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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME REGARDING SELFCARE
ACTIVITIES
AMONG PATIENTS UNDERGOING HEMODIALYSIS
IN A SELECTED HOSPITAL AT
KOLAR DISTRICT,
KARNATAKA.
Performa for Registration of Subject
For Dissertation
ARSHATHUNNISA IBRAHIM
A.E & C.S PAVAN COLLEGE OF NURSING
KOLAR.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
NAME
OF
1. CANDIDATE
ADDRESS
2.
NAME
OF
INSTITUTION
ARSHATHUNNISA IBRAHIM
THE M.SC NURSING, 1ST YEAR
AND A.E.&.C.S PAVAN COLLEGE OF
NURSING, BANGALORE – CHENNAI
BYPASS ROAD, KOLAR. 563 101.
THE A.E & C.S PAVAN COLLEGE OF
NURSING, KOLAR - 563 101.
M.SC. NURSING
COURSE OF STUDY
3.
MEDICAL
AND
AND SUBJECT
NURSING
SURGICAL
DATE
OF
4. ADMISSION TO THE 03-06-2008
COURSE
5.
TITLE
TOPIC
OF
“A STUDY TO EVALUATE THE
EFFECTIVENESS OF STRUCTURED
TEACHING
PROGRAMME
THE REGARDING
SELF
CARE
ACTIVITIES AMONG
PATIENTS
UNDERGOING HEMODIALYSIS IN
A
SELECTED
HOSPITAL
AT
KOLAR, KARNATAKA”.
6. BRIEF RESUME OF INTENDED WORK
INTRODUCTION
“An ounce of prevention is worth a pound of cure”
–william clark
The world health assembly defined health as “a state of complete
physical, mental and social wellbeing and not merely the absence of
disease or infirmity”. Health is a resource of everyday life not the
objective of living. It is a positive concept emphasizing social and
personal resources as well as physical capacities1.
Hemodialysis (also haemodialysis) is a method for removing waste
products such as potassium and urea, as well as free water from the blood
when the kidneys are in renal failure. Hemodialysis is one of three renal
replacement therapies (the other two being renal transplant; peritoneal
dialysis)2.
Hemodialysis can be an outpatient or inpatient therapy. Routine
hemodialysis is conducted in a dialysis outpatient facility, either a
purpose built room in a hospital or a dedicated, stand alone clinic. Less
frequently hemodialysis is done at home. Dialysis treatments in a clinic
are initiated and managed by specialized staff made up of nurses and
technicians; dialysis treatments at home can be self initiated and managed
or done jointly with the assistance of a trained helper who is usually a
family member.3
Many have played a role in developing dialysis as a practical treatment
for renal failure, starting with Thomas Graham of Glasgow, who first
presented the principles of solute transport across a semipermeable
membrane in 1854. The artificial kidney was first developed by Abel,
Rountree and Turner in 1913,, the first hemodialysis in a human being
was by Hass (February 28, 1924) and the artificial kidney was developed
into a clinically useful apparatus by Kolff in 1943 - 1945. This research
showed that life could be prolonged in patients dying of renal failure4.
Dr. Willem Kolff was the first to construct a working dialyzer in 1943.
The first successfully treated patient was a 67-year-old woman in uremic
coma who regained consciousness after 11 hours of hemodialysis with
Kolff’s dialyzer in 1945. At the time of its creation, Kolff’s goal was to
provide life support during recovery from acute renal failure. After World
War II ended, Kolff donated the five dialyzers he’d made to hospitals
around the world, including Mount Sinai Hospital, New York. Kolff gave
a set of blueprints for his hemodialysis machine to George Thorn at the
Peter Bent Brigham Hospital in Boston. This led to the manufacture of
the next generation of Kolff’s dialyzer, a stainless steel Kolff-Brigham
dialysis machine4.
By the 1950s, Willem Kolff’s invention of the dialyzer was used for
acute renal failure, but it was not seen as a viable treatment for patients
with stage 5 chronic kidney disease (CKD). At the time, doctors believed
it was impossible for patients to have dialysis indefinitely for two
reasons. Firstly, they thought no man-made device could replace the
function of kidneys over the long term. In addition, a patient undergoing
dialysis suffered from damaged veins and arteries, so that after several
treatments, it became difficult to find a vessel to access the patient’s
blood4.
Dr. Nils Alwall encased a modified version of this kidney inside a
stainless steel canister, to which a negative pressure could be applied, in
this way effecting the first truly practical application of hemodialysis,
which was done in 1946 at the University of Lund. Alwall also was
arguably the inventor of the arteriovenous shunt for dialysis. He reported
this first in 1948 where he used such an arteriovenous shunt in rabbits.
