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PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION DISSERTATION PROPOSAL “A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REAGARDING DIALYSIS THERAPY AMONG NURSES IN SELECTED HOSPITALS, BANGALORE. “ MEDICAL SURGICAL NURSING SUBMITTED BY Mr. OM PRAKASH M.Sc. NURSING, 1ST YEAR SRILAKSHMI COLLEGE OF NURSING, BANGALORE. 1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1 NAME OF THE CANDIDATE AND ADDRESS : Mr. OM PRAKASH SRILAKSHMI COLLEGE OF NURSING SUNKADAKATTE, BANGALORE 2 NAME OF THE INSTITUTION : SRILAKSHMI COLLEGE OF NURSING SUNKADAKATTE, BANGALORE JOSC 3 COURSE OF THE STUDY M.Sc. NURSING, 1ST YEAR AND SUBJECT MEDICAL SURGICAL NURSING 4 DATE OF ADMISSION 15.05.2010 5 TITLE OF THE TOPIC “A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING DIALYSIS THERAPY AMONG NURSES IN SELECTED HOSPITALS, BANGALORE.” 2 6. BRIEF RESUME OF THE INTENDED WORK INTRODUCTION The kidneys are two organs with several functions. They are seen in many types of animals, including vertebrates and some invertebrates. They are an essential part of the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid-base balance, and regulation of blood pressure. 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. The kidneys also produce hormones including calcitriol, renin, and erythropoietin.1 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.1 The kidneys have important roles in maintaining health. When healthy, the kidneys maintain the body's internal equilibrium of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate). Those acidic metabolism end products that the body cannot get rid of via respiration are also excreted through the kidneys. The kidneys also function as a part of the endocrine system producing erythropoietin and calcitriol. Erythropoietin is involved in the production of red blood cells and calcitriol plays a role in bone formation.[2] Dialysis is an imperfect treatment to replace kidney function because it does not correct the endocrine functions of the kidney. Dialysis treatments replace some of these functions through diffusion (waste removal) and ultrafiltration (fluid removal).[3]When someone's kidneys fail, he may be forced to go on dialysis. This process requires the assistance of medical personnel. To that end, dialysis nurses are critical; they specialize in working with patients suffering from kidney disease. Over the course of their shift, they hook up patients to dialysis machines and monitor their progress to make sure that there are no complications during the dialysis process. Dialysis nurses are required to receive medical training in nursing. Additional training in the specific care of kidney patients is also greatly encouraged.2 3 Dialysis is a mechanical process in which toxins are removed from the body by a machine. People may have to go on dialysis after their kidneys have failed. Dialysis treatments are generally given several times a week. The person sits in a chair while their blood is filtered and cleaned. Dialysis can be debilitating and unpleasant. Patients may suffer from after-effects such as extreme fatigue and they may be forced to adhere to a strict, specialized diet while on dialysis.3 The decision to initiate dialysis or hemofiltration in patients with renal failure depends on several factors. These can be divided into acute or chronic indications. Indications for dialysis in the patient with acute kidney injury are:[16] 1. Metabolic acidosis in situations where correction with sodium bicarbonate is impractical or may result in fluid overload. 2. Electrolyte abnormality, such as severe hyperkalemia, especially when combined with AKI. 3. Intoxication, that is, acute poisoning with a dialysable drug, such as lithium, or aspirin. 4. Fluid overload not expected to respond to treatment with diuretics. 5. Complications of uremia, such as pericarditis, encephalopathy, or gastrointestinal bleeding. Chronic indications for dialysis: 1. Symptomatic renal failure 2. Low glomerular filtration rate (GFR) (RRT often recommended to commence at a GFR of less than 10-15 mls/min/1.73m2). In diabetics dialysis is started earlier. 3. Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low. Dialysis nurses' primary responsibility is monitoring the health of patients undergoing the dialysis treatment. This means noting any changes in patient status as well as progression 4 of the disease. A dialysis nurse must understand how the dialysis machine works, to make sure that it is functioning properly. If the machine fails to work as it should, she must call the appropriate person to fix it. During each treatment session the dialysis nurse has various tasks that must be performed each time. The nurse will draw blood from patients, change catheter dressings, flush each catheter port with saline, make sure the catheter is free from kinks and that the saline and dialysis solution can flow. A dialysis nurse will also check the patency of fistulas and grafts. These are dialysis entry ports placed in the arm or the thigh. The site of the fistula must be kept clean to avoid infection. The nurse may administer additional medication, such as iron and vanomycin or Epogen, to help maintain red blood cell counts. A dialysis also must monitor patients to check for complications such as low blood pressure and cramping. Many problems can be fixed by a change in medication or positioning. Other problems may require the assistance of a doctor. The nurse should refer patients to kidney specialists if necessary.3 A dialysis nurse is a licensed practical nurse (LPN) or registered nurse (RN) who specializes in working with patients who have kidney disease or experienced kidney failure and who must undergo a treatment known as dialysis. In the overwhelming majority of cases, a dialysis nurse is an RN, not an LPN, because an RN has completed at least two years of training. He or she is certified in cardiopulmonary resuscitation (CPR) and generally is a certified nephrology nurse (CNN) or a certified dialysis nurse (CDN) as well. This type of nurse is among the health care providers who understand how a dialysis machine operates and who monitor the health of patients with kidney problems who must undergo dialysis. It usually is a dialysis nurse who draws blood from a patient, changes catheter dressings, ensures that catheters are cleaned and free of kinks and is a source of information about kidney disease for patients.4 6.1 THE NEED FOR THE STUDY The Centers for Disease Control (CDC) reports chronic renal failure has become a growing health problem in the United States. It also determines that one in six persons suffers 5 from renal problem. Compared with the 1990s, the number of people renal problems has raised by 16% due to occurrence of diabetes, hypertension, aging population, and obesity.5 Renal physiology is the study of kidney function, while nephrology is the medical specialty concerned with kidney diseases. Diseases of the kidney are diverse, but individuals with kidney disease frequently display characteristic clinical features. Common clinical conditions involving the kidney include the nephritic and nephrotic syndromes, renal cysts, acute kidney injury, chronic kidney disease, urinary tract infection, nephrolithiasis, and urinary tract obstruction.[1] Various cancers of the kidney exist; the most common adult renal cancer is renal cell carcinoma. Cancers, cysts, and some other renal conditions can be managed with removal of the kidney, or nephrectomy. When renal function, measured by glomerular filtration rate, is persistently poor, dialysis and kidney transplantation may be treatment options. Although they are not severely harmful, kidney stones can be a pain and a nuisance. The removal of kidney stones includes sound wave treatment, which breaks up the stones into smaller pieces which are then passed through the urinary tract. One common symptom of kidney stones is a sharp pain in the medial/lateral segments of the lower back.6 The success of haemodialysis depends on access to the circulation. Preservation of the access site should be a primary goal of patient care. Little research on nursing interventions related to vascular access exists. Access care varies from centre to centre and there are often no written protocols for guidance. The aim of the study was to determine the effect of integrated education on nurses' knowledge. The fundamental principles of vascular access should be used to help train future dialysis staff members in order to improve quality of care. We must continue to gain knowledge in this important area through nursing research and education. This research demonstrates that integrated education improves the knowledge of nurses working in a renal unit.7 Patients with chronic kidney disease (CKD) are faced with demanding treatments and need to have knowledge when taking care of their health and treatments. Patient education is an important component in the management of CKD (Klang, Bjorvell, Sundstedt, & Clyne, 1998). Patient education with good quality is based on patients' individual needs (Leino-Kilpi & Vuorenheimo, 1994), and therefore, it is important to explore knowledge expectations of 6 patients on dialysis treatment. This study helps to know the knowledge expectations of patients receiving dialysis treatment.8 Nephrology nurses use the nursing process to care for patients of all ages who are experiencing, or are at risk for, kidney disease. Nephrology has been recognized as a specialty