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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
Sunil Kumar
1.
NAME OF THE CANDIDATE AND
ADDRESS
Smt M.C Vasantha College of
Nursing Naubad Bidar
2.
NAME OF THE INSTITUTION
3.
COURSE OF THE STUDY AND
SUBJECT
1st year M.sc nursing, Medical
DATE OF ADMISSION TO THE
COURSE
12/10/2010
4.
Surgical Nursing
“A STUDY TO ASSESS THE
KNOWLEDGE AND METHODS
5.
TITLE OF THE STUDY
AND PRACTICES OF
HEMODIALYSIS CLIENTS (3060 YEARS) REGARDING
PREVENTION AND CARE OF
ARTERIOVENOUS FISTULA
IN NEPHROLOGY UNIT OF
SELECTED HOSPITALS
BIDAR WITH A VIEW TO
DEVELOP HEALTH
INSTRUCTIONAL MODULE.”
6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION
There is a pair of organs, which are always compared with “the Mother of a family”.
They show the significance of sacrifice. Very precious, valued during and after life; not
considered when intact but receives more concern when dysfunctional. So care when it is
intact. They are nothing but the retroperitoneal “kidneys”.
The kidneys, organs with several functions, serve essential regulatory roles in
most animals, including vertebrates and some invertebrates. They are essential in
the urinary system and also serve homeostatic functions such as the regulation
of electrolytes, maintenance of acid-base balance, and regulation of blood pressure (via
maintaining salt and water balance). They serve the body as a natural filter of the blood,
and remove wastes which are diverted to the urinary bladder. In producing urine, the
kidneys excrete wastes such as urea and ammonium; the kidneys also are responsible for
the
reabsorption
of water, glucose,
and amino
acids.
produce hormones including calcitriol, renin, and erythropoietin.
The
kidneys
also
Located at the rear of the abdominal cavity in the retroperitoneum, the kidneys receive
blood from the paired renal arteries, and drain into the paired renal veins. Each kidney
excretes urine into a ureter, itself a paired structure that empties into the urinary bladder.
They play a role in the acid-alkaline (PH) balance and help to control blood pressure.
They produce hormones that regulate the production and release of red blood cells from
bone marrow. They filter about 200 quarts of blood a day. They produce about two quarts
of water and waste every single day.1
Proper functioning of urinary function is essential to life. Dysfunction of the kidney
may occur at any age and with varying levels of severity. Renal failure is the severe
impairment or total lack of kidney function. In renal failure there is an inability to excrete
metabolic waste products and water as well as functional disturbances of all body
systems. Renal failure is classified as acute or chronic. Among them Chronic Renal
Failure (CRF) develops insidiously overtime and necessitates the initiation for long term
survival.2
The global scenario of End Stage Renal Disease (ESRD) patients shows that the
incidence is increasing by an average of 7.8% per year. Before 1970s glomerulo nephritis
was the most common cause for CRF worldwide. But currently diabetic mellitus and
hypertension are the leading causes for CRF. In 2005, the overall incidence of ESRD was
at the rate of 347 per million populations i.e., 77000 of the new ESRD patients lived in
urban areas and 26000 in rural settings (world statistics) which is 3% higher than in 2002.
The incident counts and rates by gender have not been changing dramatically in
recent years. The number of males beginning ESRD therapy in 2005 was 1.2 times (281
per million) greater than the number of females, and their incidence rate was 1.5 times
higher (434 per million population) than males in 2007.
According to USRDS (United States Renal Data System), there will be 7,85,000
ESRD patients in the world by 2020. According to Metropolitan Statistical Area (MSA),
the incidence rates of ESRD in high density areas for whites exceed 300 per million
populations in the Los Angeles and the lowest rate is found in the Tampa (St. Peter’s
Berg) at 199 per million population.3
The focus in CRF has changed from treating a terminally ill patient, to dealing with a
person who has a manageable chronic disease that requires long term care. The changes
in focus are the result of the technical advances in dialysis and improved surgical
techniques.