Subsequently he used such shunts, made of glass, as well as his canisterenclosed dialyzer, to treat 1500 patients in renal failure between 1946 and
1960, as reported to the First International Congress of Nephrology held
in Evian in September 1960. Alwall was appointed to a newly-created
Chair of Nephrology at the University of Lund in 1957. Subsequently, he
collaborated with Swedish businessman Holger Crafoord to found one of
the key companies that would manufacture dialysis equipment in the past
40 years, Gambro, Inc. The early history of dialysis has been reviewed by
Stanley Shaldon5.
Dr. Belding H. Scribner working with a surgeon, Dr. Wayne Quinton,
modified the glass shunts used by Alwall by making them from Teflon.
Another key improvement was to connect them to a short piece of
silicone elastomer tubing. This formed the basis of the so-called Scribner
shunt, perhaps more properly called the Quinton-Scribner shunt. After
treatment, the circulatory access would be kept open by connecting the
two tubes outside the body using a small U-shaped Teflon tube, which
would shunt the blood from the tube in the artery back to the tube in the
vein.In 1962, Scribner started the world’s first outpatient dialysis facility,
the Seattle Artificial Kidney Center, later renamed the Northwest Kidney
Centers6
A prescription for dialysis by a nephrologist (a medical kidney specialist)
will specify various parameters for a dialysis treatment. These include
frequency (how many treatments per week), length of each treatment, and
the blood and dialysis solution flow rates, as well as the size of the
dialyzer. The composition of the dialysis solution is also sometimes
adjusted in terms of its sodium and potassium and bicarbonate levels. In
general, the larger the body size of an individual, the more dialysis he will
need. In the North America and UK, 3-4 hour treatments (sometimes up
to 5 hours for larger patients) given 3 times a week are typical. Twice-aweek sessions are limited to patients who have a substantial residual
kidney function. Four sessions per week are often prescribed for larger
patients, as well as patients who have trouble with fluid overload. Finally,
there is growing interest in short daily home hemodialysis, which is 1.5 4 hr sessions given 5-7 times per week, usually at home. There also is
interest in nocturnal dialysis, which involves dialyzing a patient, usually
at home, for 8-10 hours per night, 3-6 nights per week. Nocturnal incenter dialysis, 3-4 times per week is also offered at a handful of dialysis
units in the United States4
Hemodialysis often involves fluid removal (through ultrafiltration),
because most patients with renal failure pass little or no urine. Side
effects caused by removing too much fluid and/or removing fluid too
rapidly include low blood pressure, fatigue, chest pains, leg-cramps,
nausea and headaches. These symptoms can occur during the treatment
and can persist post treatment; they are sometimes collectively referred to
as the dialysis hangover or dialysis washout. The severities of these
symptoms are usually proportionate to the amount and speed of fluid
removal. However, the impact of a given amount or rate of fluid removal
can vary greatly from person to person and day to day. These side effects
can be avoided and/or their severity lessened by limiting fluid intake
between treatments or increasing the dose of dialysis e.g. dialyzing more
often or longer per treatment than the standard three times a week, 3-4
hours per treatment schedule4.
Since hemodialysis requires access to the circulatory system, patients
undergoing hemodialysis may expose their circulatory system to
microbes, which can lead to sepsis, an infection affecting the heart valves
(endocarditis) or an infection affecting the bones (osteomyelitis). The risk
of infection varies depending on the type of access used (see below).
Bleeding may also occur, again the risk varies depending on the type of
access used. Infections can be minimized by strictly adhering to infection
control best practices4.
Heparin is the most commonly used anticoagulant in hemodialysis,
as it is generally well tolerated and can be quickly reversed with
protamine sulfate. Heparin allergy can infrequently be a problem and can
cause a low platelet count. In such patients, alternative anticoagulants can
be used. In patients at high risk of bleeding, dialysis can be done without
anticoagulation4.
6.1 NEED FOR THE STUDY
Hemodialysis is the most common method used to treat advanced and
permanent kidney failure. Since the 1960s, when hemodialysis first
became a practical treatment for kidney failure. In recent years, more
compact and simpler dialysis machines have made home dialysis
increasingly attractive. even with better procedures and equipment,
hemodialysis is still a complicated and inconvenient therapy that requires
a coordinated effort from
whole health care team, including
nephrologists, dialysis nurse, dialysis technician, dietitian, and social
worker. The most important members of health care team are patients and
their families. By learning about treatment, patients can work with health
care team to give him the best possible results, and he can lead a full,
active life7.
Healthy kidneys clean a person’s blood by removing excess fluid,
minerals, and wastes. They also make hormones that keep bones strong
and blood healthy. When kidneys fail, harmful wastes build up in body,
blood pressure may rise, and body may retain excess fluid and not make
enough red blood cells. When this happens, patients need treatment to
replace the work of failed kidneys7.
