Peritoneal dialysis: the tactile perception of clients that live with the catheter

Abstracts

OBJETIVO: Este estudo objetivou investigar a percepção tátil do cliente na convivência com o cateter de diálise peritoneal indicadora de necessidades de cuidado. MÉTODOS: Estudo de abordagem qualitativa baseado nos princípios da sociopoética e no dispositivo do grupo pesquisador. Realizado no período de março a maio de 2006, empregou dinâmica de criação artística com sete clientes, em um hospital universitário. RESULTADOS: As análises apontaram para a adaptação, a negação, o cuidado, a indiferença, o mal-estar, que revelaram as categorias auto-estima e auto-imagem. CONCLUSÕES: O grupo como sujeito ativo da pesquisa evidenciou experiências através do diálogo. Emergiram através da criatividade os saberes inconscientes, desconhecidos e inesperados.

Enfermagem; Diálise peritoneal; Percepção; Auto-imagem

WCN 2007/NURSING MEETING

Peritoneal dialysis: the tactile perception of clients that live with the catheter^*

Diálisis peritoneal: la percepción táctil del cliente en la convivencia con el catéter

Doris de Oliveira Araújo Cruz^I; Sílvia Teresa Carvalho de Araújo^II

^IMaster in Nursing, RN at Hospital Universitário Clementino Fraga Filho at Universidade Federal do Rio de Janeiro – UFRJ – Rio de Janeiro (RJ), Brazil

^IIPhD, Adjunct Professor, Board Member of the Hospital Nursing Reseach Center at the DEMC at Escola de Enfermagem Anna Nery - Universidade Federal do Rio de Janeiro – UFRJ – Rio de Janeiro (RJ), Braszl

Corresponding Author

ABSTRACT

OBJECTIVE: The purpose of this study was to investigate the clients' tactile perception toward living with a peritoneal dialysis catheter indicating their care needs.

METHODS: This qualitative study was based on the principles of social poetics and according to the research group. It was carried out in the period from March to May 2006 and it used dynamics of artistic creation with seven clients, in a university hospital.

RESULTS: The analyses pointed at the adaptation, denial, care, indifference, indisposition, ill–being, which revealed the categories self-esteem and self-image.

CONCLUSIONS: The group, as the active subject in the research, reported their experiences through dialogues. Through creativity, unconscious, unknown and unexpected knowledge emerged.

Keywords: Nursing; Peritoneal dialysis/psychology; Perception; Self concept

RESUMEN

OBJETIVO: En este estudio se tuvo como objetivo investigar la percepción táctil del cliente en la convivencia con el catéter de diálisis peritoneal indicador de necesidades de cuidado.

MÉTODOS: Se trata de un estudio con abordaje cualitativo basado en los principios de la sociopoética y en el dispositivo del grupo investigador. Se llevó a cabo en el período de marzo a mayo del 2006, empleándose la dinámica de creación artística con siete clientes, en un hospital universitario.

RESULTADOS: Los análisis señalaron la adaptación, la negación, el cuidado, la indiferencia, el malestar, reveladas en las categorías auto-estima y autoimagem.

CONCLUSIONES: El grupo como sujeto activo de la investigación evidenció experiencias a través del diálogo. Emergieron por medio de la creatividad los saberes inconscientes, desconocidos e inesperados.

Descriptores: Enfermería; Diálisis peritoneal/psicología; Percepción; Autoimagem

INTRODUCTION

This research emerged from the daily experience with clients with special health needs (SHN) in peritoneal dialysis. Their reality in face of their health condition, was sometimes verbalized and sometimes not. After joining the implementation staff of the Continuous Ambulatory Peritoneal Dialysis Program (CAPD), in 2000, in the Clementino Fraga Filho University Hospital of the Rio de Janeiro Federal University (UFRJ), when I took part in several meetings, with a view to integrate nursing assistance in an interdisciplinary context. In the practice, it was observed there were changes in the patients' current lifestyle and fear toward the future. An array of events that encompasses the individuals' experiences in particular, their formal social relations, and their living conditions: "The Contemporary discourse about health, the disease is not always truly capable of explaining the patient's daily suffering, nor the particular relation that each individual establishes with their own body"⁽¹⁾.

