Adequate self-care of dialysed patients: a review of the literature

Promoting Self-Regulatory Management of Chronic Pain Through Dohsa-hou: Single-Case Series of Low-Functioning Hemodialysis Patients

Hemodialysis patients suffer from long-term pain that drains their energy and contributes to behavioral interference and other negative effects on their daily lives that result in or exacerbate functional limitations. In addition, they deal with dietary restrictions, symptoms such as itching, lack of energy, and psychological stressors like the loss of self-concept and self-esteem. Self-regulation involves the capacity to notice, inform, and modulate responses and behavior, and research indicates that it promotes rehabilitation in chronic pain patients. Research on the aspects of self-regulation afforded by the Japanese psychotherapy Dohsa-hou correspond to psychological processes tied to the sense of self-control that clients realize over their body movements. This study pilot tested a hospital-integrated implementation of Dohsa-hou relaxation tasks as a chronic pain management behavioral intervention for five female hemodialysis patients between the ages of 59–62 years. We conducted an ABABABA single-case design to compare baseline A-phases (treatment-as-usual: TAU) taken at recurring 1 week intervals (three sessions per week for a total of 4 weeks, 12 total recordings) with an intervention of Dohsa-hou B-phases every 4 weeks (three sessions per week for 12 weeks, 36 total recordings) over the span of 4 months to compare effectiveness. Visual Analogue Scale (VAS) pain scores between phases were taken and self-regulatory progress was tracked and summarized from a series of semi-structured interviews. Visual analysis of scores for each participant as single cases indicated decreases for the Dohsa-hou phase compared to baseline treatment-as-usual. As a result, participants reported using Dohsa-hou to reduce pain and experienced improvements in quality of life associated with greater self-regulatory capacity to attend to personal care and domestic activities. These preliminary findings suggest that Dohsa-hou body movement relaxation tasks were feasible as a coping skill in a hospital-integrated setting and at home and show promise for promoting quality of life vis-a-vis the management of severe and chronic bodily pain associated with end-stage renal disease and its treatment, particularly by improving aspects of pain-mediated self-regulatory fatigue.

The Needs of Older Patients for Peritoneal Dialysis: Training and Support at Home

Chronic kidney disease (CKD) in all its stages has become an important problem for older patients, stage 3 - 5 is expected to happen in 25 to 30% of the population, and a higher prevalence can be found in residential care and nursing homes, affecting the demand for patient education. Although older patients are able and keen to learn, there are specific needs that must be addressed. The focus of this paper is to review the demands to train and maintain older patients on peritoneal dialysis (PD) at home.

Patients' adherence to aspects of haemodialysis regimens in tropical north Queensland, Australia

BACKGROUND

Patients with end-stage kidney disease often have difficulty in adhering to aspects of their haemodialysis regimens.

OBJECTIVES

This study aimed to quantify the number of patients who attended 100% of their scheduled haemodialysis sessions, and the number of patients who gained no more than one kilogram per day between dialysis sessions, over a three-month period.

DESIGN

Retrospective chart audit

PARTICIPANTS

Patients undergoing haemodialysis at an in-hospital centre in tropical Australia.

METHODS

A renal nurse audited the 72 charts pertaining to a 12-week period in 2013.

RESULTS

Patients attended 90.1% of all scheduled dialysis sessions. Forty-one patients attended all sessions, with the remaining 31 missing at least one scheduled session. One patient missed 16 scheduled sessions. The following were statistically less likely to attend all their scheduled sessions: Aboriginal and Torres Strait Islander patients; patients on a three times per week dialysis schedule; patients who had relocated from rural or regional towns and younger patients. The average daily weight gain ranged from 0.414 kg to 1.017 kg (mean = 0.885 kg). Younger patients were statistically less likely to adhere to fluid restrictions; patients without diabetes were more likely to adhere to the fluid allowances.

