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Association Between Nursing Diagnoses and Socioeconomic/Clinical Characteristics of Patients on Hemodialysis Cecília Maria Farias de Queiroz Frazão, RN, MSN, Jéssica Dantas de Sá, RN, Maria das Graças Mariano Nunes de Paiva, RN, Ana Luisa Brandão de Carvalho Lira, RN, PhD, Marcos Venícios de Oliveira Lopes, RN, PhD, and Bertha Cruz Enders, RN, PhD Cecília Maria Farias de Queiroz Frazão, RN, MSN, is a Doctoral Student at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, Jéssica Dantas de Sá, RN, is a Master’s Student at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, Maria das Graças Mariano Nunes de Paiva, RN, is a Master’s Student at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, Ana Luisa Brandão de Carvalho Lira, RN, PhD, is an Associate Professor at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, Marcos Venícios de Oliveira Lopes, RN, PhD, is a Professor at the Federal University of Ceará, Fortaleza, Ceará, Brazil, and Bertha Cruz Enders, RN, PhD, is a Professor at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.
Search terms: Nursing, nursing diagnosis, renal dialysis Author contact: [email protected], with a copy to the Editor: [email protected]
PURPOSE: To analyze the association between nursing diagnoses and socioeconomic/clinical characteristics of patients on hemodialysis. METHODS: Cross-sectional study conducted by means of interview and physical examination of 178 patients consecutively selected. FINDINGS: Nursing diagnoses within the NANDA-I domains of health promotion, nutrition, activity/rest, perception/cognition, sexuality, safety/protection, and comfort presented statistically significant association with the socioeconomic/ clinical data of age, education, sex, marital status, and duration of the chronic renal disease and hemodialysis. CONCLUSION: The nursing diagnoses in this population may be influenced by the socioeconomic/clinical data. IMPLICATIONS FOR NURSING PRACTICE: The results suggest an opportunity for improved nursing intervention in this community. OBJETIVO: Analisar a associação entre diagnósticos de enfermagem e características sócio econômicos/clínicos de pacientes em hemodiálise. MÉTODOS: Estudo transversal realizado por meio de entrevista e exame físico de 178 pacientes selecionados consecutivamente. RESULTADOS: Os diagnósticos de enfermagem dentro dos domínios da NANDA-I: promoção da saúde, nutrição, atividade/repouso, percepção/cognição, sexualidade, segurança/proteção, e conforto apresentaram associação estatisticamente significativa com os dados sócio econômicos/clínicos de idade, escolaridade, sexo, estado civil e tempo de crônica doença renal e hemodiálise. CONCLUSÃO: Os diagnósticos de enfermagem nessa população podem ser influenciados pelos dados sócio econômico/clínicos. IMPLICAÇÕES PARA A PRÁTICA DE ENFERMAGEM: Os resultados sugerem uma oportunidade para intervenções de enfermagem que melhorem esta clientela.
Chronic kidney disease (CKD) is a global public health problem. It is diagnosed with a decrease in glomerular filtration rate associated with loss of regulatory, excretory, and endocrine functions of the kidneys. When the glomerular filtration rate reaches less than 15 ml/min/1.73 m2 values, renal function failure becomes evident, and the © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 26, No. 3, July 2015
institution of dialysis or renal transplant is needed (Bastos, Bregman, & Kirsztajn, 2010; Sesso et al., 2012). Among the modalities of renal replacement therapy, hemodialysis (HD) stands out as the treatment of choice in Brazil, with 90.6% of CKD patients in HD treatment (Sesso et al., 2012). HD is the extraction of toxic nitrogenous 135
Characteristics of Patients on Hemodialysis substances from the blood while removing excess liquid accumulated in the body tissues (Sesso et al., 2012). Additionally, CKD and HD directly affect patients’ quality of life, contributing to physical limitations and significant alteration in social lifestyle (Frazao, Ramos, & Lira, 2011). Thus, chronic renal failure patients who undergo HD benefit from nursing care based on technical and scientific knowledge, a work process conceptualized within a humanized care perspective (Rodrigues & Botti, 2009), and a nursing process implemented that identifies nursing diagnoses (NDs). NDs are particularly important because they enable the nurse to construct a specific care plan based on the needs of the patient (Holanda & Silva, 2009). It is noteworthy that the use of the nursing process with emphasis on the diagnostics provides several benefits to patients, nurses, and the institution (Lira & Lopes, 2010). Such approach directs care, standardizes the professional language, and facilitates communication with patients and other members of the health team. Furthermore, it enables various evaluations of the care provided (Lira & Lopes, 2010). The identification of the association between NDs and patients’ sociodemographic and clinical characteristics enhances nurses’ understanding of the individuals who are undergoing care. Based on this analysis, nurses should consider the social needs of patients when planning their care, respect the individual aspects of each client, and eliminate, or minimize, human responses in this population. The aim of this study was to analyze the association between NDs and the socioeconomic/clinical data of patients undergoing HD treatment. The purpose was to strengthen the nurse’s care practice in the HD unit and provide means for the delivery of more adequate treatment. Materials and Methods A cross-sectional study was conducted in a reference clinic for dialysis located in a city in northeast Brazil. The population in May of 2011 comprised 330 patients registered as undergoing HD in the clinic and who were regularly monitored; data were obtained from the Integrated Control Centers Hemodialysis (NEFRODATA). The sample size was calculated using the formula for finite populations, with a confidence level of 95% (Zα = 1.96), sampling error of 5%, population size of 330, and the conservative prevalence value of 50% for the prevalence of NDs. The sample size determined was 178 individuals. The inclusion criteria for the selection of subjects were the following: that they have a clinical diagnosis of CKD, are registered and subjected to dialysis in the clinic, are between 20 and 65 years of age, and that they demonstrate suitable mental and physical condition to participate in the study at the time data were collected. Chronic renal failure patients with other nonrelated renal conditions that could change the profile of their diagnoses were excluded from the study. A nonprobability convenient sample of patients 136
