Research Topic: Self-care interventions among the patients with Chronic Kidney

Disease visiting Dialysis unit of BPKIHS

Objective: To assess the self-care interventions among the patients with Chronic
Kidney Disease visiting Dialysis unit of BPKIHS
Instructions: You are requested to answer the following questions and give your honest
opinions. The obtained information will be used for research purpose only and it will be
kept confidential.

Interview Questionnaire
Code No:
Bed No.
Diagnosis:
Section A - Demographic Data
1. Age:
2. Sex:
3. Permanent Address:
3.1 Currently living:
a) Remote area (V.D.C)
4. Marital Status:
a) Married
c) Divorced

b) City area( Municipality)

b) Un-married
d) Widow

e) Others if any
5. Educational status:
a) Illiterate

b) Literate

c) Primary level

d) secondary level

e) Higher Secondary

f) Higher education

6. Occupation:
a) Service
d) House-wife

b) Business
e) Dependent

c) Farmer
f) others

a) Hindu

b) Muslim

c) Christian

d) Buddhist

e) Others if any

7. Religion:

8. Type of family:
a) Nuclear

b) Extended

9. Number of earning members in the family:

10. Monthly income of the family (in Rs.):
a) <5000

b) 5000-10,000

c)10,000-20,000

d) >20,000

Section B
Part I Disease Specific Information
1. When were you first diagnosed as having Chronic Kidney Disease?
a) One month ago
b) one- six months ago
c. six months-one year ago
d) More than an year

2. Do you have other diseases apart from Kidney disease?

a) Yes
b) No
2.1 If Yes, mention the disease..
3. Do you have any immediate family members diagnosed as having CKD?
a) Yes
b) No
3.1 If Yes, mention the relationship..
4. Have you received adequate information about the disease condition or attended
any counseling sessions regarding self-care and nature of the disease?
a) Yes
b) No
4.1. If yes, Where and by Whom?
.....
5. What are the consequences of CKD, if not managed properly?
a) Kidneys may stop functioning
b) Fluid retention in the body
c) Cardiac problems due to electrolyte imbalances
d) I Dont Know
Part II General Care and Life Style Modification
1. Have you ever been a smoker?
a) Yes
b) No
1.1. If Yes, Did you stop smoking after being diagnosed with Chronic Kidney
Disease?
a) Yes

b) No

2. Have you ever been an alcoholic?

a) Yes
b) No
2.1 . If Yes, Did you stop alcohol consumption after being diagnosed with Chronic
Kidney Disease?
a) Yes

b) No

3. Have you changed your dietary pattern after being diagnosed with CKD?
a) Yes
b) No
4. What are the measures you have been taking for dietary control?
a) Limited fluid intake
b) Low potassium diet
c) Low salt diet
d) Others, if any

5. Do you know about preparing the vegetables by leaching technique?

a) Yes
b) No

5.1.

If Yes, is this method being followed while preparing your diet?

a) Yes
b) No
6. Have you been prescribed with any drugs to be taken on regular basis?
a) Yes
b) No
6.1. If Yes, mention the name..
6.2. Do you take it regularly, as prescribed?
a) Yes
b) No
7. Do you use any drugs like pain killers on your own, in case of any health problems
without the advice of health care provider?
a) Yes
b) No

c) Sometimes, I do

8. What do you do to monitor your fluid balance status?

a) Monitor weight on regular basis
b) Keep the record of intake and output
c) Both of the above
d) I dont follow any measures
9. Do you monitor your B.P on regular basis?
a) Yes
b) No

10. How frequently you visit hospital or contact health care provider?
a) On regular basis
b) Only, if I have any problem
c) As suggested by them
d) Not so regular
11. Do you always perform the lab tests (blood or urine samples) as prescribed by your
health care providers?
a) Yes
b) No
c) Sometimes
12. Do you talk to anybody regarding the disease or problems you are facing
associated to this?
a) Yes

b) No

12.1 If Yes, Who do you share your problems with?

a) somebody from the family
..

b) Health personnel
..

Part III Dialysis and Vascular Access care Related

1. How frequently you undergo dialysis?
a) Twice a week
b) Once a week
c. once a month
d) Not fixed
2. Which method of dialysis you have been doing till now?
a) Hemo-dialysis
b) Peritoneal Dialysis
3. Have you been suggested about making an Arterio-venous fistula?
a) Yes, I have been suggested to do so
b) No, I have not been suggested
4. Do you have an AV fistula?
a) Yes
b) No
4.1 If No, Do you have plan to get it done?
a) Yes
b) No
5. Do you follow any measures to take care of your fistula?
a) Yes
b No
5.1 If Yes, mention them
..
..
6. Do you regularly feel the thrill palpation on your AV fistula?
a) Yes
b) No
7. Do you protect your fistula arm from being punctured due to any cause or avoid
pressurizing it excessively?
a) Yes, I am conscious about it
b) No, I use it as my normal arm
8. Do you prefer wearing jewelries or any accessories on your hand with AV fistula?
a) Yes
b) No
9. Do you have any problems in receiving dialysis services?
a) No
b) Yes
9.1 If Yes, what are they?
a) Not available in nearby places
b) Waiting for the turn in queue

c) Others, if any.
10. Have you been utilizing the services provided by government of Nepal to the
patients with Chronic Kidney Disease and who are undergoing dialysis?
a) Yes, I have
b) No, I have not been able to
c) No, I havent heard of it
11. Have you ever faced any complications after dialysis?
a) Yes
b) No
If Yes, mention them..

12. Do you think self-care measures have any role in managing Chronic Kidney disease
apart from hospital based treatment?
a) Yes
b) No
c. I dont know
13. From where did you get these information regarding the self-care?
a) Doctors

b) Nurses

c) Dietician

d) Others specify