Negotiated care: a model for nursing work in the renal setting

AIM: This article outlines a model for the nursing role in the chronic health care context of renal replacement therapy. METHODS: Materials from several streams of literature are used to conceptualize the potential for nursing work in the renal setting as negotiated care. In order to present the role of the renal nurse in this way it is contextualized by viewing the renal setting as a specialized social context constituted by a dominant professional discourse and a contrasting client discourse. DISCUSSION: While performing specific therapeutic activities in accord with the dominant discourse, renal nurses can develop a relationship with the person living on dialysis, based on responsiveness to their subjective experience reflecting the renal client discourse. In contrast to the language of noncompliance prevalent in the renal setting, nurses can, through their relationship with renal clients, facilitate their attempts to negotiate the requirements of the therapeutic regime into their own personal life situation. Nurses can mediate between the dominant and client discourses for the person living on dialysis. Care describes the quality that nurses actively seek to create in their relationships with clients, through negotiation, in order to support them to live as fully as possible while using renal replacement therapy. CONCLUSION: Within chronic health care contexts, shaped by the acute curative paradigm of biomedicine, the model of nursing work as negotiated care has the potential to humanize contemporary medical technologies by responding to clients' experiences of illness and therapy.     

Living with haemodialysis when nearing end of life

Scand J Caring Sci; 2012; 26; 45–52
Living with haemodialysis when nearing end of life Aims and objectives: The aim of this study was to describe and to elucidate the meanings of being severely ill living with haemodialysis when nearing end of life. Introduction: To have end stage renal disease and to be treated with maintenance haemodialysis implies being dependent on lifelong treatment. Several studies have reported that these patients suffer a high symptom burden and an impaired quality of life due to both disease and treatment. In the dialysis unit, where the focus is on handling technology and maintaining life, end of life care may be neglected or overlooked. Nevertheless, mortality rates show that about one‐fourth of patients in haemodialysis care are in their last year of life. Design: A qualitative interpretative design was used. Methods: Serial qualitative interviews over a period of 12 months were conducted with eight patients (aged 66–87). Altogether text of 31 interviews was interpreted using a phenomenological hermeneutical method in three phases. The study is ethically approved. Findings: The structural analysis resulted in 11 subthemes and thereafter the following three themes were formulated; being subordinate to the deteriorating body, changing outlook on life and striving for upheld dignity. The comprehensive interpretation revealed that being severely ill living with haemodialysis near the end of life means living with suffering simultaneously with reconciliation and well‐being. Further, the meanings are understood as intertwined with being old. Conclusions: Findings contribute to an increased awareness of the complexities of these patients’ life worlds and their meanings, and thus of the importance to listen to their experiences and their understandings. Findings suggest that to integrate the philosophy of palliative care in haemodialysis units may improve care for patients who are living with haemodialysis and approaching the end of their lives.     

Chronic renal failure: assessing the Fatigue Severity Scale for use among caregivers

Background. Quality of life for caregivers of end‐stage renal disease patients has not been well addressed yet the physical and psychological status of this overlooked group can be important in the recovery or adaptation of patients with chronic renal failure, not to mention the caregivers themselves. One particular feature of the overall quality of life of such caregivers is that of fatigue. Aims and objectives. The purpose of the study was to test the Fatigue Severity Scale for potential usefulness in assessing fatigue among a non‐medical population, caregivers of end‐stage renal disease patients. Methods. Subjects completed a short battery of measures at either a dialysis centre or at home. Results. The Short Form‐12 of the Short Form‐36 and the Center for Epidemiologic Studies Depression Scale accounted for 56% of the variance on the Fatigue Severity Scale. The results suggest that physical fatigue may be more prominent than mental fatigue as a feature of caregiver quality of life. Conclusions. The Fatigue Severity Scale which has been used for multiple sclerosis patients may prove to be useful as a short assessment of fatigue among the non‐medical population of end‐stage renal disease caregivers. This may result in improved interventions for the population of caregivers. Relevance to clinical practice. Physicians, nurses and allied health professionals will be called on more frequently to assess and intervene with fatigued and overburdened caregivers in addition to patients themselves. A more thorough understanding of the nature of caregiver fatigue may drive changes or innovations with caregivers who are too often overlooked in the current era of scarce resources. Accordingly results of the study suggest that the direction in intervention may focus more on rest and respite as opposed to a need for psychosocial support or counselling. While there are various modes for assessing end‐stage renal disease caregivers’ fatigue, a simple measure like the Fatigue Severity Scale is brief enough to be administered without undue demand on practitioners or caregivers.     

