Running head: OUTCOMES ARE IMPROVED FOR DIALYSIS

Outcomes are Improved for Dialysis Patients when Perspective is Included in the Plan of Care Patricia Adams Ferris State University

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS Table of Contents

Abstract3 Introduction..4 Treatment Options for Kidney Failure.4 Nephrology Nurse Role....4-5 Impact of Hemodialysis on Lifestyle...5 Physical Symptoms..5-7 Psychosocial Needs..7 Educational Needs...7-8 Health Promotion.8 Conclusion...8-9 Recommendation.9 Appendix A Peer Review...10 Appendix B Glossary.11 References....12-13

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS

Abstract End Stage Renal Disease (ESRD) is on the rise with an estimated 365,000 people who require hemodialysis as a life sustaining treatment in the United States. The Quality of Life (QOL) for this population can be improved with the help of nephrology staff by including patient perception into the plan of care. Lifestyle changes, physical manifestations, psychosocial and educational needs are key components to include when engaging the patient in health promoting decisions and activities. Active patient and family involvement leads to improved patient efficacy, resulting in better outcomes. Hemodialysis patients with improved outcomes live longer with less complications. The key to achieving optimal patient outcome is by actively including patient perception and needs into the overall care of the patient. Keywords: hemodialysis, adherence, outcomes, nephrology

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS

Outcomes are Improved for Dialysis Patients when Perspective is Included in the Plan of Care Outcomes are improved for hemodialysis patients when their perception of the disease and its impact are in included in care planning. Kidney failure results in waste accumulation in the blood, fluid retention and electrolyte imbalance. Eventually, it can contribute to anemia, bone disease and cardiovascular complications. When the kidneys are working properly, one does not think much about what they do, but when they fail, patients must face this health problem on a daily basis. The impact of this disease leads to significant lifestyle changes both physically and emotionally. People who suffer from end stage renal disease (ESRD) must have some form of renal replacement therapy for survival. Healthcare professionals are the link to optimal health. The physical needs and the patients perception what he or she needs must be incorporated into the care plan. Addressing psychosocial and educational needs lead to improved overall health and quality of life (QOL). Treatment Options for Kidney Failure There are several treatment options for kidney failure: hemodialysis, home hemodialysis, peritoneal dialysis and transplant. Home renal replacement therapies are on the rise; according to the National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) there are an estimated 365,000 people on hemodialysis in the United States. In addition to the hemodialysis treatment, patients also need to follow a renal diet and restrict fluids (n.d.). Lifestyle modification is of ultimate importance to maintaining optimal health. Patients are faced not only with a life altering medical condition but a reminder about it every time they eat or drink something. The impact of this takes a physical and emotional toll. Patient engagement and perception are key components to improved quality of life. Nephrology Nurse Role

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS

The nephrology nurse specialty focuses patients with kidney disease. These nurses work closely with ESRD patients and develop close relationships with them. In the hemodialysis unit, they play an active role in the lives and well being of this population. By including a patients perception of kidney failure and its impact on their lives into the plan for dialysis patients, nephrology staff can improve patient outcomes and help patients live up to their fullest potential. Impact of Hemodialysis on Lifestyle Bayhakki & Hatthakit (2012) explain the importance of patient perception while caring for the physical, emotional and spiritual needs of the renal patient. Patients on hemodialysis not only face treatment-related stressors, but also have to deal with changes in their concept of self and self-confidence, reversal in family roles, and loss of dignity (Bayhakki & Hatthakit, 2012). This new lifestyle has a huge impact not only on the patient, but the patients support system as well. I witnessed a neighbor who was living the American dream, had a wife, a good job, two children, and a new house with a pool and then was handed the diagnosis of ESRD requiring hemodialysis. As a distant neighbor, I noticed the perfectly manicured lawn didnt look so good, the fence around the pool started to sag and the downward spiral was visible for this family. One day as my neighbor sat in his garage, I stopped to introduce myself and through our conversation he revealed how his kidneys had stopped working and that he was dependent on hemodialysis. I shared with him that I was a dialysis nurse. (P.M. Adams, personal communication, 2005). Eventually Joe was no longer able to work and live the lifestyle he had become accustomed to, the house continued to deteriorate and finally sold. Physical Symptoms Physical symptoms vary from each person and go hand in hand with the comorbid conditions in addition to kidney failure. Physical symptoms such as lethargy, weakness,