for over 35 years. In 1973, treatment for end stage kidney disease (ESRD) by hemodialysis, peritoneal dialysis, or transplantation was funded by the federal government through the Social Security program making ESRD the only disease-caused disability and became more readily available. As a result, the role of the nephrology nurse grew in scope, practice boundaries broadened, and the number of nephrology nurses climbed steadily. Nephrology nursing involves both preventing disease and assessing the health needs of patients and families. Care spans the life cycle and involves patients who are experiencing the real or threatened impact of acute or chronic kidney disease; therefore nephrology nurses must be well-educated, highly skilled, and motivated. These nurses also deal with every organ system in the body, calling for a holistic approach to patient care that is both challenging and rewarding. Driven by technological and educational advances, nephrology nursing continues to be a dynamic field with a wide variety of career opportunities for nurses at all levels.9 Nephrology nurses practice in dialysis clinics, hospitals, physician practices, transplant programs, and many other inpatient and outpatient settings. They work in primary, secondary, and tertiary care facilities as well as in patients’ homes – wherever individuals experiencing or at risk for kidney disease receive health care. In inpatient settings, patients are often critically ill and care is fast-paced and challenging. In outpatient settings, the nephrology nurse is an integral member of a multidisciplinary team that cares for patients with complex needs. The nurse in this setting functions as advocate, educator, consultant, care coordinator, and direct caregiver and oversees long-term care of chronically ill patients. As such, the nephrology nurse can have a positive impact on the quality of patients’ lives. Other opportunities in nephrology nursing include education, management, research, case management, advanced practice nursing, pediatric nephrology.10 Instructions from a physician to be carried out in the treatment of his or her patient usually involve the services of a dialysis nurse. Although the duties of these health care 7 providers can vary greatly depending on their level of education and experience, almost all of them administer medications and fluid therapy or blood products according to the doctor's orders. A dialysis nurse generally develops a long-term relationship with patients as opposed to a nurse who works in the emergency room. This contact allows the dialysis nurse to be instrumental in educating patients and encouraging them to comply fully with the diet prescribed by the physician.10 6.2 REVIEW OF LITERATURE Review of literature is a key step in research process. The major goal of the review of the literature is to develop a strong knowledge base to carry out research and non research scholarly activities. “A literature review is a complication of resources that provide the ground work for future study”. The literature reviewed has been presented under the following heading: 1. Studies related to knowledge of renal problems 2. Studies related to complications of renal failure 3. Studies related to knowledge of dialysis therapy among nurses 1. Studies related to knowledge of renal problems Renal disease might get worse if the sufferer consumes fresh meat and poultry injected with additives. According to the Clinical Journal of the American Society of Nephrology, additives such as sodium, potassium salts, and dietary phosphorus can endanger those with chronic renal problems as increasing blood pressure levels and causing sudden death. With that said, for anyone who suffers from chronic renal disease, limiting additive intake is imperative for health. It is good to look at food labels before purchasing fresh meat at the supermarket.11 8 According to the Journal of the American Society of Nephrology, seniors who have chronic renal failure are associated with an increased risk for several cancers such as lung and urinary cancer. In addition, chronic renal failure research also discloses that older men having transplantation and those with renal disease might develop certain malignant cancers. Men with renal disease face a three-fold higher risk for developing cancer compared with those who have renal function normally. It is highly recommended undergoing cancer screening for people with renal disease.12 A new study published in the journal Human Genetics discloses that African Americans deal with a four-fold increased risk and Hispanic Americans face a two-fold increased risk of having chronic renal failure compared with the entire population. Researchers confirm that the APOL1 gene is associated with the higher