Several centers around the country teach people how to perform their
own hemodialysis treatments at home. A family member or friend who
will be your helper must also take the training, which usually takes at
least 4 to 6 weeks. Home dialysis gives more flexibility in dialysis
schedule. With home hemodialysis, the time for each session and the
number of sessions per week may vary, but one must maintain a regular
schedule by giving himself dialysis treatments as often as he would
receive them in a dialysis unit7.
Even in the best situations, adjusting to the effects of kidney failure
and the time spent on dialysis can be difficult. Aside from the “lost time,”
patient may have less energy. They may need to make changes in their
work or home life giving up some activities and responsibilities. Keeping
the same schedule when kidneys were working can be very difficult that
his kidneys have failed. Accepting this new reality can be very hard on
patients and their families. A counselor or social worker can answer their
questions and help them cope7.
Many patients feel depressed when starting dialysis, or after several
months of treatment. If they feel depressed, they should be encouraged
to talk with social worker, nurse, or doctor7.
A study was conducted to assess the Daily life of patients with
chronic renal failure receiving hemodialysis treatment. Aimed at
assessing the perception of people with chronic renal failure in relation to
their daily and occupational activities. The sample was formed by 35 men
and 35 women receiving hemodialysis treatment with ages between 17
and 60 years. The instrument used was the SAOF (Self Assessment of
Occupational Functioning). The data were submitted to statistical analysis
and the areas with greater choice of the alternative "need to improve"
were habits (20%) and values (20.5%). In these areas, the proportion
related with difficulties was more evident regarding organization of the
daily life, the changes of routines and the expectations about the future.
Occupational therapy, as it presents instrumental resources to reorganize
daily life of these patients, can contribute for their care as well as with
information for nursing8.
A study was conducted among nephrology professionals to determine
the best dialysis therapy. Responses were collected from 6595 delegates
57% Physicians and 28% nurses. They concluded that peritoneal dialysis
to be the best initial therapy and frequent application of home/self care
dialysis to be the best long term therapy. High flux membranes are
strongly preferred for any extracorporeal form of therapy an
haemodiafiltration (HDF) seems to be the modality of choice among
Europeans. Asians and American gave preference to high flux
haemodialysis (HD)9.
A study was to determine the effects of hemodialysis on the
cognitive and sensory motor functioning of the adult chronic
hemodialysis
patient.
Twenty
chronically
dialyzed
adults
were
administered a repeatable battery of 14 cognitive and sensory motor tests
on 3 consecutive days. They concluded that there was little or no
evidence to suggest that well dialyzed patients undergo daily fluctuation
in their cognitive and sensory motor functioning10.
A study was conducted on quality of life and daily hemodialysis in
Atlanta These findings have come from small series of patients, however,
and may reflect an increased attention effect. Confirmation of preliminary
findings and identification of changes in other quality of life outcomes
await an adequately powered randomized clinical trial. Sleep quality,
sexual functioning, and cognitive functioning are quality of life
dimensions that may be impacted by daily hemodialysis but about which
there is limited information in the preliminary data. Results showed that
daily hemodialysis positively impacts patient’s energy and other uremic
symptoms. In addition to improvement in symptoms, patients perceived
improvement in physical and psychosocial functioning11.
Patients with Chronic renal failure (CRF) generally present late in the
course of their disease, with 66% patients first seeing a nephrologist when
they are already in End stage renal disease. Although in the developed
and industrialized world, access to renal replacement therapy (RRT) is
unrestricted and easily available, patients in India and Pakistan often have
to travel long distances to reach a kidney center because of
maldistribution of renal services in India, with most of the centers located
in large cities. Furthermore, because of the virtual absence of health
insurance plans, less than 10% of all patients with ESRD receive any
kindof RRT. Most patients entering RRT programs in the country are
funded by their employers or by charity organizations. In a study from a
private sector hospital in south India, 63% patients belonged to this
group, 30% arranged finances for their treatment by selling property, 20%
raised loans and only 4% were able to take care of their treatment costs
solely by pooling in family resources12.
As compared to 72 dialysis centers in Pakistan (0.5 pmp), there are an
estimated 400 dialysis units in India (0.4 pmp) with about 1000 dialysis
stations, more than two thirds being in the private sector. The annual cost
of hemodialysis at private hospitals can vary between $2500US/year for
twice weekly hemodialysis to $3500US/year for thrice weekly
hemodialysis. This along with the cost of 6000 IU/week for
erythropoietin ( $2500US/year) ensures that the cost of maintenance
hemodialysis is more than ten times the annual per capita GNP and, thus,
is out of reach of the vast majority of the population. Of the patients who
are started on dialysis, 69 to 71% die on dialysis or stop treatment (due to
financial reasons), the majority within the first three months of initiation
of dialysis, and only 17 to 23% patients end up having a kidney
transplant. Of the 8 to 10% who continue to be on hemodialysis, 60%
receive irregular treatments. Only 2 to 4% are started on continuous
ambulatory peritoneal dialysis (CAPD) These data are from centers
known for their prolific transplant activity, and the overall percentage of
ESRD patients undergoing a transplant is therefore likely to be only
around 5%.Most public sector hospitals and a majority of the private
sector dialysis units provide hemodialysis for four hours twice a week
using cellulosic membranes. All dialysis units reuse dialyzers after
manual cleansing and more than 80% of dialysis units continue to use
acetate buffer for hemodialysis. The dialysis prescription is generally
empirical with Kt/V <1 in the majority.15
Infections are common in patients on dialysis and are related to
inadequate dialysis, malnutrition, and frequent use of blood transfusions
to correct anemia. Together, uremic complications and infections account
for 57% of all deaths in Indian patients on dialysis, with less than 30% of
deaths due to ischemic heart disease9. The prevalence of hepatitis B and C
virus infections varies between 4 to 12% and 4 to 16%, respectively, in
Indian patients on dialysis and can lead to long-term sequelae in the posttransplant period16.