Dialysis is used to remove fluid and uremic waste products from the body when the
kidneys are not able to do so. It is proved that life could be saved in patients dying of
renal failure with dialysis. The two important types include hemodialysis and peritoneal
dialysis. Acute dialysis is indicated when there is a significant high level of serum
potassium, fluid over load, increasing acidosis and pericarditis. Hemodialysis is the most
commonly used method of dialysis. 4
Hemodialysis is the method for removing waste products from the blood when the
kidneys are in failure. Hemodialysis is one of the three renal replacement therapies, the
other two being renal transplant and peritoneal dialysis. Hemodialysis can be an
outpatient or inpatient therapy.
Routine hemodialysis is conducted in a dialysis
outpatient facility.5
History may have played a role in developing dialysis as a practical treatment for
renal failure, starting with Thomas Graham of Gasgow, who first presented the principles
of solute transport across a semi permeable membrane in 1854. The artificial kidney was
first developed in Baltimore by Abel, Rountree and Turner in 1913.
The first
hemodialysis in a human being was done by a German physician Dr.Hass in 1924 and the
artificial kidney was developed into a clinically useful apparatus by a Dutchman
Dr.Willem Kolff in 1943 to 1945. The first successfully treated patient was a 67 year old
woman in uremic coma who gained consciousness after 11 hours of hemodialysis with
Kolff’s dialyzer in 1945. As the original Kolff’s kidney was not able to remove excess
fluid, Dr: Nils Alwall encased a modified version of this dialyzer in 1946.6
Access to the patient’s vascular system must be established to allow blood to be
removed, cleansed and returned to the patient’s vascular system at rates between 200 and
800 ml/min. A most permanent access is created surgically (usually in forearm) known as
fistula, by joining an artery to vein either side to side or end to side. The arterial segment
of the fistula is used for arterial flow and venous segment for reinfusion of the dialyzed
blood. Fistula takes four to six weeks to mature or become patent before it is ready to use.
This gives time for healing and for the venous segment of fistula to dilate to
accommodate two large-bore (14-16gauge) needles.
As for CRF patients, hemodialysis should be repeated three times a week for at least
three to four hours per dialysis; it is the best method to use arteriovenous fistula (AVF) as
a vascular access. Compared to other vascular access such as venous catheter and a
synthetic graft, arteriovenous fistula is most commonly used method as it has fewer
complications.7
An arteriovenous fistula is a preferred access at any age group as stated by
Dr.
Andrew R Foraner, MD, an interventional radiologist. He says that elderly patients’
arteriovenous fistulae respond just as well as those in younger patients.8
A report given by North-West Renal Network states that there were 54% increase in
the use of arteriovenous fistula for hemodialysis between 2001 and 2003, 73% increase
between 2001 and 2004, 80% increase between 2001 and 2005 and 86% increase
between 2001 and 2006.9
In UK the rate of AV fistula in use were 51.6% with an increased rate of 6.4%
between 2007 and 2008. In France, Germany, Italy, Japan and Spain it was 62%, 83%,
60%, 62% and 69% respectively.10
In India the 1st nephrology department was started on 1st of March 1981 at Sir Ganga
Ram hospital in New Delhi and was the first hospital to provide maintenance
hemodialysis in North India. The HOD of nephrology here has pioneered the art of
vascular access by nephrologists in India, which has now being taken over by the
nephrologists all over the world. In this hospital, more than 1200 patients are undergoing
hemodialysis per month and a few thousand successful surgeries of arteriovenous fistula
are being performed here. This unit is among the centers with largest experience in
vascular access surgery anywhere in the world.11
An article on increasing use of arteriovenous fistula reveals that in Karnataka the
incidence rate of arteriovenous fistula is increasing with a rate of four to five percentage
per year. One of the major hospitals in Bidar reports that around 1250 patients are
undergoing hemodialysis in their institution per year. Among them around 1000 are CRF
patients, with arteriovenous fistula as vascular access.12
It is important to take care of the vascular access to prevent complications.
Complications can occur even if we are careful, but are much less common if you take a
few precautions such as wash the access with soap and warm water each day, and always
before dialysis, do not scratch the area or try to remove scabs, check the area daily for
signs of infection, including warmth and redness, take care to avoid traumatizing the arm
where the access is located, check that there is blood flow in the access daily. There
should be a vibration (called a thrill) over the access. If this is absent or changes, notify
your healthcare provider.13
A prospective cohort study was conducted among 470 hemodialysis patients in USA
on knowledge about the effective self management measures to care their fistula site. The
knowledge was measured using a Chronic Hemodialysis Knowledge Survey. The median
score was 65% and lower scores were associated with older age and fewer years of
education. They concluded that the patients with less knowledge may be less likely to get
involved in the care of their arteriovenous fistula. The author concludes that additional
educational interventions are needed in improving their knowledge14.