CONCLUSIONS AND APPLICATIONS TO PRACTICE

Renal services need to assist patients to adhere to their regimens. Initially, this service will examine strategies to maximise the likelihood of patients attending all of their dialysis sessions. Such an outcome will help to delay deterioration in the patients' health status, while minimising additional strain on the health service.

Non-adherence in patients on peritoneal dialysis: a systematic review

BACKGROUND

It has been increasingly recognized that non-adherence is an important factor that determines the outcome of peritoneal dialysis (PD) therapy. There is therefore a need to establish the levels of non-adherence to different aspects of the PD regimen (dialysis procedures, medications, and dietary/fluid restrictions).

METHODS

A systematic review of peer-reviewed literature was performed in PubMed, PsycINFO and CINAHL databases using PRISMA guidelines in May 2013. Publications on non-adherence in PD were selected by two reviewers independently according to predefined inclusion and exclusion criteria. Relevant data on patient characteristics, measures, rates and factors associated with non-adherence were extracted. The quality of studies was also evaluated independently by two reviewers according to a revised version of the Effective Public Health Practice Project assessment tool.

RESULTS

The search retrieved 204 studies, of which a total of 25 studies met inclusion criteria. Reported rates of non-adherence varied across studies: 2.6-53% for dialysis exchanges, 3.9-85% for medication, and 14.4-67% for diet/fluid restrictions. Methodological differences in measurement and definition of non-adherence underlie the observed variation. Factors associated with non-adherence that showed a degree of consistency were mostly socio-demographical, such as age, employment status, ethnicity, sex, and time period on PD treatment.

CONCLUSION

Non-adherence to different dimensions of the dialysis regimen appears to be prevalent in PD patients. There is a need for further, high-quality research to explore these factors in more detail, with the aim of informing intervention designs to facilitate adherence in this patient population.

Determination of the relationship between adequacy of dialysis and quality of life and self-care agency

AIM AND OBJECTIVES

To investigate the relationship between the dialysis adequacy and the quality of life and self-care agency.

BACKGROUND

Haemodialysis (HD), which is the leading treatment option for chronic renal failure (CRF), leads to significant changes in the life of the patient. These changes affecting almost all the dimensions of life also negatively affect the quality of life and self-care agency.

DESIGN

Descriptive study.

METHODS

The research was conducted with a total of 112 patients who had been admitted to two private dialysis centres between May 2009 and September 2010, who met the research criteria. The Data Collection Form for the Socio-demographic and Medical Characteristics, the Biochemical and Medical Parameters Form to determine the adequacy of dialysis, the SF-36 Quality of Life Scale and the Self-Care Agency Scale were used in the research.

RESULTS

A significant relationship was found between Kt/V, one of the parameters used for the assessment of dialysis adequacy, and the emotional role scores of the SF-36 Quality of Life Scale and between the URR level and physical functioning (r = +0.192, p = 0.045) and emotional role scores (r = +0.284, p = 0.003). No significant relationship could be found between the self-care agency and the evaluated parameters.

CONCLUSIONS

Kt/V and URR, which have an effect on dialysis adequacy, may affect the quality of life. Our results are similar to those of previous studies, which showed that Kt/V and URR affect the quality of life.

RELEVANCE TO CLINICAL PRACTICE

It was recommended to regularly control the parameters used for the assessment of dialysis adequacy and to evaluate their effects on the quality of life, to determine the most affected quality of life subparameters and to address these problems and solve them.

