Abstract
Effect of Facility-Sponsored Rehabilitation Activity on Physical Functioning in Continuous Ambulatory Peritoneal Dialysis Patients
Objectives: To assess the effect of facility-sponsored rehabilitation activities (as a component of the overall patient rehabilitation program) on physical functioning in patients receiving continuous ambulatory peritoneal dialysis (CAPD).
Methods: Data on demographic characteristics, record of participating in facility-sponsored rehabilitation activity, and physical functioning were collected for patients receiving CAPD in our program between 1 April 2006, and 31 May 2009. Using the number of instance of a patient's participation in facility-sponsored rehabilitation activities (including group travel, sport game, singing, and garden party), all patients were assigned either to group A (participation more than once) or to group B (no participation). Physical functioning expressed as a Karnofsky performance status (KPS) score was compared before and after follow-up.
Results: The study included 102 eligible patients (34 men, 68 women). At baseline, mean age of the patients in group A was younger than the mean age of the patients in group B (56.21 ± 12.54 years vs. 65.67 ± 10.62 years, p < 0.05), but there were no significant differences in KPS score (84.18 ± 12.43 vs. 82.55 ± 15.10, p > 0.05) or in CAPD vintage (25.15 ± 18.64 months vs. 26.67 ± 15.74 months, p > 0.05) between the groups. During follow-up, KPS score significantly decreased in group B (82.55 ± 15.10 vs. 69.15 ± 18.16, p < 0.05), but did not change in group A (84.18 ± 12.43 vs. 83.27 ± 12.03, p > 0.05). At the end of this study, KPS was higher in group A than in group B (e ± 12.03 vs. 69.15 ± 18.16, p < 0.05). Furthermore, controlled for age, a significantly positive correlation was found between the number of participations in facility-sponsored rehabilitation activities and KPS score in group A (r = 0.312, p < 0.05).
Conclusions: Active participation in facility-sponsored rehabilitation activities may be associated with improvement in physical functioning in chronic CAPD patients.
Treatment and Nursing Care with Peritoneal Dialysis in 7 Cases of Maintenance Hemodialysis Uremia Complicated by Cerebral Hemorrhage
Objectives: To evaluate the effect of peritoneal dialysis (PD) on maintenance hemodialysis (HD) uremic patients (pts) complicated by cerebral hemorrhage, and to improve the success rate of treatment.
Methods: We retrospectively investigated effects and prognosis in 7 pts with maintenance HD uremia complicated by cerebral hemorrhage [confirmed by computed tomography (CT)] who received PD treatment. The dose of PD was 500 – 600 mL each time, slowly increased to 1500 mL within 14 days. The concentration and number of PD exchanges were adjusted to maintain a negative balance of body fluids. Anti-inflammatory, anti–brain edema, intracranial pressure–lowering, and nutrition status–improving treatments were also used. CT images were regularly reviewed to observe changes in hemorrhagic lesions. Nursing involved close observation of vital signs, state of consciousness, dilated pupils, and changes in physical activity, assessed hourly using the Glasgow score. Nursing care included absolute bed rest during the bleeding period, moving pts to avoid bending the neck, and keeping PD fluid warm to prevent chills, to avoid coughing, and to maintain am airway. To prevent increases in intra-abdominal pressure by ultrafiltration, the volume of PD fluid was controlled within 1500 mL. Accurate calculation of the volume of a 24-hour access was important. Mild bodily dehydration was expected. To prevent complications of bleeding or leakage after intubation, maintenance HD pts with poor coagulation underwent PD the day after intubation; local wound bleeding and leakage were managed. To prevent intubation complications (avoid tube drift), slight strengthening of the bed and maintenance of the strength of the stool were necessary.
Results: Two pts died (1 from heavier brain bleeding; 1 from multiple organ failure). One pt was automatically discharged after tube drift. Four pts improved in neurologic symptoms and hematoma absorption with PD treatment. With the exception of 1 pt that returned to HD, 3 pts now on PD at home are in good condition.
Conclusions: In uremia pts complicated by cerebral hemorrhage, PD treatment is a suitable alternative method. PD can improve the treatment success rate in such pts. Close monitoring and capacity management are important to guarantee success.
A Review of Siting the Peritoneal Dialysis Catheter Exit
Introduction: To select an optimal peritoneal dialysis catheter (PDC) exit preoperatively for surgical placement of the PDC with minimal exit-site-related complications.
