PROFORMA FOR REGISTRATION OF SUBJECT
FOR DISSERTATION
SHIJI MATHEW
1st YEAR M.Sc. (NURSING)
MEDICAL SURGICAL NURSING
YEAR 2012-2014
ST. PHILOMENA’S COLLEGE OF NURSING
#4 CAMPBELL ROAD, VIVEKNAGAR P. O
BANGALORE 560047
0
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS
FOR DESSERTATION.
1 NAME OF THE CANDIDATE AND ADDRESS MS. SHIJI MATHEW
ST. PHILOMENA’S COLLEGE OF
NURSING,#4 CAMPBELL
ROAD,VIVEKNAGAR P.O
BANGALORE -560047
2 NAME OF THE INSTITUTION ST. PHILOMENA’S COLLEGE OF
NURSING.
3 COURSE OF THE STUDY AND SUBJECT M.SC NURSING
MEDICAL SURGICAL NURSING
4 DATE OF ADMISSION TO COURSE 04.JUNE.2012
5 TITLE OF THE TOPIC “A STUDY TO ASSESS THE EFFECT OF
INTRADIALYTIC ISOMETRIC
STRETCHING EXERCISES ON FATIGUE
AND GENERAL MYALGIA AMONG
PATIENTS UNDERGOING HEMODIALYSIS
IN A SELECTED HOSPITAL,BANGALORE.
1
6. BRIEF RESUME OF THE INTENDED WORK
6.1. NEED FOR THE STUDY
“Fatigue is here, in my body, in my legs and eyes. That is what gets you in the end. Faith
is only a word, embroidered.”
― Margaret Atwood, TheHandmaid's Tale
Chronic renal failure, which is otherwise known as End Stage Renal Disease is
the most common chronic disease that is budding up in the world today. The body
equilibrium is maintained when an individual take adequate amount of food and when his
body excretes the waste materials accordingly. When the kidney fails to function
appropriately it results in chronic renal failure. As a result there will be accumulation of
toxic wastes in the body which can affect other systems also.1
Around 2,786,000 people are affected by chronic renal disease worldwide.2 In
Australia, a survey done from 1991-2009, it was concluded that there was an increase in
the number of renal patients that is from 13% to 33%3. Also in USA in 2002, new
patients per year were 80,000 which had increased to 30 million by 2010.4According to a
survey conducted in 2004 including 122 countries,92% of the population is affected by
renal disease, out of which 99%are taking treatment. In India the incidence of renal
2
failure is increasing to higher rates. According to study conducted in India in 2010,almost
7.85 million people out of 1 billion population are suffering from chronic renal
failure.4More than two lakh patients who are suffering from renal failure in Karnataka.
Chronic renal disease is becoming more prevalent worldwide due to lifestyle,
hereditary and improper life practices. Poorly controlled diabetes and increased blood
pressure increases the risk of chronic kidney disease. According to National kidney and
urologic disease information clearing house, 1,80,000 people in US is affected with
chronic kidney disease as a result of diabetes.5According to a case control study
conductedin Virginia, 42% of both insulin dependent and non-insulin dependent diabetic
patients are at high risk for end stage renal disease than non-diabetic persons.6
The ultimate treatment of chronic renal disease is dialysis. Dialysis helps to
improve the health standards of the patients and thereby increases the life span into few
more years. Now there are2,164,000 patients worldwide who are undergoing dialysis as a
treatment for ESRD. Out of that1,9,29,000 patients is undergoing hemodialysis (89%)
and 2, 35,000is taking peritoneal dialysis (11%).7
In India, only 16.2%of the ESRD patients are getting peritoneal dialysis as
treatment.8Majority of ESRD patients that is around 20,000patients receive
3
hemodialysis.9In Karnataka it is noticed that 20.27%of patients will have continuous
hemodialysis and rest of others will fail to follow up.
