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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BENGALURU, KARNATAKA
PROFORMA FOR REGISTRATION OF
SUBJECTS FOR DISSERTATION
1
NAME OF
MS.JEENA RANI THOMAS
CANDIDATE
2
NAME OF THE
K.R COLLEGE OF NURSING
INSTITUTION AND
PROPERTY NO.59, 25/4/74,
ADDRESS
KATHA NO.1935,C&M COMPLEX,
OMKAR LAYOUT,
UTTARAHALLI-KENGERI
MAINROAD, BENGALURU-560060.
3
4
COURSE
STUDY 1 YEAR M.sc NURSING
AND SUBJECT
MEDICAL-SURGICAL NURSING
DATE OF
30/10/2010
ADMISSION TO
COURSE
5
TITLE OF THE
“A DESCRIPTIVE STUDY TO ASSESS THE
TOPIC
KNOWLEDGE ON MANAGEMENT OF RENAL
EMERGENCIES
WORKING
AMONG
IN
FOUNDATION
STAFF
BANGALORE
HOSPITAL
IN
NURSES
KIDNEY
BANGALORE
CITY,WITH A VIEW TO DEVELOP A SELF
INSTRUCTIONAL MODULE”
-0-
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
Renal system is an important regulator of the body’s internal environment and is essential for the
maintenance of life. Patients with renal disorders commonly experience fluid and electrolyte
imbalances and require careful assessment and close monitoring for signs of potential problems.
Acute renal failure is the common renal disorder which requires emergency treatment for the
survival of the patients. anuria, hematuria, acute graft rejection, trauma, urine retention, and
nephrotoxicity are the other renal disorders that require emergency treatment. Acute renal failure
can be managed conservatively and if it is not effective, dialysis is required.1
Anuria means no passage of urine, in practice it is defined as passage of less than 50
milliliters of urine in a day. Anuria is often caused by failure in the function of kidneys. Acute
anuria, where the decline in urine production occurs quickly, is usually a sign of obstruction or
acute renal failure. Anuria itself is a symptom, not a disease. It is often associated with other
symptoms of kidney failure. Anuria can be managed by catheterization. Haematuria is the
presence of red blood cells in the urine. It may be idiopathic and benign or it can be a sign that
there is a kidney stone or a tumor in the urinary tract. The common causes of hematuria are
kidney stones, kidney diseases, and trauma eg. blow to the kidneys and renal cell carcinoma.2
The introduction of potent immunosuppressive drugs in the past three decades has led to
a dramatic reduction in the incidence of acute rejection in kidney transplant recipients.
Balancing the need for immunosuppression to prevent allograft rejection while minimizing drug
toxicity and the risk of infections and malignancy continues to be a challenging task. Acute
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rejection is the major predictor of chronic allograft nephropathy, which is responsible for most
death-censored graft loss after the first year post transplant. It is usually treated with high doses
of steroids and in case of no response acute graft rejection can be treated with anti lymphocyte
preparation. 2
Renal injuries are the most common injuries of the urinary system. Trauma is generally
caused by falls, road traffic accidents, blows, sporting accidents, stab wounds and gunshot
wounds. Severity of renal trauma depends on the extent of the injury treatment, range from bed
rest, fluids and analgesics to surgical exploration and repair by nephrectomy. Urinary retention,
also known as ischuria, is a lack of ability to urinate. Diagnosis and treatment may require use of
a catheter or prosthetic stent. Acute retention causing complete anuria is a medical emergency,
they need emergency treatment. A person should go straight to an emergency department as soon
as possible if unable to urinate when having a painfully full bladder. Interventions for urinary
retention is aimed at re-establishing the urine flow.3
Nephrotoxicity is a poisonous effect of some substances, both toxic chemicals and
medications, on the kidneys and there are various forms of toxicity. Nephrotoxins are chemicals
displaying nephrotoxicity. Examples of nephrotoxins include diuretics, tacrolimus, radiocontrast
media, ciprofloxacilline, heavy metals and aristolochic acid. Nephrotoxicity is usually monitored
through a simple blood test and treatment includes removal of toxins from the body and
monitoring and support of kidney function, dialysis if needed and kidney transplant in severe
cases.4
The campaign of world kidney day 2011 focused on the important link between chronic
kidney disease and cardiovascular disease. A joint initiative of the International Society of
Nephrology and the International Federation of Kidney Foundation, World Kidney Day’s aim is
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to raise awareness of the importance of our kidneys to our overall health and to reduce the
frequency and impact of kidney disease and its associated health problems world wide.5
Bangalore Kidney Foundation Hospital of Bangalore was started in July1999 as a super –
specialty hospital for nephro-urology care. It is one of the South India’s leading nephro-urology
hospitals and Karnataka’s only dedicated nephro-urology centre. It has pioneered the diagnosis