尿毒清在危重症合并肾功能不全患者中的治疗作用

目的:探讨中药尿毒清在治疗危重症合并肾功能不全患者中的疗效。方法:46例收住急诊重症监护室(E ICU)合并肾功能不全的危重症患者,在给予西医基础治疗基础上加用中药尿毒清,每日30 g口服或鼻饲,连续观察至给药后9 d。记录治疗后3、5、7和9 d血清尿素氮(BUN)、肌酐(C r)、pH值、阴离子间隙(AG)、红细胞计数(RBC)、血红蛋白(Hb)、急性生理学与慢性健康状况评分Ⅱ(APACHAⅡ)等相关指标,比较治疗前后患者上述指标的变化。结果:与治疗前比较,治疗后9 d患者肾功能明显改善,BUN、C r显著降低,RBC升高,AG明显下降(P均<0.05),pH值趋于正常,APACHAⅡ评分下降显著(P<0.05)。结论:尿毒清可改善危重症患者的肾功能,同时可纠正电解质紊乱及酸碱失衡,在危重症患者综合治疗中有一定的意义。     

非药物干预对肾透析患者抑郁影响效果的网状Meta分析

目的 :分析不同非药物干预措施对肾透析患者抑郁的干预效果。方法 :计算机检索中国知网、万方、Embase、PubMed、The Cochrane Library、CINAHL Plus和Scopus数据库,检索时间为建库至2021年3月30日,纳入符合标准的随机对照研究,由2名研究者独立进行质量评价和资料提取。利用Stata 15.0软件进行网状Meta分析。结果 :共纳入32项研究,干预措施包括认知行为疗法、运动训练、穴位按摩、健康教育、放松疗法。相比于常规护理,对肾透析患者抑郁效果显著的干预措施排序为运动训练(SMD=1.34,95%CI:0.74～1.94)、健康教育(SMD=0.86,95%CI:0.32～1.41)、认知行为疗法(SMD=0.68,95%CI:0.06～1.31)。结论 :非药物干预可以改善肾透析患者抑郁水平,应优先选取规律运动训练、个体化健康教育和针对性的认知行为干预策略等措施降低患者的抑郁水平。     

Topical anaesthesia in haemodialysis: Evaluation of topical anaesthesia with lidocaine during vascular access in children undergoing long-term haemodialysis for chronic renal failure

Türkmen M, Kavukçu S, Soylu A, Ay N, Sevinç N, Sersan R. International Journal of Nursing Practice 1997; 3: 79–83
Topical anaesthesia in haemodialysis: Evaluation of topical anaesthesia with lidocaine during vascular access in children undergoing long-term haemodialysis for chronic renal failure
Children with chronic renal failure are frequently exposed to painful invasive procedures. Ointments containing lignocaine-prilocaine, when used before intravenous punctures, have been reported to lessen the pain sensation. The aim of this study was to interpret the effectiveness of lidocaine 2.5% ointment in preventing pain when used before venous and arterial punctures in children undergoing a haemodialysis programme for chronic renal failure. Eight children were included in this study. The pain level was identified by the patients using a linear analogue scale. When topical anaesthetic and placebo were compared, there was no statistical difference in interpretation of pain during arterial ( P >0.4), venous ( P >0.375) or both ( P >0.4) procedures. We conclude that lidocaine 2.5% ointment is not effective in preventing pain in children undergoing long-term haemodialysis. In these patients some other factors, like psychological factors, puncture technique and needle size must be taken into consideration for the prevention of pain.     