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS

confusion, difficulty concentrating, poor appetite, metallic taste in the mouth, dry itchy skin, skin color changesgrayish or brownish--yellow complexion, foot or ankle swelling, shortness of breath and high blood pressure are some of the body changes a person with ESRD experiences. Physical limitations of life were caused by lack of energy and weakness due to reasons such as limitation of food and fluid intake, fluid excess, and increased metabolism waste in the patients body (Bayhakki & Hatthakit, 2012). Although the standards for hemodialysis care are based on physical symptoms, when asked what affects their quality of life, patients identified lack of energy, sleep disturbance, trouble concentrating, depressed mood, dizziness/imbalance, problems walking, weakness, and dependence on others among their primary problems. (Leinau, Murphy, Bradley, & Fried, 2009). Thorough assessment and evaluation of physical symptoms by nephrology staff can help providers with treatment options to optimize quality of life (QOL) for the patient. There is evidence that better QOL and patient satisfaction are associated with better clinical outcomes. This includes reduced hospitalization rates and reduced mortality (Onazi, Jondeby, Azeem, & Sayyari, 2011). Nephrology nurses have the opportunity to identify with their patients and through empathy and caring. Nephrology staff can optimize care by utilizing a multifactorial approach to care. Nephrology staff should include problems directly related to renal failure and at the same time, include a second set of problems, identified by the patient, not specific to renal failure, but ones that affect the daily QOL for their patients. Lingerfelt & Hodnicki achieved improved patient outcomes for enhanced patient efficacy, adherence and blood pressure control in a study. This study focused on blood pressure control for patients on dialysis. Utilization of home BP measurements may provide a more accurate representation of overall BP measurement (Lingerfelt & Hodnicki, 2012). Lingerfelt & Hodnicki (2012) point out that dosing medications based on accurate blood pressure readings

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS improves patient outcomes, decreases cardiovascular complications and promotes adherence by actively involving patients in their care outside of the dialysis clinic. In this article patient perspective is enhanced as patients are actively involved in checking their blood pressure, reporting it to their healthcare provider, and then acting upon those results, whether it be a change in medication dosing or increased adherence to current dosing, ultimately reducing the risk of adverse effects of hypertension. Psychosocial Needs Including the psychosocial needs of patients and their support systems, while caring for hemodialysis patients, decreases the negative perception of the disease and at the same time

increases their social support. Positive perception of the disease leads to increased self efficacy, decreased complicatons and decreased mortality. In a study related to psychosocial factors, behavioral compliance and survival in urban hemodialysis patients, Kimmel et al. (1998) found that patients who had a negative perception of the disease, a poor social support system and who did not follow the prescribed treatment had an increased rate of mortality. During an encounter with a newly diagnosed ESRD patient, the emotional toll it had on him was indisputable. Upon further evaluation, the physical and emotional impact were identified. Fear of being a burden to his family was a larger concern than the treatment itself. After identifying how this would impact the patient and his support system, the patients perception could be included in the plan of care. Including the emotional, social and physical impact of this diagnosis leads to identification of treatment and educational goals to promote self efficacy. Educational Needs Educational needs of the patient should be based on the perception of what the patient needs to learn. If a patient has a negative perception of the disease, assessment of the underlying

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS cause of this perception should be included. As noted above, this patients needs were not only

