will you please make changes as per

will you please make changes as per the comments for this paper? Chronic kidney disease (CKD) leading to end-stage renal disease (ESRD) is a condition affecting millions of people and a leading cause of death in the United States (citation?). The treatment for ESRD is a kidney transplant, hemodialysis (HD), or peritoneal dialysis (PD[HSA1] ). PD is a treatment modality for ESRD patients who require dialysis. PD is a process in which the peritoneum is accessed via a catheter and the peritoneal membrane is used as a semi-permeable membrane to filter wastes, excess water, and electrolytes from the body (cite source). It is the most common type of dialysis and can be done either at home or in a hospital. Patients who, for medical, economical, or other reasons, are unable to undergo other types of dialysis, may be candidates for PD as an alternative therapy option. Because of its convenience and affordability, its popularity has been on the rise. Infectious complications of peritoneal dialysis include exit-site infection (ESI), tunnel infection (TI), and peritoneal dialysis-related peritonitis (PD-related peritonitis) and remain a common cause of catheter loss and discontinuation of PD. (GoÅ‚embiewska & Ciechanowski, 2021, p.1). [HSA2] Exit-Site infection is a major infection characterized by purulent discharge, with or without erythema of the skin at the catheter-epidermal interface (citation?). Swelling and granuloma may also be present. The diagnosis and the treatment of the condition rely on the culture results that may be obtained from the secretions. Infections at the exit site and peritonitis are substantial contributors to morbidity and mortality in patients undergoing PD (citation?). This paper will compare the use of polyhexanide, mupirocin, and no exit site dressings (I) with chloral-prep, gentamicin, and covering the site with a sterile gauze dressing (C) to reduce exit-site infections and peritonitis in people aged 18 to 90 who are getting Peritoneal dialysis (P).Over what period of time? One month? Three months[HSA3] ? Where is your O for outcome? Significance of the problem[HSA4] .[HSA5] Exit site [HSA6] infection (ESI) and peritonitis are two of the most common complications of PD and are associated with significant morbidity and mortality. Catheter infection-related peritonitis accounted for 13% of peritonitis episodes in a study of data from 1979 to 1995, a period before routine use of antimicrobial prophylaxis at the catheter exit site (Piraino, 2019). [HSA7] Because of the possibility of infection, it is essential to ensure that exit sites are cared for appropriately to reduce the number of infections at and[HSA8] peritonitis. PD-related [HSA9] peritonitis is the leading cause of long-term structural and functional peritoneal membrane malfunction (source?). As a result, substantial PD technique failure, hospitalizations, mortality, and healthcare costs are responsible for the limited modality options as an RRT [HSA10] and limited long-term PD use (Nochaiwong et al., 2019). It is a scenario in the hospital where patients get peritonitis due to ESI and is switched to hemodialysis[HSA11] . When a patient fails the PD modality the other option is hemodialysis which will reduce the quality of life and also has a social and psychological effect on the patient. Observational studies suggest that 3% to 10% of the episodes of peritonitis result in patient death. (Bieber & Mehrotra, 2019[HSA12] ). ESI is one of the main causes of peritonitis so exit site infection prevention should be the central focus of the PD program.[HSA13] Theoretical Framework[HSA14] This paper aims to prove that the PICO statement, “For patients age 18- 90 undergoing peritoneal dialysis, use of polyhexanide, mupirocin, and the absence of exit site dressing compared to chloral- prep, gentamicin, and covering the site with a sterile gauze dressing reduces exit site infection and peritonitis” is relevant and the interventions will have a positive impact on the defined patient population. The EBP[HSA15] Iowa research model was used in this case to assess the previous information obtained from the research conducted about peritoneal dialysis and the effects of the infection of the exit site. The model has also helped to obtain the correct assessment and information regarding the topic[HSA16] . This conceptual framework was used on account that it is “practitioner-based” [HSA17] and focuses on incorporating research into practice. Iowa model [HSA18] Image transcription text Problem-Focused Triggers Knowledge-Focused Triggers 1. Risk management data 1. New research or other literature 2. Process improve… Show more [HSA19] The[HSA20] Iowa Model Framework for implementation of evidence-based practice is a framework that is used commonly and across all corners of the world. It advocates for the many changes that have taken place in the medical field, such as the emergence of implementation science, and gives room for re-evaluation and revision of the model, which has, in turn, led to the validation of the model due to the vast knowledge that is accommodated (Cullen et al., 2022). This model was developed in the early 1990s and has since then carried