The CRF clients are more prone to develop complications related to their
arteriovenous fistula such as infection, clotting, rupture, pseudo aneurism formation and
stenosis. Moreover, the investigator felt that post-operative care of arteriovenous fistula is
very important nowadays that there is increase in number of complications due to
improper knowledge of patients and their care givers regarding care of arteriovenous
fistula. They need guidance on prevention of these complications. So the investigator felt
a need to examine the knowledge and attitude of hemodialysis clients regarding care of
their fistula site.
6.2 NEED FOR THE STUDY
The arteriovenous fistula has marked important advance allowing effective treatment
of ESRD for longer periods of time. It is proved that the quality and length of life with
chronic kidney disease can be improved by dialysis through a good vascular access.
Arteriovenous fistula has proven to be the best kind of vascular access for people
whose veins are large enough, not only because it lasts longer but it also less likely than
other types of access to form clots or become infected. A primary AV fistula should be
the access for at least 50% of all new patients initiating hemodialysis. A native fistula is
the primary access for 40% of prevalent patients undergoing hemodialysis.15
As many studies have proven that the use of arteriovenous fistula is increasing day
by day, the importance of care for it, also become unavoidable. Complications can also
occur with this arteriovenous fistula. The most frequent complication in arteriovenous
fistula is related to the vascular access site where needles are inserted. This can include
infection around the access area or the formation of clots in the fistula. The greatest
danger is that the clots may block the fistula and would have to be removed surgically.
Frequent clotting may require creating a back up fistula at another site to allow dialysis
when one access is blocked.16
The mean maturation time of a new arteriovenous fistula is about two to four months
which should be properly informed to the patients and relatives. Moreover the patients,
whose arteriovenous fistula fails to mature adequately to be used for dialysis, require
subsequent interventions to promote fistula maturation. Otherwise there will be poor
blood flow, frequent thrombosis and malfunction.17
Factors influencing fistula maturation include adequacy of vessels and type of fistula.
Several changes are critical for the successful maturation of a new arteriovenous fistula.
First, it must dilate to a caliber large enough to be cannulated repeatedly with two large
bore dialysis needles. Second, the blood flow rate in the draining vein must increase
sufficiently to accommodate the dialysis blood flow required to deliver adequate dialysis.
Third, the wall of the draining vein must hypertrophy sufficiently to seal after withdrawal
of the dialysis needle. Finally the fistula must be superficial enough for the land marks to
be appreciated and permit safe cannulation without infiltration.18
The patients and relatives should be properly educated regarding the care of
arteriovenous fistula at home. There is a list of reminders that the patients should follow
strictly to prevent the complications of arteriovenous fistula. Never touch the area that the
needle enters after skin disinfection and during dialysis, never carry heavy loads across or
on the fistula, never sleep on the fistula, always keep the access clean. Moreover, these
guidelines provide information like how to watch for the signs of complications.19
Hemodialysis patients are frequently encouraged to perform regular hand exercises
to promote maturation of a new fistula. Exercises means squeezing a rubber ball for
forearm fistula in order to increase the size of the vessels and thereby to accommodate
the large-bore needles used in hemodialysis.20
A descriptive study was conducted among 120 hemodialysis patients in London to
assess their practice in caring their fistula site. They used an observational method to
assess the practice and found that more than 50% of them are following malpractices.
Then a self instructional module was prepared to enhance their knowledge regarding the
importance of proper care of the arteriovenous fistula.21
The investigator from her personal experience while working in nephrology unit at
Calicut observed that rupture, clotting among dialysis patients with arteriovenous fistula
have occurred due to improper caring of the fistula site. The investigator found that the
clients had less knowledge on care aspect as well as complications of arteriovenous
fistula. This has motivated her to assess the existing knowledge and practice of
hemodialysis clients towards the care of their arteriovenous fistula.