about ESRD education but also about social support and ways to limit her perceived burden upon the support system. In a study about increasing the understanding of patient perspective of fluid restrictions and to ultimately improve the overall outcome of the patients well being, Mazzoni & Tovazzi (2012), explain that adherence is the key to increasing the life expectancy of the hemodialysis patient. The overall health of the patient is directly related to adherence to fluid restriction, diet, prescribed medication and prescribed hemodialysis treatment. Health Promotion In an article that advocates for self efficacy, health promotion and increased QOL by engaging the patient in an active role of self care through alternate modality choices, The American Nephrology Nurses Association President conveys the following message We (the nephrology community, all of us) have built and maintained a culture that is not patient-centered, and we continue to focus on the details of treatment, rather than on the individual being treated. We continue to have a difficult time seeing the individual needing therapy as in charge or even a partner in their care (Payne, 2013). With this being said, it is recommended that nephrology staff utilize methods of health promotion based on the internal needs of the patient not just the treatment itself. Active patient engagement in treatment choices plays and important role of improved outcomes for hemodialysis patients. Conclusion To achieve the best possible outcome for QOL and life expectancy, patient perception should be taken into consideration and included in the plan of care. By including patient perception in treatment planning, patients play active roles in their care

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS that enhances their overall QOL. As research has shown, patients with increased selfefficacy lead healthier lives, have better clinical outcomes, reduced hospitalizations and reduced mortality. The combination of physical, emotional and spiritual needs based on patient perception are key components to improved outcomes in care planning for the hemodialysis patient. Recommendation Further research related to how the impact of patient perception relates to quality

and length of life for ESRD patients is warranted. Nephrology staff is vital to the success of patient engagement and self-efficacy. To improve this lives of this population of patients, a focus on patient-centered standards of care should be utilized.

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS Appendix A Peer Review I would like to thank the following people for their contribution to the success of this paper. My peers: Theresa Nathan CCHT, Mary Jo Salliotte CCHT and Lucia Aqcaoili RN, BSNAdult Nephrology Charge Nurse. Thank you for taking the time to review and offer

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suggestions for improvement. Signatures available upon request. Dr Amidon for your guidance and rapid feedback for my very rough draft.

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS Appendix B Glossary Anemia: Deficiency of red blood cells End Stage Renal Disease: Irreversible loss of kidney function Hemodialysis: Procedure for removal of metabolic waste products and free water from the blood when the kidneys are in renal failure.

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Perception: The act or faculty of perceiving or apprehending by means of the senses or of the mind; cognition; understanding. Renal Failure/Kidney Failure: Inability of the kidney to excrete wastes and an inability to remove excess fluid and balance electrolytes Renal Osteodystrophy: A condition related to renal failure with and increase of phosphorus, a decrease of calcium and the stimulation of parathyroid function resulting in bone disease. Quality of Life: General well being for an individual with a chronic disease and the ability to achieve goals related to their health.

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS References

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Bayhakki, &. H. (2012). Lived experiences of patients on hemodialysis: A metasynthesis. Nephrology Nursing Journal , 39 (4), 295-304. Kimmel, P., Peterson, R., Weihs, K., Simmens, S., Alleyne, S., Cruz, I., et al. (1998). Psychosocial factors, behavioral compliance and survival in urban hemodialysis patients. Kidney Int. , 54 (1), 245-54. Leinau, L., Murphy, T. E., Bradley, E., & Fried, T. (2009). Relationship between conditions addressed by hemodialysis guidelines and non-ESRD-Specific conditions affedting quality of life. American Society of Nephrology , 4 (3), 572-578. doi:
10.2215/CJN.03370708.

Lingerfelt, K., & Hodnicki, D. (2012). Hypertension management in patients receiving hemodialysis: The benefits of home blood pressure monitoring. Nephrology Nursing Journal , 39 (1), 31-36. Mazzoni, V., & Tovazzi, M. E. (2012). Personal paths of fluid restriction in patients on hemodialysis. Nephrology Nursing Journal , 39 (3), 207-15. Onazi, M. A., Jondeby, M. A., Azeem, M., & Sayyari, A. A. (2011). Factors affecting Saudi hemodialysis patients' perception of healthcare providers' empathy. Arab Journal of Nephrology and Transplantaion , 4 (2), 71-6. Payne, G. M. (2013). We can do better: by changing culture to improve care. Nephrology Nursing Journal , 40 (1), 11. The National Kidney and Urologic Diseases Information Clearinghouse. (n.d.). Kidney disease statistics for the United States. Retrieved April 1, 2013, from The National

OUTCOMES ARE IMPROVED FOR DIALYSIS PATIENTS Kidney and Urologic Diseases Information Clearinghouse Web site: http://kidney.niddk.nih.gov.

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