its main purpose to be acting as a guide for conducting research and providing the required space for all information to be validated if a correct explanation and base are provided for them to be able to provide quality care to their patients(citation?) This model majorly aids in promoting the most effective implementation of evidence-based practice by identifying the problem and then using the findings acquired from conducting proper research to come up with the best and most suitable solutions when it comes to the problem in (Cullen et al., 2022). This will therefore assist in identifying the most suitable intervention, and upon implementation, the population in will obtain positive results and good treatment with quality care. The Iowa model is also known for significantly aiding to focus on the problem-focused triggers which can help to identify the problems succumbed to within the current practice and also the research being carried out can help in coming up with the correct solutions. [HSA21] For this project, the Iowa Model will specifically be used in the identification of the problems that patients aged 19-80 [HSA22] undergoing peritoneal dialysis how the use of polyhexanide, mupirocin, and the absence of exit site dressing is more effective as compared to chloral- prep, gentamicin and covering the site with sterile gauze dressing and how it will aid in the reduction of the exit- site infection and peritonitis. The first step after adopting the Iowa model involves identifying the problem that has triggered the need for change to occur. Even though clinicians from the medical field try their best to ensure that the peritoneal dialysis process is conducted with elevated practice standards, infection of the exit- site and peritonitis have been some of the major challenges that have constantly affected peritoneal dialysis patients. The infection of the exit site normally leads to its removal, which in some cases may cause adverse consequences such as health deterioration and death. Since the infections have become a menace and are affecting many patients who undergo the process, it has been identified by the medical team as a significant problem. After problem identification, the second step of the Iowa Model is conducting proper research or evaluation of the problem for the organization at large. Research regarding the causes for ESI and peritonitis was conducted. [HSA23] Once research has been carried out and proper information about the topic obtained, the next step of the Iowa Model involves creating a team of the most suitable professionals who will assist in ensuring that the evidence-based practice is correctly developed, implemented, and evaluated. In this step, a team of professionals in the field, such as doctors, advanced practice nurses, nurses who conduct peritoneal dialysis, hospital researchers and a quality care committee can be formed. In this case, infection of the exit site was identified with the use of polyhexanide, mupirocin, and no exit site dressings are important in providing the correct environment for the wound to be free from infection. [HSA24] The effectiveness of the application of mupirocin cream at the catheter exit area helps prevent ESI as well as peritonitis (citation). Such information provided by the team of professionals will be greatly beneficial since a set of solutions for the identified problems will be realized. The implementation process begins upon drafting the most appropriate solutions for evidence-based practice. The final step involves determining the strengths and the weaknesses through evaluation of the entire process. . For the current research , prevention of exit site infections with the identified solutions improves patient outcomes which strengthens the validity of the process. The weaknes of the identified solution is that some patients may still contract exit site infections, specifically the immunocompromised population. The change will be drastic and some people’s viewpoint is different and it will be difficult for them to accept the drastic change, there is a financial burden to implement EBP changes.[HSA25] Search strategy[HSA26] [HSA27] [HSA28] A comprehensive search strategy was employed to identify relevant studies for this paper. A variety of databases and search engines were accessed through the Texas Woman’s University (TWU) library, including PubMed, Google Scholar, CNAHL, and Cochrane Library.. Keywords used in the search were “peritoneal dialysis”, “exit site infection”, “peritonitis”, “polyhexanide”, “mupirocin”, “chloral-prep”, “gentamicin”, and “sterile gauze dressing”. Many articles obtained included[HSA29] most of the keywords listed, meaning the studies were comparative. Most of the studies reviewed expounded[HSA30] on the peritoneal dialysis procedure and how there are risks of infection involved. More research into the outcome of the advantage and disadvantages of different types of exit site care[HSA31] [HSA32] .