Ideal PDC exit site: 1. Below the umbilicus; 2. Within the rectus muscle; 3. Away from scars, creases, bony prominences, valleys, ridges; 4. Avoid the belt line; 5. Avoid skin folds; 6. Where the patient can visualize and access for routine exit care; 7. Comply with patient's preference
General guidelines: 1. Know the type of PDC to be placed; 2. Locate the rectus muscle; 3. Assess the abdomen while patient is lying, sitting, standing, and bending; 4. Mark the belt line; 5. Avoid skin creases, scars, bony prominences, umbilicus, and beltline
Equipment for marking the PDC exit site: 1. Marking spot; 2. Permanent marker; 3. Water-soluble pen; 4. 1- to 1.5-inch width bandage or 1-inch width micropore; 5. Explain the procedure to the patient
Method: 1. With patient in supine position, locate landmarks on the abdomen [bony prominences, scars, beltline (apply the bandage/micropore), rectus muscle (draw a line along lateral border)]; 2. Place marking spot so that the proposed PDC exit is located 2 inches below or above beltline and within the rectus muscle; 3. Sit, stand, and bend; assess the site and re-mark it if necessary; 4. Mark the proposed site with permanent marker (discuss with the patient whether the right or left position is to be chosen); 5. Document the siting
Exclusion criteria for marking the exit site above the beltline: 1. Patient uses a wheelchair; 2. Protuberant abdomen (very obese patient); 3. Surgically contraindicated (such as hernia); 4. Physical limitations
Conditions affecting the selection of Tenckhoff PDC exit site: 1. Radiation field on abdomen; 2. Abdominal hernia; 3. Hirsute abdomen; 4. Severe abdominal distention
Problems that may result from improper determination of the exit site: 1. Difficulty in accessing and visualizing the exit site for routine care; 2. Prone to episodes of exit-site infection; 3. Displacement of the cuff of Tenckhoff PDC
Selection of PDC exit site for child: Same as for adult
Selection of PDC exit site for infant: Mark the exit site as for an adult; Principles: Select a site away from the umbilicus (neonate) and avoid a low abdominal site.
Conclusions: Preoperative identification of an optimal PDC exit is crucial in long-term peritoneal dialysis therapy to minimize catheter-related complications.
Management and Education of Peritoneal Dialysis Patients by the Renal Support Team
Objective: Prevalence of peritoneal dialysis (PD) in Japan is only 3.5% of all end-stage renal disease (ESRD) patients (pts). One reason is that pts receive limited information about PD as compared with hemodialysis (HD) from medical staff. We thought that we should provide medical consultation to pre-dialysis pts not only by doctors, but also by all staff as a team. A renal support team was therefore organized, and we evaluated the beneficial effects of our system on ESRD, especially PD, pts.
Methods: Renal support team included doctors, nurses, pharmacists, dietitians, medical engineers, and medical social workers. Team conferences were routinely held to discuss how to manage the ESRD pts. Our team developed an original management guideline. Based on the guideline, nurses and other staff provided advice about diet, daily life, and other issues at each pt's level before the consultation with the doctor. If pts were to receive renal replacement therapy (RRT), they would, even from early-stage ESRD, received precise explanations about the advantages and disadvantages of each modality (PD, HD). After the start of dialysis therapy, guidance from the team continued. Every outcome was recorded in the electronic medical record, so that all staff could see each pt's details and issues. PD pts and their families attended classes to learn about diet, daily technical procedures, catheter management, complications, and regular examinations. We also had regular meetings with a social health visitor in a regional community who cared for the PD pts, aiming to assist PD pts in a social network.
Results: Team consultations were delivered to more than 100 pts, 30 started RRT, and 10 pts selected PD. Almost all cases started smoothly and safely with early education. A few cases had difficulties; however, these were resolved with team advice. All class attendees could understand deeply and also communicate information about PD issues to each other.
Conclusions: To maintain quality of life in PD pts, management and education must start from the pre-dialysis phase, and continue before and after PD start. Thus, our support team provides a great opportunity to select and maintain highly adequate RRT. In addition, our work may bring a regional enlightenment and lead to a greater prevalence of PD in Japan.
Management of a Rapidly Growing Number of Peritoneal Dialysis Patients in a Ward Not Specialized in Nephrology
Our hospital has been the leading cardiology hospital in Japan. More than 10 000 cases undergo coronary angiography and percutaneous catheter intervention every year. Many end-stage renal disease (ESRD) patients treated in our hospital also have severe cardiac disease.