Though hemodialysis plays a vital role as life saving procedure, it also has many
side effects and complications. The main side effects that are prevalent in the
hemodialysis are fatigue, muscle cramps, hypotension, fluid overload, nausea, vomiting,
headache and general myalgia.10Many End Stage Renal Disease (ESRD) patients
experience debilitating fatigue. Fatigue can be a continuum from extreme tiredness to
high energy. Deteoriation of health is common phenomenon among patients who are
undergoing dialysis. They suffer from high fatigue and pain due to frequent puncturing of
fistula. During 2009, kidney news reported that a recent study conducted by Jhamb M
revealed that 60-97%dialysis patients suffered from fatigue.11 The importance of fatigue
to patients with kidney disease is underscored by the observation that 94% of
hemodialysis patients endorsed a willingness to undergo frequent dialysis if there would
be an associated increase in energy level whereas only 19% is not willing for
hemodialysis due to fatigue.
According to United States Renal Data System 2003, annual data report 2,87,494
people in USA has undergone dialysis.12Among them 95% is reported to have fatigue and
there were 55%complaints of general myalgia in dialysis. The present cross-sectional
study was conducted from January to April 2009, in three hemodialysis units in Kuala
Lumpur and Malaysia. In this study the multidimensional fatigue inventory and
4
depression anxiety and stress score were used to determine the level of fatigue,
depression, anxiety and stress of hemodialysis patients. The data were obtained from a
sample of 116. A total of 56(54.4%) and 47(46.6%) respondents experienced a high level
and a low level of fatigue respectively.13
According to UCL discovery, dialysis patients show different symptoms due to
dialysis. The study was conducted among 550 hemodialysis patients and the study
revealed that 82% of the patients suffered from fatigue and 75% of the patients suffered
from pain.14Thesetwo were the most prominent symptoms that have been highlighted in
the study. According to survival debate conducted in Japan, Asian Americans will have
lower surviving rate than Japanese. The fatigue observed in patients who underwent
dialysis usually associated with an impaired quality of care. In India, the studies proved
that the dialysis patients will be suffering from severe fatigue of 44.7%.15
In order to overcome the general myalgia and fatigue certain exercises are in
practice rather than the medications. Several exercises have found out to be effective in
relieving fatigue and general myalgia. There are researches conducted to see the
effectiveness of graded exercises and other therapies on fatigue and myalgia. The result
shows that 84%of the participants were improved by graded exercises.90%myalgia can
be improved by the exercises.
5
According to studies it is proved that exercise can improve the muscle strength
which in turn will improve cardiovascular function and quality of life. As there are lots of
limitation placed on physical inability in renal patients isometric stretching exercises are
best suited to improve muscular strength which in turn improves the level of muscle
atrophy and fatigue in 95.7%of dialysis patients.16
Researcher came across complaints of fatigue and pain due to continuous
hemodialysis in many patients. Patients were not able to cope up with fatigue and pain
that affected the quality of life. Also the above mentioned studies and statistics prove the
prevalence of fatigue and pain in dialysis patients’ worldwide. All these combine
influenced the researcher to choose this topic for research study.
6.2. REVIEW OF LITERATURE:
A literature review is a broad, comprehensive , in depth, systematic and critical review of
scholarly publication which is related to topic.17
Review of literature in this study is organized under the following titles:
Literature related to
1 Prevalence of renal disease.
2 Impact of hemodialysis on patients with renal disease.
3. Fatigue and general myalgia on hemodialysis patients.
6
4. Effectiveness of exercises on intradialytic patients.
5. Effectiveness of isometric stretching exercise.
6.2.1 LITERATURE RELATED TO PREVALENCE OF RENAL DISEASE
Cohort study was conducted to assess the prevalence of chronic kidney disease
and progression of disease over time among patients enrolled in Houston West Nile .139
samples were selected. Prevalence was assessed by kidney disease outcomes quality
initiative criteria and urinary abnormalities. Result was 40% of participants had evidence
of Chronic Kidney Disease, 10% were in stage 3 or greater while 30% were in stage 1 or
2.There was an average change in GFR -3.7 ml/mt.18
A retrospective study was conducted to assess prevalence of chronic kidney
disease in population. A systematic review of 26 published data that is available in
MEDLINE was included. The studies were conducted in different population and the
number of participants ranged from 237-65181. The median prevalence of CKD was
7.2% in persons aged 30 years or older. Patients aged 64 years or older, the prevalence
was 23.4% to 35.8%. 9.35%were seen in men and 13% in women. African Americans
had a lower prevalence than Asians.19
7
To assess the prevalence of chronic kidney disease and its association with risk
factors in disadvantageous population, a cross sectional study comprised of 1000 samples
of age between 15-65 years were selected. Serum creatinine was measured by alkaline
pirate method and GFR by using Cockcroft-Gault and Modified Dietary Rrestriction
Diet. The analysis discovered that 13.1% of participants were detected to have chronic
kidney disease by MDRD and 16%had chronic kidney disease by Cockcroft-Gault
equation. Also 4.1% of participants were detected to have diabetes, 11.6% had
hypertension and 7.7%have proteinuria.20
6.2.2 LITERATURE RELATED TO IMPACT OF HEMODIALYSIS ON
PATIENTS WITH RENAL DISEASE:
A study was conducted to measure the quality of life of the dialysis patient. A
convenient sampling method was used to recruit patient from the outpatient units of
dialysis centre.Pearsons product moment correlation was used to examine the relationship
between the demographic variables and the overall quality of life score .The mean of the
total score was 132.5 with SD 16.68 varying between 97-179.The items means score was
3.34.21
A cross sectional study was conducted to explore the association of emotional
regulation strategy, preappraisal , suppression and their impact on patient wellbeing and
8
kidney disease management. With 106 samples of hemodialysis patients undergoing renal
replacement therapy and 94 friends or relatives were selected for the study. Outcome
parameters were measured using positive and negative affect scale, the Brief COPE
questionnaire and Brief symptom inventory. Suppression was associated with less
emotional coping (r=-0.29 p<0.01) and greater dissatisfaction with support received from
other people. (r=-0.34 P, 0.01).22
6.2.3 LITERATURE RELATED TO FATIGUE AND GENERAL MYALGIA ON
HEMODIALYSIS PATIENTS
A study was conducted in India in tertiary center to assess the prevalence of
fatigue, sleeplessness and their association among hemodialysis patients and their co-
relation with frequency and duration of hemodialysis. Convenient sampling
of47patientswasdoneand study was for more than 3 months of duration. The result
showed 68.1%of the patients are poor sleepers and 44.7% reported fatigue, 59.7% had
moderate depression and 12.6% had severe depression.23
A randomized cross over multicenter study was done to assess the fatigue in
hemodialysis patients with and without diabetes mellitus.30 hemodialysis patients were
taken as samples. Theywere asked to take dialysate glucose G200 and G100along with
the medicine. Fatigue was assessed by fatigue severity scale.Results showed that fatigue
9
was more in diabetes patients, G200=5.0+1.0, G100=4 compared tonon-diabetes patients
G200=3.5+2, G100=3.0+2.24
To assess the prevalence, cause, severity and management ofpain a prospective
cohort study was conducted with 205 Canadian hemodialysis patients. A complete
questionnaire incorporated with brief pain inventory followed by McGill pain
questionnaire was used. The result was 103 patients that are 50% had suffered from pain.
Patients with longer hemodialysis therapy had pain than patients with shorter dialysis
period.25
6.2.4 LITERATURE RELATED TO EFFECTIVENESS OF EXERCISES ON
INTRADIALYTIC PATIENTS
Twelve hemodialysis patients were selected to perform incremental constant work
rate cycle exercises test to determine endurance time, peak work rate, lower extremity
strength, power and fatigability. At the end of the study the endurance level increased
to144%.Quadriceps strength, power and fatigability increases to 16%, 15% and 43%
respectively.26
.