6.3 STATEMENT OF THE PROBLEM
A Study to Assess the Knowledge and methods and practices of Hemodialysis
Clients (30-60 years) regarding
prevention and Care of Arteriovenous Fistula in
Nephrology unit of Selected Hospitals, Bidar with a View to Develop Health
Instructional Module.
6.4
OBJECTIVES OF THE STUDY
1.
To assess the existing knowledge of hemodialysis clients regarding care of
arteriovenous fistula.
2.
To assess the existing practice of hemodialysis clients on care of their fistula
site.
3.
To associate the knowledge and practice of hemodialysis clients regarding
care of arteriovenous fistula with selected demographic variables.
6.5 OPERATIONAL DEFINITIONS
1. KNOWLEDGE: It refers to the awareness and understanding of hemodialysis
clients regarding care of their fistula site such as hygiene, prevention of accidents, and
complications (infection, clotting, rupture), Do’s and Don’ts with arteriovenous fistula
elicited with the help of a structured interview schedule.
2. PRACTICE: It refers to the actions or measures taken by the hemodialysis clients
regarding care of their arteriovenous fistula site such as hygienic care, prevention of
accidents, injuries and prevention of complications like infection, rupture, clotting; Do’s
and Don’ts with arteriovenous fistula as elicited by a non-observational checklist.
3. HEMODIALYSIS: It refers to the process in which a stream of blood taken from
an artery is circulated through a dialyzer on one side of a semi permeable membrane and
by which the water and waste products from the client’s blood is filtered through the
membrane and the purified blood is then returned to the client’s body through a vein.
4. CLIENTS: It refers to the hemodialysis patients of 20-70 years with arteriovenous
fistula in their forearm attending the nephrology unit of selected hospitals in Bidar.
5. ARTERIOVENOUS FISTULA: An arteriovenous fistula is a surgically created
connection of a vein and an artery, usually in the forearm, to allow access to the vascular
system for hemodialysis. The fistula usually becomes patent over a period of three
months to undergo hemodialysis.
6. CARE OF ARTERIOVENOUS FISTULA: It refers to the actions taken by the
clients with arteriovenous fistula in care of fistula site such as keeping the access site
clean at all times, preventing accidents, preventing complications like infection, clotting,
rupture; Do’s and Don’ts.
7. HEALTH INSTRUCTIONAL MODULE: It refers to an instructional unit which
contains a set of information regarding care of arteriovenous fistula.
6.6 ASSUMPTIONS
1) Hemodialysis clients may have knowledge regarding care of arteriovenous
fistula to some extent.
2) The level of knowledge of hemodialysis clients regarding care of their fistula
site can have an impact on their practice.
3) The health instructional module may enhance the knowledge and practice of
dialysis clients in caring their arteriovenous fistula site.
6.7 HYPOTHESES
H1: There is a significant correlation between knowledge and practice of
hemodialysis clients regarding care of arteriovenous fistula.
H2: There is a significant association of knowledge and practice of hemodialysis
clients with their selected demographic variables.
6.8 REVIEW OF LITERATURE
A literature review is an integral component of any study of research product; it
enhances the depth of knowledge and provides a clear understanding regarding a topic or
a research aspect. Literature reviews are secondary sources, and as such, do not report
any new or original experimental work. It is a critical analysis of a segment of a
published body of knowledge through summary, classification and comparison of prior
research studies and theoretical articles.22
A study was conducted to find out the incidence of CRF, among dialysis patients at
Central Military Hospital in Yemen in the nephrology department. The study was done
among 334 patients and found that 260 were CRF patients who are receiving dialysis
treatment. They concluded that in Cuba, CRF is becoming one of the major health
problems.23
A study was conducted among adults on the prevalence of CRF in India. The
background was that CRF is a debilitating condition responsible for high morbidity and
mortality and is a financial burden for the Government and the society. Because of its
costs and complexity of the treatment proper care is available to a very few patients in
India. A total of 4972 persons were contacted for the study. Their mean age was 42 ± 13
years and 56% were males. And it was found that 37 of them are having chronic renal
failure. They concluded that the prevalence of CRF in India makes it a serious problem in
need of urgent efforts to contain it.24
An editorial published in an American journal in the year 2004 says that maintenance
of patients with ESRD on long term dialysis is a triumph of modern medicine. In US
alone more than 2, 50,000 persons with ESRD are surviving because of the availability of
hemodialysis and peritoneal dialysis. And there is increasing the incidence with ESRD
who are receiving hemodialysis.25
The National Kidney Foundation Kidney-Dialysis Outcome Quality Initiative
((K/DOQI) clinical practice guidelines recommended native AV fistulas as optimal
hemodialysis vascular access. The article describes that there is much evidence that
native AV fistulae, compared to arteriovenous graft or catheters, provide longer patency
rates, require fewer interventions, have less complications and subsequently lower
mortality rates for the patient.26
A comparative study was conducted among 200 hemodialysis patients in Netherlands
to assess the effectiveness of AV fistula with regard to AV graft on decreasing the
thrombosis rates. Among study participants 100 were having arteriovenous fistula and
rest with arteriovenous graft. They found that AV fistulae have a positive impact on
decreasing future thrombosis rates and the percentage of AV fistulae in the dialysis
population increased from 28% to 65% between 1990and 2003.27
A community-based study conducted among 1000 hemodialysis patients in US
revealed that 660 of hemodialysis patients are having AV fistula as vascular access.
