Conhecendo as estrategias de acao e interacao utilizadas pelos clientes para o enfrentamento da dialise peritoneal

El articulo objetiva presentar las principales estrategias de accion e interaccion utilizadas por los pacientes de enfermedad renal cronica para el enfrentamiento de la dialisis peritoneal. El referencial teorico utilizado fue el Interaccionismo Simbolico, por tratarse de una estructura que valoriza el significado de la interaccion como determinante del comportamiento humano. La Teoria Fundamentada en los Datos se constituyo como el referencial metodologico. Luego de la obtencion de los datos, realizada mediante una rutina de entrevistas semiestructuradas, los mismos fueron grabados, transcriptos, codificados y organizados para componer la teoria explicativa sobre el fenomeno estudiado. Durante el analisis, fueron identificados varios recursos utilizados por pacientes, como la necesidad de obtener informaciones sobre dialisis peritoneal, el refugio en la espiritualidad y la falsa ilusion de cura. Se destaca tambien la red de apoyo, en la que el enfermero podra actuar como facilitador del proceso de enfrentamiento, para ayudar a los pacientes en la adaptacion a su nueva realidad.


INTRODUCTION
Chronic kidney disease (CKD) is a disease which is currently reaching growing levels in Brazil and worldwide.Those who reach the end stage of the illness need to receive one of two types of renal replacement therapy (RRT) available: hemodialysis (HD) or peritoneal dialysis (PD) 1 .
The number of dialysis patients in Brazil in 2011 was estimated at 91,314, of whom 90.6% were on HD and 9.4% on PD.This data indicates a pronounced increase in the population receiving dialysis in Brazil, which makes it fundamental to think about the nursing care directed at this population 2 .
PD is a mode of dialysis which uses the peritoneal membrane as an exchange surface for the diffusion of uremic solutes and ultrafiltration of the surplus bodily fluid in the organism, when the kidneys lose the capacity to do this.To this end, a flexible catheter is surgically implanted in the abdomen, and the client and/or her family members undertake the periodical substitution of a dialysis solution which, in contact with the peritoneal membrane, promotes the elimination of unwanted waste products from the blood, and water 3 .
In addition to the implantation of the catheter, the need to live with it on the surface of her abdomen and to make adaptations at home, the client who is going to receive PD needs to adapt her schedules, her routine and her living habits so as to fit this therapy in safely.The point at which a person needs to use PD as a method for substituting renal function is generally determined by clinical and laboratorial indicators 4 .
Because it is a method which can be undertaken in the client's home, PD leads to a series of adaptations in the environment where the therapy will take place, as well as the involvement and active participation of family members and people close to the client who has CKD in the dialytic phase.For this same reason, it falls to the nurse to assess the residence (individual room and other parts of the building) of the client who intends to be included in the PD program 5 .
Due to all the transformations that it provokes in the life of the client and her family members, one can observe that the start of PD is a critical time in an individual's existential trajectory.All the dimensions in which she exists and her whole life context are redefined, giving a new meaning to her very existence 6 .
This perception awoke the authors' interest in developing and carrying out a research project whose object was to be the meaning of coping with PD for the clients who start the above-mentioned dialytic method.
This study was undertaken in the model of a Master's dissertation, and was presented and defended in 2009, at the Anna Nery School of Nursing of the Federal University of Rio de Janeiro (EEAN-UFRJ).The present article is an excerpt of the above-mentioned dissertation.
Thus, this discussion's objective is to present the main strategies of action and interaction used by clients with chronic kidney disease for coping with peritoneal dialysis.
Considering that a recent survey 7 identified that only 8% of all theses and dissertations published in Brazil on the topic of nephrology dealt with PD, this presentation becomes even more relevant, as it provides current and specific reflection on the nursing care for this clientele.