Each individual is unique and has a right to participate in decision
making and to receive competent care. Health care systems are complex
and changing. Co-ordination and colloboration are necessary in order to
meet recipient’s needs. The learners with divergent backgrounds and
abilities should be stimulated to develop self awareness and increasing
self direction and independence4.
Kidneys do much more than remove wastes and extra fluid. They
also make hormones and balance chemicals in the system. When kidneys
stop working, problems with anemia and conditions that affecting bones,
nerves, and skin arise. Some of the more common conditions caused by
kidney failure are extreme tiredness, bone problems, joint problems,
itching, and “restless legs.” Restless legs will keep you awake due to
twitching and jumping7.
It is estimated that nearly 75000 to 10000 people in the UK and
300000 to 400000 people in the US have some degree of chronic renal
failure. Each year an estimated 42 000 Americans die of irreversible
kidney failure 55-65% of deaths occurring during chronic renal failure are
possibly resulting from cardio vascular complications. It is also estimated
that 40 new patients per million population need treatment for end stage
renal failure17.
Chronic renal failure in the young is a problem which is being
increasingly
recognized
because
of
its
varying
etiopathogenic
significance in various parts of the world. In India according to the
statistics available about 30000 new cases of chronic renal failure are
detected every year18.
There were estimated to be 1.2 million dialysis patients worldwide in
200219.Based on an average annual growth rate of 6%, there are now
around 1.5 million dialysis patients20.
Important informative teaching about disease codition and self care
activites to patients undergoing hemodialysis about their diet, drugs,
presonal hygiene, prevention of complications and exercise can improve
their knowledge level and will help igorant client’s population.
6.2 REVIEW OF LITERATURE
Review of literature is a key step in research process. It refers to an
extensive, exhaustive and systemic examination of publication
relevant to the research project.
According to polit and Beck (2000) “A Broad, comprehensive, in
depth, systemic and critical view of scholarly publications,
unpublished materials, audio visual materials and personal
communication is called review of literature21.
The review was considered under two sections.
Section 1: studies related to the impact of diet on renal failure.
Section 1: studies related to Hemodialysis
SECTION 1
A Sudy
treatment
conducted to assess the benefit of salt restriction in the
of
end
stage
renal
disease
patients
undergoing
hemodialysis.Most haemodialysis (HD) centers use anti-hypertensive
drugs for the management of hypertension, whereas some centers apply
dietary salt restriction strategy. In this retrospective cross-sectional study,
assessment of the effectiveness and cardiac consequences of these two
strategies were checked. They concluded that salt restriction reduces
intradialytic hypotension in hemodialysis patients22.
A study conducted to assess the effect of dietary protein restriction on
progression of kidney disease. This was a randomized controlled trial
from 1989 to 1993 of 585 patients with predominantly nondiabetic kidney
disease and a moderate decrease in glomerular filtration rate (25 to 55
mL/min/1.73 m(2) [0.42 to 0.92 mL/s/1.73 m(2)]) assigned to a lowversus usual-protein diet (0.58 versus 1.3 g/kg/d). They used registries to
ascertain the development of kidney failure (initiation of dialysis therapy
or transplantation) or a composite of kidney failure and all-cause
mortality through December 31, 2000. Cox regression models and
intention-to-treat principles to compute hazard ratios for the low- versus
usual-protein diet, adjusted for baseline glomerular filtration rate and
other factors previously associated with the rate of decrease in glomerular
filtration rate. They estimated hazard ratios for the entire follow-up period
and then, in time-dependent analyses, separately for 2 consecutive 6-year
periods of follow-up. Kidney failure and the composite outcome occurred
in 327 (56%) and 380 patients (65%), respectively. After adjustment for
baseline factors, hazard ratios were 0.89 (95% confidence interval [CI],
0.71 to 1.12) and 0.88 (95% CI, 0.71 to 1.08), respectively. Adjusted
hazard ratios for both outcomes were lower during the first 6 years (0.68;
95% CI, 0.51 to 0.93 and 0.66; 95% CI, 0.50 to 0.87, respectively) than
afterward (1.27; 95% CI, 0.90 to 1.80 and 1.29; 95% CI, 0.94 to 1.78;
interaction P = 0.008 and 0.002, respectively). They concluded that the
efficacy of a 2- to 3-year intervention of dietary protein restriction on
progression of nondiabetic kidney disease remains inconclusive23.