C. M. F. de Queiroz Frazão et al. who were treated in the clinic during the months of data collection was used. The subjects were consecutively selected according to their arrival in the HD clinic. An interview and physical examination form was constructed for the collection of data. The questionnaire was based on related clinical assessment, CKD, and ND literature (Bickley, 2010; Herdman, 2012; Oliveira et al., 2008; Roy & Andrews, 2009). It consisted of three sections: demographic and clinical data; the NANDA-I (2012–2014) domains, except for the growth and development areas; and data pertaining to the general physical examination and of specific body segments. Data were collected from October 2011 to February 2012 by three nurses and five undergraduate research assistants during the HD sessions of the participants. The research assistants were previously trained in a 10-hr course that addressed the pathophysiology of CKD, changes experienced by patients on HD, NANDA-I NDs, and the general physical examination and of body parts. The course was taught by three nurse specialists in HD and the project leader, who is experienced in nursing care of renal patients in dialysis and NDs. Data were then submitted to an individual process of clinical judgment for the identification of the NDs. This process had two phases: the analysis, which included the categorization of the data and the identification of any existing gaps; and the synthesis, which comprised grouping, comparison, identification, and the search for relationships of etiological factors (Cerullo & Cruz, 2010). The NDs were then revised by two research team members to enhance consensual judgment and greater accuracy. No consensual statistic was used because of the small number of participant judges. The socioeconomic, clinical, and ND data were stored in a database constructed for this purpose. The analysis was conducted by means of a statistical program that generated descriptive data and the p value for the chi-square, and Mann–Whitney U tests were conducted to verify the existence of associations between variables. A significance level of 5% (p < .05) was accepted. The study was approved by the research ethics committee of the responsible institution (Protocol 115/11; Certificate of Presentation for Ethics Appreciation No. 0139.0.051.000111). All the respondents signed an informed consent form. Results The results showed that the majority (52.2%) of the patients were men with a mean age of 46.6 years (±12.3), had an average of 8.5 years (±4.8) schooling, and 62.9% had stable marital companions. Regarding clinical data, the predominant vascular access was the arteriovenous fistula (93.8%), and the median time of CKD diagnosis and of HD therapy was 6 and 4 years, respectively. The average urea removal index (Kt/V) was 1.5 (±0.6). In relation to ND data, the average number of NANDA-I diagnoses identified per patient was 6.6 (±2.3). The patient group had a total of 24 diagnoses, namely risk for infection-
C. M. F. de Queiroz Frazão et al.
Characteristics of Patients on Hemodialysis
Table 1. Analysis of the Association Between Nursing Diagnoses and Socioeconomic/Clinical Chronic Aspects in Renal Failure Patients Undergoing Hemodialysis; natal-RN, Brazil, 2013 Nursing diagnoses
Years of studya
Marital stateb
Agea
Incomea
Genderb
Siteb
Months of diseasea
Months of dialysisa
Urea (Kt/V)a
A B C D E F G H I J K L M N O P Q R S T
0.628 0.118 0.079 0.000* 0.993 0.492 0.845 0.415 0.450 0.044* 0.037* 0.083 0.86 0.170 0.216 0.753 0.182 0.156 0.029* 0.479
0.568 0.180 0.844 0.270 0.774 0.126 0.064 0.002* 0.204 0.123 0.564 0.126 0.639 0.781 0.132 0.064 0.807 0.423 0.257 0.441
0.033* 0.081 0.246 0.396 0.146 0.360 0.863 0.825 0.866 0.280 0.093 0.952 0.919 0.024* 0.068 0.028* 0.500 0.072 0.009* 0.365
0.423 0.965 0.947 0.158 0.275 0.169 0.994 0.818 0.105 0.169 0.599 0.886 0.863 0.249 0.796 0.117 0.704 0.006* 0.524 0.927
0.318 0.496 0.425 0.211 0.831 0.276 0.949 0.015* 0.491 0.020* 0.790 0.649 0.607 0.662 0.219 0.174 0.375 0.208 0.881 0.294
0.672 0.647 0.874 0.291 0.291 0.291 0.291 0.291 0.648 0.589 0.372 0.242 0.590 0.350 0.265 0.988 0.394 0.953 0.137 0.996
0.876 0.135 0.319 0.015* 0.016* 0.015* 0.164 0.164 0.133 0.064 0.847 0.776 0.863 0.814 0.419 0.836 0.149 0.500 0.821 0.182
0.086 0.518 0.133 0.837 0.001* 0.837 0.837 0.837 0.176 0.069 0.895 0.310 0.863 0.330 0.008* 0.464 0.026* 0.090 0.098 0.325
0.955 0.309 0.804 0.199 0.199 0.199 0.199 0.199 0.090 0.357 0.095 0.743 0.830 0.882 0.721 0.229 0.645 0.484 0.297 0.775
a
Mann–Whitney U test. Chi-square test. *p value < 0.05. A, inefficient self-health management-00078; B, situational low self-esteem-00120; C, constipation-00011; D, deficient knowledge-00126; E, dressing self-care deficit-00119; F, impaired dentition-00048; G, diarrhea-00013; H, sexual dysfunction-00059; I, acute pain-00132; J, chronic pain-00133; K, fatigue-00093; L, hypothermia-00006; M, insomnia-00095; N, impaired skin integrity-00046; O, impaired physical mobility-00085; P, imbalanced nutrition: less than body requirements-00002; Q, ineffective protection-00043, R, risk for injury-00035; S, risk for falls-00155; T, excess fluid volume-00026. b
00004 (100%), excessive fluid volume-00026 (99.4%), hypothermia-00006 (61.8%), fatigue-00093 (47.2%), ineffective self-health management-00078 (42.7%), impaired dentition-00048 (38.2%), risk for falls-00155 (37.1%), impaired physical mobility-00085 (35.4%), sexual dysfunction-00059 (28.7%), insomnia-00095 (25.3%), deficient knowledge-00126 (18.5%), chronic pain-00133 (15.7%), ineffective protection-00043 (12.9%), situational low self-esteem-00120 (12.4%), acute pain-00132 (11.2%), dressing self-care deficit-00109 (11.2%), impaired skin integrity-00046 (6.7%), constipation-00011 (5.6%), risk for injury-00035 (2.8%), imbalanced nutrition: less than body requirements-00002 (1.1%), and diarrhea-00013 (1.1%). The results of the association analysis between the NDs selected and socioeconomic/clinical variables are demonstrated in Table 1. Discussion In the present study, the nursing diagnosis ineffective self-health management-00078 showed statistical association with the age variable. It is known that difficulties in following the treatment regimen are common in CKD patients. Additionally, socioeconomic factors and ignorance of the disease process may accelerate the disease course, contributing to the presence of ineffective self-care for health (Bisca & Marques, 2010).