Databases from the year of 2005-2009 which were collected from CINAHL,
MEDLINE, MedicLatina, SportDicus were reviewed to assess the effectiveness of
exercise on hemodialysis patients.640 patients were included in 16 studies. Standard
10
mean deviation was used to summarize the effects of exercises.Moderate evidence exists
on positive effects of aerobic training on peak oxygen consumption at the graded exercise
test (SMD 6.55; CI 95%: 4.31-8.78). There is high evidence on positive effects of
strength training on health related quality of life (SMD 11.03; CI 95%: 5.63-16.43).27
The researcher conducted a blind placebo controlled study on hemodialysis
patient with erythropoietin on aerobic exercise and muscle strength. The intervention was
progressive isotonic exercises and ergometric exercises for experimental group for 12
weeks and 5 months. While control group underwent non progressive exercises. They
inferred that the mean score on the physical function subscale of short form of 36 of 76 of
100. The exercise programme improved physical impairment measures and general
myalgia but had no effect on quality of life.28
6.2.5 LITERATURE RELATED TO EFFECTIVENESS OF ISOMETRIC
STRETCHING EXERCISE:
A randomized pilot trial study was done to measure the effect of intradialytic low
intensity strength training or stretching exercises which was conducted twice weekly. A
totalof 48 sessions of exercise program were given for 50 participants of age 69 ± 13
11
years who is receiving hemodialysis for 3-4years.The measurement was done with base
line median short physical performance battery score.ShortPhysical Performance Battery
score showed improvement in strength training group when compared to control group
with scores of 21.1% vs. 0.2%respectively.29
The purpose of the study was to investigate the hypothesis that reductions in Na+,
K+, ATPase activity are associated with neuromuscular fatigue following isometric
exercise. These results demonstrate that Na+, K+, ATPase activity is reduced by sustained
isometric exercise and this is due to loss of excitability30
Above mentioned studies gives the evidence of patients undergoing hemodialysis
suffers from fatigue and general myalgia which had become the inevitable part of their
life.
6.3. STATEMENT OF THE PROBLEM:
“A STUDY TO ASSESS THE EFFECT OF INTRADIALYTIC ISOMETRIC
STRETCHING EXERCISES ON FATIGUE AND GENERAL MYALGIAAMONG
PATIENTS UNDERGOING HEMODIALYSIS IN A SELECTED HOSPITALS IN
BANGALORE”.
12
6.4. OBJECTIVES OF THE STUDY
The objectives of the study are to:
1. assess the level of fatigue and general myalgia among hemodialysis patients.
2. assess the effect of intradialytic isometric stretching exercises among hemodialysis
patients.
3. associate the effect of intradialytic isometric stretching exercises on fatigue and general
myalgia with selected demographic variables.
6.5. HYPOTHESIS:
H1: There will be a statistically significant difference in the level of fatigue following
intradialytic isometric stretching exercises as measured by fatigue scale,p<0.05 level of
significance.
H2: There will be a statistically significant difference in the level of general myalgia
following intradialytic isometric stretching exercises as measured by general myalgia
scale<0.05 level of significance.
H3: There will be a statistically significant association between the level of fatigue
following intradialytic isometric stretching exercises with demographic variables<0.05
level of significance.
13
H4: There will be a statistically significant association between the level of general
myalgia following intradialytic isometric stretching exercises among hemodialysis
patients.
6.6. OPERATIONAL DEFINITION OF TERMS:
EFFECT:
In this study, it refers to the desired change in level of fatigue and general myalgia
following intradialytic isometric stretching exercises among hemodialysis patients.
