RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.

Name of candidate and address

MISS.LIYA JOHN
M.SC NURSING
SJCON,BANGALORE

2.

Name of the institution

ST.JOHNS COLLEGE OF NURSING

BANGALORE

3.

Course of study, subject

M.SC NURSING,
MEDICAL SURGICAL NURSING

4.

Date of admission to course

MAY 3RD 2010

5.

Title of the topic

ASSESSMENT OF RENAL DIETARY

ADHERENCE AMONG
HAEMODIALYSIS PATIENTS

6. Brief Resume of intended work

6.1. Need for study
Chronic kidney diseases have become a major cause of global morbidity & mortality even in
developed countries. The burden of chronic kidney disease in INDIA cannot be assessed
accurately. The approximate prevalence of CKD IS 800 per million populations (PMP), &
incidence of end stage renal disease is 150- 200 PMP1
India has close to 950 nephrologists all over the country. There are 700 dialysis centers with a
total of 4000 dialysis machines, predominantly in private sector & mainly concentrated in cities,
especially metros. There are around 20, 000patients undergoing dialysis at these centers. The
patients on CAPD number less than 5000. Clearly, choices & facilities for RRT are
predominantly focused on maintenance hemodialysis & are woefully inadequate2
The management of ESRD requires significant life style adjustments. Patients with ESRD are
required to follow a complicated treatment protocol that includes frequent hemodialysis sessions,
severe dietary restrictions, a complex medication regimen, & an exercise prescription. Failure to
follow this regimen may result in short & long term consequences for health & survival. In short
term, nonadherence to treatment regimens may increase the likelihood of emergency & hospital
admissions. The development of additional co morbidities, like cardio vascular disease, &
mortality are potential long term consequences. Adherence to dietary restrictions is an important
determinant of health outcomes for patients with ESRD, an increase risk of complication & death
is associated with dietary non adherence3
In 14 studies (31%), investigators assessed the prevalence of fluid & dietary non adherence in
patients with ESRD receiving hemodialysis. Non adherence ranged from 40% to 85%. Variation
in prevalence of dietary adherence across these studies was likely related to the use of self report
measures of adherence with little psychometric support & lack of reliable, valid & objective gold
standard measure of adherence. Such inconsistent findings are likely to be due to the
multidimensional & multifaceted nature of adherence & difficulties associated with the accurate
measurement of adherence. 3.1
The study identified participants reason for good, marginal, poor adherence. Most common
reason for non adherence was barriers such as side- effect, deteriorating illness, forgetting &
competing outside stressors. This study provides direction for adherence promotion in future.4
Dietary risks for hemodialysis patients increases if non adherent to prescribed dietary regimen.
As a result fluid retention & weight gain as well as increase in blood pressure & strain on the
heart occurs due to fluid nonadherence .Eating food rich in potassium may cause alteration in the
chemical balance that control the heart beat, leading to dangerous disruption in hearts rhythm
.Eating food rich in phosphorus may cause calcium leeching from bones, leading to increased
likelihood of fractures. Studies have shown that those patients who had greater than 5.7%
Interdialytic weight gain (IDWG) had a35% higher risk of death whereas those with a PO4>7.5
had a 13% higher risk of death.5
The investigator during her clinical experience has come across a number of patients who have
numerous numbers of queries regarding dietary regimen, some felt great difficulty to adhere to

dietary restriction, some are unwilling to accept such complicated treatment protocol, some due
to depressive symptom may decrease oral intake. So this prompted investigator to study
knowledge, attitude & behaviors related to dietary adherence of patients undergoing
hemodialysis.