The diagnosis deficient knowledge-00126 was associated with the variables years of schooling and time of CKD. A study conducted on the quality of life of HD patients showed that the level of education is a key factor for such a state because it suggests that the patient assimilates the health advice provided by the health team (Frazao et al., 2011). Thus, the low education level of patients and population may hinder the understanding of renal disease and contribute to the nonadherence to treatment. Alternative means of education while respecting the cognitive limits of each individual are, therefore, essential in such cases. The diagnosis dressing self-care deficit-00109 was found to be statistically associated with the time of the CKD and the duration of HD. Similarly, a moderate level of dependence on self-care to dress in patients who had an average of 53.41 months of diagnosis of CKD and 41.13 months of dialysis was reported in another study (Oller et al., 2012). This suggests that prolonged CKD and treatment time impose various restrictions and limitations upon patients’ performance of daily living activities that require assistance from others. Such condition requires that the nursing care plan be prepared in partnership with the patient and the caregiver if the established goals are to be optimized. The diagnosis impaired dentition-00048 was found to have statistical association with the time of CKD. These findings were also supported in a related survey conducted with patients on HD that identified impaired dentition in
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Characteristics of Patients on Hemodialysis 41.30% of the respondents who were on treatment for about 4 years. Most of these patients were edentulous or had less than 10 dental units (Gonçalves et al., 2011). Several factors contribute to the injury in the dental arch of chronic renal failure patients on HD, namely poor oral hygiene habits, decrease in salivary flow rate, salivary pH changes, chronic immunosuppression, reduced wound healing power, alveolar destruction because of malnutrition, and renal osteodystrophy (Muñoz, Restrepo, & Manizales, 2011). Such factors can be augmented in the course of renal disease, which may explain the association found in this study. Early referral of these patients to the professional responsible for oral health should be a priority goal of nursing. The nursing diagnosis sexual dysfunction-00059 was associated with gender identification and marital status. The literature highlights that sexual changes present in this population are usually related to physical and emotional problems resulting from HD. It also emphasizes that sexual problems are mainly reported by male and married patients (Koc & Saglam, 2013). This denotes the importance of nurses’ attention to these associated factors, so as to provide emotional support and suggest strategies to minimize the problem. The diagnosis chronic pain-00133 was statistically associated with the variables gender and years of schooling. This ND was related to renal osteodystrophy, which is manifested by uncontrolled increase of phosphate which promotes bone mineralization. Osteodystrophy is a painful condition that hinders the performance of a patient’s daily activities and increases the risk of fractures and mortality (Blair et al., 2013). To minimize the pain in these patients, nurses’ intervention with nonpharmacological measures is recommended. The diagnosis fatigue-00093 was found to be statistically associated with the variable years of schooling. Fatigue causes limitations in the performance of daily life activities in this clientele. This diagnosis is directly related to anemia generally found in these patients, and is therefore characterized as a major complication of CKD (National Kidney Foundation, 2006). The low education level presented by the subjects in this study reflects the existing difficulties in therapeutic adherence, possibly related to the low family income of patients, which hinders their access to proper diet, thereby enhancing the causes of decreased red blood cells. The diagnosis impaired skin integrity-00046 was statistically associated with age, which can be explained by the aging process of the skin and its progressive sensitivity. Studies show that with aging, the need for special skin care emerges because of the decrease in the skin’s barrier functions and in the perception of traumatic stimuli (Lira et al., 2012). Other literature highlights that skin problems are exacerbated in patients on HD. These patients generally have frequent skin changes, uremic pruritus, and calciphylaxis, conditions that do not respond to dialysis, and therefore represent a major therapeutic challenge (Lupi et al., 2011). 138