risk of renal disease. The gene that enables someone to have renal failure must be identified to determine ways to decelerate renal disease.13 Babies born weighing less than 5.5 pounds have an increased risk of renal failure of up to 70% later in life compared with babies of normal weight. The American Journal of Kidney Diseases explains that normal kidney development might be affected by the confined growth of a fetus, which leads to form smaller kidney at birth. They become vulnerable to renal function loss due to infections or diseases like diabetes. Researchers have found a correlation between low birth weight in babies and renal failure later in life. In addition, researchers further suggest that anyone who is genetically small be aware of preventing obesity, avoiding medicine overdose, and exercising to stay healthy.14 2. Studies related to complications of renal failure According to the British Heart Foundation, four million people in Britain take the drugs. Some side-effects from the drugs are already known but new UK data has highlighted a range of other possible problems. The study found that some statins can lead to an increased risk of liver dysfunction, acute kidney failure, muscle damage known as myopathy and cataracts. Sideeffects that are already known include insomnia, constipation or diarrhoea, headaches, loss of appetite and loss of sensation or pain in the nerve endings of the hands and feet. The study 9 involved more than two million patients in England and Wales aged 30 to 84, of whom 225,922 (10.7%) were new users of statins, 159,790 (70.7%) were prescribed simvastatin, 50,328 (22.3%) atorvastatin, 8,103 (3.6%) pravastatin, 4,497 (1.9%) rosuvastatin and 3,204 (1.4%) fluvastatin.The results showed that statins were linked to a decreased risk of oesophageal cancer but increased risk of moderate or serious liver dysfunction, acute renal failure, moderate or serious myopathy and cataracts.There was no evidence of statins being linked to a range of other cancers or Parkinson's disease.The authors wrote: "Adverse effects were similar across statin types for each outcome except liver dysfunction where risks were highest for fluvastatin."The authors said the higher the dose of a statin, the more at risk a patient was from acute renal failure and liver dysfunction.15 A team of researchers from the John Hopkins University, through their study suggest that dialy supplementation of potassium citrate may prevent the incidence of painful kidney stones, a common side-effect that affect epileptics due to their strict compliance to high-fat ketogenic diet. Kidney stones is an adverse event associated with ketogenic diet that affects approximately 6 percent of children. The objective of the study is to assess if daily supplementation of potassium citrate would help reduce the risk of kidney stones. For this study, the researchers recruited a total 313 children who are on ketogenic diet from 2000 to 2008 at the John Hopkins Hospital with month of follow-up. From the 2000 to 2005, the children with identified hypercalciuria were treated with Polycitra K at 2mEq/kg per. Whereas since 2006, all children who were started on ketogenic diet were empirically started on Polycitra K supplementation.The results of the study show that of the 198 children who received Polycitra K only 2 percent of children developed kidney stones when compared to the 10.5% children who did not receive the supplements. According to the researchers, empiric administration of Polycitra K to children immediately at their commencement of ketogenic diet in the year 2006 were seven times less likely to develop kidney stones when compared to to those who were given supplements only after the detection of hypercalciuria.16 10 3. Studies related to knowledge of dialysis therapy among nurses According to Niedzwiecka A, Nowicki M, Tkaczyk M conducted the study on healthcare institutions--including dialysis units--are expected to provide their patients with broad-spectrum and high-quality services. Nurses are the members of the therapeutic team who spend most time with the patient undergoing renal replacement therapy, and thus the image of the whole dialysis unit depends on their work. The aim of the study was to assess the dialysis patients' expectations towards their nurses. The study group consisted of 150 adult dialysis patients treated with hemodialysis in dialysis units in Lodz region. The participants were asked to fill out an anonymous questionnaire specially tailored for the study. They showed that dialysis patients were generally satisfied with the level of care provided by nurses and described them as reliable, professional and well-qualified. Patients especially valued kind attitude, smile and friendliness of the