Brief Resume of the Intended Work

A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE[SIM] ON KNOWLEDGE OF CRF PATIENTS’ REGARDING DIETARY REGULATIONS SUBJECTED TO HEMODIALYSIS IN A SELECTED HOSPITAL.

M. Sc Nursing Dissertation Protocol submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

By

Mr.ANU AMBAT

M .Sc NURSING 1ST YEAR

2010-2012

Under the Guidance of

Mrs.kalaivani MSc Nursing

HOD, Department of medical surgical Nursing

Nightingale College of Nursing

Guruvanna Devara Mutt

Near Binnyston garden

Bangalore –23.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / Mr.ANU AMBAT
I YEAR M.Sc. NURSING,
NIGHTINGALE COLLEGE OF NURING
GURUVANNA DEVARA MUTT, NEAR BINNYSTON GARDEN,
MAGADI ROAD
BANGALORE-23
2 / NAME OF THE INSTITUTION / NIGHTINGALE COLLEGE OF NURING, GURUVANNA DEVARA MUTT, NEAR BINNYSTON GARDEN, MAGADI ROAD,
BANGALORE-23
3 / COURSE OF STUDY AND SUBJECT / M.sc nursing IN MEDICAL SURGICAL NURSING
4 / DATE OF ADMISSION TO THE COURSE / 15/09/2010
5 / TITLE OF THE TOPIC:
A STUDY TO ASSESS THE EFFETIVENESS OF SELF INSTRUCTIONAL MODULE[SIM] ON KNOWLEDGE OF CRF PATIENTS’ REGARDING DIETARY REGULATIONS SUBJECTED TO HEMODIALYSIS IN A SELECTED HOSPITAL.
6.0 / BRIEF RESUME OF THE INTENDED WORK:
7
8 / INTRODUCTION
Renal disease is one of the most common health problems seen now days. Incidence of chronic renal failure varies among states and countries. Men and women are equally affected by the problems. Incidence is highest among middle aged people.1
Progressive deterioration of renal function eventually develops over a period of years. There is an increasing evidence that dietary regulations impact on risk of developing chronic kidney disease and the risk of progression of CKD Equally important is the consideration that patient with CKD are more likely to die from cardiovascular disease than to reach the End stage renal failure.2
The purpose of this diet is to maintain a balance of electrolytes, minerals, and fluid in patients who are on dialysis. The special diet is important because dialysis alone does not effectively remove all waste products. These waste products can also build up between dialysis treatments. Most dialysis patients urinate very little or not at all. Therefore, fluid restriction between treatments is very important. Without urination, fluid will build up in the body and lead to excess fluid in the heart, lungs, and ankles.3
Hypertension in patient who has diabetes should be managed aggressively; the goal of less than 130/80 mm of Hg should be attained if clinicians seek to reduce cardio- vascular morbidity and mortality for these patients.
The balance of blood chemistry is fundamentally affected by nutrition and the dietary intake of specific nutrient. Therefore the management of renal patient includes dietary restriction and regulation. Initial management aims to lower blood urea level, balance electrolytes, lower plasma phosphate level and regulate fluid balance. Along with other conducive factors diabetes is at least moderately modifiable so adequate treatment may protect the renal system andameliorate or prevent further renal damage.5
Dietary regulations like adequate in protein, adequate in calories, low to moderate in potassium, low in sodium, low in phosphorus, controlled in fluids, weight reduction increased physical activity may help a lot, cessation of smoking alone can decrease kidney failure by as much as 30 percent.6
6.1 NEED FOR STUDY
The American Diabetes Association clinical practice recommendation note that between 20-30% of people with type I and type II diabetes shows increased incidence of nephropathy although a considerably smaller fraction of those with type II progress to ESRD.7
A research made for researchable factors says that correction of those factors like hypertension, urinary tract infection, urinary tract obstruction nephrotoxic medication will result in improved renal function.8
Risk reduction measures taken to present complication like cardio vascular disease may also help delay in progression of ESRD. Researcher Keeth and collegues found and concluded that prevention and treatment of diabetes and hypertension and others co morbidities are vital.9
6.2REVIEW OF LITERATURE
INTRODUCTION
Review of literature is a key step in the research process. Review of literature is an extensive, exhaustive and systematic examination of publications, relevant to the research project. Review of literature is an important source for development of research problem. It helps to gain insight into the research problem and provides information of what has been done previously. It helps the researcher to be familiar with the existing studies and also provides basic for Research design, methodology, and tool for data collection.
Literature review is a complication of resources that provides the ground work for the further study. (Talbott, 1995). One of the most satisfying aspects of the literature review is the contribution it makes to the new knowledge insight and general scholarship of the researcher. Chronic kidney disease is otherwise referred as chronic renal failure.10
The review of literature for the present Study will be done on diet regulations of hemodialysis client’s from published articles, textbooks, reports, newsletters, pub med and internet search. The reviewed publications have been organized and presented as follows:
a)Literature related to dietary regulations for CRF patients’ in hemodialysis:

Stark, Susan (MS, RD, CSR); Snetselaar, Linda PhD, RD; Hall, Beth RD; Stone, Roslyn A. PhD; Kim, et all conducted a study in England on 2008 about Nutritional Intake in Adult Hemodialysis Patients As research pertaining to the nutritional intake of hemodialysis patients is limited, this pilot project was designed to describe the nutritional quality of foods consumed by hemodialysis patients and variation by day of the week. Dietary recalls were obtained from 22 hemodialysis patients and analyzed using the Nutrition Data System for Research. Few statistically significant differences were found by day of the week, but several dietary deficits were noted. The data suggest poor intake of calories, protein, and several vitamins and minerals, as well as excess sodium consumption. Additional research is needed to document dietary patterns of hemodialysis patients.11

Guzzo I,Mancini E,Wafo SK,Ravà L,Picca S. Conducted a study in UK on 2009 Residual renal function (RRF) has been associated with a better nutritional status in adult patients on chronic dialysis. We have retrospectively analyzed 3-day dietary reports and simultaneous urea kinetic monitoring data (n = 179) of 30 children,
adolescents and young adults on chronic HD. The protein catabolic rate (PCR) was calculated and normalized by body weight (nPCR).In children, adolescents and young adults on chronic HD treatment, RRF positively affects nutrition independently of HD efficiency and rhGH treatment.12
Mayers JD conducted a qualitative study in UK on 2010 about Dietary restrictions in maintenance hemodialysis: experiences of English speaking West Indian adults. Dietary therapy is a critical component of the hemodialysis prescription. The purpose of this qualitative study was to investigate and describe the lived experience of dietary restrictions in English-speaking, West Indian (WI) adults on maintenance hemodialysis. A phenomenological approach using open-ended interviewing strategies was employed. The findings from this study will add knowledge and understanding in caring for the renal failure population as their numbers continue to increase within this ethnic group.13
Fouque D,Laville M conducted a study in France on 2008 about low protein diets for chronic kidney disease in non diabetic adults. For more than fifty years, low protein diets have been proposed to patients with kidney failure. However, the effects of these diets in preventing severe kidney failure and the need for maintenance dialysis have not been resolved. Statistical analyses were performed using the random effects model and the results expressed as risk ratio (RR) for dichotomous outcomes with 95% confidence intervals (CI). Collection of the number of "renal deaths" defined as the need for starting dialysis, the death of a patient or a kidney transplant during the study ten studies were identified from over 40 studies. Reducing protein intake in patients with chronic kidney disease reduces the occurrence of renal death by 32% as compared with higher or unrestricted protein intake. The optimal level of protein intake cannot be confirmed from these studies.14

Jerrilynn DBurrowes, PhD, RDJerrilynn DBurrowes, PhD, RD,BrettLarive, MS,David BCockram, PhD, RD et all coducted a cross sectional study in new York on 2009 about Effects of dietary intake, appetite, and eating habits on dialysis and non-dialysis treatment days in hemodialysis patients: the mean weight-adjusted DEI for the entire cohort was less than the HEMO study standard of care (SOC) of ≥28 kcal/kg/day, whereas on NDD, several subgroups reported dietary protein intakes that were closer to the study’s SOC. These included men, patients under 50 years of age, nonblack participants, those without diabetes, those with a normal or mild Index of Co-Existing Disease score, and those on dialysis for more than 5 years. Protein and energy intakes declined with worsening self-reported appetites in both DD and NDD after adjusting for other subgroup effects. Dietary energy and protein intakes of HEMO study participants were lower on DD than on NDD, and also lower than the SOC on both days, particularly with regard to energy intake.15