C. M. F. de Queiroz Frazão et al. The nursing diagnosis impaired physical mobility-00085 was found to be statistically associated with the duration of the HD. Such finding was also present in a study that reported that most patients (96.66%) with mean HD time of 2–3 years showed some impairment in physical mobility, mainly general weakness and cramps, which affected their physical activity (Terra et al., 2010). It is necessary, therefore, to advise these patients on major HD complications and their prevention whenever possible. The diagnosis imbalanced nutrition: less than body requirements-00002 achieved statistical association with the age variable. In a study conducted with 53 patients undergoing HD, the main nutritional findings included hypoalbuminemia and hyperlipidemia. These conditions are the result of the changes in nutritional metabolism, quite common in the dialysis population (Liu et al., 2011). In such a situation, the nurse should refer the patient to the nutrition service and promote dietary programs that minimize nutritional changes and functional complications, while respecting the patient’s preference and age. The diagnosis risk for injury-00035 was statistically associated with the income variable. A study denotes the frequency of cutaneous manifestations in patients with CKD and the changes in the basal and intermediate layers of the epidermis that affect the nerve endings, and that negatively influence the quality of life resulting from the decreased functional activity. Other changes that occur, such as decreased hydration, pruritus, and hyperpigmentation, are factors that increase the fragility of the skin and the consequent risk of injury for these patients. So the conduction of an adequate dialysis is presented as a determining factor in the prevention of skin changes. A dialysis can be jeopardized as a result of poor income to access to health services provided to the customers surveyed in Brazil (Lupi et al., 2011). The nursing diagnosis ineffective protection-00043 was associated with the duration of HD. This result was corroborated in another study that identified this diagnosis in 100% of HD patients (Holanda & Silva, 2009). The literature highlights the multifactorial nature and the interrelationship of the various mechanisms that may contribute to the advancement of CKD, including the glomerular hemodynamic response to loss of nephrons, proteinuria, and the pro-inflammatory and fibrotic results (Bucharles & Pecoits-filho, 2009). Complementing these findings, Riella (2010) found that the accumulation of uremic toxins in chronic renal failure patients was associated with a number of physiological disorders in the body, including the immunological disorders, which are responsible for the occurrence of infections. In these renal failure patients, cellular immunity is compromised. Furthermore, lymphopenia, thymic hypoplasia, delay of healing of surgical wounds, and decreased inflammatory response are present (Riella, 2010). These changes favor an ineffective protection diagnosis among these patients. The risk for falls-00155 was statistically associated with the variables age and years of schooling. A study conducted
C. M. F. de Queiroz Frazão et al. with renal HD patients identified decreased functional ability, aerobic endurance, muscular strength, and mobility (Frazao et al., 2011). These perspectives corroborate with the findings of this study. Thus, it is the health professionals’, particularly nurses’, function to promote the health education of these clients, with the objective of obtaining greater therapeutic adherence of patients and their quality of life. However, this is to be done with consideration of the socioeconomic and clinical data of the clients. Conclusion Based on the statistical associations identified in this study, it is concluded that the NDs in chronic renal failure patients undergoing HD are related to selected socioeconomic and clinical variables. The diagnoses with the highest degree of associations were dressing self-care deficit and months of HD, poor knowledge and education, sexual dysfunction and marital status, impaired physical mobility and months of HD, risk for injury and income, and risk of falling and age. The main socioeconomic and clinical variables that were associated with NDs were education, age, and months of CKD and HD. Thus, it is noticed that the socioeconomic and clinical data of these individuals can directly influence the presence of NDs. Another highlight is the importance of multidisciplinary care in solving some problems identified in renal failure patients on HD. The associations identified in this study are presented as a contribution to nursing practice for a better quality of care. It enabled the analysis of the human responses of chronic renal patients in view of their socioeconomic and clinical status and provide better targeting of nursing care for the real needs of this clientele. The perceived limitations in this study relate to its realization only with chronic renal failure patients on HD. Such analysis could be undertaken with patients that perform peritoneal dialysis and with the elderly clients. The difficulty experienced in the study was the lack of scientific literature with a focus on the research theme that might support or refute the identified associations. Acknowledgments. Original article based on the master’s dissertation entitled “Nursing diagnoses in patients on hemodialysis: Similarities between the adaptation model and NANDA International” presented at the Federal University of Rio Grande do Norte in 2012. The study was funded by the National Council for Scientific and Technological Development (CNPQ) (Process 483285/2010-2), Brazil. References Bastos, M. G., Bregman, R., & Kirsztajn, G. M. (2010). Doença renal crônica: Frequente e grave, mas também prevenível e tratável (Chronic kidney disease: Frequent and severe, but also preventable and treatable). Revista da Associação Médica Brasileira, 56(2), 248–253. Retrieved from http://www.scielo.br/pdf/ramb/v56n2/a28v56n2.pdf
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Association Between Nursing Diagnoses and Socioeconomic/Clinical Characteristics of Patients on Hemodialysis Cecília Maria Farias de Queiroz Frazão, RN, MSN, Jéssica Dantas de Sá, RN, Maria das Graças Mariano Nunes de Paiva, RN, Ana Luisa Brandão de Carvalho Lira, RN, PhD, Marcos Venícios de Oliveira Lopes, RN, PhD, and Bertha Cruz Enders, RN, PhD Cecília Maria Farias de Queiroz Frazão, RN, MSN, is a Doctoral Student at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, Jéssica Dantas de Sá, RN, is a Master’s Student at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, Maria das Graças Mariano Nunes de Paiva, RN, is a Master’s Student at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, Ana Luisa Brandão de Carvalho Lira, RN, PhD, is an Associate Professor at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil, Marcos Venícios de Oliveira Lopes, RN, PhD, is a Professor at the Federal University of Ceará, Fortaleza, Ceará, Brazil, and Bertha Cruz Enders, RN, PhD, is a Professor at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.