A study conducted to evaluate the effect of very low protein diet
on progression of kidney disease. This analysis includes 255 trial
participants with predominantly stage 4 nondiabetic chronic kidney
disease. A low-protein diet (0.58 g/kg/d) versus a very low-protein diet
(0.28 g/kg/d) supplemented with a mixture of essential keto acids and
amino acids (0.28 g/kg/d) Kidney failure developed in 227 (89%)
participants, 79 (30.9%) died, and 244 (95.7%) reached the composite
outcome of either kidney failure or death. Median duration of follow-up
until kidney failure, death, or administrative censoring was 3.2 years, and
median time to death was 10.6 years. In the low-protein group, 117
(90.7%) participants developed kidney failure, 30 (23.3%) died, and 124
(96.1%) reached the composite outcome. In the very low-protein group,
110 (87.3%) participants developed kidney failure, 49 (38.9%) died, and
120 (95.2%) reached the composite outcome. After adjustment for a
priori-specified covariates, hazard ratios were 0.83 (95% confidence
interval, 0.62 to 1.12) for kidney failure, 1.92 (95% confidence interval,
1.15 to 3.20) for death, and 0.89 (95% confidence interval, 0.67 to 1.18)
for the composite outcome in the very low-protein diet group compared
with the low-protein diet group. I t was concluded that assignment to a
very low-protein diet did not delay progression to kidney failure, but
appeared to increase the risk of death24.
SECTION2
A Study conducted to assess the impact of renal impairment on
systemic exposure of new molecular entities to evaluate the recent
new drug applications. The impact of the 1998 renal guidance was
aMEs) approved over the past 5 years (2003-2007). The survey results
indicate that 57% of these NDAs included renal impairment study data
that 44% of those with renal data included evaluation in patients on
hemodialysis, and that 41% of those with renal data resulted in
recommendation of dose adjustment in renal impairment. In addition, the
survey results provided evidence that renal impairment can affect the
pharmacokinetics of drugs that are predominantly eliminated by nonrenal
processes such as metabolism and/or active transport. The latter finding
supports
our
updated
recommendation
to
evaluate
pharmacokinetic/pharmacodynamic alterations in renal impairment for
those drugs that are mainly eliminated by nonrenal processes, in addition
to those that are mainly excreted unchanged by the kidney25.
A study conducted to see if the increased removal of high molecular
weight toxins improves the survival of hemodialysis patients. This
prospective clinical trial in which patients with end-stage renal disease
were randomized to treatment with online high-flux hemofiltration or
low-flux hemodialysis. Over a 3-year follow-up period, survival was
significantly better in patients who received online hemofiltration than in
patients who received low-flux hemodialysis. In addition, the average
duration, but not the frequency, of hospitalization, and the incidence of
intradialytic hypotension, were lower in the hemofiltration group than in
the hemodialysis group. The study concludes that increased removal of
large molecules can decrease the high morbidity and mortality associated
with end-stage renal disease. However, the applicability of the findings to
the general population of patients with end-stage renal disease might be
limited by the small size of the study, the demographics of the study
population, and the high dropout rate26.
A study was conducted to evaluate the gender dependent impact of
cardiovascular and non-cardiovascular mortality in end stage renal
disease patients undergoing hemodialysis. Investigation was done to see
whether mortality risk factors are gender dependent in haemodialysis
patients. Patients (n = 230; 118 women, 112 men) on haemodialysis were
followed for 52 months to assess the incidence of death due to
cardiovascular or non-cardiovascular causes. Survival was compared by
Cox regression analysis using age, diabetes, pre-existing coronary
disease, troponin T and C-reactive protein as covariates. In total, 120
participants (52.2%) died within the 52 months of follow-up: 57 patients
died of cardiovascular disease, 35 patients died of infectious diseases.
Cox regression revealed that age, pre-existing coronary heart disease and
troponin T were independent all-cause mortality risk factors for both
sexes. Analyzing men and women separately revealed that diabetes and
C-reactive protein seemed to be stronger risk factors for all-cause
mortality in women. Cardiovascular mortality was predicted by troponin
T in women (relative risk = 5.16, 95% CI: 1.67-15.88; p = 0.004), but not
in men (relative risk = 1.69; 95% CI: 0.72-3.96; p = 0.23). This study
showed for the first time that the impact of risk factors in predicting death
due to cardiovascular disease is clearly gender dependent27.