6.2. Review of literature

A review of literature is a key step in the research process & is an extensive, exhaustive
&systematic examination of publications relevant to the research project. It helps to develop an
insight into the area of investigation & directs the researcher to develop a plan. This portion deals
with the review of literature related to the present study.
The literature has been briefly reviewed under the following heading:
1. Literature related to impact of dietary regimen on quality of life of hemodialysis patients
2. Literature related to dietary & fluid adherence of patients undergoing hemodialysis.
1 .Literature related to impact of dietary regimen on quality of life of hemodialysis patients
A study done to assess impact of super bowel parties on nutritional parameters among
hemodialysis patients. Findings revealed that 15 patients who attended a party had increased
serum phosphorous level & interdialytic weight gain from baseline. These increases were
statistically significant compared with patients who did not attend a party6.
A study was done on adequacy of nutritional status & quality of life in patients on chronic
hemodialysis done by Hase et al. (1998) in Gujarat, India, wherein 28 patients were assessed by
Karnofsky index & SF-36 health survey questionnaire for quality of life. Lower level of quality
of life particularly in role functioning &vitality was reported7
.
A dietary survey in Indian hemodialysis patients revealed that dietary deficiency of both protein
& calories was64.9%. Intake was better on non dialysis days as compared with dialysis days 8
A Study done in Switzerland on prevalence & consequence of non adherence to hemodialysis
regimen. Findings of study revealed that about 40% of samples were having shortness of breath,
muscle cramping, lung edema &hypertension due to non adherence with fluid restriction9
A study done on assessment of nutritional status of dialysis patients in Germany. The study was
done based on clinical assessment & biochemical parameters. Findings revealed poor health
status due to malnutrition i.e. common in dialysis patients.10
O Brien (1990) believes that episode of extreme non compliance should be understood either as
simply an expression of the patients frustration with strict renal dietary restriction or some case
of denial of illness.11

Jiro Takaki and Eiji Yano, the authors assessed gender differences between the relationships of
self-efficacy and the internal health locus of control with compliance in hemodialysis patients.
Using a self-efficacy scale for health-related behavior and the Japanese version of the Health
Locus of Control Scale, the authors studied individuals who had been regularly undergoing
hemodialysis for longer than 1 year. Blood urea nitrogen, serum potassium, and interdialytic
weight gain were used to measure compliance. On the basis of blood urea nitrogen or serum
potassium levels, the authors found that female patients who had higher self-efficacy or internal
health locus of control were less compliant. The decrease of interdialytic weight gain
accompanying increased self-efficacy was more significant in men than it was in women. 12
Numerous studies of the factors which mostly influence the morbidity & mortality of dialysis
patients are underlying disease or consequence of co morbid condition that result from either
inadequate predialysis care, poor compliance to dietary & fluid regimen or late referred to
specialised nephrological team. 13
2. Literature related to dietary & fluid adherence of patients undergoing hemodialysis.
A study done in Malaysia on assessment of nutritional compliance among patients in dialysis
centers of National Kidney Foundation & to identify common reason behind lack of compliance.
The results were self reported nutritional compliance among HD patients was 94% when
compared to actual compliance of 48%Common reason behind lack of compliance were lack of
family support, financial constraints, co existing morbidities, misinformed calorie intake &
unwillingness to change life style.g14
A study done among 62 patients in Western Cape on assessing dietary & fluid adherence among
hemodialysis patients attending public sector. Hierarchical regression analysis revealed that
theory of behavior was able to significantly explain 15.5% of the variance in self reported dietary
& fluid adherence.15
A study done in France among 60 hemodialysis patients in order to assess knowledge, attitude &
behavior towards dietary adherence. Findings is that both Hispanic & 17 other patients were
adherent to diet.16
A cross-sectional study done in Hungary on 107 samples to assess dietary self efficacy,
Compliance attitude & behaviors & staff patient relationships& laboratory outcomes. Study
done using questionnaire &previous 6 months laboratory outcome. Results indicated that dietary
self-efficacy determined both behaviors &laboratory outcomes. Patient with greater dietary selfefficacy had lower serum potassium &weight gain, showed favorable compliance attitudes &
behaviors toward prescribed regimen& fostered better relationship with staff.17
A study was done in Ireland ,35 patients participated in study - assessing adherence to dietary
recommendation for hemodialysis patient using renal adherence attitude questionnaire (Raaq) &
the renal adherence behavior questionnaire (Rabq)The findings of study reflect some of key
issues in the area of adherence. Attitude & behavior so identified can then be targeted for specific
counseling.18
A study done to investigate whether knowledge of the diet & medical consequences of
noncompliance influences dietary compliance among patients on hemodialysis. Seventy one of

the eligible 82 patients participated in the study. Interviewer administered questionnaire &
assessed knowledge. Findings were more than one third of patients were non compliant with at
least one dietary restriction. Phosphorus dietary restrictions were the most commonly abused &
potassium the least.19
A study done in Florida, USA to investigate racial differences in the relationship between spouse
marital adjustment and dietary adherence of chronic hemodialysis patients. Sixty-eight adult
patients and their spouse were subjects. Fifty-two percent of the patients were Caucasians while
48% were Afro-Americans. Spouses completed the Locke-Marital-Questionnaire (LMQ) and
provided demographic data pertaining to their patient spouses. The patients' predialysis
potassium levels (indices of food intake compliance) for the previous three months were matched
with the respective questionnaires. Afro-American spouses, especially males, evidenced
significantly lower marital satisfaction than Caucasian spouses. Afro-American female patients
seemed to be most compliant as far as food intake was concerned. Although the spouse LMQ
score was negatively correlated with interdialysis weight gain. Afro-Americans who generally
scored lower on the LMQ did not differ from Caucasians in so far as their adherence to the
dietary regimen was concerned.20
A study done in Pittsburgh, USA to assess whether skipping hemodialysis treatments and failing
to adhere to prescribed diets are thought to injure hemodialysis patients. Of 739 patients, 67
were classified as skippers because they were absent for greater than 3% of scheduled
treatments.. Skipping was associated with a lower likelihood of kidney transplantation in those
younger than 65 years (OR, 0.41; 95% CI, 0.18 to 0.93). These findings show that hemodialysis
patients of black race and those with current tobacco or illicit drug use are at risk for skipping
dialysis treatments. Skipping treatments and markers of poor dietary adherence are strongly
associated with greater risk for death. Targeting high-risk patients to understand reasons for
nonadherence and to intervene could prevent premature death.21
A Case study also shows that dietary adherence is important. Riled Skiley is a 64-year-old
woman with ESRD caused by long-standing hypertension. Within 2 months of initiating
hemodialysis, Riled Skiley has had six episodes of excessive interdialytic weight gain, averaging
about 6 kg (these typically happen on Mondays). After the most recent occurrence, the nurse
talked with RS to obtain a detailed psychosocial historys and the nurse discussed how
overindulgence during these dinners is contributing to the swelling that Riled observed, and the
negative health ramifications that result.. Riled and the nurse jointly devised a plan to convene a
meeting with the family to solicit their understanding and support for Riled adherence to dietary
and fluid restrictions. Outcomes improved immediately, and Riled had no excessive interdialytic
weight gain for the next 3 weeks--the nurse continued to provide ongoing encouragement22

6.3 Problem statement

A study to assess the renal dietary adherence among patients undergoing hemodialysis in selected
hospital, Bangalore with a view to develop informational pamphlet.

6.4. Objectives of the study

1. To assess renal dietary adherence among patients undergoing hemodialysis
2. To determine association between dietary adherence with objective assessment of biochemical
parameters.
3. To determine association between dietary adherence & selected baseline variables.

6.5. Operational definitions:

1. RENAL DIET-In this study renal diet refers to the dietary regimen that is instructed to the
patient by the Dietician.
2. ADHERENCE-Refers to stick firmly to(Oxford dictionary)
In this study adherence refers to the extent to which a person follows prescribed dietary regimen
as measured by scores obtained through a structured questionnaire & objective assessment of
biochemical parameters such as potassium, phosphorous, albumin and interdialytic weight gain.
3. HEMODIALYSIS PATIENT In this study hemodialysis patient refers to the patients who are
diagnosed to have chronic renal failure & are on maintenance hemodialysis attending dialysis
unit of St. Johns Medical College Hospital, Bangalore.
4. INFORMATIONAL PAMPHLET
It is a small booklet or leaflet containing information. (Oxford dictionary)
In this study, Information pamphlet comprises of pictures & written information regarding
dietary guidelines for patients undergoing Hemodialysis.
5. DEMOGRAPHIC VARIABLES- In this study, demographic variables refers to age, sex,
duration of dialysis, educational status, income, type of family, place of living, diabetic or non
diabetic.

6.6. Assumption
1. Patients with CKD, undergoing Hemodialysis will have some knowledge about dietary
restriction
2. Each individual is unique in terms of adherence
3. Information pamphlets will be a useful tool in helping the patients to adhere to the dietary
regimen.

6.7. Delimitation
This study is limited to patients on maintenance hemodialysis & treated in dialysis unit at
St.Johns Medical College Hospital, Bangalore.

6.8. Projected outcome:

The finding of this study will reveal extent of dietary adherence among patients undergoing
Hemodialysis. This will help to develop an information pamphlet for patients undergoing
hemodialysis which will serve as a guideline for improving patients dietary adherence.

7. MATERIAL & METHOD

7.1. SOURCE OF DATA
7.1.1 Research design
Descriptive research design will be adopted for present study.

7.1.2. Setting
The setting selected for this study is dialysis unit at St. Johns Medical College Hospital,
Bangalore. It is a 1200 Bedded multispecialty hospital. It has well established dialysis unit
located on the second floor. It comprises of 32 beds. On an average 110 patients come for
dialysis per month. Dialysis for patients is scheduled in following timings i.e.4am-8am, 812noon, 1-4pm& 4-8pm. Also patients are grouped as group I & group II. Group I come on
Monday, Wednesday & Friday. Group II come on Tuesday, Thursday & Saturday

7.1.3 Population
The population of this study comprises of all patients undergoing hemodialysis & who attends
dialysis unit at SJMCH during data collection period.

7.2. METHOD OF DATA COLLECTION

7.2.1 Sampling procedures:
Simple Random sampling technique will be used to select the sample for the study.

7.2.2 Sampling size

In the present study sample consists of 65 patients undergoing hemodialysis

7.2.3 Inclusion criteria for sampling

1. Patients who are on maintenance hemodialysis.
2. Patient who have been on hemodialysis minimum for 3-6 months
3. Patients who are willing to participate
4. Patients who are on regular hemodialysis twice weekly
5. Patient who can understand commonly spoken languages.

7.2.4. Exclusion criteria for sampling

1. Patients who are on hemodialysis thrice a week.
2. Patients who are critically ill.
3. Patients who are irregular for hemodialysis.

7.2.5. Instrument used

The instruments that will be used for the study include:
Section 1:-Demographic data
Section 2:-Questionnaire
Section3:-Objective assessment of bio chemical parameters

7.2.6. Data collection method

After obtaining administrative permission, the study will be conducted in the dialysis unit at
SJMCH, Bangalore. Consent from the patients who are undergoing Hemodialysis will be taken.
Then investigator will select the sample according to inclusion & exclusion criteria using simple
random sampling technique. Then interview is done followed by questionnaire administration.
After which retrospectively biochemical parameters are recorded.

7.2.7. Data analysis plan

Both descriptive and inferential statistics methods will be used.

7.3. Does the study require any investigation or intervention to be conducted

on patients or other humans or other animals? If so describe briefly.
No

7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Ethical clearance has been obtained from the research committee of St.Johns College of Nursing
,Bangalore.

List Of References:
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online]2009[cited2009feb5];111(3):
Availablefrom: http://content.karger.com/produktedb/produkte.asp

2)Khanna U.The economics of dialysis in India. Indian J of Nephrol[Serial

Online]2009[Cited2010Nov5];19(1):1-4.Available from http://wwwindianjnephrol.org/text.asp
3) Khalil A.A, Frazier S.K. Depressive symptoms & dietary non adherence in patients with end
stage renal disease receiving Hemodialysis: A review of quantitative evidence. J Of Mental
Health Nurs[serial online]2010[cited.2010May];31(5):324-30
Available from http://www.ncbi.nlm.nih.gov/pubmed
4)Atwood R, Haase J, McGee SR, Blackwell G, Earnest D, etal.Reason related to adherence in
community based field studies .Patient education & counseling.[Serial online]1992[cited
June1992]; 19(3):51-59
Available from. http://www.sciencedirect.com/science=?ArticleURL
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Jan 2006.Available from http://www.jrnjournal.org/article
6)Sharma M,Rao M, Jacob S, Jacob C.K,A dietary survey in Indian Hemodialysis. J.Ren.Nutr,
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http://ndt.ofordjournals.org/cgi/content/abstract/563
9)Sheng L.C, Yeng J.L.I, Ling. G.T.H, Ling G.G.Developing a nutrition education pack for
Malaysian hemodialysis patient,(serial online)2001[citedoct2001}11(4):220-227Available from
http://www.jrnjournal.org/article/s/05/2276/abstract/889
10) Davison AM.Oxford textbook of clinical nephrology
Available from. http://boojs.google.co.in/books?id=LF
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the Internal Locus of Control With Compliance in Hemodialysis Patients. Behavioral Medicine.
2006; 32(1): 5-11 Available from. http://www.ncbi.nlm.nih.gov/pubmed/14702581

12)Davison AM. Oxford textbook of clinical nephrology:2003Available from

http://books.google.co.in/books?id=LF3j

13) Lopex C.M. Dietary adherence in Hispanic Patients Receiving Hemodialysis. J. Ren.
Nutr.1999;4(2):23-25
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medical consequences of noncompliance by patients on Hemodialysis are not predictive of
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17)Vlaminck H, Maes.B,Jacobs.A, Reyntjens.S, Evers G. The dialysis diet and fuid nonadherence questionnaire: validity testing of a self- report instrument for clinical practice. Jr. of Cl
Nsg.2001;10:707-15.
18) Mcgee.H.M, Rushe .H. Assessing adherence to dietary recommendations for Hemodialysis
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questionnaire (Rabq).Jr of behavioral medicine.1992; 15(4):343
19) White CA, Pilkey RM, Lam M , Holland DC. Pre-dialysis clinic attendance improves quality
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20) Somers E , Tucker CM. Spouse marital adjustment and patient dietary adherence in chronic
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Jan; 6(1-2): 69 76
21) Unruh ML, Evans IV, Fink NE, Powe NR, Meyer KB; Choices for Healthy Outcomes in
Caring for End-Stage Renal Disease (CHOICE) Study Skipped treatments, markers of nutritional
nonadherence, and survival among incident hemodialysis patients
22 White RB Adherence to the dialysis prescription: partnership with patients for improved
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http://www.findarticles.com/p/articles/mi_m0ICF

Signature of Candidate

Remarks of the Guide

10

Name and Designation of

10.1 Guide

MRS SUSAN KUMAR

ASSOCIATE PROFESSOR
ST JOHNS COLLEGE OF NURSING
BANGALORE

10.2Signature
10.3. Co-Guide (if any )

10.4.Signature

11

11.1.Head of the Department

11.2 Signature
12

12.1.Remarks of the Chairman and Principal

12.2.Signature

DR GOKULNATH
PROFESSOR
HEAD OF NEPHROLOGY
DEPARTMENT
ST.JOHNS MEDICAL COLLEGE
HOSPITAL

MRS MADONNA BRITTO

PROFESSOR
HEAD OF MEDICAL SURGICAL
NURSING DEPARTMENT
ST.JOHNS COLLEGE OF NURSING