Effects of a self-care education program on quality of life after surgery in patients with esophageal cancer

In recent years, the number of quality-of-life (QOL) studies on patients with esophageal cancer has increased; however, the number of studies related to the effects of self-care education programs on QOL of these patients is scarce. This article reports on the effects of a self-care education program on QOL for patients with esophageal cancer in Babol, Iran. The quasi-experimental study had a convenience sample of 105 patients with esophageal cancer referred to oncology centers in Babol City. A quasi-random allocation technique was used to divide the sample into experimental (n = 55) and control (n = 50) groups. Appropriate instruments were used to measure QOL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-30 and Quality of Life Questionnaire-Oesophageal 18). Questionnaires were completed by the respondents before and 3 months after implementing the educational program that consisted of group discussion, lectures, and pamphlets. There was no significant difference between QOL mean score of both groups before the intervention; however, after implementing the educational program, the QOL significantly improved in the experimental group (p = .001), whereas QOL decreased in the controls. We conclude that self-care education programs have positive effects on the QOL of patients with esophageal cancer. Planning and implementing such self-care education programs, when patients are under treatment, can help them improve their QOL.

Influence of family carers on haemodialyzed patients' adherence to dietary and fluid restrictions: an observational study

AIM

  To determine the influence of a family carer on haemodialyzed patients''adherence'.

BACKGROUND

  There is extensive evidence showing that successful treatment of patients with end-stage renal disease is directly related to patients''adherence'. The parameters indicative of a good adherence are potassium and phosphate serum levels and the interdialytic weight gain. Haemodialyzed patients may have scarce adherence to food and fluid intake restrictions, and medications schedule.

DESIGN

  Case-control study carried out in a haemodialysis centre in Italy.

DATA SOURCES

  The data were collected during 2010.

METHODS

  A total of 72 subjects with end-stage renal disease participated in the study. The subjects assisted by a family carer were identified as cases (n = 36), whereas those who did not have a family carer, as controls (n = 36). All subjects were followed up (4 months) and checked up regarding interdialytic weight gain, and serum levels of potassium and phosphate. Important differences in potassium and phosphate serum level and interdialytic weight gain between the two groups were evaluated separately using a repeated measures anova test.

RESULTS

  Participants in the case group showed significantly lower phosphate and potassium serum levels and a lower interdialytic weight gain during follow-up when compared to controls.

CONCLUSIONS

  The presence of a family carer improves patients' adherence, particularly as far as phosphate levels are concerned, since phosphate intake plays a fundamental role in avoiding long-term complications in end-stage renal disease patients.

Hemodialysis arteriovenous fistula self-cannulation: moving theory to practice in developing patient-teaching resources

PURPOSE/OBJECTIVES

This article discusses how Orem's theory was applied to the revision of supporting documents in the patient-teaching process and subsequently the nurse's role in the patient's learning experience.

BACKGROUND/RATIONALE

Teaching based on didactic, provider-focused objectives is ineffective in meeting patient's learning needs. There is a lack of conclusive research on the development of appropriate patient-teaching endeavors for the acquisition of knowledge and skills related to the performance of hemodialysis arteriovenous fistula self-cannulation.

DESCRIPTION OF THE PROJECT/INNOVATION

To prepare patients for home hemodialysis, Orem's self-care-deficit nursing theory was used to guide the revisions of a patient assessment and learning documentation template, the development of a self-cannulation teaching resource and to foster a renewed sense of the nurse's role in the teaching process.

INTERPRETATION/CONCLUSION

The application of self-care-deficit nursing theory to the update and development of patient-teaching documentation and resources for self-cannulation provides the nurse with a theoretical approach to assess, plan, evaluate, and document teaching from a patient-focused perspective. Theory in practice provides a means to support and highlight the role of nurses in the patient-learning process. The utilization of practical activities to introduce theory into teaching provides a means to structure care processes and to enhance nurse's adoption of theory in practice.

IMPLICATIONS

Orem's theory provides a relevant, useful framework to guide nurses in teaching patients self-care. Research on the exploration of nurse's attitudes related to the benefit of adopting theory when teaching patients to perform hemodialysis self-care is needed.

Dietary and fluid compliance: an educational intervention for patients having haemodialysis

AIM

This paper is a report of a study conducted to determine the effect of an educational intervention on dietary and fluid compliance in patients having haemodialysis.

