Bonomini et al (1985) noted that the optimal time at which the individual concerned can benefit most from commencing renal replacement therapy is controversial
Indeed for some individuals fast-track transplantation is a possibility. Not disputed is the fact that the later in progression of renal failure and the later the patient has access to renal replacement therapy, the poorer the outcome on terms of morality and morbidity rates and quality of life experienced during this period.
Renal patients may be managed as outpatients, on nephrology wards is specialist renal units and in the community. Education regarding
chronic renal insufficiency can begin when the patient first attends the renal clinic. It is difficult to determine when to introduce dialogue regarding renal replacement therapy options in most centres discussions
2
about treatment modalities may begin when the creatinine is in the region
of 400-500 umol/I and when progression to end-stage appears inevitable. In most cases providing there are no medical contra-indications to one particular treatment patients are able to make decisions about their choice of treatment modality. Although complete freedom or range of choice can be limited because of resource implications.
Nurses play a pivotal role in renal care within a multidisciplinary team. Although much of the direct patient care and decision-making regarding patient management may be nurse led. Nurses tend to be at the forefront of patient education. Treatment of renal insufficiency is invasive and unpleasant. The condition and its treatment can effect the patient’s social and family life and their ability to work. Patients have reported that they do not mind who gives them the information that they deem they need, but it is vital that they have a trusting and ongoing relationship with that person, and that the information should not be censured, even though it may be hard to accept at times. As noted by O’Donnel & Turner (1999).
In the early stages of renal insufficiency regulation of diet such as a reduction in salt, potassium and protein, control of fluid intake and use of medications such as antihypertensives and diuretics may minimise symptoms as suggested by Marone (1994).
3
However the benefit of a low protein diet in delaying progression of chronic renal insufficiency is known to be limited. And may lead to the patient starting dialysis in a malnourished state as suggested by Klohr et al (1994). Such treatment will become insufficient as renal function worsens, and when end stage renal insufficiency becomes evident, renal replacement therapy will become necessary to sustain life. The treatment of chronic renal insufficiency can be divided into conservative management and more definitive forms of treatment, including peritoneal dialysis, haemodialysis and renal transplantation. The choice of therapy depends on a number of facts such as a patients overall condition and vascular competence, age, life style, aetiology of renal insufficiency, social support, mental alertness, consultant and patient preference and therapy availability as noted by Coup (1998). Where the onset of end stage renal insufficiency has been gradual, the patient and family may have had time to adjust to the idea of dialysis and make an informed choice about treatment modalities. Patients may initially feel relief at starting dialysis when symptoms of uraemia have been troublesome. However if the onset of dialysis has been sudden an acute crisis phase of adjustment may be experienced, with feeling of shock, disbelief, desperation and depression. Arriving at some level of acceptance is
4
associated with periods of contentment, often alternating with periods of
depression. Fricchine et al (1992). Returning to some previously meaningful activity may often facilitate the adaptation process. Many patients experience feelings of intense hopelessness, in their attempts to adapt to the illness. On one hand patients may wish to be passive and dependant, while being expected by the healthcare team to be active and independent and this may promote a feeling of being “trapped”as stated by Reischman and Levy (1997). It is important to understand that such a process is not always clear cut and individual respond differently to the realities of end-stage renal insufficiency. Levvy (1981).
Individuals with renal insufficiency are likely to appraise aspects of their environment as damaging or potentially threatening. Therefore renal patients faced with the environment of a dialysis unit and the demands of learning complex life sustaining skills may experience feelings of overwhelming stress. Renal care staff who are required to support patients and their families through the transition process to dialysis care must bear this in mind.
Buckman (1992) has suggested that the impact of a particular illness on an individual and his/her family can be difficult to estimate and can
only be assessed in the context of that person’s life.
5
The crisis of illness can also be linked to life transitions which may in turn affect a persons response to illness and care as noted by Wright (a) etal (1993).
Brannon and Feist (1992) suggests that the impact of having a chronic illness not only affects the individual but also the family. A patients understanding of the illness will have an essential importance with regards to their own response and their attitude towards the illness and each other.