Search terms: Nursing, nursing diagnosis, renal dialysis Author contact: [email protected], with a copy to the Editor: [email protected]
PURPOSE: To analyze the association between nursing diagnoses and socioeconomic/clinical characteristics of patients on hemodialysis. METHODS: Cross-sectional study conducted by means of interview and physical examination of 178 patients consecutively selected. FINDINGS: Nursing diagnoses within the NANDA-I domains of health promotion, nutrition, activity/rest, perception/cognition, sexuality, safety/protection, and comfort presented statistically significant association with the socioeconomic/ clinical data of age, education, sex, marital status, and duration of the chronic renal disease and hemodialysis. CONCLUSION: The nursing diagnoses in this population may be influenced by the socioeconomic/clinical data. IMPLICATIONS FOR NURSING PRACTICE: The results suggest an opportunity for improved nursing intervention in this community. OBJETIVO: Analisar a associação entre diagnósticos de enfermagem e características sócio econômicos/clínicos de pacientes em hemodiálise. MÉTODOS: Estudo transversal realizado por meio de entrevista e exame físico de 178 pacientes selecionados consecutivamente. RESULTADOS: Os diagnósticos de enfermagem dentro dos domínios da NANDA-I: promoção da saúde, nutrição, atividade/repouso, percepção/cognição, sexualidade, segurança/proteção, e conforto apresentaram associação estatisticamente significativa com os dados sócio econômicos/clínicos de idade, escolaridade, sexo, estado civil e tempo de crônica doença renal e hemodiálise. CONCLUSÃO: Os diagnósticos de enfermagem nessa população podem ser influenciados pelos dados sócio econômico/clínicos. IMPLICAÇÕES PARA A PRÁTICA DE ENFERMAGEM: Os resultados sugerem uma oportunidade para intervenções de enfermagem que melhorem esta clientela.
Chronic kidney disease (CKD) is a global public health problem. It is diagnosed with a decrease in glomerular filtration rate associated with loss of regulatory, excretory, and endocrine functions of the kidneys. When the glomerular filtration rate reaches less than 15 ml/min/1.73 m2 values, renal function failure becomes evident, and the © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 26, No. 3, July 2015
institution of dialysis or renal transplant is needed (Bastos, Bregman, & Kirsztajn, 2010; Sesso et al., 2012). Among the modalities of renal replacement therapy, hemodialysis (HD) stands out as the treatment of choice in Brazil, with 90.6% of CKD patients in HD treatment (Sesso et al., 2012). HD is the extraction of toxic nitrogenous 135
Characteristics of Patients on Hemodialysis substances from the blood while removing excess liquid accumulated in the body tissues (Sesso et al., 2012). Additionally, CKD and HD directly affect patients’ quality of life, contributing to physical limitations and significant alteration in social lifestyle (Frazao, Ramos, & Lira, 2011). Thus, chronic renal failure patients who undergo HD benefit from nursing care based on technical and scientific knowledge, a work process conceptualized within a humanized care perspective (Rodrigues & Botti, 2009), and a nursing process implemented that identifies nursing diagnoses (NDs). NDs are particularly important because they enable the nurse to construct a specific care plan based on the needs of the patient (Holanda & Silva, 2009). It is noteworthy that the use of the nursing process with emphasis on the diagnostics provides several benefits to patients, nurses, and the institution (Lira & Lopes, 2010). Such approach directs care, standardizes the professional language, and facilitates communication with patients and other members of the health team. Furthermore, it enables various evaluations of the care provided (Lira & Lopes, 2010). The identification of the association between NDs and patients’ sociodemographic and clinical characteristics enhances nurses’ understanding of the individuals who are undergoing care. Based on this analysis, nurses should consider the social needs of patients when planning their care, respect the individual aspects of each client, and eliminate, or minimize, human responses in this population. The aim of this study was to analyze the association between NDs and the socioeconomic/clinical data of patients undergoing HD treatment. The purpose was to strengthen the nurse’s care practice in the HD unit and provide means for the delivery of more adequate treatment. Materials and Methods A cross-sectional study was conducted in a reference clinic for dialysis located in a city in northeast Brazil. The population in May of 2011 comprised 330 patients registered as undergoing HD in the clinic and who were regularly monitored; data were obtained from the Integrated Control Centers Hemodialysis (NEFRODATA). The sample size was calculated using the formula for finite populations, with a confidence level of 95% (Zα = 1.96), sampling error of 5%, population size of 330, and the conservative prevalence value of 50% for the prevalence of NDs. The sample size determined was 178 individuals. The inclusion criteria for the selection of subjects were the following: that they have a clinical diagnosis of CKD, are registered and subjected to dialysis in the clinic, are between 20 and 65 years of age, and that they demonstrate suitable mental and physical condition to participate in the study at the time data were collected. Chronic renal failure patients with other nonrelated renal conditions that could change the profile of their diagnoses were excluded from the study. A nonprobability convenient sample of patients 136