and treatment of renal diseases in the state of Karnataka, India and promotes the cause of kidney
disease patients through partnerships with Health care institutions. Its objectives are to provide
affordable renal health care for the needy, facilitate accessible renal health care to all affected
and create awareness of renal health issues.6
6.1. NEED FOR THE STUDY
The kidney is the body’s natural filtration system. They play a major role in regulating fluid
balance in the body, eliminating or conserving water as needed. They play a similar role with the
different electrolytes .The kidneys also get rid of waste products. They perform the critical task
of processing approximately 200 quarts of fluid in the blood streams every 24 hours. Waste
products like urea and toxins, along with excess fluids, are removed from the blood stream in the
form of urine. Acute renal failure (Acute kidney injury) is a common syndrome in hospitals. It is
associated with a mortality rate which varies according to definition. As the assessment of renal
function in man is only indirect and limited by the inability to obtain tissue, to reliably and
continuously measure renal blood flow and the need to derive indirect information on glomerular
filtration rate and tubular cell status through urine analysis.3
Renal emergencies will examine how your patient loses renal function, what early
warning signs will be seen and how to properly respond to acute renal dysfunction to avoid
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complications. Renal function is not just good or bad. Rather, it should be thought of as on a
continuum ranging from 0 percentage to100 percentage. Patient will be somewhere along that
scale and nurses job is to know where they lie on that scale in terms of renal function.8
According to the 2004 report from the US Renal Data System, the number of patients
with renal disease receiving therapy in 2002 was 431284. This number is a 4.6 percentage
increase over the number from the year 2001. The adjusted rate for renal disease was 1435 cases
per million population, 72 percentage of patients were undergoing dialysis, the other 122374 had
a functioning transplant. The adjusted rate of renal disease for the white population was 1060
cases per million for the African American population, 4467 cases per million; and for the Native
American population, 2569 cases per million.9
Since kidney failure can be caused by many things, prevention is difficult. Medicine
that may impair kidney function should be given cautiously. Patients with preexisting kidney
conditions who are hospitalized for other illness or injuries should be carefully monitored for
kidney failure complications. Treatment and procedures that may put them at risk for kidney
failure like diagnostic tests requiring radiocontrast agent or dyes should be used with extreme
caution.2
Acute kidney failure is common among hospitalized patients. It affects some 37percentage of patients admitted to the hospital and approximately 25-30percentage of patients
in the Intensive care unit. The older adult is more susceptible than younger adult to acute renal
failure. Mortality rate of acute renal failure is 5percentage to 25percentage higher in older adults
than in younger adults. A continual increase in the incidence of traumatic renal injuries is related
to an increase in the mechanization and speed of transportation and to the increase in violent
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crimes and injuries. The majority of incidence occurs in men younger than 30 years of age. The
severity of renal trauma depends on the extent of the injury.4
Acute graft rejection is related primarily to activation of T-cells, which inturn;
stimulate specific antibodies against the graft. Various clinical syndromes of rejection can be
correlated with the length of time after transplantations. Acute graft rejection appears within the
first 6 post-transplant months and affects approximately 15percentage of transplanted kidneys.
Roughly 20percentage of patients with transplants experience recurrent rejection episodes.4
In the present scenario, most of the people are prone to renal disorders and it stands as
one of the major problem in the health sector. The diagnosis and management of renal
emergencies necessitates adequate knowledge and efficient skills. Nurses are the backbone of
health care delivery system as they are involved in the health care management of renal
emergencies and it is very important that they should be thorough with knowledge of all the renal
emergencies and its proper management. During the clinical experience at Bangalore Kidney
Foundation hospital, the researcher came across many nurses having inadequate knowledge
regarding management of patient with renal emergencies. So the researcher felt that, there is a
need to enhance the knowledge of staff nurses regarding management of patient with renal
emergencies.
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6.2. REVIEW OF LITERATURE
Review of literature related to incidence of renal emergencies.