I increased the reflection about each individuality and the difficulty that most individuals have of touching themselves, accepting and living with the implanted catheter and with the fact that it is permanent, as well as their responsibility of performing their own dialysis. Therefore, I discovered that, for some clients, it was not easy and obvious to imagine a "tiny plastic tube" as a permanent part of them, and to touch, perceive and live with it as an appendix to their bodies.

By delimiting the client's tactile perception toward living with the peritoneal dialysis catheter as the study object, I aimed to understand, based on the client's perspective, the perception, living and preservation related to the fundamental access to their life maintenance. The objective was to analyze the client's tactile perception toward living with a peritoneal dialysis catheter, indicating the need for nursing care.

It was understood that the nurse's political-social responsibility also includes to value the clients' perception in their adjustment to the treatment's initial stages, in ambulatory as well emergency services. This is based on the characteristic they have in common; the catheter insertion, which, according to our study, results in a metamorphosis in their bodies.

Although men capture information through receptive systems, the latter are changed by individual and collective culture. The body is the means by which a model of the world is formed, and the absorbed information is thus transformed into culture through body senses⁽²⁾.

It was also highlighted that the tactile perception is our very first form of communication and learning about the world. This perspective defines touch as an exercise of one of the human senses, and this communication obeys social customs and cultural patterns⁽²⁾.

On the other hand, "to be involved, to experience empathy and maintain mutual respect in an interaction implies spending energy". Furthermore, to understand the client in all his or her human dimensions and to respect him or her as such, it is indispensable "to hear the silence, that is, the non-verbal communication (NVC)"⁽³⁾.

Is up to the nurse, still in the interpersonal communication area, to consider the channels referring to the sense organs, mainly vision, hearing and touch, while scent and taste must also be considered. In a communicative act, one or more associated channels are used, and the effective use of our senses is what insures the precise perception of the message⁽³⁾.

In this sense, by valuing the client's imaginary as source of information, nurses benefit from the possibility of improving nursing care suitability. This unveiling of the imaginary allows to understand not only the images stored in one's conscious mind, but also to search the different behavior reactions that each client shows when confronting with the disease and the dialysis treatment⁽⁴⁾.

THEORICAL FRAMEWORK

The sociopoetic approach, inserted in nursing research, calls to creativity, sensitivity, memory, imagination and all that can be called "poetic" – from the greek "poiesis", which means "production, creation" – a resource that releases the group and personal knowledge in a critical and implicit sense, the respect to the attendees⁽⁵⁾:

This focus recognizes man as the subject and not the object of research, inserted in the construction of society and in the direction of social change through critical and critic-inviting dialogue⁽⁶⁾.

Hence, the exercise of body senses is used to produce analytic categories and to understand the client's perception of life towards living with a catheter. When analyzing the data, I tried to reach an understanding based on the group's body senses, and I valued their non-verbal communication and the meanings they assigned to the tactile perception toward living with the catheter⁽³⁾.

It is worth to highlight that, within one's consciousness, self-esteem interacts with other human personality characteristics. Consciousness is what guides one's options and decisions to transform and be transformed, a support to self-support and self-preservation. Self-knowledge and self-development are promoted by self-esteem and shape "a subtle care, a type of food for the spirit"⁽⁷⁾.

Therefore, the nurse, while interacting with the client, seeks good self-esteem, generating a capacity to adapt to the real world in health problems, and studies show how this "heals the individual, making him or her capable of walking with their own feet". Therefore, "when we accept certain things does not means that we like them, to accept it does not imply to like, rather it means that living without denying that a fact is a fact"⁽⁸⁾.

It should also be emphasized that good self-esteem reflects the implicit judgment of our capacity to deal with the challenges in life, feeling confidently adequate, i.e., capable and worthy of happiness. By developing our self-esteem, we expand our capacity to be happy⁽⁸⁾.

If we provide people with the opportunity to develop their self-esteem, consequently, their own perspective regarding their self-image will be positive, since they will no longer be in conflict with themselves or with the world⁽⁸⁾.