b)Literature related to regarding CRF patients in hemodialysis:
Segall L,Covic A,Mardare N,Ungureanu S,Marian S,Busuioc M,et all conducted a study in spain on 2008 about Protein-calorie malnutrition is a common complication and an important predictive factor for mortality in patients with end-stage renal disease on maintenance dialysis. Therefore, nutritional status needs to be regularly assessed in these patients by using several methods. if malnutrition is diagnosed, its causes should be thoroughly searched for and properly treated. Biochemical tests included protein equivalent of nitrogen appearance (nPNA), and predialysis serum albumin, creatinine, total cholesterol, bicarbonate, and hemoglobin levels. We used BIA to estimate body composition – In hemodialysis patients, advancing age, diabetes, heart failure and decreasing Hb levels are associated with worse nutritional status, as estimated by anthropometry, biochemical markers and BIA. Whether treatment of co morbidities such as heart disease and anemia may improve nutritional status in these patients is an important issue that deserves further research.16
Supasyndh O,Satirapoj B,Seenamngoen S,Yongsiri S,Choovichian P,Vanichakarn S.et all conducted a study in Thailand on 2009, in that the study background is Multiple lines of evidence have indicated that the dose of hemodialysis (HD) affects patient outcome. However in developing countries,
about three-fourths of end stage renal disease patients undergo twice-weekly HD. No data studied the outcome and nutritional status between twice- and thrice-weekly hemodialysis patients.17
Zuniga San Martín C,Dapueto P J,Muller O H,Kirsten L L,Alid A R,Ortiz M L. A study conducted in Spain on 2009 regarding health-related quality of life among patients on chronic hemodialysis ,is associated with mortality, complications and compliance to treatment.In patients on hemodialysis had values below the referential score in subjects with diabetes and coronary artery disease, poor nutritional status and a low educational and socioeconomic level. The incorporation of support professionals, such as social workers, psychologists, dieticians, covering psychosocial factors, could improve the patient’s quality of life.18
Ewers b,Riserus u,Marckmann p. in Denmark on 2009 examined the effects of commercially available unsaturated fat dietary supplements on blood lipids, and on markers of malnutrition and inflammation, in an adult population of hemodialysis patients. the results is according to a per-protocol analysis of 14 study completers, fat supplementation resulted in significantly increased total energy intake (+1.6 ml/day, or 380kcal/day) and an increased dietary fat energy percentage (+9%). we observed no significant changes in blood lipids. dry body weight (+0.49kg, p=.04) increased, and serum c-reactive protein concentration fell (-1.69mg/l, p=.01), with fat supplementation. intention-to-treat analysis of 39 participants confirmed the absence of adverse blood-lipid changes. unsaturated fat supplentation increased total dietary energy intake to
recommended levels, had no adverse impact on blood lipids, improved nutritional status as assessed according to dry body weight, and reduced systemic inflammation as assessed according to c-reactive protein serum concentrations.adding unsaturated fat to the diet seems to be a safe and way to prevent and treat malnutrition in hemodialysis patients.19
Kannampuzha J,Donnelly SM,McFarlane PA,Chan CT,House JD,et all conducted a study in Canada on2010 regarding patients on conventional hemodialysis have elevated markers of oxidative stress and chronic inflammation, which may contribute to a high prevalence of cardiovascular disease. Glutathione (GSH), an important intracellular antioxidant, requires cysteine as a rate-limiting amino acid for its synthesis and riboflavin for its regeneration.There were no significant differences among groups in eGSH concentration, EGRAC, dietary protein intake, and SGA score. SHD patients had significantly higher plasma Cys (P < .001) and Hcy compared with HNHD and HC groups (P 0 .048). Vitamin C was significantly lower (P = .01) and CRP significantly higher (P =0.048) in both HD groups compared with HC.eGSH concentration appears to be unaffected by dialysis dose in well-nourished HD patients.20
MacLaughlin HL,Cook SA,Kariyawasam D,Roseke M,van Niekerk M,Macdougall IC conducted a study in London on 2009 regarding Obesity increases the comorbidity-adjusted relative risk of developing end-stage renal disease. Body mass index (BMI) > 30 kg/m(2) was a contraindication for transplant in our renal unit until 2008. The weight-management program group showed significant weight loss and weight-loss maintenance in obese patients with CKD and potentially enables obese patients with CKD to undergo kidney transplant.21
Niemczyk S,Sikorska H,Wiecek A,Zukowska-Szczechowska E,Załecka K,Gorczyńska J et all conducted a study in Poland on 2010 regarding chronic kidney disease is frequently associated with protein-energy wasting related to
chronic inflammation and a resistance to anabolic hormones such as insulin and growth hormone (GH). In this study, we determined whether a new GH-releasing hormone Super-agonist (AKL-0707) improved the anabolism and nutritional status of no dialyzed patients with stage 4-5 chronic kidney disease randomized to twice daily injections of the super-agonist or placebo. After 28 days, this treatment significantly increased 24-h GH secretion by almost 400%, without altering the frequency or rhythmicity of secretary bursts or fractional palatial GH release, and doubled the serum insulin-like growth factor-1 level. There was a significant change in the Subjective Global Assessment from 'mildly to moderately malnourished' to 'well-nourished' in 6 of 9 patients receiving AKL-0707 but in none of 10 placebo-treated patients. By dual-energy X-ray absorptiometry, both the mean fat-free mass and the body mineral content increased, but fat mass decreased, all significantly. In the AKL-0707-treated group, both serum urea and normalized protein equivalent of nitrogen appearance significantly decreased with no change in dietary protein intake, indicating a protein anabolic effect of treatment. Thus, our study shows that stimulation of endogenous GH secretion by AKL-0707 overcomes uremic catabolism of patients with advanced chronic kidney disease.22