Annual expenditure were also estimated and found that it is less in AV fistula based
access as compared to other modalities. They concluded that AV fistula placement is
cost-effective and so they are providing financial incentives in the form of higher
reimbursement to encourage wider use of AV fistula placement.28
An international journal recommended national guide lines to promote fistula use
among hemodialysis patients. Increasing hemodialysis prevalence requires increasing
fistula placement, improving maturation of new fistulae and enhancing long term patency
of mature fistulae for dialysis. Whether a mature fistula achieves long term patency,
depends on the ability to prevent rupture of the fistula thrombosis and to correct it as
early as possible.29
A quasi experimental study was done on incidence of micro inflammation of AV
fistula among 47 patients with maintenance hemodialysis. They were divided into three
groups such as patients with initial hemodialysis and new fistula, patients treated with
hemodialysis for long term with well functioning vascular access, and maintenance
hemodialysis patients with vascular dysfunction under group one, two and three
respectively. Biomedical parameters were determined and found that patients in group 3
had a thicker internal layer of vessels. They concluded that vascular access dysfunction
including micro inflammation is a major clinical complication in the hemodialysis
population and has a direct effect on dialysis outcome. 30
A study was conducted among 15 patients to investigate the effect of venous stenosis
on early patency by examining the peri-operative arterial and venous pressures of the
fistula. A thrill was palpable over the anastomosis in 10 patients and absent in 5 patients.
In conclusion, patients with venous obstruction the fistula had a much higher venous
pressure than those with a patent fistula. If venous stenosis is suspected, measurement of
fistula pressures may be useful for determining the early patency of AV fistulae.31
An article published in Oxford journals reveals the complications of a neglected AV
fistula. Creation of fistulae provides readily available vascular access for hemodialysis in
patients with ESRD. However it is associated with various potentially serious
complications if left unattended. They report a case of 63-yr old male presenting with
forearm fistula who was admitted in the emergency department of St. George hospital,
London, following the rupture and severe hemorrhage after a fall. They concluded that if
it is not attended properly it may lead even to death due to excessive bleeding.32
An article emphasizes on the importance of keeping the vascular access clean.