Caring relationship in a context: fieldwork in a medical ward

The aim of this study was to investigate how the caring relationship is formed in a medical context. The data were collected using participant observation with field notes and analysed by an interpretive phenomenological method. The context circumstances in a medical milieu demanded exacting efficiency and risks to oppress the caring relationship, subsequently causing demands in nursing practice. Three themes of the caring relationship were identified as respect for each other and for themselves, responsibility to reach out to each other and engagement. Patients' and nurses' awareness in encounters drove the forming of a caring relationship that went beyond the individual nurse and patient. This study implicates the importance of an understanding of how context circumstances create the foundation of the caring relationship.     

Living as a family in the midst of chronic illness

Aims and objectives

The aim of the study was to illuminate the meaning of lived experience of living as a family in the midst of chronic illness.

Background

Chronic illness implies a change for both the individual and the family. In this changed situation, all family members seem to benefit from sharing experiences and receiving support. Current research highlights the individual patient's or family member's perspectives on chronic illness, but family systems nursing (FSN) studies are warranted.

Design

A qualitative design with a FSN approach was chosen.

Method

Repeated qualitative narrative interviews with seven families living with chronic illness were performed. A phenomenological hermeneutic analysis, inspired by Ricoeur, was used to interpret the data.

Results

The phenomenon can be described as an ongoing movement towards well‐being. The results included two themes and five sub‐themes. The first theme was ‘Co‐creating a context for living with illness’ with the subthemes; ‘learning to live with the expressions of illness’ and ‘communicating the illness within and outside the family’. The second theme was ‘Co‐creating alternative ways for everyday life’ with the subthemes; ‘adapting to a new life rhythm’, ‘altering relationships’ and ‘changing roles and tasks in the family’.

Conclusions

Living as a family in the midst of chronic illness can be described as an ongoing process where the family members co‐create a context for living with illness. They also co‐create a context for alternative ways of everyday life.

Relevance to clinical practice

Knowledge about lived experience of living as a family in the midst of chronic illness can help nurses to adopt a FSN care perspective. This can increase the chances of taking advantage of the ways family members manage situations together, as well as highlight resources within the family.     

FOSIDIAL: a randomised placebo controlled trial of the effects of fosinopril on cardiovascular morbidity and mortality in haemodialysis patients. Study design and patients' baseline characteristics

The prevalence of end stage renal disease (ESRD) is growing in western countries. Patients with ESRD are more frequently elderly and diabetic and are exposed to very high cardiovascular morbidity and mortality. The main aim of the FOSIDIAL study is to assess the efficacy and safety of fosinopril, an angiotensin converting enzyme (ACE) inhibitor, in reducing the mortality and cardiovascular events in haemodialysis patients presenting with left ventricular hypertrophy. A total number of 397 patients are included in the study. They are aged 50-80 years (average 66.7 years) and have been undergoing haemodialysis for 4.8 years. All have left ventricular hypertrophy with cardiac mass index > 100 g/m2 in women and > 130 g/m2 in men, measured within 3 months prior to inclusion. Baseline cardiac mass index is 174 g/m2. After a 2 week placebo period, the patients are randomised into two groups receiving either fosinopril 5-20 mg/day, or a placebo for a duration of 24 months. The target dose is reached at the sixth, seventh or eighth week of treatment. Depending on tolerance, 300 patients reached the maximum recommended dose. Patients are subsequently assessed clinically every 3 months until the end of the study. The primary outcome is a composite endpoint of fatal and nonfatal major cardiovascular events. Secondary endpoints are individual cardiovascular events, event-free survival, overall mortality and all-cause hospitalisations. The trial began in October 1998. All patients were included by December 2000 and follow-up is ongoing. The last visit for the last patient is scheduled for 30 December 2002. We report here on the study design and the baseline characteristics of the study population.     