nurses. Fully professional care was noticed by 25.7% of patients. Patients dialyzed for a longer period of time (over 10 years) described nurses' knowledge, practical skills and independence with more criticism. A quarter of them stated that nurses always relied on the doctor's decision. The study revealed that dialysis nurses' work, practical skills and attitude were assessed very well by patients. Their level of satisfaction would be higher if nurses spent more time and initiated more discussion with the patients. The high merit that nurses received should be considered as a stimulus that ought to increase the professional independence and quality of dialysis nurses performance.17 A descriptive study of the cultural competence of hemodialysis nurses. McMaster University School of Nursing, Faculty of Health Sciences, 1200 Main Street West, Hamilton, They conducted study Within a society that is becoming increasingly multicultural, it is vital for nurses to become culturally competent in order to meet the needs of a culturally diverse population. Cultural knowledge plays a primary role in influencing the quality of care that nurses provide on a daily basis. The purpose of this descriptive study was to assess the cultural competence level of hemodialysis nurses. The study was conducted in an outpatient setting at a large teaching hospital in Canada. The Inventory for Assessing the Process of Cultural Competence-Revised (IAPCC-R) was used as the questionnaire for this study. A convenience sample of 58 hemodialysis nurses completed the IAPCC-R tool. Data were analyzed using 11 descriptive statistics. The nurses had a mean score of 65.58% on the IAPCC-R tool, indicating that they were culturally aware, but not culturally proficient. Further analysis of the IAPCC-R results showed that the nurses were lacking information in the area of cultural knowledge, but that they were motivated to become culturally competent. The findings from this study indicated that, in a society that is becoming increasingly multicultural, hemodialysis nurses were motivated to become culturally competent. There is a need for nurse educators to support nurses to reach this goal.18 This article describes the particular challenges encountered at a chronic kidney disease teaching event for nurses, including the problems of coaching learners with varied experience and using appropriate teaching methods to ensure learners remain focused. The importances of different learning styles are also discussed in reference to the relevant research. The pros and cons of a lecture-type presentation are explored and an example of a more varied lecture-style is provided. The case is also made for a facilitative approach to teaching that encourages deeplevel learning. It is suggested that using vivid examples, such as case studies, can facilitate engagement with the presented material, encouraging learners to ask 'what-if' questions that are designed to develop critical thinking. This approach assists learners to build their knowledgebase on both academic and real-life experience.19 According to Badzek LA, Cline HS, Moss AH, The study was to determine what percentage of elderly patients (age 65 years and older) nephrology nurses (NN) believe should not be dialyzed and to identify NN perceptions and concerns about the inappropriate use of dialysis for these patients. The design was descriptive using a cross-sectional survey instrument. Data was collected in 1996 from 393 NN (44% response rate), with a mean age of 41 years and 9 years of dialysis experience. The sample was 1,000 NN randomly selected from 7,000 members of the American Nephrology Nurses'Association (ANNA) who selected hemodialysis as a special area of interest. Quantitative analysis of respondents revealed that NN felt that 15% of elderly dialysis patients (EDP) should not be dialyzed, and 80% were troubled by decisions to start dialysis for some elderly patients. Content analysis of qualitative responses supported the NN concerns revealed in the quantitative analysis. Five themes with interrater reliability of > 98% were identified: quality of life (QoL), patient/family inadequate knowledge, patient 12 influences on decision making age, and other (cost/legal reasons). QoL issues accounted for 75% of NN responses. Statistical analyses including an ANOVA, t-tests, and chi square failed to identify relationships between themes and demographic factors, such as age, gender, years of experience, education level, unit profit status, and type of staff position. The researchers conclude that NN believe dialysis is inappropriate for a significant percentage of EDP, these perceptions and concerns are widespread, and QoL issues are key factors in decisions to withhold or withdraw dialysis. NN