C. M. F. de Queiroz Frazão et al. who were treated in the clinic during the months of data collection was used. The subjects were consecutively selected according to their arrival in the HD clinic. An interview and physical examination form was constructed for the collection of data. The questionnaire was based on related clinical assessment, CKD, and ND literature (Bickley, 2010; Herdman, 2012; Oliveira et al., 2008; Roy & Andrews, 2009). It consisted of three sections: demographic and clinical data; the NANDA-I (2012–2014) domains, except for the growth and development areas; and data pertaining to the general physical examination and of specific body segments. Data were collected from October 2011 to February 2012 by three nurses and five undergraduate research assistants during the HD sessions of the participants. The research assistants were previously trained in a 10-hr course that addressed the pathophysiology of CKD, changes experienced by patients on HD, NANDA-I NDs, and the general physical examination and of body parts. The course was taught by three nurse specialists in HD and the project leader, who is experienced in nursing care of renal patients in dialysis and NDs. Data were then submitted to an individual process of clinical judgment for the identification of the NDs. This process had two phases: the analysis, which included the categorization of the data and the identification of any existing gaps; and the synthesis, which comprised grouping, comparison, identification, and the search for relationships of etiological factors (Cerullo & Cruz, 2010). The NDs were then revised by two research team members to enhance consensual judgment and greater accuracy. No consensual statistic was used because of the small number of participant judges. The socioeconomic, clinical, and ND data were stored in a database constructed for this purpose. The analysis was conducted by means of a statistical program that generated descriptive data and the p value for the chi-square, and Mann–Whitney U tests were conducted to verify the existence of associations between variables. A significance level of 5% (p < .05) was accepted. The study was approved by the research ethics committee of the responsible institution (Protocol 115/11; Certificate of Presentation for Ethics Appreciation No. 0139.0.051.000111). All the respondents signed an informed consent form. Results The results showed that the majority (52.2%) of the patients were men with a mean age of 46.6 years (±12.3), had an average of 8.5 years (±4.8) schooling, and 62.9% had stable marital companions. Regarding clinical data, the predominant vascular access was the arteriovenous fistula (93.8%), and the median time of CKD diagnosis and of HD therapy was 6 and 4 years, respectively. The average urea removal index (Kt/V) was 1.5 (±0.6). In relation to ND data, the average number of NANDA-I diagnoses identified per patient was 6.6 (±2.3). The patient group had a total of 24 diagnoses, namely risk for infection-
C. M. F. de Queiroz Frazão et al.
Characteristics of Patients on Hemodialysis
Table 1. Analysis of the Association Between Nursing Diagnoses and Socioeconomic/Clinical Chronic Aspects in Renal Failure Patients Undergoing Hemodialysis; natal-RN, Brazil, 2013 Nursing diagnoses
Years of studya
Marital stateb
Agea
Incomea
Genderb
Siteb
Months of diseasea
Months of dialysisa
Urea (Kt/V)a
A B C D E F G H I J K L M N O P Q R S T
0.628 0.118 0.079 0.000* 0.993 0.492 0.845 0.415 0.450 0.044* 0.037* 0.083 0.86 0.170 0.216 0.753 0.182 0.156 0.029* 0.479
0.568 0.180 0.844 0.270 0.774 0.126 0.064 0.002* 0.204 0.123 0.564 0.126 0.639 0.781 0.132 0.064 0.807 0.423 0.257 0.441
0.033* 0.081 0.246 0.396 0.146 0.360 0.863 0.825 0.866 0.280 0.093 0.952 0.919 0.024* 0.068 0.028* 0.500 0.072 0.009* 0.365
0.423 0.965 0.947 0.158 0.275 0.169 0.994 0.818 0.105 0.169 0.599 0.886 0.863 0.249 0.796 0.117 0.704 0.006* 0.524 0.927
0.318 0.496 0.425 0.211 0.831 0.276 0.949 0.015* 0.491 0.020* 0.790 0.649 0.607 0.662 0.219 0.174 0.375 0.208 0.881 0.294
0.672 0.647 0.874 0.291 0.291 0.291 0.291 0.291 0.648 0.589 0.372 0.242 0.590 0.350 0.265 0.988 0.394 0.953 0.137 0.996
0.876 0.135 0.319 0.015* 0.016* 0.015* 0.164 0.164 0.133 0.064 0.847 0.776 0.863 0.814 0.419 0.836 0.149 0.500 0.821 0.182
0.086 0.518 0.133 0.837 0.001* 0.837 0.837 0.837 0.176 0.069 0.895 0.310 0.863 0.330 0.008* 0.464 0.026* 0.090 0.098 0.325
0.955 0.309 0.804 0.199 0.199 0.199 0.199 0.199 0.090 0.357 0.095 0.743 0.830 0.882 0.721 0.229 0.645 0.484 0.297 0.775
a
Mann–Whitney U test. Chi-square test. *p value < 0.05. A, inefficient self-health management-00078; B, situational low self-esteem-00120; C, constipation-00011; D, deficient knowledge-00126; E, dressing self-care deficit-00119; F, impaired dentition-00048; G, diarrhea-00013; H, sexual dysfunction-00059; I, acute pain-00132; J, chronic pain-00133; K, fatigue-00093; L, hypothermia-00006; M, insomnia-00095; N, impaired skin integrity-00046; O, impaired physical mobility-00085; P, imbalanced nutrition: less than body requirements-00002; Q, ineffective protection-00043, R, risk for injury-00035; S, risk for falls-00155; T, excess fluid volume-00026. b
00004 (100%), excessive fluid volume-00026 (99.4%), hypothermia-00006 (61.8%), fatigue-00093 (47.2%), ineffective self-health management-00078 (42.7%), impaired dentition-00048 (38.2%), risk for falls-00155 (37.1%), impaired physical mobility-00085 (35.4%), sexual dysfunction-00059 (28.7%), insomnia-00095 (25.3%), deficient knowledge-00126 (18.5%), chronic pain-00133 (15.7%), ineffective protection-00043 (12.9%), situational low self-esteem-00120 (12.4%), acute pain-00132 (11.2%), dressing self-care deficit-00109 (11.2%), impaired skin integrity-00046 (6.7%), constipation-00011 (5.6%), risk for injury-00035 (2.8%), imbalanced nutrition: less than body requirements-00002 (1.1%), and diarrhea-00013 (1.1%). The results of the association analysis between the NDs selected and socioeconomic/clinical variables are demonstrated in Table 1. Discussion In the present study, the nursing diagnosis ineffective self-health management-00078 showed statistical association with the age variable. It is known that difficulties in following the treatment regimen are common in CKD patients. Additionally, socioeconomic factors and ignorance of the disease process may accelerate the disease course, contributing to the presence of ineffective self-care for health (Bisca & Marques, 2010).