BACKGROUND

Many of the clinical problems experienced by patients having haemodialysis are related to their failure to eat appropriate foods and restrict their fluid intake. Educational intervention in patients having haemodialysis to improve their compliance with dietary and fluid restrictions appears to be effective.

METHODS

Sixty-three patients having haemodialysis in three general hospitals in Tehran, Iran, were allocated into two groups at random for oral and/or video education. They were asked to give demographic and medical data. Bimonthly average values of serum potassium, sodium, calcium, phosphate, albumin, creatinine, uric acid, and blood urea nitrogen and interdialytic weight gain were measured before and after the teaching programmes. The data were collected in 2007.

FINDINGS

Compliance in terms of biochemical parameters and interdialytic weight gain was observed in 63.5% and 76.2% of patients in the oral and video teaching groups respectively. Statistically significant correlations were observed between demographic variables (age, educational level and occupation) and dietary and fluid compliances (P < 0.001). There was no difference between the effectiveness of two educational interventions.

CONCLUSION

Nurses should emphasize sodium compliance in patients having haemodialysis and explain its adverse effects, such as excessive weight gain, hypertension, and peripheral oedema.

The UK Expert Patients Program: lessons learned and implications for cancer survivors' self-care support programs

Globally, the enablement of self-care is increasingly being recognised as an essential component of chronic disease management. Within the UK a key self-care policy initiative is the Expert Patients Program. Developed from the Chronic Disease Self-Management Program, this is a 6 week self-management education program for people with different chronic diseases, facilitated by lay volunteers. As an example of a major public health initiative designed to enhance self-management in long-term conditions, this paper draws on evaluations of the EPP and CDSMP and analyzes the implications for the development of similar programs for cancer survivors. There are a number of evaluations of the CDSMP which suggest significant improvement in participants' chronic disease management self-efficacy and some evidence of healthcare utilization reduction. However, whilst the national evaluation of the EPP demonstrated similar improvements in self-efficacy and health status, there was no significant effect on healthcare utilization. Trials of such programs need to be treated with some caution as participants are often not typical of the general population, and as a complex intervention effectiveness is inherently difficult to assess. Qualitative evaluations revealed that the EPP's strength was derived mainly through peer support and learning. Nevertheless, a number of contextual problems were identified including recruitment, clinicians' lack of engagement with the program and inflexible course materials. Lay-led self-care support programs such as the EPP have a significantly positive effect on self-efficacy which could be of benefit to cancer survivors. However, a number of lessons should be learned from the EPP when developing similar initiatives for cancer survivors.

Patients' views regarding choice of dialysis modality

BACKGROUND

Increasing patient numbers have resulted in pressure on dialysis centres and a need to reorganize dialysis treatment. This study explored patients' experiences with different dialysis modalities and investigated issues related to the patient's choice of modality, especially 'out-of-centre' dialysis (i.e. modalities other than CHD).

METHODS

Six focus group interviews were conducted with 24 dialysis patients, 3 pre-dialysis patients and 18 relatives. Each focus group comprised patients on one type of dialysis, i.e. CHD, self-care CHD, HHD, CAPD/APD, aAPD or pre-dialysis patients. Based on a semi-structured interview guide, the group discussions centred on advantages and disadvantages of dialysis modalities, problems experienced and their (possible) solutions and patient involvement in choice of modality.

RESULTS

The focus groups participants considered that each dialysis modality has its advantages and disadvantages. Flexibility, independence and feelings of security were key factors in determining choice of modality, with maintenance of a normal life being a major goal. Patients and their relatives want to participate in choice of modality, but a genuine offer of out-of-centre dialysis including professional support and appropriate and timely education is needed to encourage a greater use of modalities other than CHD.

CONCLUSIONS

No single dialysis modality emerged as offering the best solution for patients with end-stage renal disease. In the absence of absolute clinical contraindications, the treatment of choice should be the modality that best accommodates the patients' preferences for their daily activities and lifestyle. A move towards more patients on out-of-centre dialysis requires a greater focus on pre-dialysis patients and closer consideration of patients' preferences and current lifestyle.