INTRADIALYTIC ISOMETRIC STRETCHING EXERCISES:
It refers to the type of static exercise where the patient perform isometric
resistance of the muscle groups and researcher opposes with mild stretching for a period
of 7-15 seconds followed by relaxation for 20 seconds during 2 hours of dialysis.
FATIGUE:
In this study, it refers to physical and mental exhaustion triggered by repeated
cycles of dialysis.
14
GENERAL MYALGIA:
General myalgia is a generalized body pain associated with metabolic changes in dialysis
patients.
6.7. ASSUMPTIONS
The study is based on the following assumptions:
Fatigue and general myalgia is common among dialysis patients.
Intradialytic isometric stretching exercises minimizes general myalgia and fatigue among
hemodialysis patients.
6.8. DELIMITATIONS:
The study is delimited to:
Patients undergoing dialysis in St. Philomena’s Hospital.
7. MATERIALS & METHODS:
7.1. SOURCE OF DATA:
Hemodialysis patients in St .Philomena’s Hospital, Bangalore.
7.1.1 Research Design:
15
Pre experimental one group pretest posttest research design is selected to conduct study.
E
O2
E: Experimental group; hemodialysis patient.
O1:pretest;level of fatigue and general myalgia
X:Treatment;intradialytic isometric stretching exercises
O2:posttest; general myalgia and fatigue level
7.1.2 Settings:
The study will be conducted in hemodialysis unit of St.Philomena’s hospital whichis a
500 bedded hospital with 8 bedded hemodialysisunit with 16patients undergoing
hemodialysis everyday.
7.1.3Population:
Patients undergoing three cycles of hemodialysis in a week in the hemodialysis unit of St.
Philomena’s hospital, Bangalore.
7.2 METHODS OF DATA COLLECTION
7.2.1 Sample Size:
The sample size consists of 30 hemodialysis patients who satisfy the sample selection
criteria.
16
E:EXPERIMENTAL GROUP
Hemodialysis patients
O1: PRE TEST
Level of fatigue and general myalgia
X: TREATMENT
Intradialytic isometric stretching exercises
O2: POST TEST
Fatigue and general myalgia level
7.2.2 Sampling Technique:
Non probability, convenient sampling technique.
7.2.3 Inclusion Criteria:
The clients who are
between the age group of 20 to 60 years.
Undergoing more than three cycles of hemodialysis in a week.
able to read and write in English, Tamil, Hindi or Kannada.
willing to participate in the study.
7.2.4 Exclusion Criteria:
The clients who are
with upper and lower limb pathologies.
Emergency hemodialysis patients.
7.2.5 Tools Used For Study
Instruments used for the study:
Section A:
To assess the demographic variables-age, sex, educationalstatus lifestyle, occupation,
income and associated disease conditions.
17
Section B:
Fatigue scale
General myalgia scale.
7.2.6 Data Collection Method:
Formal permission will be obtained from head of the institution.
Ethical clearance have been obtained from Institution Ethical Review Board(IERB) of St.
Philomena’s Hospital.
Informed consent will be taken from hemodialysis patients.
Pre exercise fatigue and general myalgia level will be measured.
Administration of intradialytic isometric stretching exercises.
Post exercise level of fatigue and general myalgia.
7.2.7 Data Analysis Method:
Data analysis will be done by using descriptive and inferential statistics.
Descriptive statistics:
Mean, median and standard deviation is used.
Inferential statistics:
Paired‘t’ test and chi square test is done.
18
7.3. DOES THE STUDY REQUIRE ANY INTERVENTIONS OR
INVESTIGATIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN
OR ANIMAL?
Yes, intervention in the form of intradialytic isometric stretching exercise will be
administered for hemodialysis patients.
7.4. HAS THE ETHICAL CLEARANCE BE OBTAINED FROM YOUR
INSTITUTIONS IN CASE OF PATIENTS?
Ethical clearance has been obtained from Institution Ethical Review Board (IERB) of St.
Philomena’s Hospital, Bangalore.
19
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