Recently, the importance of residual renal function (RRF) for patient prognosis has been emphasized. To maintain RRF and to improve survival in our patients, we adopted a “peritoneal dialysis (PD) first” policy starting last April. Since then, the number of patients choosing PD as the first treatment modality has been rapidly growing to 50%. Last year, 58 patients (39 men, 18 women; averaged age: 66.7 years) have started PD. This rate is much greater than overall PD utilization rate in our country.
We should educate new PD patients every week; however, our hospital ward is not specialized in nephrology, but also handles hematology and urology. This situation led to a significant paradigm shift in our concept about PD therapy. Now we consider PD not as a highly specialized therapy for selected, motivated patients and expert PD doctors and nurses, but as “ordinary therapy” that almost all ESRD patients should use at the start of dialysis therapy.
Every nurse—even if a non expert in nephrology—should know about this ordinary therapy. We have 40 nurses in our ward, and 31 (78%) can manage and educate PD patients. We also use a clinical pathway and checklist for our patient education program. The greatest benefit of these tools is that they make patient and hospital staff share their care and education plans. Hospital staff can provide same care and education procedures without being influenced by their nursing skill level, and patients can understand their treatment goals at a glance on admission.
Conclusions: The “PD first” policy changed our concept of PD. The clinical pathway and checklist allowed us to achieve standardization of PD education in a non nephrology-specialized ward.
Model Nursing Care on Exit-Site Infection in Continuous Ambulatory Peritoneal Dialysis (PD) Patients Covered by the “PD First” Policy Project in Thailand
In 2002, the Thai government launched a health care scheme in Thailand to cover 48 million people who are not government-related and not private employees. This scheme is “universal coverage” health care. In October 2007, the Thai government officially announced a “peritoneal dialysis (PD) first” policy for people with end-stage renal disease (ESRD) and made it effective 1 January 2008. Currently, more than 3000 new PD patients have received treatment. We studied data from 23 continuous ambulatory PD (CAPD) hospitals (so-called Phase I CAPD hospitals) that had experience with PD before the policy.
Objectives: To demonstrate the model of nursing care in an exit-site-care training program.
Methods: Our descriptive study developed a model of nursing care in an exit-site-care training program based on experience and interviews with CAPD nurses from other hospitals. The model was preliminarily applied in new CAPD patients.
Results: The model that was developed consisted of: (1) a lesson plan, including basic knowledge and various media (VCD, flip chart, PowerPoint presentation); (2) training and practice with demonstrated models (aseptic technique, hand-washing, and wound dressing); (3) review of the techniques and retraining until patients absolutely correctly understood exit-site care. Most patients started their training 1 week after Tenckhoff catheter implantation. The duration of the training course was 3 – 5 days, but a longer duration may be needed in some patients. No centers use mupirocin or other antibiotics applied at the exit site. Most centers use their own checklist for their exit-site training program.
Conclusions: Comparisons of various methods of exit-site care in randomized trials are limited. We demonstrated an exit-site training program for CAPD patients and caregivers.
Model of Home Visit for Continuous Ambulatory Peritoneal Dialysis (PD) Patients Covered by the “PD First” Policy Project in Thailand
In 2002, the Thai government launched a health care scheme in Thailand to cover 48 million people who are not government-related and not private employees. This scheme is “universal coverage” health care. In October 2007, the Thai government officially announced a “peritoneal dialysis (PD) first” policy for people with end-stage renal disease (ESRD) and made it effective 1 January 2008. Currently, more than 3000 new PD patients have received treatment. We studied data from 23 continuous ambulatory PD (CAPD) hospitals (so-called Phase I CAPD hospitals) that had experience with PD before the policy.
Objectives: To develop a model of home visits for CAPD patients.
Methods: A descriptive analytic study was performed to develop a home visit form using home-visit records created by PD nurses from 4 phase I CAPD hospitals.
Results: A Home Visit Program form for CAPD patients covered by the “PD first” policy project in Thailand has been developed. There are 4 categories for assessment of patients during the home visit, including (1) baseline characteristics; (2) environment; (3) self-care (exit-site care, exchange procedure, and PD record of drainage volume); and (4) caregiver.