A systematic review of the prevalence and determinants of nonadherence to phosphate binding medication in patients with end-stage renal disease

Background

Cardiovascular events are the leading cause of death in end stage renal disease (ESRD). Adherence to phosphate binding medication plays a vital role in reducing serum phosphorus and associated cardiovascular risk. This poses a challenge for patients as the regimen is often complex and there may be no noticeable impact of adherence on symptoms. There is a need to establish the level of nonadherence to phosphate binding medication in renal dialysis patients and identify the factors associated with it.

Methods

The online databases PsycINFO, Medline, Embase and CINAHL were searched for quantitative studies exploring predictors of nonadherence to phosphate binding medication in ESRD. Rates and predictors of nonadherence were extracted from the papers.

Results

Thirty four studies met the inclusion criteria. There was wide variation in reported rates of non-adherence (22–74% patients nonadherent, mean 51%). This can be partially attributed to differences in the way adherence has been defined and measured. Demographic and clinical predictors of nonadherence were most frequently assessed but only younger age was consistently associated with nonadherence. In contrast psychosocial variables (e.g. patients' beliefs about medication, social support, personality characteristics) were less frequently assessed but were more likely to be associated with nonadherence.

Conclusion

Nonadherence to phosphate binding medication appears to be prevalent in ESRD. Several potentially modifiable psychosocial factors were identified as predictors of nonadherence. There is a need for further, high-quality research to explore these factors in more detail, with the aim of informing the design of an intervention to facilitate adherence.

Nurses’ responses to expert patients: The rhetoric and reality of self-management in long-term conditions: A grounded theory study

BACKGROUND

Against the backdrop in the western world of increasing prevalence of chronic disease, active and informed patients and a policy emphasis on self-management, this English study explored health professionals' responses to expert patients.

OBJECTIVES

To:

DESIGN

A grounded theory approach was utilised with two concurrent data strands.

SETTING

A relatively affluent English county including community, primary and secondary care settings.

PARTICIPANTS

Via purposeful and theoretical sampling 100 health professionals (nurses, doctors, physiotherapists) and 100 adults affected by chronic disease participated.

METHODS

Focus groups, interviews and observation.

RESULTS

Nurses were found to be most anxious about expert patients when compared to other professionals, which appeared to be linked with a lack of professional confidence and unfounded fears regarding litigation. However, nurse specialists often provided a negative case for this. As a whole, nurses were most able to meet the emotional needs of patients, but apart from nurse specialists did not articulate this as a skill.

CONCLUSION

Apart from nurse specialists the majority of nurses appeared limited in appropriately facilitating self-management. It is suggested that this is linked to an ongoing nursing culture of patient as passive, an over-emphasis on empirical knowledge and a feeling of vulnerability on the nurses' part towards expert patients. The findings also indicate a rhetoric rather than reality of autonomous nursing roles within the chronic disease management agenda.

Self-Care and Well-Being Model for Elderly Women: A Comparison of Rural and Urban Areas

The purposes of this study were to examine the relationships among age, social class, perceived health, self-care, and well-being in urban and rural elderly women and to validate and compare two models using these two groups. A causal model of self-care and well-being was proposed for this study based on Orem's self-care model and empirical data. Data were collected using a survey-interview method. Of the 351 elderly women recruited, 159 were in the urban group and 192 in the rural group. Two models of self-care and well-being were tested using path analysis with the LISREL 8 program. The resultant models yielded a Chi-squared of 1.98 with two degrees of freedom (p = 0.37) in the urban group and a Chi-squared of 4.20 with three degrees of freedom (p = 0.24) in the rural group, indicating good fit between the data and the two models. These two models provide guidelines for community nurses to design appropriate self-care programs for elderly women.