In summary, touch transcends physical contact and transmits comfort and affection to face the treatment⁽⁹⁾.

In the hospital context, special emphasis is given to feelings of insecurity and gaining strength because the client needs support to deal with the unknown, and the touch from one's hands is worth a thousand words, revealing feelings of a need for affection, hope, and faith⁽³⁾.

METHODS

The qualitative-approach study occurred in the period of March to May 2006, at the Nephrology Service of the Clementino Fraga Filho University Hospital of the UFRJ. It was based on the dialectic method, according to the analytic approach of the research group (RG) inserted in the dialogue, collaboration and union, valuing the collective creation in data production.

The peritoneal dialysis sector of this institution has an interdisciplinary staff and establishes a pleasant and client-receptive environment. People in the staff address each other by the first names and in a cordial manner, and this partnership was fundamental to develop the research, providing everything that was necessary within the sector's resources.

Participants were chosen from the active registry of the CAPD or automatic peritoneal dialysis program. All of them had renal NES and were users of peritoneal dialysis catheter. The exclusion criteria were: locomotion difficulties, access to transportation, and physical health. Seventeen clients were invited so that six to 12 could be selected⁽⁵⁾.

Three meetings were held and organized in the same way: same length (two hours), physical space, relaxation, and snack. The meetings occurred in the client's cafeteria, near the dialysis waiting room, but not during meals, thus allowing privacy to the group. The room was prepared with tables, chairs, crayons and paper, and a stereo and CDs with relaxing music and bossa nova.

Through relaxation, we tried to touch the individual's unconscious – historical and socially constituted. In this stage, we searched the collective unconscious of the research-group"⁽¹⁰⁾.

First, the participants introduced themselves, with background music playing. The consent form was read, and participants were asked permission to record their voices. A simplified relaxation technique was performed, respecting individual limitations. Afterwards, the researcher presented the guiding theme: "How you feel the dialysis catheter through touch?". Each participant was then asked to draw a body with a catheter based on the guiding theme. After they all completed the activity, each client showed the picture they had drawn and described it's meaning.

Some of them were unacquainted and expressed satisfaction in sharing common experiences.

The researcher analyzed the data by classes after the first meeting. The data was then returned to the RG for validation in the form of phrases in pieces of paper, and participants were asked to build a story by pasting the phrases in the subsequent meetings.

The researcher performed a classificatory study, and the categories were selected by analyzing the data through the sense of touch, and based on the theoretical frameworks, considering the meaning attributed by the participants.

RESULTS

Thirteen clients answered to the first invitation, and, of these, seven point exclusively to the touch perception, without any other associated sense. There were four women and three men, two of which were aged between 30-49 years, three between 50 and 69 years, and two older than 70 years. All of them were married. Their treatment time ranged from 13 to 47 months. About any previous treatments, four had been subjected to hemodialysis, two for three sessions, one for eleven months, and one for seven years, the latter has a transplanted two years before.

Of these clients, two were accompanied in conservative ambulatory treatment, before initiating the renal replacement therapy. The results showed, based on the statements, there was similarity in the co-researchers' language.

The philosophical concepts referring to the generating theme emerged along the data production by the research group, when carried with them: reason, intuition, emotion and sensation.

The Chart 1 shows the results of the perception thorough touch.

Considering that the analytical categories are related to self-esteem and self-image, they are identified by the number of times they appeared in the statements as a manifestation of touch:

- Catheter/Abdomen Function- related to the technique used (17 statements);

- Care in maintaining the access (9 statements);

- Ill-being, like noticing the liquid and catheter (13 statements);

- Well-being related to lifestyle and the dialysis modality (8 statements);

- Adaptation for lack of options (3 statements);

- Indifference- perceives and lives with it, but is not importuned (5 statements).

DISCUSSION

The analysis of the verbalized expressions clearly evidences the client's difficulty of touching his or her own body: "I draw a catheter here but I feel curious then I put my hand this way, I feel it like this " The patient points to the catheter. In general, the physical touch is not "felt" as a sensation, rather as an emotion, verified by expressions that denotes feelings like: "deeply touched", "don't touch me", "keep in touch", among others^(11-12).