The diagnosis deficient knowledge-00126 was associated with the variables years of schooling and time of CKD. A study conducted on the quality of life of HD patients showed that the level of education is a key factor for such a state because it suggests that the patient assimilates the health advice provided by the health team (Frazao et al., 2011). Thus, the low education level of patients and population may hinder the understanding of renal disease and contribute to the nonadherence to treatment. Alternative means of education while respecting the cognitive limits of each individual are, therefore, essential in such cases. The diagnosis dressing self-care deficit-00109 was found to be statistically associated with the time of the CKD and the duration of HD. Similarly, a moderate level of dependence on self-care to dress in patients who had an average of 53.41 months of diagnosis of CKD and 41.13 months of dialysis was reported in another study (Oller et al., 2012). This suggests that prolonged CKD and treatment time impose various restrictions and limitations upon patients’ performance of daily living activities that require assistance from others. Such condition requires that the nursing care plan be prepared in partnership with the patient and the caregiver if the established goals are to be optimized. The diagnosis impaired dentition-00048 was found to have statistical association with the time of CKD. These findings were also supported in a related survey conducted with patients on HD that identified impaired dentition in
137
Characteristics of Patients on Hemodialysis 41.30% of the respondents who were on treatment for about 4 years. Most of these patients were edentulous or had less than 10 dental units (Gonçalves et al., 2011). Several factors contribute to the injury in the dental arch of chronic renal failure patients on HD, namely poor oral hygiene habits, decrease in salivary flow rate, salivary pH changes, chronic immunosuppression, reduced wound healing power, alveolar destruction because of malnutrition, and renal osteodystrophy (Muñoz, Restrepo, & Manizales, 2011). Such factors can be augmented in the course of renal disease, which may explain the association found in this study. Early referral of these patients to the professional responsible for oral health should be a priority goal of nursing. The nursing diagnosis sexual dysfunction-00059 was associated with gender identification and marital status. The literature highlights that sexual changes present in this population are usually related to physical and emotional problems resulting from HD. It also emphasizes that sexual problems are mainly reported by male and married patients (Koc & Saglam, 2013). This denotes the importance of nurses’ attention to these associated factors, so as to provide emotional support and suggest strategies to minimize the problem. The diagnosis chronic pain-00133 was statistically associated with the variables gender and years of schooling. This ND was related to renal osteodystrophy, which is manifested by uncontrolled increase of phosphate which promotes bone mineralization. Osteodystrophy is a painful condition that hinders the performance of a patient’s daily activities and increases the risk of fractures and mortality (Blair et al., 2013). To minimize the pain in these patients, nurses’ intervention with nonpharmacological measures is recommended. The diagnosis fatigue-00093 was found to be statistically associated with the variable years of schooling. Fatigue causes limitations in the performance of daily life activities in this clientele. This diagnosis is directly related to anemia generally found in these patients, and is therefore characterized as a major complication of CKD (National Kidney Foundation, 2006). The low education level presented by the subjects in this study reflects the existing difficulties in therapeutic adherence, possibly related to the low family income of patients, which hinders their access to proper diet, thereby enhancing the causes of decreased red blood cells. The diagnosis impaired skin integrity-00046 was statistically associated with age, which can be explained by the aging process of the skin and its progressive sensitivity. Studies show that with aging, the need for special skin care emerges because of the decrease in the skin’s barrier functions and in the perception of traumatic stimuli (Lira et al., 2012). Other literature highlights that skin problems are exacerbated in patients on HD. These patients generally have frequent skin changes, uremic pruritus, and calciphylaxis, conditions that do not respond to dialysis, and therefore represent a major therapeutic challenge (Lupi et al., 2011). 138