Conclusions: The Home Visit Program form includes essential activities. The form is expected to predict or discover patient problems. A home visit should be conducted at least twice each year. More frequent visits are suggested in problem cases, such as recurrent peritonitis.
Major Problems during Home Visits for Continuous Ambulatory Peritoneal Dialysis (PD) Patients Covered by the “PD First” Policy Project in Thailand
In 2002, the Thai government launched a health care scheme in Thailand to cover 48 million people who are not government-related and not private employees. This scheme is “universal coverage” health care. In October 2007, the Thai government officially announced a “peritoneal dialysis (PD) first” policy for people with end-stage renal disease (ESRD) and made it effective 1 January 2008. Currently, more than 3000 new PD patients have received treatment. We studied data from 23 continuous ambulatory PD (CAPD) hospitals (so-called Phase I CAPD hospitals) that had experience with PD before the policy.
Objectives: To analyze major problems during home visits for CAPD patients under the “PD first” policy.
Methods: A descriptive study used interviews with PD nurses from 23 phase I hospitals to identify the top three major problems during home visits for CAPD patients. Data were collected during October 2007 – April 2009.
Results: The top three problems were found to be (1) poor sanitization, such as a dirty environment (74%); (2) poor PD technique (65%); (3) PD exchanges performed by an untrained caregiver (48%). Less-frequent problems included an improper PD solution stock area, economic problems, frequent change of caregiver, and psychological depression.
Conclusions: The major problems found during home visits for CAPD patients were discovered to be mainly a result of poor environment and technical problems. These problems may cause PD-related peritonitis and technical failure. Community and educational supports are needed to correct these problems.
Model of Counseling on Modality Selection in Continuous Ambulatory Peritoneal Dialysis (PD) Patients Covered by the “PD First” Policy Project in Thailand
In 2002, the Thai government launched a health care scheme in Thailand to cover 48 million people who are not government-related and not private employees. This scheme is “universal coverage” health care. In October 2007, the Thai government officially announced a “peritoneal dialysis (PD) first” policy for people with end-stage renal disease (ESRD) and made it effective 1 January 2008. Currently, more than 3000 new PD patients have received treatment. We studied data from 23 continuous ambulatory PD (CAPD) hospitals (so-called Phase I CAPD hospitals) that had experience with PD before the policy.
Objectives: To demonstrate a model of counseling on modality selection in CAPD patients covered by the “PD first” policy project in Thailand
Methods: A descriptive study to develop a model of counseling on modality selection in CAPD patients.
Results: We developed this work flow for counseling on modality selection in CAPD patients: (1) patient and family preparation (patient evaluation and selection using the National Health Security Office criteria, including medical criteria and social criteria; medical criteria were checked by a nephrologist, and social criteria were checked by a PD nurse manager and a social worker); (2) home-visit program for a pre-dialysis patient performed by a PD nurse manager, a social worker, and medical personnel from the primary care unit; (3) educational information on modality selection using various media (VCD, flip chart, PowerPoint presentation), including government policy, all modalities, complications; (4) patients suitable for CAPD referred to a nephrologist and renal team to set up Tenckhoff catheter implantation and PD prescription.
Conclusions: We developed a model of counseling on modality selection in CAPD patients. This work flow is easy to use and may help to select only patients suitable for CAPD.
Home Visits in Continuous Ambulatory Peritoneal Dialysis: Problems and Nursing Strategy
Objective: To use home visits to discover the usual problems in home peritoneal dialysis (PD) and to develop corresponding nursing strategies.
Methods: Between Jan 2008 and Dec 2008, 102 CAPD patients [pts: 56 men, 46 women; average age: 70.7 ± 15.5 years; median PD duration: 32 mos (range: 6 – 108 mos)] at our center accepted home visits. Each pt was visited once, and each visit lasted 2 hours. All the visited pts had begun their regular PD treatment more than 6 months earlier. The home visit program included evaluation of the family environment, the concept of asepsis, the techniques of PD, self-management, family support, nutrition, and quality of life. Instructions were given according to the problems found during the home visits, and dialysis prescription was adjusted if necessary.