As to their hands, these too express feelings of fear, of the difficult moment, of being abandoned, of loneliness, through cold and trembling hands. The fear also represents the apprehension and uneasiness due to the dependency on others. There is also a fear of the unknown and, especially, of death⁽³⁾.

It is worth stressing the verbalization of a co-researcher about the statement's form: "I felt with the catheter, so I did it this way", reaffirmed the comment said while building the story as self-support and self-preservation: "anyway we feel it, wanting or not, we feel it. There are moments in which we forget it, and sometimes I even forget that I have a health problem".

Similarly, there is the revelation that through touch one is capable of reading the other's soul and it is understood that the sensations are recognized and distributed throughout the according to the movement's characteristics⁽³⁾. Like any communication system, emotions are subject to a convention system that dictates the intensity, situation, reason, and form⁽¹³⁾. The co-researcher states: "At night, I can hardly sleep at all, with my belly full of water, and by morning I wake up very ill, agonized!"

Despite they had directly referred to the way they felt the catheter in the abdomen, the female clients showed personal differences, valuing the reactions they reported about the tactile perception: "I don't know that I don't have something in my belly and when I take a shower, it's there". Women live face touch better, they feel better toward touching and been touched⁽¹⁴⁾.

During the philosophical moment of the studies, the dynamics with the research group showed that the touch assumes the body's general dimension for its capacity to distribute sensations continuously. "And it looks like all that is said about the body is, one way or another, involved with emotions"^(3-13).

In summary, the statements showed the importance of living with the catheter, and the client's perception through touch pointed at care, highlighting as the main aspects in the daily living the catheter/abdomen function, the adaptation and the ill-being/well-being.

The described elements pointed out the nursing care needs : lack of initial guidance (another institution), long wait for routine injectable medications and laboratory exams, the extreme difficulty to receive the automatic dialysis machine, inoperable catheter re-implant, and the opening of a collective space for clients to express their difficulties, realities and the diversion denoted in the study.

FINAL CONSIDERATIONS

The construction of collective knowledge with the researched group, clients with SHN in the peritoneal dialysis program, allowed an active and collective subject role in the knowledge production.

This was the first research in the unit, and data evidenced the life experiences among the clients, through dialogue. People, despite attending the same sector and co-inhabiting the same institutional space, did not know each other. There was the exchange of information and experiences that, despite some had been in treatment for more than three years, they had not known themselves yet.

Another essential element worth mentioning is that the whole body was used as knowledge source: intuitive, emotional, sensitive, gestural, sensual, rational and imaginative, produced and valued from an individual and collective construction, whose perception began with the presentation of one's own body, though represented by separate body senses. These take over one's thoughts, and the production was managed by emotions. They involved themselves wholeheartedly in the activity, living a unique moment and experimenting the taste of expressing themselves through drawings with care and zeal, at ease to free their imagination.

Nevertheless, the use of artistic data production techniques revealed the unconscious, unknown, unexpected knowledge as data that expressed the people's soul, a rich production of subjective and objective data. There was an individual search for totality in his or her existence, and the reality of the nurse committed with the care offered as well.

The data related to the clients perception about the catheter evidence its necessity, even if causes ill-being. The alternation between well-being and ill-being results from the client's adaptation to the daily living with the catheter in their bodies. In addition, though indifference had been frequently pointed out, this posture remits to the need of essential nursing care for the client's psycho-affective support and in maintaining the catheter.

Thus, to face the specific challenge of working with SHN patients undergoing peritoneal dialysis requires a physical and mental availability in the care.

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*

Trabalho extraído da Dissertação de Mestrado "Perceber e (Con)viver com o cateter de diálise peritoneal: uma contribuição do cliente para a enfermagem através dos sentidos corporais" apresentada à Escola de Enfermagem Anna Nery da Universidade Federal do Rio de Janeiro – UFRJ – Rio de Janeiro (RJ), Brasil.

Publication Dates

• Publication in this collection
  23 June 2008
• Date of issue
  2008