A retrospective study was conducted with an aim to describe the use of emergency department
hemodialysis in the management of Renal failure patients. Data were collected on presenting
complaint, diagnosis, and indication for hemodialysis, pharmacologic treatment, airway
management, cardiovascular stability, and disposition. Fifty episodes of hemodialysis were
identified in 37 different patients. The study concluded that emergency department hemodialysis
in conjunction with additional medical care is a useful emergency medicine technique that can
prevent hospital admission in patients with acute renal emergencies.10
A descriptive study was carried with an aim to analyze the prevalence and outcome of
acute kidney injury in patients with severe burn injury. Acute kidney injury is a common
complication in patients with severe burn injury and one of the major causes of death .This
search yielded 57 articles and abstracts with relevant epidemiologic data of acute kidney injury
in the burn patients. Of these, 30 contained complete mortality data of the patients with burn
injury and control population, which revealed a 3 to 6 fold higher mortality for acute kidney
injury patients in univariate analysis, depending on the applied definition. Acute kidney injury
occurred in one quarter of patients with severe burn injury, when defined by the need for renal
replacement therapy. This study concluded that acute kidney injury remains prevalent and is
associated with increased mortality in patients with severe burn injury.11
A descriptive study was carried out about Cortinarius poisoning characterized by a
delayed acute renal failure. The aim of this literature review is a better description of Cortinarius
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poisoning. The 245 cases were collected and 90 cases could be analyzed in detail. Acute renal
failure progressed towards chronic renal failure in half of the cases; intermittent hemodialysis or
kidney transplantations were necessary in 70percentage of those cases. The study concluded that
Cortinarius poisoning is severe and ingestion of Cortinarius species must be systematically
suspected whenever tubulo-interstitial nephritis is diagnosed, especially as mushrooms may have
been ingested 1-2 weeks before.12
A prospective study was carried out on acute renal failure patients receiving acute
continuous hemodiafiltration in an intensive care unit. Acute continuous hemodiafiltration
consisted either of continuous arteriovenous hemodiafiltration or of continuous veno-venous
hemodiafiltration. Eighty of these patients were receiving artificial ventilation at the time of
acute continuous hemodiafiltration 45 had more than four failing organs. Despite the degree of
illness severity, 42 patients survived to discharge from hospital. The study concluded that the
advantages associated with the use of acute continuous hemodiafiltration therapies are clinically
significant and support the view that acute continuous hemodiafiltration is a modality of renal
replacement most suited to critically ill patients with acute renal failure.13
A randomized study was conducted regarding Polyomavirus-associated nephropathy
which is an important cause of kidney graft loss but there is no consensus on its management.
This study aimed to systematically document all published treatments for Polyomavirusassociated nephropathy to determine the most effective therapy. The primary outcome was graft
failure rate, and secondary outcomes included acute rejection rate. The study concluded that
there does not seem to be a graft survival benefit of adding cidofovir or leflunomide to
immunosuppression reduction for the management of Polyomavirus associated nephropathy.
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However, the evidence base is poor and highlights the urgent need for adequately powered
randomized trials to define the optimal treatment of this important condition.
Review of literature related to knowledge of staff nurses on management of patients with
renal emergencies
A cohort study was carried out to evaluate a health rating for renal failure patients that were
completed by patients, nurses, and nephrologists. Raters showed good agreement, although
agreement was higher between nephrologists and nurses than between health professional and
patients. All three ratings and the combined rating corresponded significantly to objective
measures of health status. Uremic symptoms, emergency hospital admissions, diabetes mellitus,
and recent Myocardial Infarction correlated uniquely and most consistently with subjective
health ratings. The study concluded that the health rating is reliable and relates to the current
status of the patient. Performance was superior for the combined score that incorporated ratings
by patients, nurses, and nephrologists.14
A descriptive study was carried out to find the use of an emergency response team for
unwell patients has provided an improvement in hospital care standards by reducing medical and
postoperative adverse outcomes. Use of a nurse emergency team for patients treated with
continuous renal replacement therapy also has potential to reduce adverse outcomes with
continuous renal replacement therapy. The 'human resource' is the biggest challenge in
developing a suitable response team 24/7.The study concluded that Intensive care unit and
nephrology nurses work in a collaborative approach for Continuous renal replacement therapy
and a response team would be more easily established and may not be required continuously.15
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A study was conducted to describe the culture and everyday practices of vascular access
cannulation of the Arterio- venous fistula from the perspective of the hemodialysis nurse. An
ethnographic research design was employed, utilizing qualitative methods. Ten hemodialysis
nurses were interviewed using a semi-structured interview tool, and a number of themes were
generated from the interviews. Moreover, the decrease in opportunities to practice cannulation
has resulted in wide variation in skill level among hemodialysis nurses. Results of this study
may be helpful in understanding the culture of cannulation in a chronic hemodialysis unit and in
directing future educational, supportive, and practice interventions for hemodialysis nurses.16
A study was conducted to determine the effect of integrated education on nurse’s
knowledge of hemodialysis access. The fundamental principles of vascular access should be used
to help train future dialysis staff members in order to improve quality of care. Nurses must
continue to gain knowledge in this important area through nursing research and education. The
study concluded that integrated education improves the knowledge of nurses working in a renal
unit.17
STATEMENT OF THE PROBLEM
“A descriptive study to assess the knowledge on management of renal emergencies among staff
nurses working at Bangalore Kidney Foundation Hospital in Bangalore city, with a view to
develop a Self Instructional Module.”