C. M. F. de Queiroz Frazão et al. The nursing diagnosis impaired physical mobility-00085 was found to be statistically associated with the duration of the HD. Such finding was also present in a study that reported that most patients (96.66%) with mean HD time of 2–3 years showed some impairment in physical mobility, mainly general weakness and cramps, which affected their physical activity (Terra et al., 2010). It is necessary, therefore, to advise these patients on major HD complications and their prevention whenever possible. The diagnosis imbalanced nutrition: less than body requirements-00002 achieved statistical association with the age variable. In a study conducted with 53 patients undergoing HD, the main nutritional findings included hypoalbuminemia and hyperlipidemia. These conditions are the result of the changes in nutritional metabolism, quite common in the dialysis population (Liu et al., 2011). In such a situation, the nurse should refer the patient to the nutrition service and promote dietary programs that minimize nutritional changes and functional complications, while respecting the patient’s preference and age. The diagnosis risk for injury-00035 was statistically associated with the income variable. A study denotes the frequency of cutaneous manifestations in patients with CKD and the changes in the basal and intermediate layers of the epidermis that affect the nerve endings, and that negatively influence the quality of life resulting from the decreased functional activity. Other changes that occur, such as decreased hydration, pruritus, and hyperpigmentation, are factors that increase the fragility of the skin and the consequent risk of injury for these patients. So the conduction of an adequate dialysis is presented as a determining factor in the prevention of skin changes. A dialysis can be jeopardized as a result of poor income to access to health services provided to the customers surveyed in Brazil (Lupi et al., 2011). The nursing diagnosis ineffective protection-00043 was associated with the duration of HD. This result was corroborated in another study that identified this diagnosis in 100% of HD patients (Holanda & Silva, 2009). The literature highlights the multifactorial nature and the interrelationship of the various mechanisms that may contribute to the advancement of CKD, including the glomerular hemodynamic response to loss of nephrons, proteinuria, and the pro-inflammatory and fibrotic results (Bucharles & Pecoits-filho, 2009). Complementing these findings, Riella (2010) found that the accumulation of uremic toxins in chronic renal failure patients was associated with a number of physiological disorders in the body, including the immunological disorders, which are responsible for the occurrence of infections. In these renal failure patients, cellular immunity is compromised. Furthermore, lymphopenia, thymic hypoplasia, delay of healing of surgical wounds, and decreased inflammatory response are present (Riella, 2010). These changes favor an ineffective protection diagnosis among these patients. The risk for falls-00155 was statistically associated with the variables age and years of schooling. A study conducted
C. M. F. de Queiroz Frazão et al. with renal HD patients identified decreased functional ability, aerobic endurance, muscular strength, and mobility (Frazao et al., 2011). These perspectives corroborate with the findings of this study. Thus, it is the health professionals’, particularly nurses’, function to promote the health education of these clients, with the objective of obtaining greater therapeutic adherence of patients and their quality of life. However, this is to be done with consideration of the socioeconomic and clinical data of the clients. Conclusion Based on the statistical associations identified in this study, it is concluded that the NDs in chronic renal failure patients undergoing HD are related to selected socioeconomic and clinical variables. The diagnoses with the highest degree of associations were dressing self-care deficit and months of HD, poor knowledge and education, sexual dysfunction and marital status, impaired physical mobility and months of HD, risk for injury and income, and risk of falling and age. The main socioeconomic and clinical variables that were associated with NDs were education, age, and months of CKD and HD. Thus, it is noticed that the socioeconomic and clinical data of these individuals can directly influence the presence of NDs. Another highlight is the importance of multidisciplinary care in solving some problems identified in renal failure patients on HD. The associations identified in this study are presented as a contribution to nursing practice for a better quality of care. It enabled the analysis of the human responses of chronic renal patients in view of their socioeconomic and clinical status and provide better targeting of nursing care for the real needs of this clientele. The perceived limitations in this study relate to its realization only with chronic renal failure patients on HD. Such analysis could be undertaken with patients that perform peritoneal dialysis and with the elderly clients. The difficulty experienced in the study was the lack of scientific literature with a focus on the research theme that might support or refute the identified associations. Acknowledgments. Original article based on the master’s dissertation entitled “Nursing diagnoses in patients on hemodialysis: Similarities between the adaptation model and NANDA International” presented at the Federal University of Rio Grande do Norte in 2012. The study was funded by the National Council for Scientific and Technological Development (CNPQ) (Process 483285/2010-2), Brazil. References Bastos, M. G., Bregman, R., & Kirsztajn, G. M. (2010). Doença renal crônica: Frequente e grave, mas também prevenível e tratável (Chronic kidney disease: Frequent and severe, but also preventable and treatable). Revista da Associação Médica Brasileira, 56(2), 248–253. Retrieved from http://www.scielo.br/pdf/ramb/v56n2/a28v56n2.pdf
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