Cleanliness is one way someone on hemodialysis can keep their fistula uninfected. Keep
an eye out for infections, which can often be detected when there is pain, tenderness,
swelling or redness around the access area and also be aware of any fever or flu-like
symptoms. The article also instructs the patients to contact health professional if they get
an infection to catch it early and treat it properly.33
A study was conducted among 55 hemodialysis patients with CRF who are having
AV fistula. It revealed that a simple, incremental resistance, exercise training program
can cause a significant increase in the size of the cephalic vein commonly used in the
creation of an AV fistula. The increase in size and the resultant probable increase in
blood flow might accelerate the maturation of native AV fistula, thereby lessening the
morbidity associated with vascular access.34
An information booklet narrates the care of arteriovenous fistula as follows: place ice
cubes put in a plastic bag and covered in a towel over the fistula site for pain or swelling,
carefully wash the stitches or staples with soap and water when the patients are allowed
to take bath, change your bandage any time it gets dirty or wet, do not keep the limb with
fistula bent for a long time.35
A patient education book gives information on ‘care of your AV fistula’ which acts
as a patient education guide to protect the AV fistula. The instructions are follows: do not
allow anyone to take BP in the affected limb, do not allow anyone to stick or take blood
from the affected limb, avoid sleeping on the affected limb, do not wear tight straps,
jewels or clothes that restrict the movement of the limb, do not carry any heavy objects or
lift heavy objects greater than 5 pounds with the affected limb. It also explains how to
watch for signs of clotting.36
A nurse-led clinic focusing on education and self-care for patients with advanced
renal failure was introduced in a renal outpatient clinic in Sweden. The purpose was to
enhance patients' disease-related knowledge, involvement, and self-care ability. The
participants in the nurse-led clinic chose 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 self-care 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 knowledge.37
7. MATERIALS AND METHODS
7.1 SOURCE OF DATA
The data will be collected from the hemodialysis clients with arteriovenous
fistula attending the nephrology unit of selected hospitals, Bidar
7.2 METHOD OF DATA COLLECTION
I.
RESEARCH DESIGN
The research design will be Non-experimental; Descriptive Correlational design.
II.
RESEARCH VARIABLES
A) STUDY VARIABLE
The knowledge and practice of hemodialysis clients regarding care of
arteriovenous fistula.
B) DEMOGRAPHIC VARIABLES
The demographic variables of the clients such as age, gender, educational
status, occupation, family income, religion, previous exposure to any information,
duration of illness, duration of treatment(hemodialysis), site of fistula, schedule of
hemodialysis.
III. SETTING
The setting will be the nephrology unit of the selected hospitals in Bidar
IV.
POPULATION
In this study the target population is the clients with arteriovenous fistula,
between the age group of 30-60 years undergoing hemodialysis at nephrology unit
of selected hospitals, Bidar.
V.
SAMPLE
Hemodialysis clients who are fulfilling the inclusion criteria will be the
sample. Sample size will be 90.
VI. CRITERIA FOR SAMPLE SELECTION
INCLUSION CRITERIA
1. Clients admitted with diseases like CRF or ESRD undergoing
hemodialysis in nephrology unit of selected hospitals.
2. Clients of both IPD and OPD undergoing hemodialysis in selected
hospitals, Bidar.
3. Clients with arteriovenous fistula undergoing dialysis for a minimum
period of six months.
4. Clients who are willing to participate in the study.
5. Patients between the age group of 20 and 70.
6. Clients who are able to read and understand Kannada or English.
EXCLUSION CRITERIA
1. Clients having vascular access other than AVF such as AV graft, catheters
or cannula undergoing hemodialysis in nephrology unit of selected
hospitals Bidar.
2. Clients who are emotionally unstable and those with behavioral disorders.
3. Clients whose vital signs are unstable or fluctuating.
4. Clients who have undergone arteriovenous fistula recently within three
months.
VII.
SAMPLING TECHNIQUe.
Non-probability sampling technique. 35 hemodialysis patients will be
selected based on purposive sampling method.
VIII. TOOLS FOR DATA COLLECTION.
Section A: A structured interview schedule will be used to assess the demographic
data (age, gender, educational status, occupation, family income, religion,
previous exposure to any information, duration of illness, duration of
treatment(hemodialysis), site of fistula, schedule of hemodialysis).
Section B: A structured interview schedule will be used to assess the knowledge
among hemodialysis clients regarding the care of arteriovenous fistula.
Section C: The practice of hemodialysis patients with arteriovenous fistula
towards the care of AV fistula will be elicited by a non-observational check list.
IX. METHODS OF DATA COLLECTION.
After obtaining formal permission from the concerned authority and getting
informed consent from samples, assuring about confidentiality of information, the
investigator will administer the structured interview schedule to assess
demographic variables, knowledge and non-observational check list to assess the
practice regarding care of arteriovenous fistula among hemodialysis clients.
X. PLAN FOR DATA ANALYSIS.
The data collected will be analyzed using descriptive and inferential
statistics.
DESCRIPTIVE STATISTICS:
Frequency, Percentage distribution, Mean and Standard Deviation will be
used to assess the knowledge and practice of hemodialysis clients with
arteriovenous fistula regarding care of arteriovenous fistula.