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6.3.
OBJECTIVES OF THE STUDY
1. To assess the knowledge of staff nurses regarding management of patients with renal
emergencies.
2. To determine the association between the knowledge of staff nurses on management of
patients with renal emergencies with selected demographic variables.
3. To prepare and distribute self instructional module to the staff nurses regarding management
of patients with renal emergencies.
6.4. RESEARCH HYPOTHESIS
H1-There will be significant association between the knowledge of staff nurses regarding
management of patients with renal emergencies with the selected demographic variables.
6.5 VARIABLES UNDER STUDY
Study Variables: Knowledge of staff nurses regarding management of patient with renal
emergencies.
Attribute variables: Age, sex, education, occupation, religion, socioeconomic status, source of
information.
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6.6 OPERATIONAL DEFINITIONS
Assess: To measure the knowledge of staff nurses regarding management of patients with renal
emergencies.
Knowledge: The information possessed by staff nurses regarding management of patients with
renal emergencies.
Renal emergencies: Any deviation or failure of healthy kidney that require emergency treatment
such as acute renal failure, anuria, haematuria, trauma, acute graft rejection, urinary retention,
poisoning.
Self instruction module: A learning package which consists of information regarding the
management of renal emergencies which helps the staff nurses to meet any renal emergencies.
6.7.
ASSUMPTIONS
1. The staff nurses may have inadequate knowledge regarding management of patients with renal
emergencies.
2. The knowledge acquired by staff nurses helps in better management of patients with renal
emergencies.
6.8. DELIMITATIONS
The study is limited to
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1. Staff nurses who are working in Bangalore kidney foundation hospital.
2. Staff nurses who are available during the period of study.
3. Staff nurses who are willing to participate in the study.
7.1. MATERIALS AND METHODS
Sources of data: Data will be collected from staff nurses working in Bangalore kidney
foundation hospital.
Research design: Descriptive research design
Research approach: Non-experimental research approach.
Research setting: The study will be conducted in Bangalore kidney foundation hospital.
Sample size: 40 staff nurses working in Bangalore kidney foundation hospital.
Sample technique: Purposive sampling technique.
SAMPLING CRITERIA
Inclusion criteria
1. Staff nurses working in Bangalore kidney foundation hospital.
2. Staff nurses who are available at the time of data collection.
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3. Staff nurses who are willing to participate in the study.
Exclusion criteria:
1. Staff nurses who are not willing to participate in the study.
2. Staff nurses who are not available at the time of study.
DURATION OF THE STUDY
This study will be done in 2-4 weeks time.
TOOLS FOR DATA COLLECTION
PART A: Items on demographic variables.
PART B: structured questionnaire on knowledge of staff nurses regarding management of
patients with renal emergencies.
DATA COLLECTION PROCEDURE:
Formal permission will be obtained from the administrative heads (Director) and head of nursing
services to conduct the study. The researcher introduces herself to the in charge sisters of
various departments of Bangalore kidney foundation hospital. The staff nurses selected for the
study will be approached and consent will be taken to participate in the study. An interview
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schedule will be conducted and necessary instructions will be given to them. The time taken to
complete an interview for each patient is approximately 50-60 minutes.
7.2. DATA ANALYSIS METHOD
Descriptive statistics: Data will be analyzed by means of percentage, mean, mode, median and
standard deviation.
Inferential statistics:
1. Independent unpaired ‘t’ test to find the knowledge of staff nurses regarding management
of patients with renal emergencies.
2. Chi-square test to determine the association between knowledge of staff nurses regarding
management of patients with renal emergencies.
7.3. Does the study require any investigation or interventions to be conducted on patients
or other human or animal?
No, only educational intervention to be conducted on knowledge of staff nurses regarding
management of patients with renal emergencies in Bangalore Kidney Foundation Hospital.
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7.4. Has the ethical clearance been obtained from your institution?
Yes, Ethical clearance will be obtained from the research committee of K.R College of Nursing,
Bengaluru.