Results: The CAPD problems found included unsuitable family environment [n = 14,13.7% (2 pts raised pets at home, 6 homes were not clean enough, 6 pts had no separate rooms for doing PD exchanges)]; disinfection of rooms by ultraviolet light not properly achieved (n = 36, 35.3%); and the PD flow sheet was not acceptable (n = 65, 63.7%). Three pts did not wash hands before the exchange; 62 did not use a mouth-muffle. Expired antiseptics and asepsis articles were used by 19 pts; aseptic technique was ignored by 24. Sixteen pts did not calculate ultrafiltration, and 5 pts used overheated fluid. Self-management was not properly achieved in 46% of pts (16 pts did not control intake, 8 pts did not come for a change of transfer set, 23 pts did not accept the evaluation of PD). Nursing strategies included 1-to-1 training on the major problems found, organizing lectures, raising awareness about asepsis, and providing some disinfectant lotion when lotion was expired. Pictures of correct and incorrect methods of PD performance were collected and used for PD training. Pts who continued PD for more than 1 year received repeated training and examinations. Visited pts were compared with pts who had peritonitis (P) and exit-site infection (ESI) during 2007. Results indicated that, in 2007, the incidence of PD-related P was 0.29 per pt–year and the incidence of ESI was 0.09 per pt–year. Visited pts had an incidence of PD-related P of 0.11 per pt-year and an incidence of ESI of 0.04 per pt–year. The incidence of PD-related P was significantly lower after the home visits and guidance by nurses (p < 0.01).
Conclusions: Through regular home visits, we determined that disinfection and isolation were the major problems. By detecting the problems so that pts could be guided, home visits helped to reduce P, ESI, and repeated hospitalizations. They also helped to reduce medical expenditures by families and society.
Clinical Features and Nursing Strategies for Aged Patients on Peritoneal Dialysis
Objectives: To describe the clinical features of aged patients (pts) undergoing peritoneal dialysis (PD) and to summarize the PD nursing strategies for aged pts.
Methods: Clinical data for the pts more than 70 years of age followed in the PD center of Peking Union Medical College (PUMC) Hospital from September 1999 to June 2005 were retrospectively analyzed. Quality of life (QOL) of the pts was measured by the Short Form 36 (SF-36) and Kidney Disease Quality of Life (KDQOL) questionnaires. Nursing processes were reviewed.
Results: Data from 62 pts (age: 74.9 ± 4.9 years; oldest: 86 years; duration of PD therapy: range: 1 to 108 months; median: 23 months; average: 32 ± 27 months) were analyzed. All pts finished a standardized training program with regular follow-up. During therapy, Kt/V and creatinine clearance values declined significantly, and 30 cases of peritonitis were recorded, for an incidence of 1 episode every 67.7 pt–months. There were also 24 cases of exit-site infection, and 2 cases of abdomen hernia. Hospitalization was reported in 18 cases (incidence: 1 in 112.8 pt–months). QOL was measured in 27 aged pts, who scored lower in physical functioning on the SF-36 than did younger pts (39.1 ± 30.4 vs. 58.6 ± 30.2, p = 0.007). However, the scores of the aged pts were not significantly different from those of the younger pts in all other domains of the SF-36 and KDQOL. In 30 pts who died, causes were heart failure (n = 13), lung infection (n = 6), myocardial infarction (n = 5), and cerebral vascular disease (n = 4). The adjustments in nursing procedure for aged PD pts included improving the training program with lower speed and more repetition and practices; emphasizing the psychiatric nursing program; adjusting the PD prescription more frequently and responding to clinical events in time; emphasizing nursing measures to prevent and treat complications such as peritonitis and malnutrition; providing qualified nursing for diseases affecting organs other than kidney (heart failure, lung infection, cardiovascular and cerebrovascular events).
Conclusions: Aged pts can successfully manage PD therapy and achieve good QOL after standardized training. However the prevalence of complications and diseases in organs other than kidney increases in aged PD pts, and specific nursing adjustments are required for dealing with these problems.
Rhuepo Noncompliance is High in Peritoneal Dialysis Patients
Background: Injections of recombinant human erythropoietin (rHuEPO) are needed for peritoneal dialysis (PD) patients to maintain hemoglobin. Compliance with rHuEPO injections is a part of self-management in PD patients. This study examined the rate of rHuEPO compliance and investigated the factors that affected rhEPO compliance in PD patients.
Methods: Noncompliance was defined as use of other than the prescribed dose (10% high or low), missed injections twice each month, or a prescription for dose adjustment not followed. The study enrolled 103 prevalent patients [average age: 59.1 ± 13.1 years; median dialysis vintage: 20 months (range: 3 – 98 months)] from January 2008 to January 2009. Age, sex, dialysis vintage, diabetes, Charlson comorbidity index, and social support were recorded. The rate of noncompliance and factors affecting compliance were reported.