THEORETICAL FRAMEWORK
Given the importance of the meaning which the study proposes, the authors chose to use Symbolic Interactionism (SI) as the axis for reflection, analysis and discussion of the data.Symbolic interactionism privileges meanings as determinant factors in human behavior, considering these values to be constantly revisited and transformed based on the interactive process of the individual with the elements of her own universe 8 .
In using symbolic interactionism in this study, the authors' intention was to investigate each significant element for the subject who starts on PD.In this way, it was possible to investigate the strategies used by the clients to deal with starting PD.
According to the premises of symbolic interactionism, this process of the attribution of meanings is, in its entirety, constant and dynamic, as the interactive process of the human being with her own universe occurs all the time.This idea is of special interest for nurses, as it presupposes the possibility of professional intervention as a way of altering the course of the behavior of the clients under their care, with a view to a better experience of their reality.
Some authors 9 emphasize empathy as an essential element for dialog to be constituted as a key instrument of the care desired by the clients who have been affected by a specific chronic pathology.
Thus, considering the relational aspect of nursing care, the use of symbolic interactionism in this discussion becomes more appropriate, given the value of the interactive element for the practice of nursing care.

METHODOLOGICAL FRAMEWORK
To continue with the study, the authors used Grounded Theory (GT) as a methodological axis.Grounded Theory is considered a type of research with an interpretive character, with a close link with symbolic interactionism 10 .This is due to the fact that GT aims to explain a specific scene of the social sphere, that is, in the environment where the various interactive possibilities and their respective consequences are processed and develop 11 .

Strategies for coping with peritoneal dialysis
Characterized as qualitative research, GT presupposes a series of codification processes through which the data is worked on in a systematic way for the elaboration of a central axis, the explanatory core of phenomenon which the intention is to investigate.In all, GT suggests three ensuing processes: open codification, axial codification, and selective codification 12 .
As it is a method which values the happenings in a given social scene, GT is able to propose explanatory theories which are very close to the reality.Thus the data is obtained by the researcher and worked on systematically and concomitantly, until the final elaboration of the explanatory proposal 11 .
So as to group the various categories and subcategories which arise from the codification process, some authors 12 developed an explicatory paradigm structure, which includes a series of five conditions related to the phenomenon studied: Causal conditions; Intervenient conditions; Context; Action and Interaction Strategies, and Consequences.
The aim of this discussion is to present the action and interaction strategies used by the clients with chronic kidney disease for coping with the new context, that is, the set of responses which the individual presents for dealing with PD 12 .
This study was carried out in agreement with the norms of resolution 196/96, which deals with Research Involving Human Beings.The research was undertaken in a University Hospital in Rio de Janeiro, whose Research Ethics Committee approved the investigation under number 2343-CEP/HUPE.
The interviews were held between July and September 2009.All the participants in the study did so voluntarily, following exposure to the study's aims and after signing the Terms of Free and Informed Consent.
The sample group included 8 clients receiving PD without having previously received hemodialysis.The profile of the interviewees included 5 female clients and 3 males, with ages varying between 27 and 80.All the clients had been receiving PD for a period less than or equal to one year.
A semi-structured interview script was used to collect the data, and the statements were recorded digitally for later transcription and analysis.The interviews were carried out individually, in the interviewees' homes, in a private place, following previous arrangement, without family members being present, and lasted an average of 50 minutes.
As the data was collected and prepared for analysis, other statements were included, until the authors arrived at a total of eight clients, who were identified as: Blue, Red, Pink, Purple, Orange, Black, Brown and Green.
It is important to stress that GT presupposes a dynamic and integrative movement of the data, this being dissociated purely for purposes of presentation and discussion.Below, one can see the diagram used for the discussion of the action and interaction strategies used by clients with CKD coping with PD.
The diagrams are visual resources proposed by GT, consisting of graphical representations to permit the better visualization and understanding of the phenomenon in focus 11 .