Permission will be taken from Bangalore kidney foundation hospital
The informed consent will be obtained from the samples for their willingness to participate in the
study.
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REFERENCES
1. Polaski A.L, Tatro S.E, LuckMann’s core principles and practice of medical-surgical nursing.
Saunders publications; p.958, 889-890
2. Suzanne C.S, Brenda.B. Text book of Medical Surgical Nursing.10 th ed. Philadelphia:
Lippincott Williams and Wilkins publications; p.1515-1520
3. Lewis S.M, Heitkemper M.M. Dirksen S.R. Medical Surgical Nursing-Assessment and
Management of Clinical problems, 6th ed. Mosby publications; p.1191, 1199, 1210.
4. Gelmez M, Akcaoqlu T, EDNTNA/ERCA journal zooz, Jan-Mar; vol.28 (1):33-5.Available
from:http://www.ncbi.nlm.nih.gov/pubmed/12035900
5. Start planning next World Kidney Day now! 10 March 2011. World kidney day. Available
from URL: http://www.worldkidneyday.org/fragment-0
6. Available from URL: http://wikimapia.org/124897/NU-Hospitals-not-Bangalore-KidneyFoundation
7. Available from URL: http://www.themedguru.com/directory/Bangalore-kidney-foundationbkf-
111.html
8. Available from URL: http://www.ed4 nurses.com/Renal emergencies.
9. Available from URL: http://www.summa-ems.org/mod/resource/view.php2.id25/Adult EMS
protocols.
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10. Cotera A, Lorca.E, Saffie A, Continuous hemodialysis in the treatment of chronic renal
insufficiency in emergencies, Revista medica de chile,1992 Dec;vol.120(12);pp:138892.Available from:http://www.ncbi.nlm.nih.gov/pubmed/1343379.
11. Brusselaers.N, Monstrey.S, Colpaert.K, Decruyenaere.J, Outcome of acute kidney injury in
severe burns: a systematic review and meta- analysis, Journal of Intensive care
medicine.2010Jan; vol 36(6):915-25 Epub 2010 Mar 24
12. Danel V.C, Saviuc P.F, Garon D, Main features of Cortinarius spp. Poisoning-a literature
review, Toxicon; official journal of the international society on Toxinology, 2001 Jul; vol39 (7),
pp.1053-60.
13. Bellomo R, Boyce N; Acute continuous hemodiafiltration: a prospective study of 110
patients and a review of the literature, American journal of kidney diseases: the official journal
of the national kidney,1993 May,vol 21(5),pp.508-18,Available from URL: http: //www. nchi.
nlm. nih.gov/ pubmed/8488819
14. Devins G.M, Paul L.C, Barre P.E, Mandin H, Taub K, Convergence of health ratings across
nephrologies, nurses, and patients with renal disease, Journal of clinical epidemiology,
2003Apr;vol56(4);326-31.
15. Baldwin T, Is there a need for a nurse emergency team for continuous renal replacement
therapy; Contributions to nephrology, 2007, 156,191-6
16. Wilson B, Harwood L, Oudshoom A, Thompson B, The culture of vascular access
cannulation among nurses in a chronic hemodialysis unit; CANNT Journal=journal ACITN;
2010 Jul-Sep;vol 20(3);35-42
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17. Zobel G,Rodl.S, Urlesberger B, Kuttnig H,Ring E, Continuous renal replacement therapy in
critically ill patients;Kidney international supplement 1998 May:66,S 169-73,Available
from:http://www.nchi.nlm.nih.gov/pubmed/9573597
18. Bellomo R, Boyce N; Acute continuous hemodiafiltration:a prospective study of 110 patients
and a review of the literature,American journal of kidney diseases:the official journal of the
national kidney,1993 May, vol 21(5),pp.508-18,Available from:http://www.nchi.nlm.nih.gov/
pubmed/8488819
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9
SIGNATURE OF THE
CANDIDATE
10
REMARK OF THE GUIDE
11
NAME AND THE DESIGNATION
OF
A. GUIDE
MRS.ROOPA SARITHA REDDY
ASST. PROFESSOR,
DEPARTMENT OF MEDICAL
SURGICAL NURSING,
B.SIGNATURE
K R COLLEGE OF
NURSING,BANGALORE
C.CO- GUIDE
D. SIGNATURE
E. HEAD OF THE
DEPARTMENT
F. SIGNATURE
12.
REMARKS OF THE PRINCIPAL
MRS.ROOPA SARITHA REDDY
May be approved
SIGNATURE
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