[HSA33] [HSA34] Literature review[HSA35] Several studies compared the use of polyhexanide, mupirocin, and no exit site dressings (I) to chloral-prep, gentamicin, and covering the site with a sterile gauze dressing (C) to prevent exit site infections and peritonitis in people between the ages of 18 and 90 who were getting Peritoneal dialysis (P). [HSA36] There were observational studies, case-control studies, and randomized controlled trials among the articles reviewed. In a unique case study conducted by GoÅ‚embiewska, E., & Ciechanowski, K[HSA37] . a patient with polycythemia vera on peritoneal dialysis developed ESI due to skin infection. Risk factors of ESI include poor competency of ES[HSA38] care, poor catheter immobilization, history of catheter-pulling injury and mechanical stress on ESI (citation) . This strengthens the importance of methods of exit site care as well as proper teaching and PD training. (GoÅ‚embiewska & Ciechanowski, 2021, p. 3)[HSA39] [HSA40] Use of polyhexanide for skin care rather than saline, iodine, or chlorhexidine [HSA41] [HSA42] After researching what causes infection to the exit site and catheter, it was realized that not only the dressing method may affect the site but also whether the patients used normal saline for site cleansing or povidone-iodine (citation). Additionally, it was then noted that itching and skin irritation on the exit site, which mostly leads to infection, happens way less to the patients treated with saline compared to those treated with iodine. A randomized, double-blind, controlled protocol study conducted by Nochaiwong et al.(2019) on the prevention of peritonitis reported that the daily application of chlorhexidine gluconate for exit-site care may induce local skin irritation, which could limit patient acceptability and long-term complianceNochaiwong et al., 2019, p. 2[HSA43] Polyhexanide is therefore considered more effective in this case as compared to the use of chloral-prep for disinfection of the exit site skin. Based on the results, it[HSA44] was discovered that using polyhexanide minimizes skin stimulation, reducing infection[HSA45] . Use Mupirocin as compared to gentamicin to reduce site infection and Peritonitis.[HSA46] Mupirocin[HSA47] t is an antibiotic that has excellent activity against gram-positive infections and also has little to no effect on gram-negative bacteria (citation). This antibiotic has been tested and proven to effectively prevent exit-site infection and peritonitis in patients undergoing peritoneal dialysis (Obata, 2020). The application of mupirocin has therefore been adopted by most healthcare centers and tagged a standard effective [HSA48] due to its positive impact on patients. In 2005, it was reported that the use of mupirocin was associated with a lower catheter infection and led to decreased peritonitis (citation). The superiority of this antibiotic over gentamicin was also demonstrated in subsequent studies; therefore, the mupirocin antibiotic was recommended for patients undergoing peritoneal dialysis (citation). In a multicenter, observational, international study of PD patients by Boudville N et al.,(2018)[HSA49] found that significant practice differences exist between countries. Differences were most notable in the domains of frequency and monitoring of PD-related infection rates, use of periprocedural, [HSA50] antibiotic prophylaxis, type of exit-site cleaning strategy, use and choice of exit-site antimicrobial prophylaxis strategies[HSA51] and the use of antifungal therapy during a course of antibiotic therapy (Boudville et al., 2018, p. 2122)[HSA52] Practicing absence of exit site dressing to the patients undergoing Peritoneal dialysis.[HSA53] In[HSA54] a study conducted by Bieber & Mehrotra., (2019) [HSA55] 72 patients who underwent peritoneal dialysis to determine the various infections associated with peritoneal dialysis mentioned that the literature has not shown consistently that the routine placement of a dressing at the PD catheter exit site daily is necessary to prevent exit site infection and there is some suggestion that it may actually, increase the rates of infection (Bieber & Mehrotra, 2019, p. 24) [HSA56] Dressing of the exit site with the use of sterile gauze dressing is one of the previously used methods for patients undergoing peritoneal dialysis. However, continuous study and research have continued to prove that covering the site may be of little benefit when it comes to the incidence of ESI or PD- related infections (citation). It has been stated that the most convenient and efficient technique is the non-dressing technique with only prophylactic topical mupirocin cream application (citation). This method has been stated to be more cost-effective and has fewer disposables[HSA57] , providing the correct environment for the exit site to react normally (citation). The studies also show that a covered dressing may be a pathway for the organisms to access the exit site (citation). This is because a covered dressing does not inhibit the micro-organisms in but rather provides[HSA58] an acceleration for bacterial growth. This has further proven r that the absence of an exit site dressing should be practiced in the PD programs to reduce site infection and peritonitis[HSA59] . [HSA60] References[HSA61] Bieber, S., & Mehrotra, R. (2019). Peritoneal dialysis access associated infections. Advances in Chronic Kidney Disease, 26(1), 23-29. Retrieved February 13, 2023, from https://doi.org/10.1053/j.ackd.2018.09.002 Boudville, N., Johnson, D. W., Zhao, J., Bieber, B. A., Pisoni, R. L., Piraino, B., Bernardini, J., Nessim, S. J., Ito, Y., Woodrow, G., Brown, F., Collins, J., Kanjanabuch, T., Szeto, C.