INFERENTIAL STATISTICS:
Correlation Coefficient formula will be used to determine the correlation
between knowledge and practice regarding care of arteriovenous fistula.
Chi-square test will be used to determine the association of knowledge and
practice with demographic variables.
XI.
PROJECTED OUTCOME.
The investigator will assess the level of existing knowledge and practice on
care of arteriovenous fistula among hemodialysis clients with AV fistula. Based
on the findings obtained, the investigator will prepare a health instructional
module regarding care of arteriovenous fistula, which will help the clients to
improve their knowledge and follow proper practices in the care of arteriovenous
fistula.
8. LIST OF REFERENCE:
1. http://en.wikipedia.org/wiki/Kidney
2. Suzanne C Smeltzer, Brenda G Bare. Brunner and Suddharth’s Text Book of
Medical-Surgical Nursing. 10th ed. Philadelphia: Lippincott publishers; 2000;
1285, 1321, 1326.
3. Incidence ESRD 2005. Available from http://www.usrds.com
4. Lewis SM, Collier IC, Heitkemper MM. Medical Surgical Nursing-Assessment
and Management of Clinical Problem. 7th ed. Missouri: Mosby publications;
2002; 1372, 1379, 1392.
5. Renal Replacement Therapies. Available from http://www.kidney.org.
6. Dialysis history. Available from http://www.niddk.nih.gov.
7. Joyce M Black, Jane H Hawks, Annabelle M Keene. Medical Surgical Nursing.
6th ed. Philadelphia: W.B. Saunders Company; 2001; 891-894.
8. Andrew R Foraner. For Old and Young Dialysis Patients Arteriovenous Fistula
Remain Pure Gold. 2009 Mar; Available from http://esciencenew.com
9. Fistula First. Available from http://www.nwrenalnetwork.org.
10. ESRD
Network
Results
2002-2007.
Available
from
http://www.nkudic.niddk.nih.gov.
11. Department of Nephrology India. Available from http://www.sgrh.com.
12. Increasing Incidence Rate- Arteriovenous Fistula. 2007 Oct; Available from
http://www.issuu.com.
13. Berns
M.
Patient
Information-
Hemodialysis.
Available
from
http://www.uptodate.com.
14. Clavanaugh KL, Wingard RL. Patient Dialysis Knowledge is Associated with
Permanent Arteriovenous Access Use in Chronic Hemodialysis. Clin J Am Soc
Nephrol. 2009 May; 4(5): 950-56.
15. ESRD Clinical Performance Measures Project. Annual Report 2007. Available
from http://www.cms.hhs.gov.
16. Stewen MH. Increasing Arteriovenous Fistula in Hemodialysis Patients: Problems
and Solutions. Official Journal of ISN. 2007 Jul 15; 22(2): 522-528.
17. Voormolen, Eduard HJ. Non-maturation of arm AVF for HD access: a systematic
review of risk factors and results of early treatment. J Vasc Surg. 2009 May;
49(5): 1325-36.
18. Guidelines
for
Vascular
Access.
2008
June;
Available
from
http://www.kidney.org/professionls/KDOQI/guidelines.
19. Vascular Access for Hemodialysis: How should I Care of my Vascular Access
2008. Available from http://en.wikipedia.org.
20. Oder TF, Uribarri J. Effect of exercise on maturation of AVF in HD dialysis
patients. ASAIO Journal. 2003 Sep; 49(50): 554-55.
21. Mendelssohn DC. Ethier J. Assessment of Practice on Care of Fistula 2005.
Available from http://www.ncbi.nlm.gov
22. Literature Review: Writing Audio Duke University.
http://uwp.aas.duke.edu/wsstudio.
2001. Available from
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9.
SIGNITURE OF THE CANDIDATE
10.
REMARKS OF THE GUIDE
11.
NAME AND DESIGNATION
OF PRINCIPAL (IN BLOCK LETTERS)
11.1 GUIDE
11.2 SIGNITURE
11.3 CO GUIDE (IF ANY)
11.4 SIGNITURE
11.5 HEAD OF THE DEPARTMENT
11.6 SIGNITURE
12
REMARKS OF
PRINCIPAL
12.2 SIGNITURE
THE
CHAIRMAN
AND