A quasi-experimental study carried out to determine the effects of the
Continuous Care Model on stress, anxiety, and depression in patients on
hemodialysis in Hamedan, Iran in 2005. Thirty-eight patients were
selected randomly and the Depression Anxiety Stress Scale (DASS-21)
was used for data collection. Data analysis showed a significant
relationship between applying the Continuous Care Model and DASS-21
scores. It was concluded that applying this care model can improve the
lives of patients on hemodialysis28.
A study conducted to assess the impact of nurse-led clinic on self care
ability, disease specific knowledge and home dialysis modality.focus was
on education and self-care for patients with advanced renal failure in a
renal outpatient clinic in Sweden. The purpose was to enhance patients'
disease-related
knowledge,
involvement,
and
self-care
ability.
Comparision of patient outcomes with the nurse-led clinic to the previous
model of care were seen. The participants in the nurse-led clinic choose
and started dialysis in a self-care alternative and also had a functioning,
permanent dialysis access to a greater extent than the patients in the
comparison group. Those choosing home-hemodialysis rated their selfcare ability higher. The participants rated self-care and effects of
treatment options on family and everyday life as the most important
disease-related areas of knowledge29.
A study conducted to assess the utility of Leventhal's Self-Regulatory
Model (SRM) to predict self-care behavior with regard to dietary,
medication, and fluid regimes in end-stage renal disease (ESRD) patients.
In
this prospective study, ESRD patients treated via hospital-based
haemodialysis (N=73) were screened for cognitive deficits and completed
questionnaires that enquired about illness perceptions, coping strategies,
knowledge of kidney disease, and psychological distress at Time 1.
Physiological proxy measures of self-care behaviors regarding diet
(serum potassium levels), fluid intake (mean and standard deviation of
interdialytic weight gain), and medication (serum phosphate levels)
regimes were collected 3 weeks later at Time 2. They concluded that the
SRM has predictive utility. Psychological interventions should focus on
alleviating disease-specific distress and challenging erroneous timeline
perceptions in order to increase adherence to dietary and medication
regimes in ESRD patients. A more specific measure of coping for ESRD
is required to clarify the role of coping strategies in this population.
Younger, male patients should be targeted for extra support with fluid
restrictions30.
A study conducted to assess the changes in clinical condition of
hemodialysis patients in Italy. The considerable evolution in treatment
modalities has lead to a significant increase in the efficacy and tolerability
of dialysis. However, physicians have to deal with illnesses in long term
dialysis survivors that may be a consequence of inadequate renal
replacement therapy rather than the dialysis procedure. Cardiovascular
diseases are the leading cause of death and, although many of the risk
factors are the same as in the general population (i.e. hypertension), some
appear to be specific to CRF (i.e. hyperparathyroidism, anaemia). Age is
the most important demographic factor associated with increased
mortality. The increasing incidence of ESRD diabetic patients, as well as
malnutrition, also contributes to higher mortality in RRT. The therapeutic
answer to a worsening in clinical condition is adequate medical care
(starting in the conservative phase), with particular attention being given
to
correcting
anaemia,
hypertension,
volume
overload
and
hyperparathyroidism, and preventing malnutrition. Treatment modalities
also play a crucial role. The study concluded that adequate dialytic dose
(and possibly time) can reduce morbidity and mortality, and on-line
sodium and potassium modelling can improve intradialytic cardiovascular
stability and reduce arrhythmias. Long-term treatment with synthetic
high-flux membranes may confer some beneficial effect on beta2-m
amyloidosis-related morbidity and may also reduce mortality. Family and
social support greatly affect the quality of life of the patients. However
technologically advanced, no procedure can succeed unless it is
performed in the context of humanised health care directed towards
patient needs31.
A study conducted to assess the mortality and morbidity on
maintenance hemodialysis patients in Italy. Despite the many technical
advances in medical care and dialysis delivery, mortality and morbidity
remain high in end-stage renal disease (ESRD) patients. A number of
factors seem to contribute. Cardiovascular diseases are the leading cause
of death: volume overload, anaemia, hypertension, arteriovenous fistula,
uremia-related myocardial cell injury all contribute to the development of
ischemic heart disease and congestive heart failure. The underlying
disease is determinant for prognosis, with diabetics displaying an excess
cardiovascular mortality. Elderly are also more likely to experience
intercurrent medical conditions, vascular disease and diabetes, thus
increasing the risk of death. Protein-energy malnutrition and wasting also
contribute to the higher mortality in renal replacement therapy. Although
nowadays high-risk patients are dialyzed too, the rate of acceptance of
ESRD patients still varies widely in different countries, possibly because
of hidden selection criteria. The patients in the registries with a higher
acceptance rate are more likely to be affected by co-morbid conditions
and greater disease severity; the assessment of these co-morbid conditions
is extremely important when comparing outcomes in different
haemodialysis populations. Dialysis adequacy, obtained by means of
longer duration of the treatment, is also of paramount importance; it
allows minimizing the clinical effects of ultra filtration and ensure that
correct dry weight is reached. This means decreasing the incidence of
intradialytic hypotensive episodes, but also improving blood pressure
control, a strong predictor of survival. Family and social support, together
with adequate medical care, greatly affect the quality of life of patients
and can improve compliance to dialysis, diet and drugs and therefore
survival32.