RESULTS
In the face of the changes arising from the PD, the client with CKD seeks emotional resources for dealing with the inevitable: renal replacement therapy.Below, the authors shall describe the various resources which the client develops for dealing with the everyday in order to adapt to her new condition of life, seeking to harmonize the dialytic therapy and her own universe.
To think about the action and interaction strategies, in this case, means thinking about the resources created by the clients for living with the beginning of the dialysis, experiencing the shock and becoming engaged in living with the new context.
In this study, the action and interaction strategies were grouped around the category: Lighting the path to living with peritoneal dialysis.In the process of analysis, the action and interaction strategies were presented and discussed through the following subcategories: Finding out about PD; Interacting with people who undertake this method; Relying on the support network; Minimizing the negative aspects of PD; Seeking support from a metaphysical force; Thinking that hemodialysis would be worse, and; Thinking of stopping with PD if cured.
Seeking information on PD -In facing PD, the client enters a completely unknown universe.In that moment, the vacuum created by misinformation can become harmful and unproductive.Once the period of shock has passed, the client becomes aware of the first information and in so doing finds that information is liberating, as it removes barriers and reduces difficulties.
On becoming informed about PD, the subject is transported from the condition of hostage to fear to a stage of someone who knows about the method.In this situation, the information appears as a liberating entity, reducing the distress and making the person believe that the chances of carrying on living are good.
The things the nurse said...that she showed me in the book (the training manual), that she showed me at the start of the therapy... What could happen...So I was like...I didn't think it was the end of the world.PINK A fairly propitious time for adding to information on the issue with the client starting PD is specific training directed at the procedure.During a series of approximately eight to ten meetings, a health professional, preferably the nurse, presents the details of how to undertake the technique of PD, the care steps involved, and the consequences and implications.
These meetings, initially aimed at training for the start of the therapy, can and must be used as a space for sharing information, which the client can take advantage of to air her feelings and clear up doubts.
Clients emphasize the start of the therapy as a time of living with the unknown, while in the next period they can distinguish a possibility of life, as they consider the impact of the information.In this way, the information positions the subject and causes her to appropriate the dialytic practice; that is to say, it makes her active in the situation she is facing, rather than a mere spectator.
In the beginning, I didn't know anything... and now, [...] I lead my life practically normally.The fact of finding things out helped me enormously.GREEN Knowledge is specified as a tool for the acceptance of the dialysis, as the episodes of difficulty and fear are related to the doubts and uncertainties.After learning about the method, the client not only realizes that the dialysis is possible, but begins to experience feelings of safety and tranquility.
The information may be acquired in various ways.Dialogue, as long as it is receptive and encouraging, has a unique importance at the start of dialysis.On the other hand, information worked on in the practice makes the event easier to assimilate.
The data also indicates the need to really see how the PD works out in practice, as a way of settling the clients' initial disquiet.

I really thought I was going to die. That shows you how little I knew, right? I had never met anybody doing this, never had any contact with anybody -and that would have made it easier, because I would have seen that it wasn't that big a deal. ORANGE
Interacting with people who are receiving this method -Just as seeing the PD method contributed to the clients' understanding and comprehension of the therapy, through understanding the knowledge, having contact with somebody who receives this method seems to impact positively on the client initiating the treatment.
Thus, in addition to the emphasized desire to see PD, some clients state that they feel more confident because of the fact of having spent time with a person who undertook this method.At this point, which is marked by the start of the method in their lives, the clients use these memories to deal with the event in a more pleasant way.