may decrease the inappropriate use of dialysis by identifying QoL factors for EDP, facilitating discussions with family members and nephrologists, and continuing to advocate for the rights of EDP with poor QoL.20 According to Gelmez M, Akcacoglu T, they conducted the study on the success of haemodialysis depends on access to the circulation. Preservation of the access site should be a primary goal of patient care. Little research on nursing interventions related to vascular access exists. Access care varies from centre to centre and there are often no written protocols for guidance. The aim of the study was to determine the effect of integrated education on nurses' knowledge. The fundamental principles of vascular access should be used to help train future dialysis staff members in order to improve quality of care. We must continue to gain knowledge in this important area through nursing research and education. This research demonstrates that integrated education improves the knowledge of nurses working in a renal unit.21 Statement of the problem: ‘‘A study to assess the effectiveness of structured teaching programme on dialysis therapy among nurses in selected hospitals, Bangalore.” 6.3 Objectives of the study 1. To assess the pre test knowledge of staff nurses regarding dialysis therapy. 2. To determine the effectiveness of structured teaching programme by comparing pre test and post test knowledge scores among nurses in dialysis unit. 3. Find the association between knowledge scores and selected demographic variables. 13 4. To develop an information booklet on dialysis treatment in unit. 6.4 Operational definitions 1. Assess: In this study it refers to the organized systematic continuous process of collecting data among staff nurses regarding dialysis therapy. 2. Effectiveness: Refers to the differences obtained in post test knowledge scores with that of pretest knowledge scores on dialysis therapy among nurses working in dialysis unit. 3. Knowledge: In this study it refers to the correct response of staff nurses to the structured questionnaire on dialysis therapy. 4. Structured teaching programme (STP): Refers to the systematically structured teaching activities designed to provide information on dialysis therapy-its descriptions and Interventions; using lecture method assisted with variety of AV aids for duration of one hour. 5. Dialysis: Dialysis is a mechanical process in which toxins are removed from the body by a machine. People may have to go on dialysis after their kidneys have failed. 6. Staff Nurses: In this study it refers to a person educated and trained to work in hospital which includes GNM staff, graduate and post graduate nursing staff. 7. Hospital: It is a selected institution in Bangalore which is providing complete health care, both curative and preventive. 6.5 Hypothesis H1: There will be significant difference in the post test of knowledge scores than the pretest knowledge scores on dialysis among nurses H2: There will be significant association with the knowledge scores and their selected demographic variables. 6.6 Delimitations 1. The study is limited to nurses working in renal unit. 14 2. The study has evaluation of knowledge on only one observation. 3. The study assesses only knowledge scores. 6.7 Variables Dependent variable: Knowledge of nurses on dialysis therapy Independent variable: Structured teaching programme 7 MATERIAL AND METHODS 7.1 Sources of data The data will be collected from the staff nurses those are working in dialysis unit in selected hospital Bangalore. 7.1.1 Research design The research design adopted for present study is descriptive design. 7.1.2 7.1.3 7.1.4 Research The research approach adopted for the present study approach is an evaluative research approach. Setting of the The study will be conducted in dialysis unit in study selected hospitals at Bangalore. Population The population for the present study comprises of staff nurses who are working in renal unit. 7.1.5 Sampling The proposed sampling technique adopted for the technique present study is simple random technique. 15 7.1.6 Sample size The proposed sample size of this study consists of 60 staff nurses. SAMPLING CRITERIA 7.1.7 Inclusion criteria 1. Staff nurses who are working renal unit. 2. Nurses who are willing to participate. 3. Both female and male nurses can participate 4. Nurses who are available during data collection. 7.1.8 Exclusion 1. Staff nurses who not willing for the study. criteria 2. Staff nurses who are not working in the renal unit. 7.2 DATA COLLECTION METHOD 7.2.1 Tool for data The tool for the proposed study is self collection administered structured knowledge questionnaire which would be developed by investigator with the help of extensive literature and experts opinion. 