-C., & Perl, J. (2018). Regional variation in the treatment and prevention of peritoneal dialysis-related infections in the peritoneal dialysis outcomes and practice patterns study. Nephrology Dialysis Transplantation, 34(12), 2118-2126. Retrieved February 13, 2023, from https://doi.org/10.1093/ndt/gfy204 Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H., & Wagner, M. (2022). Iowa implementation for sustainability framework. Implementation Science, 17(1). Retrieved February 13, 2023, from https://doi.org/10.1186/s13012-021-01157-5 GoÅ‚embiewska, E., & Ciechanowski, K. (2021). Repeat exit site infection in peritoneal dialysis patient with polycythemia vera – a case report. BMC Infectious Diseases, 21(1). Retrieved February 13, 2023, from https://doi.org/10.1186/s12879-021-06342-x Nochaiwong, S., Ruengorn, C., Noppakun, K., Panyathong, S., Dandecha, P., Sood, M. M., Saenjum, C., Awiphan, R., Sirilun, S., Mongkhon, P., Chongruksut, W., & Thavorn, K. (2019). Comparative effectiveness of local application of chlorhexidine gluconate, mupirocin ointment, and normal saline for the prevention of peritoneal dialysis-related infections (cosmo-pd trial): A multicenter randomized, double-blind, controlled protocol. Trials, 20(1). Retrieved February 13, 2023, from https://doi.org/10.1186/s13063-019-3953-8 Obata, Y., Murashima, M., Toda, N., Yamamoto, S., Tsujimoto, Y., Tsujimoto, Y., Tsujimoto, H., Yuasa, H., Ryuzaki, M., Ito, Y., Tomo, T., & Nakamoto, H. (2020). Topical application of mupirocin to exit sites in patients on peritoneal dialysis: A systematic review and meta-analysis of randomized controlled trials. Renal Replacement Therapy, 6(1). Retrieved February 13, 2023, from https://doi.org/10.1186/s41100-020-00261-4 Perl, J., Fuller, D. S., Bieber, B. A., Boudville, N., Kanjanabuch, T., Ito, Y., … & Johnson, D. W. (2020). Peritoneal dialysis-related infection rates and outcomes: results from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). American Journal of Kidney Diseases, 76(1), 42-53. https://doi.org/10.1053/j.ajkd.2019.09.016 Piraino, B. M. (2019). Putting peritoneal dialysis catheter infections into perspective. American Journal of Kidney Diseases, 74(5), 705-707. Retrieved February 13, 2023, from https://doi.org/10.1053/j.ajkd.20 Comments [HSA1]A paragraph is considered 3 sentences or more. Consider combining this paragraph to the one below or adding another sentence. [HSA2]Please review proper APA 7 format for referencing [HSA3]Watch your spacing. Please refer to APA 7 formatting for spacing [HSA4]Significance of Problem (10 pts) Clearly states why chosen topic is important. Uses appropriate data to support topic. [HSA14]Theoretical/Conceptual Framework (20 pts) Identifies theoretical model or evidence-based practice model to serve as the framework. Explains why this theory was chosen as the framework. Describes how this theory is relevant and how used for this paper. [HSA27]Search Strategy (10 pts) Summarizes search methods used and findings. Defines inclusion and exclusion criteria. – 5 points. Incomplete [HSA28]Review title case headings and proper apa guidelines on titles [HSA29]The articles were not in , your PICO was the topic of research [HSA30]You did not discover the studies, you reviewed them [HSA31]Spacing [HSA32]Missing inclusion and exclusion criteria. Also missing how you narrowed down your findings. Did you change the years/dates/only english articles, ect [HSA33]This sentence reads like a fragment. [HSA34]Review of Literature (30 pts) 6-8 peer reviewed, current journal articles (within 5 years) with substantive data for your problem – Studies relate directly to the PICO . Succinctly summarizes articles on how they support, or do not support, stated problem. Addresses strength of literature using an identified data stratification method (i.e. level of evidence). – level of evidence not addressed, no p-values given for validity of data, no mention of sample sizes Attaches a summary of the matrix outlining included works, study attributes, expert opinion, evidence level ranking, and significant findings – not completed Provides a brief synthesis of the matrix findings in the body of the paper that includes support and contradictory findings in the literature review related to the problem.- not discussed in the summary of findings -15 points [HSA60]Paper Content, Flow, and Style/Evaluation (10 pts) Succinctly covers the required content 10-15 pages.-some content missing (Lit review) Demonstrates professional writing throughout the paper. Logically organizes the content with respect to flow and progression. No spelling errors, correct use of grammar. Sentence structure review required Includes copy of the matrix as an appendix.-not listed as appendix, need to review APA 7 format for appendices Reference list in correct APA format.- Not references correctly. Requires review -6 points [HSA61]Please review proper APA 7 format for referencing. All of these references are incorrectly documented.

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