Strategies for coping with peritoneal dialysis
There are, in the trajectory of the client starting PD, many conceptions and influences in relation to the method, originating from a variety of experiences.Regarding this aspect, it may be that the client passes through repeated processes of applying meaning to the dialysis, until the consolidation of her experiences firms into an opinion which is her own.
Everything flows together to form a symbolic representation which the subject builds of PD, and because of this it is very important for it to be as close to reality as possible.In this way, the client will not feel deceived by the health team, which can seriously harm the therapeutic relationship.
Relying on the support network -A third strategy detected as a way of dealing with starting PD is found in the relationship with others, and in the support offered by the team.The relationship with the health professionals creates confidence and becomes established as a mainstay, a column of support for the client.Symbolically, it is as if the client were able to stand up, once she has this support.
At the start of PD, it is common for the client to feel alone, isolated, as if she were the only person to pass through the situation in question.As time passes, and as the natural process of adaptation occurs, for all that she suffers the events in her being, she notices the existence of people around her who are ready to help her and to facilitate the beginning of the therapy.
The emotional support, consolidated based on the involvement with others, has significant importance regarding the health team, which clients on PD start to consider as an extension of their family.
In fact, at some points, the commitment and the attention necessary at the start of the method are such that only a family member can carry them out.The team, therefore, comes to take on symbolically the position of a second family, at which time the bad feelings and negative manifestations tend to dissipate.
I felt as if the nurse ended up taking on the role of mother to me, because she managed to be firm when she needed to be, but could also be very tender, very attentive and that is very important... Very, very important.And because of this, what was it that happened?I started feeling that feeling of... well, of love, really!Really, they care for the client as if they were family, for a member of the family.That's how I felt, and this was fundamental in my accepting the situation, because it ended my distress, it took away the doubt, the uncertainty, all my feelings... everything calmed down.RED In opening herself to dialog, the client also opens herself to new possibilities, above all if the conversation were established with somebody whom she trusts.When she asks questions, showing her problems, she allows another to give opinions on her own life.Thus, in speaking about the difficulties in the method, about doubts and other questions, the same can be resolved.
So, today, it's very important to speak about the treatment, how it went, how everything was one... how I came to accept it... the feeling of companionship, of knowing that I could rely on the team... all this was very important.RED Minimizing the negative aspects of PD -One way of accepting a given situation considered important or wide-reaching is to reduce it to a situation which can be resolved easily, or which has less frightening dimensions.
Thus, the client uses this resource so as to better accept PD in her life.One can observe a strategy of association with other contexts in her life, as she seeks to allocate PD to a level of lower significance than other events already experienced.

I said: No, doctor, I'm being careful, because I'm diabetic... That is to say, I'm careful nowadays... I'm conscientious. Now, a person who isn't [diabetic]... well, that's more difficult. In my case, no... because I was already on a diet anyway. BLACK
In a universe already occupied by a series of requirements, the details of PD pass to take up merely one more space.The client's life history progressively facilitates the incorporation of the therapy, as for dealing with the shock she constructs psychological resources which arise from previous experiences in her existential trajectory.

So this [PD] is just one more little thing which I have to take care of, and that's all. It's one more list of foods... a list of medications... it's one more list of various other things which I have to do, and that's all. [My life history] helped me to pass through this period. PURPLE
On the other hand, the clients who don't have health problems also try to reduce the advent of PD, minimizing its meaning so as to accept it better.Symbolically, they make an effort to consider it as merely a health treatment, carried out whenever possible and with relative commitment.

Strategies for coping with peritoneal dialysis
It is quite interesting to note that some clients use rationalization, placing their feelings in second place and being fairly objective so as to give meaning to PD.In this situation, the method is compared to the act of walking or moving.
Even the peritoneal dialysis catheter, which is commonly a problematic element due to its compromising the client's appearance, can be reduced, so as to be better accepted.
[So PD would be like] learning to walk, to learn how to use the thing which would make me a normal person again.The only thing is, there's this thing hanging there, like a belt hanging from my body, and that's all.PURPLE Seeking support in a metaphysical force -In a different way, clients seized by fear and uncertainty may opt for the emotional route to accept the method.Thus, at times, they place their hopes in the divine, in the intangible, as a way, even, of accepting PD and its implications.
During the crisis period, any strategy employed by the client so as to incorporate the therapy into her everyday is valid for her.Accepting the restrictions, the necessities and the implications of the method is no easy task, and doing so based only on logical bases may not be enough.
Believing that one's life is governed by a superior divine force is a way of applying meaning to one's sacrifice as noble.Accepting the fact as the Divine Will makes it better and makes the client accept the situation being lived through as inevitable, for all that it is incomprehensible.
I also accepted the dialysis well because I am deeply religious... so, firstly, I prayed for great strength from God.I prayed for strength as soon as I found out, I was asking God for strength.So I think it was God who was helping me and giving me strength.GREEN At this point what happens, for some, is fruit of the divine will.All -the bad times, the strength, the courage, the sadness -is considered a stage to be accomplished as part of some unknown, incomprehensible and unfathomable design.In this way, this bestows strength on the client, such that she surprises herself in seeing her ability to rise above the moment of crisis.