Results: Using the noncompliance definition, the patients were assigned either to a compliance group (n = 64) or to a noncompliance group (n = 39, 37.9%). Patients in the noncompliance group reported more difficulties with rHuEPO injections than did the compliance group, including longer distance from the site of medical service (p < 0.01), self-reported injection pain (p = 0.00), and more side effects related to rHuEPO injection (p < 0.05).
Conclusions: Our study showed that obstacles in rHuEPO injections were related to rHuEPO noncompliance. Strategies such as a change in the type of rHuEPO and improvement in injection technique might be helpful in reducing the rate of rHuEPO noncompliance.
Seasonal Variation of Systolic Blood Pressure Was Improved by Nursing Intervention in Peritoneal Dialysis Patients
Objectives: Elevated systolic blood pressure (SBP) is associated with poor outcomes. Previous studies revealed that SBP has seasonal variations in peritoneal dialysis (PD) patients (pts). The current study used nursing interventions to improve the seasonal variation of SBP.
Methods: Using weather conditions in Beijing, Mar – May, Jun – Aug, Sep – Nov, and Dec – Feb were respectively defined as spring, summer, autumn, and winter. Blood pressure (BP) measurements were taken in each pt in hospital at least once monthly (“white coat” hypertension excluded), and the average BP in each season was calculated. Nursing interventions—increase in the frequency of clinical and telephone visits, especially to pts whose BP changed more at different seasons; telling pts how to correctly monitor BP and reminding them to take anti-hypertension medication regularly; making sure that pts could adjust their medication in time when BP was changed; keeping good emotions, reminding pts to keep warm in the cold season—were given to the pts starting in Nov 2006. The study included 76 pts (26 men, 50 women; average age: 60.57 ± 13.67 years [range: 28.08 – 83.54 years); dialysis vintage: 23.23 ± 17.23 months (range: 3–89.3 months)] with complete information. SBP in each season was compared for Dec 2005 – Nov 2006 and Dec 2006 – Nov 2007. Total Na excretion and total fluid excretion in the same season but in different years were also compared.
Results: Primary causes of end-stage renal disease included diabetes (n = 14, 18.42%), hypertension (n = 10, 13.16%), interstitial nephritis (n = 19, 25%), chronic glomerulonephritis (n = 11, 14.47%), other diseases (n = 16, 21.05%), and unknown (n = 6). SBP was found to be high in winter and low in summer during 2006 – 2007 (2006: 139.30 ± 18.80 mmHg winter vs. 126.70 ± 19.37 mmHg summer; 2007: 130.60 ± 20.83 mmHg winter vs. 123.77 ± 19.02 mmHg summer). Diastolic BP (DBP) did not show any seasonal changes. Compared with 2006, BP in winter, spring, and autumn 2007 declined by 5 – 10 mmHg (p < 0.01). In 2007, total Na and fluid excretion were increased, but the differences were not statistically significant (p > 0.05).
Conclusions: After nursing interventions, seasonal changes of BP improved, but still occurred. The question of whether control of seasonal variation in SBP contributes to better outcome needs to be further elucidated.
Obesity Was Successfully Controlled by Nursing Intervention—Case Report
Background: Because glucose in peritoneal dialysis (PD) fluid brings extra energy, PD patients have a high risk of overweight. As a risk factor, obesity needs to be managed by nursing interventions. A case of PD-associated obesity successfully controlled by nursing intervention is reported here.
Case: A 47-year-old woman had been treated with PD for 1 year, using a daily PD dose of 8 L. At PD initiation, weight was 55 kg, height was 152 cm, and body mass index (BMI) was 23.8 kg/m2. Her urine volume held at 1.2 L daily without edema in both lower limbs. Because of appetite improvement after PD, her body weight and BMI increased to 64.3 kg and 27.8 kg/m2 respectively. The patient felt tired and did only light housework. Her daily protein intake (DPI) was calculated to be 1.27 g/kg, and her daily energy intake (DEI) to be 172.96 kJ/kg (41.28 kcal/kg). Her body weight needed to be managed by diet restriction and physical exercise.
Methods: Using a social function deficiency screening form, the patient was evaluated and introduced to gymnastic exercise. Using a diet guide, the patient was given specific advice concerning diet and helped with self-adjustment. The patient was told how to identify edema and fat accumulation.