Hyperhomocysteinaemia and vascular access thrombosis among chronic hemodialysis patients in Taiwan: a retrospective study

Vascular access thrombosis (VAT) is an important cause of morbidity for chronic haemodialysis (HD) patients. Some risk factors for VAT have been well-defined for chronic HD patients from western countries. However, only a few such factors have been confirmed for Taiwanese patients. This study attempted to determine the association between hyperhomocysteinaemia and the incidence of VAT for chronic HD patients in Taiwan. We retrospectively enrolled a total of 196 patients into this study during 2003. The patients were separated into VAT (n = 142) and control (n = 54) group. The participants of the VAT group were identified as those having one or more VAT, and the participants of the control group were those with no VAT in the past. The mean follow-up period was 48 months. The mean serum homocysteine levels were 29.5 +/- 9.6 and 29.1 +/- 9.5 micromol/l for the VAT (n = 142) and the control (n = 54) group, respectively. There was no significant difference in the level of homocysteine between the VAT and the control group (p = 0.70). Female chronic HD patients had significantly greater mean total homocysteine levels than male (30.89 micromol/l, 95% CI 28.84-32.94 vs. 28.06 micromol/l, 95% CI 26.32-29.82, respectively, p = 0.038). That synthetic graft was a significant risk factor for VAT was determined using multivariate logistic regression analysis. There was no association between serum total homocysteine levels and the incidence of VAT in chronic HD patients in Taiwan.     

Pharmacokinetics of single‐dose rosiglitazone in chronic ambulatory peritoneal dialysis patients

Background: End‐stage renal disease (ESRD) is associated with marked alterations in the pharmacokinetics of many drugs, not only from reduction in renal clearance but also from changes in metabolic activity, bioavailability, volume of distribution and plasma protein binding. Objective: To study the pharmacokinetics of a single 8‐mg oral dose of rosiglitazone in patients with ESRD and requiring long‐term chronic ambulatory peritoneal dialysis (CAPD). Method: The medication was administered just before the first exchange of peritoneal dialysis fluid on the day that blood and peritoneal dialysate collection was performed. Results: In our CAPD patients the mean (±SD) T_max and T_1/2 of rosiglitazone were 1·20 ± 0·26 and 21·38 ± 21·96 h respectively. These values were different to those reported for healthy volunteers reported in previous studies. The mean area under the concentration–time curve (AUC_(0–∞)) and an average maximum observed plasma concentration (C_max) of rosiglitazone in our CAPD patients were 4203·56 ± 2916·97 ng h/mL and 409·67 ± 148·89 ng/mL respectively. These appear no different from those reported in healthy volunteers . Conclusion: The apparently significant difference in T_1/2 of rosiglitazone in CAPD patients compared with healthy volunteers suggest that dose adjustment may be necessary in order to avoid toxicity.     

Social isolation: a practical guide for nurses assisting clients with chronic illness.

Social isolation is a serious problem in our society, and the chronically ill are especially vulnerable. The lack of needed and wanted social contacts is a serious source of discomfort that can lead to further health problems. Many factors are involved, including limited mobility, lack of transportation, apparent and hidden disabilities that are socially undesirable, lack of employment, drained relationships with caregivers, changes of social roles, and emotional and psychological stress and dysfunction. Nurses are in a unique position to intervene on behalf of those social isolates. Practical interventions include contacting peer counselors, referring the patient to a support group, helping to rebuild the family network, enhancing the patient's spirituality, helping the patient use Internet-based supports, and practicing the therapeutic use of self Social isolation is a threatening condition for many people, but it has many solutions. In order to provide holistic care, nurses can address this problem on an individual and societal level.     