You know, I cried when I found myself in that situation [of having to do dialysis], I cried... but God gave me so much strength [... ] And thanks to God I was able to accept it in a way that I think many wouldn't even believe. GREEN
Other clients credit the success of the treatment to the divine, as if it were a Design to be accepted.At this point, the client makes a direct correlation between the fact of being saved from suffering and divine intervention.Thinking that hemodialysis would be worse -In this category, it is perceived that the client accepts PD thinking of the method as better, when compared to hemodialysis.It should be emphasized that from the scientific point of view neither method is better than the other.Both have a common aim and do it well, as long as used and carried out appropriately.
I went to the hemodialysis room to learn about it...And I think that hemodialysis is worse because as well as staying for four hours sat there filtering the blood... here is also the risk you run...Because I found out about the risk of having a heart attack...

And the malaise the person feels when undergoing hemodialysis... you can't even compare it [with PD]! ORANGE
Due to hemodialysis being a more known method, it is common for the clients to be prejudiced against it.A preference for PD, a previously unknown method, seems to come from this fact.
Until then, nobody had ever spoken about this to me...This horrible word..

. That's how you hear it: hemodialysis! Hemodialysis! It really feels like the bogeyman has come to get you! BROWN
Thinking about stopping with PD if one is cured -Living with the fact that CKD is incurable, which entails renal replacement therapy until the end of life, can be a load which is too heavy for the client to bear.The data shows that in their zeal to find a way to accept PD, the clients can create a false illusion of cure, as a way of bearing their condition better.This is a questionable strategy, as it does not deal with real facts, bearing in mind that the possibilities of a cure and stopping with the method are remote.The harm of this type of denial of the disease can be significant as the clients perceive the need to undertake this therapy for a long period of their lives, or even for their entire lives.

Strategies for coping with peritoneal dialysis
When some people told me that PD might not be for ever...That my kidney could function again, I became even keener on doing PD.He [the doctor] told me this there in the hospital...And he told me that there are cases of functioning coming back.And I heard about one clinic, a doctor told me about this, which discharged four people who had been doing hemodialysis, because their kidneys resumed functioning.ORANGE In cases like this, it falls to the nurse to clarify, with delicacy and care, that CKD is a progressive and irreversible disease.Even in the cases in which the clients stop carrying out dialysis, they need to be followed-up by the health team so as to monitor their renal function.Supporting the hope of being cured, at these times, is not a desirable attitude.