A study conducted to assess the effectiveness of a self-monitoring
tool on perceptions of self-efficacy, health beliefs, and adherence in
patients receiving hemodialysis. A monthly intervention using a pretest,
posttest design over a 6-month period. Both the treatment and control
groups were randomly selected and received surveys to assess health
beliefs, perceptions of self-efficacy for performing specific healthful
behaviors, and renal diet knowledge at baseline, before intervention, and
6 months later. The treatment group also received monthly feedback of
monthly phosphorus levels and interdialytic weight gains. A university
hospital-based 43-chair ambulatory dialysis center was selected. Forty
patients with end-stage renal disease (25 men and 15 women, age 26 to
78 years), on chronic hemodialysis for at least 2 months and with a
history of noncompliance with phosphorus and/or fluid restrictions for 1
or more months. Self-efficacy, health beliefs, knowledge, biochemical,
and demographic variables were analyzed. Analysis of variance tests of
repeated measures were used to examine relationships between adherence
with phosphorus and fluid restrictions to health beliefs and perceptions of
self-efficacy after training in self-monitoring. Overall, there were no
significant improvements in adherence with phosphorus and fluid
restrictions between the two groups, although a comparison within the
groups revealed the treatment group had a statistically significant
decrease in mean phosphorus levels of 7.14 to 6.22 mg/dl (P = .005) from
baseline to month 3. However, because this value was not maintained, it
was not statistically significant. No significant differences existed
between the two groups for health beliefs and perceptions of self-efficacy.
Knowledge scores in the treatment group, however, improved
significantly as compared to the control group (P = .008) and was a
significant increase from baseline (P =. 002). In the control group, all
scores fell slightly but this difference was not significant. They concluded
that benefits of patient self-monitoring and behavioral contracting upon
adherence in patients on hemodialysis are inconclusive, as serum
phosphorus and interdialytic weight gains did not differ between the two
groups. The interventional tools also appeared to have little effect on
perceptions of self-efficacy and health beliefs. Trends of improvement,
however, did exist for phosphorus within the treatment group and subjects
in this group had a statistically significant increase in knowledge scores
over time33.
A study conducted to assess the impact of co-morbid risk factors at the
start of dialysis, upon survival of end stage renal disease. 29 co-morbid
risk factors in 683 patients with end-stage renal disease who started
dialysis from 1970 through 1989, with follow-up through 1992.
Quantization of dialysis patient co-morbidity, as a measure of patient
illness, is lacking in the general nephrology literature. Seven co-morbid
risk factors have been reserved for new dialysis patients: hypertension,
low albumin, cerebral vascular disease, peripheral vascular disease, preexisting cardiac disease, abnormal EKG/old myocardial infarction, and
congestive heart failure. Except for low serum albumin, the proportion of
patients with the six other co-morbid risk factors has increased
significantly over this 20-year period (p < 0.0001, chi-square test for
hypertension, peripheral vascular disease, pre-existing cardiac disease,
abnormal EKG/old myocardial infarction, And congestive heart failure,
and p < 0.006 for cerebral vascular disease). In addition, the co-morbid
risk factors of hypertension, low serum albumin, and pre-existing cardiac
disease at the start of dialysis were strongly prognostic of survival. The
Cox proportional hazards regression model identified these three risks,
among other factors, that were significantly associated with a decreased
survival, with risk ratios ranging from 1.40-1.66. They concluded that
those incoming end-stage renal disease patients, who recently start
dialysis, are sicker than in the earlier years34.
Based on the review of literature and personal experience of the
investigator during practice in the field of nursing found that patients
undergoing hemodialysis had lack of knowledge on self care activities
and their disease condition. This gap of knowledge necessitates the need
for systematic education to improve the knowledge level of the clients
thereby reducing further complications.
STATEMENT OF THE PROBLEM
A study to evaluate the effectiveness of structured teaching
programme regarding self care activities among patients undergoing
hemodialysis in a selected hospital at kolar district, Karnataka.
6.3OBJECTIVES:
 To assess the existing knowledge regarding self care
activities among patients undergoing hemodialysis.
 To evaluate the effectiveness of structured teaching
programme regarding self care activities among patients
undergoing hemodialysis.
 To find the association between post test knowledge
score with their selected demographic variable
6.4 OPERATIONAL DEFINITIONS:
Evaluate:
Refers to judgment made based on knowledge gained by structured
teaching programme on self care activities among patients undergoing
hemodialysis.