Results: The patient's DPI and DEI decreased to 0.65 – 0.88 g/kg and 111.66 – 144.68 kJ/kg (26.65 – 34.53 kcal/kg) respectively. At 6 months after the intervention, her body weight decreased from to 60 kg, BMI decreased to 25.9 kg/m2, and subjective global assessment revealed a patient with good nutrition status. Laboratory tests showed a serum albumin of 41 g/L. Left and right hand-grip strength was 270 N and 280 N respectively. The patient felt full of energy and could take part in social activity. Self-management abilities also gradually improved.
Conclusions: Nursing interventions and patient education are very important in the prevention of obesity in patients on PD.
Nursing Intervention in Peritoneal Dialysis Patients with Diabetic Nephropathy to Balance Capacity
Objectives: Because of nursing interventions for diabetic nephropathy in patients on peritoneal dialysis (PD), these patients know a great deal about volume overload and their own capacity to maintain volume balance to improve the quality of PD and survival.
Methods: We studied 27 PD patients (14 men, 13 women; age: 64.65 ± 9.72 years; average duration of dialysis: 5.76 ± 6.13 months) with type 2 diabetic nephropathy in our hospital from December 2007 to December 2008. Every patient had been on PD for more than 1 month. We established a track record of patient volume. At monthly health talks and collective feedback from individual telephone conversations, patients learn more about water and salt load, and we learn about the capacity of patients to manage the situation. We observed each patient for 3 months to compare changes in capacity. Capacity observed included water intake, edema, blood pressure, weight, blood glucose, serum Na, chest tightness and dyspnea, and improvement in appetite.
Results: Ultrafiltration and urine volume were not significantly different (p > 0.05) after nursing interventions, but 24-hour water intake and serum Na significantly decreased.
Conclusions: PD nurses should pay more attention to the volume in PD patients with diabetic nephropathy and actively seek the reasons for any overload. They should develop an effective and comprehensive system of care and intervention, establish an effective care plan, and establish and improve an effective social support system for patients. With genuine rehabilitation, encouragement, and help, PD patients can enjoy life and achieve their own social value.
Too Late to Begin: Comparison of Diabetic and Nondiabetic Peritoneal Dialysis Duration
Aim: To investigate the physical state of end-stage renal disease (ESRD) patients before peritoneal dialysis (PD) start, and to compare the PD duration in diabetic (DM) and nondiabetic (non-DM) patients.
Methods: We investigated 180 ESRD patients from the PD center of Peking University First Hospital from January 2007 to December 2008. We randomly selected 180 patients (90 DM, 90 non-DM) from among all the hospitalized ESRD patients preparing to start PD. We collected clinical data such as symptoms, comorbidities, medications, and measured serum creatinine (sCr), urea, creatinine clearance (CCr), albumin, hemoglobin, Ca, and P, among other parameters, just before PD start. We compared the two groups in every aspect.
Results: In comparison with non-DM ESRD patients, diabetic ESRD patients had a higher CCr (7.56 ± 3.81 mL/min vs. 5.28 ± 1.90 mL/min, p < 0.05), a lower sCr (657.93 ± 244.36 μmol/L vs. 864.60 ± 326.76 μmol/L, p < 0.05), lower urea (24.20 ± 10.52 mmol/L vs. 29.39 ± 11.92 mmol/L, p < 0.05), and higher hemoglobin (90.38 ± 19.99 g/L vs. 85.60 ± 18.55 g/L, p < 0.05). But compared with non-DM ESRD patients, DM ESRD patients had lower albumin (33.62 ± 5.60 g/L vs. 35.77 ± 6.31 g/L, p < 0.05) and lower serum P (1.62 ± 0.40 mmol/L vs. 1.88 ± 0.62 mmol/L, p < 0.05). In DM ESRD patients, 64.4% (58/90) had complications of cardiac insufficiency, and 18.8% (17/90) needed urgent dialysis as compared with 53.35% of non-DM patients (p < 0.05). Among timely dialysis patients, 89.1% (161/180) were referred from chronic kidney disease programs or pre-dialysis consultation.
Conclusions: The timing of dialysis in ESRD patients was generally late, especially in DM ESRD patients, 64.4% of whom had complications. The program of pre-dialysis management and consultation should contribute a more positive attitude toward dialysis.