Breath analysis in patients with end-stage renal disease: effect of haemodialysis

Background There is no agreement about exhaled nitric oxide (FE_NO) and its change after haemodialysis (HD) in end‐stage renal disease (ESRD) patients. To comprehensively assess NO production in the respiratory system, NO metabolites in exhaled breath condensate (EBC) needs to be measured in addition to FE_NO, taking into account the influence on these markers of airway pH, which may be regulated by ammonia (), present in large amounts in the breath of ESRD patients and removed by HD. Study design FE_NO and NO metabolites (NOx, , ), pH and in EBC were measured in 12 ESRD patients, before and after HD. Twelve healthy subjects acted as controls. Results FE_NO values of ESRD patients were similar to normals, while EBC‐NOx, , and pH were significantly higher in ESRD patients compared to normals (EBC‐NOx 12·3, range 11·1–41·9 µm vs. 9·4, range 4·6–10·9 µm , P = 0·007; 4·70, range 1·17–8·22 µm vs. 0·90, range 0·72–1·17 µm , P = 0·023; 2340, range 1325–3922 µm vs. 660, range 406–872 µm , P < 0·001; pH 7·16, range 6·82–7·44 vs. 6·60, range 6·42–6·76, P = 0·004, respectively). HD caused a mild significant decrease of FE_NO, and normalization of , NOx, and pH. A significant positive relationship between EBC‐pH and EBC‐ before and after HD (r² = 0·65, P = 0·000) was observed, explaining higher than normal EBC‐pH before HD, while no relationship was found between EBC‐pH and FE_NO or NO metabolites. Conclusion Oxidative stress, and not EBC‐pH, is the most probable cause of increased NO metabolites in ESRD patients before HD.     

序贯结肠透析治疗早中期慢性肾功能衰竭的临床研究

目的:观察序贯结肠透析对早中期慢性肾功能衰竭(肾衰)患者的疗效。方法:对142例早中期慢性肾衰患者进行序贯结肠透析治疗,并根据其中医辨证分型具体用药,观察其临床症状;同时选取63例慢性肾衰患者作为对照,给予低蛋白饮食 必需氨基酸。观察两组治疗前后血肌酐、尿素氮、尿酸、内生肌酐清除率、K 、N a 、C l-、C a2 、P3-以及中分子物质水平的变化。结果:142例患者中,各种慢性肾衰的临床症状明显好转,血肌酐〔(443.6±73.5)μm o l/L比(283.5±38.7)μm o l/L〕、尿素氮〔(15.3±4.5)mm o l/L比(8.6±3.3)mm o l/L〕、尿酸〔(512.6±86.5)μm o l/L比(243.1±33.6)μm o l/L〕及中分子物质(0.44±0.06比0.32±0.04)水平均显著下降,内生肌酐清除率〔(9.87±3.31)m l/m in比(15.60±4.63)m l/m in〕明显升高,与对照组比较差异也有显著性。两组治疗前后电解质无明显变化。结论:序贯结肠透析对早中期慢性肾衰患者疗效显著,可有效延缓早中期慢性肾衰的进展。     

A structured literature review of pain assessment and management of patients with chronic kidney disease

Aims and objectives. This paper reviews the literature concerning nurses’ assessment and management of pain in adult patients with chronic kidney disease, and proposes implications for clinical practice to support the control of pain in these patients. Background. Chronic kidney disease is a worldwide public health concern with increasing incidence and prevalence, poor patient outcomes and high cost. Patients with kidney disease often experience pain. Optimal pain assessment and management are key clinical activities; however, inadequate pain control by health professionals persists. Renal failure compounds this problem because of the small margin between pain relief and toxicity, and the patient's concomitant health problems. Conclusions. The literature review uses 93 articles that were published in medical‐ and other health‐related journals, including 12 medical and pharmaceutical studies specifically relating to pain control in adults with kidney disease. Very little research has been conducted on pain in patients with kidney disease prior to requiring dialysis or kidney transplantation for survival. However, past research showed pain is common and analgesics are underprescribed in patients on dialysis in end‐stage kidney disease. The review indicates that an interest in nephrotoxicity and analgesic‐induced morbidity dominates over an interest in pain relief in patients with kidney disease. Most analgesics are excreted renally or by the liver, and the use of simple analgesics such as paracetamol is cautioned. Relevance to clinical practice. Findings from the literature review highlight specific difficulties relating to effective pain control in patients with chronic kidney disease. Research is required to identify and overcome barriers to effective pain management, including the development of specific tools to facilitate interventions that optimize analgesic outcomes in patients with chronic kidney disease.