Effectiveness:
The evaluation of outcome of knowledge and skills on renal failure
and self care activities among patients undergoing hemodialysis.
Structured teaching programme:
Referred to a system of instructions designed to impart information on
renal failure and self care activities of patients undergoing
hemodialysis.
Knowledge:
Cognitive ability of patients regarding renal failure and self care
activities of patients undergoing hemodialysis.
Renal failure:
Loss of kidney function. May be acute or chronic, resulting in rise in
serum creatinine and urea nitrogen levels.
Self care activities:
Activities performed by the individual themselves relating to diet,
drugs, personal hygiene, exercise and prevention of complications in
order to keep themselves healthy.
Hemodialysis:
An artificial means of kidney circulation to remove waste products
from the body by diverting toxin laden blood from client into the
dialyzer and then returning the clean blood to the client.
6.5 HYPOTHESIS:
There will be no significant difference between the pre test and post
test scores regarding self care activities among patients undergoing
hemodialysis
6.6 VARIABLES
6.6-1 DEPENDENT VARIABLE:
Knowledge of hemodialysis patients regarding self care activities.
6.6-2 INDEPENDENT VARIABLE:
Structured teaching programme on self care activities in hemodialysis
patients.
7 MATERIALS AND METHODS:
7.1 SOURCE OF THE DATA:
Patients undergoing hemodialysis in a selected hospital at kolar.
7.2 METHODS OF DATA COLLECTION
7.2.1 RESEARCH DESIGN:
A quasi experimental research design will be adopted.
7.2.2 SETTING:
The study will be conducted in two hospitals namely
RL
Jalappa
Hospital and research center,Tamaka,kolar district situated 5kms away
from Pavan college of nursing having 850 bed strength and Srinarasimha
raja hospital(SNR),Kolar which is situated 2 kms away from pavan
college of nursing, having 500 bed strength.
7.2.3 POPULATION:
The population for the present study comprises of patients who are
undergoing hemodialysis.
7.2.4 SAMPLE:
Patients who are undergoing hemodialysis age groups between 13 to 65
years of both sexes at selected hospitals.
7.2.5 SAMPLE SIZE:
60 hemodialysis patients.
7.2.6 SAMPLING TECHNIQUE:
Simple random sampling technique.
7.2.7 SAMPLING CRITERIA:
INCLUSION CRITERIA:
 Patients who are undergoing hemodialysis with age groups
between 13 to 65 years of both sexes.
 Who can understand and speak Kannada or English.
 Patients who are willing to participate in the study.
EXCLUSION CRITEIA:
 Patients who are unable to speak and understand Kannada or
English.
 Patients who are not willing to participate in the study.
 Patients suffering with other associated diseases.
7.2.8 TOOL OF DATA COLLECTION:
Structured interview schedule will be used for data collection.
The tools consist of two sections.
Section A: - consist of demographic data of subject.
Section B: - consist of knowledge question regarding Self care
Activities Among hemodialysis patients.
7.2.9 METHODS OF DATA COLLECTION:
Structured interview schedule will be used to collect the data from
dialysis patients.
The purpose of the study will be explained and consent from the
participant will obtained to involve in the study.
The tentative period of data collection will be 6 weeks, before that
tool will be developed and after validation by the experts, further
refinement of the tool will be done. After that the pilot study will be
conducted.
7.2.10 DATA ANALYSIS AND INTERPRETATION:
Data will be analyzed on the basis of objective and hypothesis by
using descriptive and inferential statistics. Frequency percentage mean
and standard deviation will be used for descriptive statistics. In
inferential statistics the chi -square test will be used to find the
association between posttest knowledge level with their selected
demographic variables and paired t test will be used to know the
effectiveness of structured teaching program on self care activities
among hemodialysis patients. The result will be presented in the form
of tables, graphs and diagrams.
7.3 Does the studies require any investigation or intervention to be
conducted on patient/ Sample populations or other humans or
animals?
Yes. The study will be conducted on the hemodialysis patients.
Since it is a Quasi experimental design, it requires intervention on self
care activities. Structured teaching programme will be given to the
hemodialysis patients. It will not have any harm to the patient.
7.4 Has Ethical clearance been obtained from your institute?
Yes. Prior permission will be obtained from the concerned
authorities of SNR hospital and RL Jalappa hospital in kolar to
conduct a Study and also from research committee of Pavan College
of nursing kolar. The purpose of study will be explained to the
hemodialysis patients of the selected hospitals. Scientific objectivity
of the study will be maintained with honesty.
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9
SIGNATURE OF
CANDIDATE:
THE
10
REMARKS OF THE GUIDE:
11
NAME AND DESIGNATION :
11.1 GUIDE
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF THE
DEPARTMENT
11.6 SIGNATURE
12 REMARK OF CHAIRMAN
AND PRINCIPAL
12.1 SIGNATURE: