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Comfortandfluidretention.pdf
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 25
Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
K idney failure with subsequent hemodialysis (HD) is not only disruptive to lifestyles of patients and families, but also
has concerning financial implications. Decreasing the burden of treatments, such as fluid restrictions for patients with end stage renal disease (ESRD), with the potential of improving adherence may improve quality of life and extend the lifespan. Adherence to fluid restrictions is
difficult for patients receiving HD (Welch, 2001). Adherence can demand major lifestyle modifications because of the many restrictions imposed by the treatment regimen, not only in one’s physical routines, but also in aspects of imposed social interruptions that can impact quality of life (Tovazzi & Mazzoni, 2012). Nonadherence to fluid restrictions among patients receiving HD, lead- ing to fluid retention between treat- ments, may result in increased co- morbidities and death. Research has been inconclusive in determining options to enhance adherence to fluid restrictions in adult patients receiving HD. There is a lack of knowledge about which factors affect this popula- tion’s health-seeking behaviors relat- ed to fluid restriction adherence.
Karen M. Estridge Diana L. Morris
Katharine Kolcaba Chris Winkelman
Continuing Nursing Education
Karen M. Estridge, DNP, RN, is an Assistant Professor, Assessment Coordinator; College of Nursing and Health Sciences, Ashland University, Ashland, OH.
Diana L. Morris, PhD, RN, FAAN, FGSA, is an Associate Professor, Director of the University Center on Aging and Health; Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
Katharine Kolcaba, PhD, RN, is an Associate Professor, Emeritus; School of Nursing, University of Akron, Akron, OH.
Chris Winkelman, PhD, APRN, CCRN, CNE, FCCM, FAANP, is an Associate Professor; Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
Further examination about this aspect of treatment for kidney failure is needed to inform potential new oppor- tunities for intervention. Therefore, this project sought to answer the fol- lowing research question: What is the relationship between comfort and fluid retention among adults receiving chronic HD? Based upon the theoreti- cal framework and literature, we hypothesized that patients with greater comfort would be associated with a lower fluid retention.
Problem The number of patients undergo-
ing HD continues to increase in the
United States. According to the 2017 annual report by the United States Renal Data System (USRDS), there were over 703,243 prevalent ESRD cases, which is an increase of 3.4% from the previous year. Of those cases, 63.3% were treated with HD therapy. There was also an increased incidence of newly reported cases of ESRD that reached 124,114 in 2015. For year 2015, estimated Medicare spending for patients with chronic kid- ney disease (CKD) and ESRD aged 65 years and older exceeded $98 bil- lion (USRDS, 2017). One major contributor to CKD
and ESRD costs is the failure of patients to follow prescribed treat-
Copyright 2018 American Nephrology Nurses Association.
Estridge, K.M., Morris, D.L., Kolcaba, K., & Winkelman, C. (2018). Comfort and fluid retention in adult patients receiving hemodialysis. Nephrology Nursing Journal, 45(1), 25-33, 60.
Successful hemodialysis treatments for patients with renal failure depend on patient adherence to prescribed treatment regimens. Lack of adherence may contribute to patient discomfort between hemodialysis treatments. This article reports a descriptive, correla- tional feasibility study that utilized Kolcaba’s Comfort Theory as a framework. The pur- pose of the study was to determine a potential relationship between comfort and fluid retention (a proxy for adherence) in adults with end stage renal disease receiving hemodialysis. A convenience sample of 51 patients receiving hemodialysis was studied. Comparisons of patient weight gain between hemodialysis treatment sessions measured fluid retention by proxy. Results indicated no significant relationship between the vari- ables of comfort and adherence to fluid restrictions. However, this finding has potential to support clinical practice to minimize weight gain to sustain comfort. Awareness of comfort as a consideration for adherence to prescribed treatment regimens may help nurses coach individuals to improve treatment adherence.
Key Words: Hemodialysis, comfort, adherence, interdialytic weight gain.
Acknowledgement: The authors would like to thank Dr. Jacqueline K. Owens for her kind and invaluable assistance with manuscript preparation and editing.
Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity.
Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation can be found on page 34.
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Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
ment regimens. Poor patient adher- ence is a serious problem that leads to medical, social, emotional, and eco- nomic consequences that could ulti- mately compromise empirically based treatment guidelines (Howren et al., 2016). The meta-analysis by Welch and Thomas-Hawkins (2005) was inconclusive in determining suc- cessful options to avoid fluid retention and promote fluid restriction adher- ence in patients receiving chronic HD, and noted insufficient data avail- able to inform clinical practice guide- lines. Tovazzi and Mazzoni (2012) suggested that adherence to restric- tions includes individual motivations, mental control, and patient experi- ences, including time and a support system.
Theoretical Framework The guiding framework for this
preliminary feasibility study was Kolcaba’s (1994) Comfort Theory. Comfort is essential for all persons, especially those with healthcare needs. Kolcaba (1991) defined com- fort through the domains of ease, relief, and transcendence in physical, psychospiritual, environmental, and sociocultural contexts. Increased comfort for patients receiving HD
may lead to improved adherence to fluid restrictions by these individuals as needs are addressed or met. Kolcaba’s (2007b) Comfort Theory
suggests that increased comfort leads to health-seeking behaviors in the popula- tion receiving HD. Positive patient out- comes may include improved adher- ence, decreased dialysis times, reduced dialysate usage, decreased nursing hours, and overall improved lived experience for patients. As a result, improved institutional outcomes of reduced co-morbidity and mortality rates could occur (see Figure 1). Kolcaba (2003) stated that “adopting the Theory of Comfort will demon- strate that institutions with higher nurs- ing staffing, professional atmosphere, and patient-oriented value systems are more likely to achieve financial and health-related goals” (p. 153).
Literature Review Multiple studies have been conduct-
ed related to Comfort Theory. Kolcaba and associates have studied patients in hospice care (Kolcaba, Dowd, Steiner, & Mitzel, 2004; Vendlinski & Kolcaba, 1997), those with early stage breast can- cer (Kolcaba & Fox, 1999), patients with chronic urinary bladder syndrome (Dowd, Kolcaba, & Steiner, 2000), and
those undergoing end of life experi- ences (Novak, Kolcaba, Steiner, & Dowd, 2001). Additional studies consid- ered holistic comfort in perianesthesia patients (Wilson & Kolcaba, 2004), pro- tocols in pediatric patients (Kolcaba & DiMarco, 2005), hand massage in nurs- ing home residents (Kolcaba, Schirm, & Steiner, 2006), and comparison of touch, coaching, and interventions in college students (Dowd, Kolcaba, Steiner, & Fashinpaur, 2007). In these studies, comfort interventions produced positive correlations with various health-seeking behaviors. Davison and Jhangri (2010) sur-
veyed 591 patients receiving HD and concluded that symptom burden in patients with ESRD was substantial with a tremendous impact. Approxi - mately 50% of patients with ESRD experienced chronic pain, with 82% reporting this pain as having moder- ate to severe intensity. Bourbonnais and Tousignant (2012) studied 25 patients receiving outpatient HD and found that actual discomfort could be categorized into 4 themes: physical (procedural and joint pain), clinic dis- comfort (chairs, temperature), emo- tional and social pain (time sacrifice and isolation from lengthy treat- ments), and managing pain in the context of the dialysis unit (seeking
Figure 1 Kolcaba’s Conceptual Framework
Conceptual Framework for Comfort Theory
Healthcare Needs of Patient/ Family
Comforting Interventions
Intervening Variables
Enhanced Comfort
Health- Seeking Behavior
Institutional Integrity
Best Practices
Best Policies
External Behaviors
Peaceful Death
Internal Behaviors
Source: Kolcaba, 2007b. Used with permission.
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 27
comfort measures during HD treat- ments). The more fluid retention patients experienced, the longer the actual dialysis treatment, and thus, more discomforts. They further found that unresolved discomforts can have a profound effect on patients’ willing- ness to continue dialysis or other treatment regimens. Factors identified in the literature
have suggested why patients receiving HD may not practice adherence to prescribed fluid regimens. For exam- ple, Kugler, Maeding, and Russell (2011) conducted a cross-sectional, multicenter, comparative study of 456 adult patients receiving HD in 12 out- patient HD clinics. This study con- cluded that nonadherence persists as one of the most challenging tasks for patients with chronic conditions, sug- gesting that patient condition-related, socioeconomic, and healthcare sys- tem-related factors may contribute to nonadherence to diet and fluid restric- tions. In relation to HD and the impact
on comfort, a study by Kutner, Zhang, McClellan, and Cole (2002) found an association of three psy- chosocial variables that also impacted adherence during treatment to which the patients consented. Variables included little or no perceived control over future health, depression, and perceived effects of kidney disease on daily life. It is evident that adherence to fluid
restrictions is difficult and can lead to negative outcomes. Adherence can impact care, patient comfort, and ulti- mately, institutional outcomes, includ- ing costs for this population. The pur- pose of this study was to determine the relationship between comfort and fluid retention (a proxy for adherence) in adults with ESRD who receive HD.
Methods
Design The study was a descriptive, corre-
lational, cross-sectional design. This feasibility study sought to determine if a relationship existed between the two variables of adherence to fluid
restrictions (measured via fluid reten- tion) and comfort.
Setting The study was conducted at two
for-profit dialysis clinics in the Midwest of the United States. Both clinics were proximately located, managed by the same corporation, and shared a medical director and upper level administrative team. The clinics were housed in free-standing, single-story buildings with surround- ing private parking lots and easy entry access for patients. Patients reported for treatments three days per week with varying shifts. Most HD treatments lasted approximately four hours.
Sample A convenience sample of adults
with ESRD was enrolled. Eligibility criteria included persons aged 18 years or older who received HD treatments in one of two dialysis clinics in the Midwest. Participants were required to obtain a score of at least 8 of 10 on the Short Portable Mental Status Questionnaire (SPMSQ), a brief ques- tionnaire to assess patients for organic brain dysfunction (Pfeiffer, 1975); have decisional capacity; and possess the ability to read. Co-morbidities (dia- betes, hypertension, lung disease, heart disease, or primary renal disease) were permitted and recorded. Ex - clusion criteria were weight greater than 500 pounds and/or patients who experienced an acute event (new onset influenza, dialysis-related conse- quences requiring non-typical, intense care) on a day of data collection.
Variables Comfort. The operational defini-
tion of comfort was the score on a Likert-type scale using Kolcaba’s (2007c) General Comfort Question - naire (GCQ), adapted for this popula- tion per Kolcaba’s (2007a) guidelines (see Figure 2). The instrument for this study contained 48 self-report items. Responses to items were scored on a 6-item Likert scale ranging from 6 (strongly agree) to 1 (strongly dis- agree). Higher scores reflect higher
levels of comfort. Twenty-five nega- tively worded questions appeared on the questionnaire to reduce response bias. The questionnaire was adminis- tered at the beginning of the study to determine the comfort level for each participant. Previous reliability testing of
Kolcaba’s General Comfort Ques - tionnaire yielded a Cronbach’s alpha of 0.88 (Kolcaba, 1992). The adapted Hemodialysis Questionnaire yielded a Cronbach’s alpha of 0.85. The reading level of the tool was grade 2.5 accord- ing to the Flesch-Kincaid Grade Level via Microsoft Windows 2007 (Microsoft Corporation, 2007).
Fluid retention. Fluid retention as a proxy for adherence was opera- tionally defined as the patient’s inter- dialytic weight gain (IDWG) of 2.5 kilograms (kg) or less during the week and 3.5 kg or less over a 2-day week- end or holiday period, as suggested by the study dialysis clinics. The mean was calculated by averaging the IDWG of visits over the 2-week study, excluding holidays. The IDWG was measured as the amount of weight gained between the conclusion of one dialysis treatment and the beginning of the next dialysis treatment. Welch (2001) reported that although the weight gain criterion for nonadher- ence varies among studies, generally, daily weight gain greater than 1 kg to 1.5 kg is considered in excess. López-Gómez, Villaverde, Jofre,
Rodriguez-Benítez, and Pérez-García (2005) defined IDWG as “mainly the result of salt and water intake between two dialysis sessions” (p. S-63). López- Gómez and colleagues (2005) also noted that IDWG varies between patients but is a common method of measuring compliance/adherence. Ideally, when patients receiving chronic HD followed the prescribed fluid restriction regimen, the patient’s IDWG should not increase beyond expected parameters as determined by the physician. Fluid retention was measured by pre-HD and post-HD weight measurements in increments of 0.1 kg via electronic scale.
Demographic items. The pri- mary investigator (PI) created a
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Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
demographic tool consisting of 16 items, found in Table 1. Items includ- ed age; sex; race, marital status; edu- cation level; history of HD treat- ments, fluid intake, salt intake via consumed foods, and urinary output; health insurance; and co-morbidities.
Protection of Human Subjects The study commenced upon ap -
proval from the university’s and dial- ysis setting’s Institutional Review Boards (IRBs). All participants re - ceived three weekly HD treatments at one of two dialysis clinics in the Midwest. Patients were approached two weeks prior to the study and informed of the opportunity to partic- ipate. Signed consent was obtained at that time.
Procedure The Hemodialysis Questionnaire
was adapted according to instructions provided on Dr. Kolcaba’s website (Kolcaba, 2007a). To establish face validity of the adapted comfort tool, two authors (Estridge and Kolcaba), reviewed each question for clarity. Prior to administration of the Hemodialysis Questionnaire, the sur- veys (Hemodialysis Questionnaire and demographic questionnaire) were piloted with seven patients at a similar HD clinic in the Midwest. We anticipated that some patients
might need assistance due to the number of items on the Hemodialysis Questionnaire and completing the questionnaire during their HD treat- ment. The PI also developed a proto- col to use should a participant request assistance in completing the surveys. The protocol included individual assistance by the PI at the bedside, instructions for reading questions to the subjects if necessary, and offering a large-print visual card to assist in readability and understanding of the survey’s Likert scale. Approximately 80% of partici-
pants required at least some assis- tance to complete all items in the sur- veys; this may be because all patients were connected to the HD machines
Figure 2 Adapted General Comfort Questionnaire
Hemodialysis Questionnaire 1. My body is relaxed right now. 2. I feel useful because I’m working hard. 3. I have enough privacy. 4. There are those I can depend on when I need help. 5. I don’t want to exercise. 6. My condition gets me down. 7. I feel confident. 8. I feel dependent on others. 9. I feel my life is worthwhile right now. 10. I am inspired by knowing that I am loved. 11. These surroundings are pleasant. 12. The sounds keep me from resting. 13. No one understands me. 14. My pain is difficult to endure. 15. I am inspired to do my best. 16. I am unhappy when I am alone. 17. My faith helps me to not be afraid. 18. I do not like it here. 19. I am swollen right now. 20. I do not feel healthy right now. 21. This room makes me feel scared. 22. I am afraid of what is next. 23. I have a favorite person(s) who makes me feel cared for. 24. I have experienced changes which make me feel uneasy. 25. I am hungry. 26. I would like to see my doctor more often. 27. The temperature in this room is fine. 28. I feel very tired. 29. I can rise above my pain. 30. The mood around here uplifts me. 31. I am content. 32. This chair (bed) makes me hurt. 33. The view inspires me. 34. I am thirsty. 35. I feel out of place here. 36. I feel good enough to walk. 37. My friends remember me with their cards and phone calls. 38. My beliefs give me peace of mind. 39. I need to be better informed about my health. 40. I feel out of control. 41. I feel crummy because I am bored. 42. This room smells terrible. 43. I am alone, but not lonely. 44. I feel peaceful. 45. I am depressed. 46. I have found meaning in my life. 47. It is easy to get around here. 48. I need to feel good again.
Note: Adaptations from the original GCQ are bolded. Source: Tool created by Karen M. Estridge; adapted from Kolcaba, 2007a.
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Table 1 Demographic Data of Sample
Age
Mean 64 years Median 65 years Youngest 44 years Oldest 87 years
Sex Male 28 (54.9%) Female 23 (45.1%)
Marital status
Married 21 (41.2%) Never married 6 (11.8%) Single (living with someone) 3 (5.9%) Separated 2 (3.9%) Divorced 14 (27.5%) Widowed 5 (9.8%)
Race Caucasian 24 (66.7%) African American } other 15 (29.4%) American Indian } other 2 (3.9%)
Education level
Less than 8 years 2 (3.9%) High school or equivalent 35 (68.6%) Vocational/technical degree 9 (17.6%) Bachelor’s degree 2 (3.9%) Master’s degree 1 (2.0%) “Other” 2 (3.9%)
Employment status
Employed 36 hours/week 1 (2.0%) Employed 16 to 35 hours/week 3 (5.9%) Unemployed 5 (9.8%) Unable to work 25 (49%) Retired 17 (33.3%)
Payment source Medicare/Medicaid 51 (100%) Additional insurance (non-exclusive) 23 (46%)
Diseases/other conditions (non-exclusive)
Cardiovascular disease 47 (92.2%) Diabetes mellitus 29 (56.9%) Lung disease 5 (9.8%) Other 12 (23.5%) More than one medical condition 35 (68.8%)
Treatment history
Received treatments 4 months to 1 year 15 (29.4%) Received treatments 2 to 5 years 29 (56.9%) Received treatments more than 6 years 5 (9.8%) Other 2 (3.9%)
Treatment session duration
3 hours in length 4 (7.8%) More than 3, but fewer than 4 hours 22 (43.1%) 4 hours 20 (39.2%) More than 4 hours in length 5 (9.8%)
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Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
during data collection and eagerly accepted the offer of help. The PI fol- lowed the protocol to provide assis- tance. No missing data were noted because of assistance from the PI with survey completion.
Data Management Data were entered into the
Statistical Package for the Social Sciences (SPSS) – 19 (SPSS for Windows, Rel. 19.0., 2010) for analy- sis. Correlations were calculated between the summed one-time com- fort scores and mean IDWG, as meas- ured over a period of four weeks.
Planned Analysis All data were planned to be sum-
marized by means (ratio level) and frequencies (interval, ordinal, and nominal level) as appropriate. A test of association was planned for the study’s single research question: What is the relationship between comfort and fluid retention among adults receiving HD? This was an early feasibility study with no previ- ous reports in the literature, so a test of association was a reasonable approach. Both variables (comfort and IDWG) were ratio level; thus, Pearson’s r was the best test of associ- ation. If assumptions for this test sta- tistic (i.e., linearity, outliers/extreme
values, and restriction of range) were not met, we planned to use a Kendall’s rank test to ensure viola- tions of assumptions around Pearson’s would not lead to erroneous results. Secondary analysis of selected
patient characteristics to determine if there were differences in either com- fort or IDWG were also undertaken using independent t tests. Assumptions for this test statistic were examined (the need for a correction when unequal variances occurred) were undertaken to yield optimal results.
Results
Sample Fifty-one adult subjects participat-
ed in this study. Demographic infor- mation was obtained to describe per- sonal characteristics and lifestyle related to being a patient receiving HD. Complete demographic infor- mation is presented in Table 1. The demographic survey also
included questions about dietary habits that may contribute to IDWG. There were seven items related to food intake, fluid intake, and urinary output. These data are summarized in Table 2. Regarding usual comfort and/or
discomfort, 13 (25.5%) subjects took prescription medications for pain
more than once daily. Subjects were also asked about the number of edu- cational sessions they received regarding fluid restrictions. Twenty- four (47.1%) received less than 5 ses- sions, 11 (21.6%) received 6 to 9 ses- sions, 9 (17.6%) received 10 or more events, 5 (9.8%) were not sure of the number of educational events, and 2 (3.9%) did not know if they had received any education.
Comfort The Hemodialysis Questionnaire,
used to measure comfort, contained 48 self-report, comfort-related items as described above. The maximum obtainable comfort score was 288. In this sample, total comfort scores ranged from 146 to 258, with a mean score of 203.25 (standard deviation [SD]=26.09) and median score of 202.00 (see Table 3).
Interdialytic Weight Gain Subjects were weighed prior to
and immediately following each treat- ment per clinic policy. Subjects’ weights were extracted from patient charts for measurement from two weeks immediately prior to the administration of the Hemodialysis Questionnaire to avoid any Hawthorne effect, bias, or change in routine by participants. Holidays and
Table 2 Participants’ Salty Food Consumption
Foods consumed greater than once weekly
• Potato chips, corn chips, pretzels 13 (25.5%) • Pickles, canned meats, clam soups, salty fish 18 (35.5%) • Frozen, prepared meals 4 (7.8%) • Packaged meat, cheese, prepared pasta 23 (45.1%) • Salty meat: hot dogs, deli lunch meats, sausage 16 (31.4%)
Daily fluid intake
• Less than 8 ounces 5 (9.8%) • Up to 16 ounces 9 (17.6%) • Up to 24 ounces 12 (23.5%) • UP to 32 ounces 15 (29.4%) • Greater than 32 ounces 10 (19.6%)
Daily urinary output • 0 ounces 1 (21.6%) • 4 to 8 ounces 19 (37.3%) • Greater than 8 ounces 21 (41.2%)
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extended weekends were avoided to preserve subjects’ normal pattern of weight gain. The average IDWG ranged from 0.92 to 5.8 kg. The mean average weight gain was 2.71 kg, with an SD of 1.1. Table 4 reports weight gain overall and by sex.
Hypothesis Testing The association between comfort
and fluid retention was not significant (r=0.028; p=0.844). Scatter plots indi- cated a restricted range in weight gain, and restricted ranges of vari- ables may deflate the correlation value; thus, a Kendall’s tau (rank) was undertaken. This test does not have an assumption around data distribu- tion. Kendall’s rank analysis was also insignificant (r=0.01; p=0.909). The confidence interval (CI) was small and crossed zero, further supporting no effect. Assuming an insignificant effect size of less than 0.10 (0.09), this preliminary feasibility study had a power of 59.5% to detect an associa- tion between comfort and IDWG.
Secondary Analyses To further understand how patient
characteristics may relate to comfort and IDWG, we undertook additional analyses. We investigated correlations between sex and race with comfort scores because both women and non- Whites have different expectations related to comfort and healthcare out- comes (fluid-related weight loss) in the literature (Novak et al., 2001; Zhang & Baik, 2013).
Gender and comfort. Women rated comfort slightly higher (n=23; M=205.17; SD=26.89) compared to men (n=28; M=201.68; SD=25.79). An independent t test indicated there was no significant difference based on sex regarding comfort (t=0.472; df=49; p=0.639).
Race and comfort. Summary data revealed the mean comfort score for Whites at 204.47 (SD=19.25) and all others at 202.65 (SD=229.12). These differences were tested with an independent samples t test, and no
significance was demonstrated in comfort reported between Whites and nonwhites (t=0.266; df=44.85; p=0.791).
Gender and weight gain. The mean IDWG was 2.55 kg for women and 2.83 kg for men, further detailed in Table 4. Independent samples t test supported a finding of no significant difference between weight gain in women compared to men (t=0.362; df=49; p=0.364).
Race and weight gain. For com- parison purposes related to race, non- whites included African Americans (n=15) and Native Americans (n=2). The IDWG for Whites (n=34; M=2.49 kg; SD=1.00) was lower than the IDWG for nonwhites (n=17; M=3.14 kg; SD=1.17). These results are summarized in Table 5. An inde- pendent t test for differences for IDWG for race was significant (t=1.106; p=0.015). There was a signif- icant difference in weight gain, with nonwhites gaining more weight between dialysis treatments in this sample.
Discussion There was no significant relation-
ship between comfort and IDWG. This finding was different than what
Table 3 Comfort Scores of Participants
Minimum Score Maximum Score Mean Score Standard Deviation Total Sample 146 243 203.25 26.09
Male 146 243 201.68 25.79 Female 150 242 205.17 28.89
Table 4 Participant Interdialytic Weight Gain (IDWG) in Kilogram by Sex
Minimum IDWG Maximum IDWG Mean IDWG Standard Deviation Total Sample 0.92 5.80 2.71 1.10
Male 1.03 5.81 2.83 1.20 Female 0.92 4.93 2.55 0.97
Table 5 Participant Interdialytic Weight Gain (IDWG) in Kilogram by Race
Mean IDWG Standard Deviation Total Sample 2.71 1.10
Caucasian (N=34) 2.49 1.00 Other (N=17) 3.14 1.17
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we hypothesized based on Kolcaba’s theory. Although results were not sta- tistically significant, this finding has potential clinical importance. Com - fort Theory suggests that as persons pursue comfort interventions, they also engage in health-seeking behav- iors (Kolcaba, 2003). In a study by Smith and colleagues (2010), psycho- logical factors, physical factors, beliefs, attitudes, self-efficacy, and environmental factors affected pa - tients receiving HD and adherence to fluid restrictions. A pattern of seeking healthy behaviors was not strongly supported in this preliminary study. This study’s results are similar to Welch’s (2001) study results, which determined that successful adherence to treatment regimens was influenced by patient willingness (or not) to fol- low restrictive and often uncomfort- able lifestyle changes. Study results offer evidence to support current clin- ical practice to minimize IDWG to sustain comfort. Specifically, data did not support
the assertion that subjects with the least weight gain had greater association with comfort or vice versa. In this study, correlations between comfort scores and weight gain were very small, ranging from 0.01 to 0.28, indi- cating a small rather than moderate effect size. These small correlations and lack of significance initially suggested that comfort and IDWG of an average of 3 kg were not related. However, because most patients were dialyzed at 2- to 3-day intervals, and averaged a weight gain of 3 kg between dialysis periods, it is not surprising that patients did not report a change in comfort. The mean IDWG in this study (2.7 kg) is very close to guidelines suggested for patient management (i.e., 2.5 kg is the goal). It may be that an average of under 3 kg of weight gain is not suffi- cient to be associated with a decrease in comfort; it is a weight gain that neither increases nor decreases comfort. Alternatively, this study was under- powered, and a larger sample size or one with a wider range of weight gain may yield significant associations between comfort and IDWG. Secondary analyses did not sup-
port a difference in reports of comfort between sexes; comfort was similar between women and men. Similarly, self-reported comfort was compara- ble between Whites and non-Whites. This is somewhat different than what has been reported in the literature and may be specific to the sample of patients with ESRD and receive HD regularly. Further, there was no signif- icant difference between men and women in the IDWG. One recent report indicates men
are more likely to have a greater IDWG (Artan et al., 2016). In our study, men and women had similar IDWGs. It may be because our study was underpowered to detect this dif- ference or that these subjects were more compliant/adherent to treat- ment because they had weight changes close to clinical goals. The only significant finding was
that Whites had a significantly reduced IDWG compared to non- whites. In this sample, Whites had an average IDWG at the clinical goal of less than 2.5 kg between HD treat- ments. However, the difference of 0.65 kg IDWG may not be clinically important, and the average of 3.14 kg IDWG in nonwhites is very close to a 20% variation (considered reasonable in many patient-centered outcomes). It is not clear if the clinical goal of 2.5 kg was based on a homogenous or heterogeneous population. The clini- cal implication for nurses who spe- cialize in dialysis treatment is that non-Whites may need more educa- tion or increased effort around self- management approaches to help them achieve clinical goals.
Limitations The greatest limitations of this fea-
sibility study were its preliminary nature and the convenience sam- pling. As a preliminary study, it was not powered adequately to detect dif- ferences in comfort. However, an effect size can now be used to deter- mine sufficient sample size for future studies. Convenience sampling may limit generalizability. Subjects were fairly homogenous, self-selected, and voluntarily reported dietary and fluid
intake. Finally, patients who were less successful in adhering to fluid restric- tion guidelines may have opted out of this study. Other potential limitations includ-
ed a possible bias in subject responses from overhearing socially desirable responses by other participants. Question fatigue due to the number of items (48 questions with six possi- ble responses on the Hemodialysis Questionnaire) may have contributed to the narrow range of results. In addition, scheduling practices and clinic policy sometimes meant patients were at the facility much longer than the scheduled HD treat- ment, which may also have con- tributed to subject fatigue.
Implications for Clinical Practice Consistent with Kolcaba’s (2003)
theory, determining patient health- care needs, providing comfort inter- ventions, identifying challenges, set- ting goals to establish health-seeking behaviors, and instituting supportive nursing actions to promote well-being will lead to best practices in providing comfort measures to patients receiv- ing HD. It is yet to be determined if enhanced long-term comfort because of following restricted fluid intake guidelines will occur. Awareness of unique comfort needs as a considera- tion for adherence to prescribed treat- ment regimens may help nurses coach individuals with ESRD. Ghimire, Castelino, Lioufas,
Peterson, and Zaidi (2015) and Zhang and Baik (2013) suggest significant findings of an IDWG difference in the context of race. This finding, and the call from Frazão and colleagues (2015) for individualized education, may offer implications for practice helpful to address various patient dis- parities. Specific implications for clin- ical practice resulting from this cur- rent study include: • Increase nurse awareness about
potential population differenc - es. With increased awareness of potential differences in comfort and adherence needs, nurses can individualize interventions to sup-
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 33
port difficult treatment regimens. More precise nursing interventions that include variables, such as cul- tural practices or food preferences of different races, may help in - crease adherence.
• Consider comfort care specifi- cally with respect to adherence to difficult regimens. Careful evaluation of comfort care tenets, specifically as they may impact adherence, may assist vulnerable patients to achieve better out- comes. According to the Comfort Theory, holistic comfort is the immediate experience of being strengthened through ease, relief, and transcendence (Kolcaba, 2003). Nurses providing HD must accurately assess specific individ- ual patient comfort needs because these may vary by race, ethnicity, or other patient lifestyle practices. This holistic comfort may empow- er patients receiving HD to improve self-care and increase adherence to fluid restrictions.
• Continue to set weight gain goals during HD to minimize IDWG. It is important to learn that a weight gain of 2.7 kg (average) between dialysis treatments is not associated with comfort/discom- fort. This finding begins to establish the mid-to-upper value of weight gain that may impact comfort. It is important for nurses to
explore individual characteristics and needs to effectively plan care with patients struggling to address difficul- ties of managing fluid intake (Tovazzi & Mazzoni, 2012). By intentionally learning more about each patient, including personal responses and overall comfort status, nurses provid- ing HD may better target unique aspects of nursing care to meet each patient’s needs.
Conclusion and Recommendations for Further Research Further studies about patients
receiving HD based on Comfort Theory are necessary to determine relevant nursing interventions to sig- nificantly impact comfort for this pop-
ulation. This study yields preliminary results that support the clinical goal of gaining about 1 kg/day of no dialysis. It would be interesting to study the outliers in future research because extremely high (6 to 7 kg) or low (less than 2 kg) weight gainers may have different perceptions of comfort. Expanding the study to include
eight or more weeks of IDWG meas- urement may help accurately deter- mine a potential relationship between comfort and adherence to fluid restric- tions. In addition to extending the duration of measurement, repeated Hemodialysis (comfort) Question - naires would provide additional infor- mation about adherence of patients receiving HD and accompanying val- ues of comfort. Studies that include numerous HD clinics with greater numbers of subjects would provide useful data to assist nurses to more accurately provide supportive care to this population of patients.
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continued on page 60
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 134
Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
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In accordance with ANCC governing rules Nephrology Nursing Journal Editorial Board state- ments of disclosure are published with each CNE offering. The statements of disclosure for this offer- ing are published below.
Paula Dutka, MSN, RN, CNN, disclosed that she is a coordinator of Clinical Trials for the following sponsors: Amgen, Rockwell Medical, Keryx Biopharmaceuticals, Akebia Therapeutics, and Dynavax Technologies.
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Tamara M. Kear, PhD, RN, CNS, CNN, disclosed that she is a member of the ANNA Board of Directors, serves on the Scientific Advisory Board for Kibow Biotech, Inc., and is employed by Fresenius Kidney Care as an acute hemodialysis RN.
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Learning Engagement Activity For additional information, read the following Nephrology Nursing Journal article: Aji, L., & Beck, D. (2017). Effect of fluid status on access blood flow measure-
ments as observed in a hospital-based hemodialysis unit servicing inpa- tients and outpatients. Nephrology Nursing Journal, 44(5), 462-464.
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Nephrology Nursing Journal January-February 2018 Vol. 45, No. 160
Comfort and Fluid Retention continued from page 33
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