Nurse Led Intervention on Self Care Adherence and Quality of Life

Introduction

Chronic kidney disease (CKD) is an abnormality in the structure and function of the kidney that has been present for at least three months and has health implications. It is classified based on the cause, glomerular filtration rate, and albuminuria rate.1 The worldwide prevalence of CKD is 10%, with more than 800 million people affected by it.2 The nationwide population-based survey of Nepal showed that the overall prevalence of CKD is 6.6%, with approximately 1,895,080 people affected by it.3

People with CKD cannot filter out urine; as a result, the patient has retention of metabolic wastes and increased metabolic acidosis. People with CKD develop signs and symptoms of uremia, like shortness of breath, leg swelling, muscle cramps, heartburn, itching, sexual dysfunction, poor sleep, pain, drowsiness, joint pain, reduced mobility, and fatigue. These changes in the body result in peripheral edema, hypertension, reduced exercise capacity, and the development of cardiovascular disease. 1, 4

The treatment options available for kidney disease are lifestyle changes, medicines, dialysis, and kidney transplantation. In dialysis, there are peritoneal dialysis and hemodialysis.1, 4 Worldwide, an estimated 4.9 million people are receiving hemodialysis treatment.5 In America, out of 808,000 patients with kidney failures, about 556,000 people are undergoing hemodialysis treatment.6 In Nepal, approximately 3,775 people receive hemodialysis treatment from 60 centers.7

Hemodialysis, which uses an artificial kidney, removes extra fluids, toxins, and solutes.8 Kidney Disease Outcome Quality Initiatives (K/DOQI) recommends thrice-weekly maintenance hemodialysis with a minimum of three hours per session.9 Most of the patients in Nepal undergo twice-weekly in-center hemodialysis sessions. 7, 10 People undergoing hemodialysis have multiple problems like fluid and electrolyte imbalance, volume overload, swollen ankles, shortness of breath, tiredness, and difficulty sleeping.11

Hemodialysis patients must follow their dialysis schedule and comply with dietary recommendations and fluid and salt restrictions. Besides this, there is a fear of morbidity and mortality in these groups of patients. 12 Mental health issues like anxiety and depression are highly prevalent in people with hemodialysis, at 49.6% and 55%, respectively.13 The prevalence of anxiety ranges from 27-69 % and depression from 11% -78% in the context of Nepal.14-19 The Presence of these issues affects various aspects of physical, mental, emotional, social, and family domains of quality of life and vice versa. 13 The dialysis and the presence of multiple symptoms reduce the person's ability to work, and these patients need to adhere to treatment.20

Self-care adherence is the specific recommended behaviors a person initiates and maintains to improve and sustain their health. These are the combination of activities that include controlling weight, adherence to prescribed medications, eating a healthy diet, altering fluid and salt intake, engaging in adequate physical activity, participating in exercise, ventilating feelings, and alcohol and smoking cessation.21,22 In dialysis patients, objective measures of self-care adherence can be assessed by evaluating interdialytic weight changes, blood pressure, serum phosphate and sodium levels, and functional independence.23 The improvement in self-care adherence score correlated with the improvement in quality of life score. 24

Research suggests that the pooled prevalence of worldwide dietary non-adherence ranges from 47% to 73%, and fluid non-adherence ranges from 50% to 71%.25 In Nepal, adherence to fluid and diet was 49% and 43%, respectively.26 The patient on dialysis has to restrict their salt intake to less than 2 gm /day and fluid intake to less than 500 ml plus previous output to maintain their inter-dialytic weight gain.4 Inter-dialytic weight gain is an important assessment tool for salt and fluid intake and an essential parameter of salt and fluid adherence. The weight should be less than 1.5 kg between two hemodialysis sessions, and there should be no more than a 1 kg weight gain per day between sessions.27 The inter-dialytic weight gain percentage should be lower than 4 to 4.5 % of dry weight. Inter-dialytic weight gain in kilograms is the difference between pre-dialysis and post-dialysis weights. The inter-dialytic weight gain in percentage is the difference between pre- and post-dialysis weights divided by the dry weight in kg, multiplied by 100.28

Physical activity is another essential part of self-care adherence.23 A large survey across 12 countries found that 44% had never been involved in any exercise.29 A study from Nepal showed that only 42.5% were involved in some physical activity, whereas 57.5% were not involved in any kind of physical activity.30 The participants in another study on knowledge of self-care management scored the lowest on the knowledge level of exercise (47.27±20.59 out of 100).31 Exercise not only prevents complications but also contributes to better health. It is the leading factor in improving the performance status and quality of life of people undergoing hemodialysis. 32, 33 Established guidelines recommend that hemodialysis patients perform 150 minutes of moderate-intensity activity or 75 minutes of vigorous activity per week. These can be done during or outside dialysis.34, 35

According to the Centers for Disease Control and Prevention, health-related quality of life is "an individual's or group's self-perception of their physical and mental health over time." It is a measure of a person's being.36 Patients undergoing hemodialysis experience multiple symptoms and lifestyle changes, and because of this, their everyday health-related quality of life (HRQOL) is affected. HRQOL is a key outcome, serving as an indicator of the impact of health status on quality of life and as a powerful predictor of the relative risk of death and hospitalization. 37 Several studies have shown that hemodialysis patients experience a decreased quality of life. 38-42

