of a partner or the patient’s own family is important for the correct implementation of a home dialysis procedure. Training for home hemodialysis
The use of home hemodialysis is only possible if both the patient and his or her partner have the skills to perform the dialysis treatment correctly. Because of this, it is essential to undergo a preparatory period in a special dialysis center in order to prepare and apply the necessary skills. The purpose of this period is to train the patient and his or her partner and to determine whether home treatment is feasible from a medical and, if necessary, psychological point of view. In order to achieve uniform documentation and comparable training, a standardized training catalog is required. The components of the standardized training catalog for performing home hemodialysis:
First training section
- Adequate preparation or testing of the material to be used and the necessary equipment must be guaranteed. This includes, but is not limited to, flushing the dialysis machine, testing that it is free of disinfectants, and preparing the materials needed for dialysis. Furthermore, it must be ensured that the patient and his partner are able to set up the dialysis machine. Part of the set-up is, for example, the attachment of the blood tubing system.
- From the staff of the supervising dialysis center is additionally to ensure that both the patient concerned and the partner are sufficiently informed about the dialysis solution. Here, among other things, the knowledge of necessary electrolyte concentrations is to be checked. In addition, there should be adequate knowledge of physical parameters such as conductivity, transmembrane pressure (TMP), as well as general aspects of hygiene in dialysis.
- The importance of various physiological parameters should also be known to perform home hemodialysis. As example parameters can be mentioned the blood pressure, body temperature, pulse, dry weight and residual diuresis, the necessary or allowed amount of drinking and dietary instructions.
- To achieve optimal function of hemodialysis, it must be known how to connect to dialysis and how to set the ultrafiltration volume. It must also be possible for the individual to record dialysis data in weekly and monthly logs. In addition, the patient should be able to check the machine. Of critical importance is the puncture by the partner or the patient himself.
- For dialysis to be properly completed by the patient, it must be known how to return the blood, remove the puncture cannulae, care for puncture sites and clean the dialysis machine.
- The user of the dialysis machine should also have sufficient and sound information about the vascular access required for dialysis. Also complication possibilities with fistulas should be known.
Second training section
- The laboratory values and urinary substances should be able to be named and classified from the present value.
- Furthermore, the patient should be able to explain the individual device functions including setting, meaning and control.
Third training section
- The patient must have the ability to verify heparinization (treatment with heparin for anticoagulation) by taking a blood sample for coagulation determination. Also, the correction of possible incidents must be sufficiently trained and later reviewed.
- To improve patient safety during hemodialysis, education must be provided on what to do in the event of, for example, a drop or rise in blood pressure, muscle spasms, or even an air embolism. The knowledge to prevent hyperkalemia (excess potassium) must also be present in the patient.
Fourth stage of training
- In this training section, the focus is on providing the information, such as how to calculate water treatment and material ordering and storage.
Fifth training section
- In the last section is the repetition of all training sections, so that subsequently the preparation of the first home dialysis can be realized. There is also a discussion of both medical and nursing care.
Training for home peritoneal dialysis
- Begins with preparation for correct behavior in the performance of home peritoneal dialysis on the fourth day after implantation. The dialysis center staff will guide the patient on how to perform a bag change, for example. However, since the handling of peritoneal dialysis can be considered relatively difficult at the beginning of training, the patient is first trained under supervision on an exercise apron. This is to ensure that both the patient and his catheter are protected.
- During the training, the bag changes for dialysis treatment are performed by the staff. One starts here with a small filling volume, so that a slow habituation to the applied volume in the abdominal cavity can take place. This also leads to good healing of the catheter. Until the time of discharge, the applied volume is continuously increased.
- In order to prevent bacterial contamination of the apparatus and thus minimize the risk of peritonitis (inflammation of the peritoneum), various hygiene rules should be observed when using the necessary equipment. Of important importance, among others, is that bag changes at home should be performed exclusively in a clean locked location. To further reduce the risk of contamination, peritoneal dialysis should never be started without a mouth guard. Furthermore, care should be taken to ensure that the required work surface is not contaminated and is adequately disinfected. In addition to disinfecting the work area, it should also be ensured that hands have been disinfected prior to dialysis treatment. There is no need for additional hand washing for disinfection. Since disinfection can significantly reduce the germ load, but it is not possible to achieve freedom from germs, the dialysis patient must not touch the open transfer system or the open bag connection during the bag change.
- To prevent infections at the catheter exit site, special personal hygiene is required that is adapted to the dialysis treatment. Part of this special body care is daily showering, keeping in mind that the dressing must be removed at the beginning of the hygiene measure. Once this is done, the patient should inspect the catheter exit site for any special features. To prevent a change in the position of the peritoneal dialysis device, the exit site of the catheter should always remain untouched, if possible. This site should only be dabbed dry with sterile compresses. If the cleaned exit site of the catheter is not irritation-free, it must be covered with a sterile compress. Subsequently, the compress is fixed with several strips of plaster.
- In order for home peritoneal dialysis to have the same or improved therapeutic success, it is necessary that various controls are performed regularly at home. Similar to home hemodialysis training, the patient receiving peritoneal dialysis treatment must also be trained to recognize and treat complications. An example of this is discoloration of the dialysate, which can be the sign of various complications. Any leaked dialysate must be checked for clarity. In order to give patients a means of comparison, the dialysate should be compared with the color of clear apple juice. If a cloudiness is now visible during this comparison, this could be a sign of the development of peritonitis (inflammation of the peritoneum).In this case, it should be noted that peritonitis must be excluded without delay and treated directly if confirmed. However, in addition to the inflammatory reaction as a reason for turbidity, proteinuria (increased excretion of protein with the urine) must also be considered. To clarify this suspicion diagnostically, the patient should look for fibrin threads. If a reddish discoloration in the dialysate is detected, then a blood admixture must be feared, which must result in a rapid clarification.