Wright (b) etal (1993) recognises that in most chronic illness, the affected individual is first to seek health care, but help must come from within the family setting. Illness affects the family as a whole, and the family affects the individuals response to illness. The nurse must recognise individuals and families as interacting, active wholes. Family health may be defined as a dynamic relative state of wellbeing. Five dimensions have been identified as : biological, pscychosocial, sociological, spiritual and cultural which all combine into a holistic human system. Family nursing advances, continues and reinstates family health.
“All chronic illness potentially includes the loss of bodily control, self identity and close relationships” (Sourkes 1982 p.39).
6
Thomas (1997c) has noted that renal insufficiency may affect both
sexual desire and the ability to engage in sexual intercourse. There are various physical and psychological causes. Some physical causes include hormone imbalance, anaemia leading to tiredness, side affects of medication and vascular problems. Psychological causes may include depression, poor self image/ body image, role changes and lack of confidence in sexual identity. Nurses may feel unable to help at times as they may lack the necessary counselling skills. They may be embarrassed in dealing with patients personal problems or be afraid of causing patient distress. In some pre-dialysis clinics sexual counselling and where appropriate referral to a erectile dysfunction specialist nurse is available.
Dialysis and transplantation affects body image. Patients may feel different, unattractive and ill at ease with their bodies. Access surgery may often result in multiple scarring, involving the arms, chest and abdomen.
Thomas (1997d) states that few patients take all the advice that is given by medical and nursing staff, or follow instructions all the time. This may represent a healthy and adaptive sign rather than otherwise, unless of course, patients put themselves at serious risk. Renal patients have little chance of hiding the fact that they are not following advice. As
7
blood results, blood pressure readings and weight gain will reveal
evidence of under dialysis, diet fluid abuse and failure to take medication if this is the case. Although persistent non-adherence or a maladaptive coping strategy would almost certainly be a cause for concern.
Patients where possible should be encouraged to continue their activities and lifestyle as best they can. As with all individuals advice about smoking and alcohol is recommended.
Employment is often a matter of concern and depending on the nature of their work, the patient should be encouraged to stay in employment providing this is their wish. A period of sickness is almost always required when renal replacement therapy is first commenced. Employers may be prepared for this if there is advanced planning. Referral to the social worker may be appropriate to allow an opportunity to discuss financial and other concerns.
Within the field of nephrology, health care staff have continued to search for ways of understanding factors that potentially shape an individuals ability to adapt to prescribed treatment regimens,
Christenen etal (1996) noted that research into Locus of Control uncovered a complex relationship between perceived control and psychological adjustment. Locus of Control has been suggested to be less important than the patients overall sense of control over life.
8
Bremer etal (1995) has suggested that interventions designed to increase an individuals perception of control are likely to have a positive impact on qualative aspects of treatment. In order to improve a patients potential quality of life, the renal care team must consider his/her sense of agency. When patients see themselves as possessing control over non health aspects of life such as employment and community issues they may respond better to treatment.
The types of stressor and coping methods and their impact on quality of life was the focus of Lok ‘s 1996 survey. This survey revealed limitation of physical activity as the most troublesome stressor for the dialysis patient. Followed by a decrease in social life, uncertainty about the future, fatigue and muscle cramp. Problem solving methods were considered to be more effective than affective measures in dealing with stressors. Quality of life was perceived as below average in both haemodialysis and continuous ambulatory peritoneal dialysis. However, continuous ambulatory peritoneal dialysis patients experience a higher quality of life than haemodialysis patients. The length of time on the dialysis programme was not related to coping behaviour. The findings of this study can further help renal nurses to provide support, information and alternative solutions and to assist the patient to make better use of
problem solving methods to enhance the quality of life on dialysis.
9
In conclusion, further studies could be conducted on chronically ill patients to compare their coping mechanisms and quality of life with those of renal patients. To aid renal nurses to further enhance renal patients’ quality of life and compliment pre-dialysis education.
Chronic renal insufficiency can present with unpredictable and numerous challenges to the patient and their families. Nursing intervention in the psychosocial adaptation process can make a difference to the final outcome. As previously noted, it is recognised that the nurse has the closest contact with the renal patient. As part of the multidisciplinary team an astute and caring nurse may be able to positively alter the patients negative perception of their illness, themselves and responses of others.