Nursing-led interventions are a care delivery model in which a nurse initially assesses, evaluates, and, based on these findings, plans her intervention or seeks a multidisciplinary/interdisciplinary effort to address the patient's problems.43

The KDIGO guideline 2024 recommends that people with chronic kidney disease receive care from a multidisciplinary care team. This care should include individualized education and counselling on lifestyle modification, including diet, exercise, smoking cessation, medication, and psychological support.1 A systematic review and meta-analysis on the role of educational/cognitive, counseling/behavioral interventions led to a significant reduction in interdialytic weight gain (mean difference in weight- 0.15 kg) in the intervention group compared to no intervention. Psychological interventions were associated with a reduction in interdialytic weight gain of 0.26 kg compared with the intervention group.44 Other studies have failed to demonstrate significant differences in objective self-care adherence parameters between groups.45, 46

The study conducted in Iran showed that the nurse-led education program, together with nurse-led telephone follow-up and a distribution of patient education booklets,t showed significant improvement in adherence score compared to control groups.47 Another study conducted in Turkey, where nurse-led telephone-based education and counselling resulted in significant improvements in self-care skills and quality of life.48

General Objective: To evaluate the effect of nurse-led interventions on self-care adherence and quality of life among patients undergoing hemodialysis

Specific Objectives:

* To compare the average values of self-care adherence score (adherence to diet and fluid, exercise, and clinical parameters) between the nurse-led intervention group and the usual care group at 4 months and at 6 months. * To compare the quality of life (QOL) scores between the intervention and usual care groups at 6 months baseline.

Research Hypothesis

1. There is no significant difference in the mean values of self-care adherence among patients undergoing hemodialysis who receive a nurse-led intervention compared to those who receive usual care at 4 and 6 months. 2. There is no significant difference in the average Kidney Disease Quality of Life (KDQOL) score between patients undergoing hemodialysis who receive a nurse-led intervention and those who receive usual care over 6 months.

Study Variables Independent variables: Nurse-led intervention Nurse-led intervention: Comprises an education and counselling session, a reminder call, and distribution of "Self-care booklet for hemodialysis patients."

1. Education and counselling session by nurses (laptop-based):

* 1st session (1 to 2 weeks of about 20 minutes): By this session, the nurse makes patients aware of existing interdialytic weight gain status, blood pressures, body mass index, and physical activity. Covers a brief introduction to kidney functions, chronic kidney disease, risk factors, treatment options, dry weight, its importance, and motivational examples. The participants were counselled on the need for behavior change, and assessed whether their behavior is problematic. * 2nd Second session (3 to 4th weeks, about 30 minutes): Increase awareness about healthy behavior, introduction to diet, salt, and fluid, and dietary recommendation session for electrolytes like sodium, sources of potassium and phosphorus, and protein-rich foods, monitoring these parameters in blood, strategies to reduce salt and fluid intake * 3rd Session (5th to 6th weeks, duration 25 min): 3rd session, increase awareness and importance of physical exercise with focus on aerobic, stretching exercises, and deep breathing exercises * 4th session (7 to 8 weeks, duration 25 to 30 min): Introduction to mental health, importance of mental health, common mental health problems in hemodialysis patients, strategies to improve mental health ( ventilation of feelings, quit smoking), 2. Reminder call: Patients will be called once a week on a non-dialysis day. Patient will receive six calls altogether after the third session, once a week on a non-dialysis day. The call will last 3-5 minutes over 6 weeks. The main focus will be on the targeted interdialytic weight control (\<1.5kg) relating to patients' baseline values and between values. Furthermore, patients are encouraged to limit intake of foods rich in sodium, potassium, and phosphorus. Patients are encouraged to engage in physical activity (exercise) and to vent their feelings to a close person. 3. Self-care booklet for hemodialysis patients: Patient will be provided with the small booklet at the end of the last educational session. This booklet has been constructed and reviewed by two nephrologists, two nurse specialists, a physiotherapist, a psychologist, and a nutritionist.

Primary variables: Self-care adherence Clinical parameters: interdialytic weight gain Subjective adherence score: Will be assessed by the self-constructed tool on diet, fluid, and salt restriction, as well as monitoring of weight and blood pressure. Physical activity score using the International Physical Activity Questionnaire.

Secondary variables: Quality of life, Blood pressure, and Body mass index. Quality of life will be subjectively assessed by the Kidney Disease Quality of Life score (KDQOL-SF 36)

Site and its Justification: This study will be conducted at Nepal Medical College and Teaching Hospital. This center is a tertiary care center with around 450 beds. The center has started hemodialysis services around two decades ago (2005, Feb 16). It is the renowned center for hemodialysis services, with approximately 29-31 patients undergoing hemodialysis per shift, and about 213 patients currently receiving this service.

Research Design: Quantitative design. This study w

• Quality of life score [Срок оценки: The change in score at baseline and at 6 months will be compared.]
• Body mass index [Срок оценки: baseline and at 4 and 6 months]
• pre dialysis systolic blood pressure [Срок оценки: 4 months and 6 months baseline . The difference in pre hemodialysis systolic blood pressure at baseline and at 4 and 6 months will be used .]
• pre hemodialysis diastolic blood pressure [Срок оценки: at 4 months and 6 months from baseline. The difference in diastolic blood pressure at baseline and at 4 months and 6months will be measured.]