DISCUSSION OF DATA
It is interesting to observe that some strategies described by the subjects studied correspond to viable, achievable and credible ways.For example, to make use of more complete information on the dialytic method, its limitations and possibilities is a tool which is consistent with reality.
Once well-informed, the client can strengthen her determination to follow the treatment, perceiving what is real and driving away thoughts associated with myths and distorted information.Situations are not rare in which the nurse needs to work to undo wrong information.
The search for information on PD appears as one of the most relevant strategies presented by the subjects of the study for coping with PD.On this issue, it is important to reiterate that the source of the information, at times, is another client undertaking the method.To this end, the source of information serves not only as a disseminator of the method, but, above all, as a describer of feelings and, so to speak, a de-mystifier.In addition to this, he or she may provide greater security to the client considering the delicacy of the situation.
A good general level of information regarding PD and its specific characteristics can represent a protective factor, contributing to a better quality of administration of the dialytic technique 5 .
To this end, it falls to the health team, above all to the nurse, as the educating agent, to provide the necessary clarifications, especially directed at each individual's questions.
It's relevant to think of the health team as the vehicle for information about the need for dialysis, both aggravating and mitigating.It's the health team that informs people about the imminence of the need for dialysis.The clients refer to this time as being one of great fragility and one in which the attitude of the health professionals seems to have extreme relevance 4 .
Another resource brought up by the interviewees is related to the consolation obtained through religion.In general, nursing emphasizes the need for recognition of religion and spirituality as one of the dimensions of the individual 13 .
One recent study 14 backs up the idea that religion must be taken into account during the planning of nursing interventions for the improvement of the quality of life of individuals affected by chronic diseases.
It falls to the nurse to recognize these practices with the group of family members/patients in question, as in addition to understanding the meaning which these people attribute to the disease, the nurse will be able to intervene positively.
Religion offers important support for the family members, through the involvement of the religious community, which shares the care with the family.Knowing the family's religious and spiritual practices, the nurse can understand their attitudes to the disease and therapeutic processes, helping them to keep up practices which promote health 13 .
It falls to the heath professional to work on and use this resource as a strategy for promoting receptiveness, leading to acceptance of the method.It is not recommendable to encourage the religious appeal with a view to a cure or to end dialysis, given that the disease is chronic.
This reflection is important, as one of the resources described by the interviewees was related to the hope of a cure, so as to be able to stop PD.At some times, the clients do indeed get to the point of creating fantasies and illusions regarding a cure, as if the method were a transient event in their lives.
This characteristic is something related to the situation itself of the chronic nature of kidney disease in its end stage.The limited comprehension of this condition, and even the mitigation of the signs and symptoms after starting the therapy, seem to lead the individual to the belief that a cure is possible.
One study, which discusses the compliance of clients with chronic diseases with treatment 15 , highlights the difficulty people have in understanding these conditions as long-term situations.
For these people, the treatment needs to be signified as mitigative and not as a means of a cure; this because PD provides only the elimination of liquids and undesirable solutes from the blood, rather than the restoration of renal Santos FK, Valadares GV Strategies for coping with peritoneal dialysis function.The authors, further, stress that: "the compliance of chronically-ill patients with efficient treatment is a constant challenge for nursing professionals" 15 .
In relation to the fact of comparison between the two methods, the data indicates a preference for PD and better acceptance of it, due to fear of HD.One should bear in mind that this study was undertaken with people who never received HD, PD being their first dialytic method.
One study undertaken comparing the two methods 16 emphasizes that "the quality of life was similar between the two modalities".Therefore, it is recommendable that both methods be represented impartially, clearly and objectively, with the advantages and disadvantages of both being pointed out.
It is not desirable to present either of the methods to the detriment of the other, given the possibility of undertaking both during the therapeutic trajectory of the individuals affected by CKD 16 .This is, therefore, a strategy for coping with PD that should not be supported by the nurses.
Another action and interaction resource for perseverance with the method is to use the support network.It is fundamental for the client to feel confidence in the treatment and in the health team, and to that end, interaction is an essential tool: positive interaction will result in beneficial action.This is one of the factors which ensures the success of therapy in the home, as indicated by the study cited below: It is believed that many factors are closely related to the success of the therapy, these being: the commitment of the carers, responsible involvement in the treatment, absolute compliance with medical advice, a good relationship between the health team, the patient and the carer, family and social support, and appropriate conditions in terms of food, personal hygiene, and the home, among others 5 .
It should be stressed, at the end of this discussion, that many of these findings and observations are specific to the study setting presented.The fact of not having been administered in or compared with other dialysis centers is, therefore, a limitation of the present study.The authors believe, however, that it is a tendency and, further, that these reflections can contribute significantly to the care of the client undergoing PD.

FINAL CONSIDERATIONS
The path of the client receiving PD is described as full of uncertainties, fears and difficulties in adaptation.In this trajectory, which is symbolically full of shadows and darkness, the action and interaction strategies appear as a means of illuminating the path to be followed.If dialysis appears as darkness, the mixture of feelings, doubts, fears and abandonment are a way of lighting this path.
Thus, with the description of the strategies used by the clients for better accepting and living with peritoneal dialysis, one has the chance of understanding that the client who starts PD needs to find reasons to carry on with it, as her survival depends on this therapy.
Knowledge promotes the autonomy of the client in the face of an unknown situation.There are many ways of acquiring this knowledge.Contact with an individual who already undergoes the method stands out, due to the influence which this person can exercise on the client in coping with the situation, in addition to the contact with the health professional and appropriate educational material.
In knowing the strategies used in coping with PD, it falls to the nurse to participate in this process in which the client gives meaning to this method, informing her, encouraging her, and supporting her such that she may adapt to the method's requirements, or alternatively, facilitating the fitting in of the dialysis in a universe with innumerable peculiarities, in a safe and productive way.

I
prayed to God to give me strength, that He would guide me for the better.I prayed to Him a lot...I asked for a great deal of Him [... ] that He would relieve me of many things, many pains...And you can see that in my operation I didn't feel anything.BLUE