7.2.2 Procedure of The plan of data collection for the proposed data collection study is as follows: *. Permission will be obtained from the hospital authorities and respondents. *. Pre test will be conducted using structured knowledge questionnaire subsequently, structured teaching programme will be given on same day. 16 *. On the seventh day, post test will be conducted using same structured knowledge questionnaire. *. Proposed data collection period will be 30 days. 7.2.3. Data analysis Data analysis through method inferential statistics. descriptive and 1. Descriptive statistics: Frequency, means, mean percentage and standard deviation of describe their demographic variable. 2. Inferential statistics: Paired ‘t’ test to compare pre and post test knowledge scores. Chi-square test will be used to find out the association between selected demographic variable and knowledge scores. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION TO BE CONDUCTED ON THE PATIENTS, OR OTHER HUMANS OR ANIMALS? Yes 7.4 ETHICAL CLEARANCE The main study will be conducted after the approval of research committee. Permission will be obtained from the concerned head of the institution. The purpose and details of the study will be explained to the study subjects and an informed consent will be obtained from them. Assurance will be given to the study subject on the confidentiality of the data collected from them. 17 8. LIST OF REFERENCES: 1. [ cited 2010 Oct 5]; Available from: URL:http://www.wikipedia.org 2. [ cited 2010 Oct 5]; Available from: URL: http://www.bbraun.com 3. [ cited 2010 Oct 5]; Available from: URL: http://www.kidneyatlas.org 4. Berns JS, O’Neill (2008) “Performance of procedures by nephrologists and nephrology fellows at U.S nephrology training program” Clin.J. Am Soc. Nepral 3 (4): 941-7 5. [ cited 2010 Oct 5]; Available from: URL: http://www.annanurse.org 6. Tzur S et al. Missense Mutations in the APOL1 Gene are Highly Associated with End Stage Kidney Disease Risk Previously Attributed to the MYH9 Gene. Human Genetics, 2010. 7. [ cited 2010 Oct 5]; Available from: URL: http://www. med.epe.edu.tr 8. Wong, Germaine et al. Association of CKD and Cancer Risk in Older People. Journal of the American Society of Nephrology, 2009. 9. Richard Sherman, MD, and Ojas Mehta, D.O. Phosphorus and Potassium Content of Enhanced Meat and Poultry Products: Implications for Patients Receiving Dialysis. Clinical Journal of the American Society Nephrology, 2009. 10. Nephrology Nursing Journal, May-June, 2008 by Mirkka Rantanen, Tapio Kallio, Kirsi Johansson, Sanna Salantera, Heli Virtanen, Helena Leino-Kilpi 18 11. White, Sarah et al. Is Low Birth Weight an Antecedent of CKD in Later Life? A Systematic Review of Observational Studies, American Journal of Kidney Diseases, 2009. 12. Pendse S, Singh A, Zawada E. Initiation of Dialysis. In: Handbook of Dialysis. 4th ed. New York, NY; 2008:14-21 13. Brundage D. Renal Disorders. St. Louis, MO: Mosby; 1992 http://www.kidneyatlas.org/book5/adk5-01.ccc.QXD.pdf Atlas of Diseases of the Kidney, Volume 5, Principles of Dialysis: Diffusion, Convection, and Dialysis Machines 14. [ cited 2010 Oct 5]; Available from: URL: http://www.homedialysis.org/learn/types/ 15. Eric Kossoff, Assistant Professor; Division School of Medicine, Department SOM Neuro Pediatric Neurology, Harriett Lane 2158, The Johns Hopkins University, Baltimore, Maryland. Phone: 410-955-4259. E-mail: [email protected]. 16. Niedźwiecka A, Nowicki M, Tkaczyk M.Polish Mother's Memorial Hospital Research Institute, Lódź, Department of Nephrology and Dialysis. [email protected] 17. Mahabeer SA. McMaster University School of Nursing, Faculty of Health Sciences, 1200 Main Street West, Hamilton, ON L8N 3Z5. [email protected] 18. Noble H. City University, School of Community and Health Sciences, London. 2009 Mar 26-Apr 8;18(6):374-7. 19. Thompson KF, Bhargava J, Bachelder R, Bova-Collis R, Moss AH. Heartland Kidney Network, Kansas City, MO, USA. Nephrol Nurs J. 2008 SepOct;35(5):461-6, 502; quiz 467-8. 20. Badzek LA, Cline HS, Moss AH, Hines SC. School of Nursing, West Virginia University, Morgantown, WV, USA. Nephrol Nurs J. 2000 Oct;27(5):462-70; discussion 471-2. 19 21. Gelmez M, Akçaoglu T. Haemodialysis Unit, Eagen University Hospial, Dialysis Center, Izmir, Turkey. [email protected] EDTNA ERCA J. 2002 Jan-Mar;28(1):33-5. 20 9 Signature of candidate 10 Remarks of the guide Satisfactory Mrs. LAVANYA 11 Name and designation of (in block letters ASST.PROFESSOR MEDICAL SURGICAL NURSING. 11.1 Guide 11.2 Signature 12 12.1 Head of the Department Mrs. LAVANYA ASST. PROFESSOR MEDICAL SURGICAL NURSING, SRI LSKSHMI COLLEGE OF NURSING, BANGALORE. 12.2 Signature 13.1 Remarks of the Principal 13 13.2 Signature 21