Incidence of Renal Failure in Selected Adopted Communities of Lyceum of the Philippines University Kidneys are responsible for many

functions in the body. Failure of one part to function could be very crucial for it could lead to the suppression of all the other parts of the human body. Thus, this case is called Renal Failure. Renal Failure is an acute deterioration in kidney function manifested as an inability to eliminate waste products and regulate fluid balance. The buildup of waste materials that accumulates affects multiple organ systems. (Robertson, 2006). Renal failure occurs in either an acute or chronic failure. The acute form most often occurs because of a sudden body insult, such as severe dehydration. On the other hand, the chronic form results from extensive kidney disease, such as hemolytic- uremic syndrome or glomerulonephritis (Reddy &Murra, 2009). Other causes of acute renal failure include prolonged anesthesia, hemorrhage, shock, severe diarrhea, or sudden traumatic injury. It can also occur in children who are placed on cardiopulmonary bypass while undergoing heart surgery, who receive common antibiotics (aminoglycosides, penicillin, cephalosporin, and sulfonamides), who swallow a poison such as arsenic (found in rat poison), or who are exposed to individual wastes such as mercury. All of these conditions appear to lead to renal ischemia, which ultimately leads to acute renal failure. (Pilliteri, A. 2010). Acute kidney failure is potentially life-threatening and may require intensive treatment. However, the kidneys usually start working again within several weeks to months after the underlying cause has been treated. The high mortality related to ARF has not changed for over 4 dead in spite of increasingly complex technologies to treat acute renal failure one could argue that today patients with acute renal failure often have associated multiple organ dysfunction syndrome (MODS) and have complex illness and comorbiditics compare with patients 40 years ago. In some cases, chronic renal failure or end-stage renal disease may develop. Death is most common when kidney failure is caused by surgery, trauma, or severe infection in someone with heart disease, lung disease, or recent stroke. Old age, infection, loss of blood from the intestinal tract, and progression of kidney failure also increase the risk of death. (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001530/) Acute renal failure occurs in 5 percent of hospitalized patients. Etiologically, this common condition can be categorized as prerenal, intrinsic or postrenal. Most patients have prerenal acute renal failure or acute tubular necrosis (a type of intrinsic acute renal failure that is usually caused by ischemia or toxins). (Am Fam Physician 2000;61:2077-88).

Incidence of Renal Failure

Every year, millions of people battle kidney disease. There are many different types of this disease, but the most common, which is increasing every year at a rate of six to eight percent, is chronic kidney disease. Kidney disease goes through several stages, with the final stage being end-stage kidney disease (ESKD), also referred to as end-stage renal disease (ESRD). According to the World Health Organization, an ageing population, and increasing rates of type 2 diabetes and hypertension are driving the increase of ESRD. Currently, there are over 1.4 million people on life-saving dialysis (mostly in high-income countries), and the number is growing by about eight percent every year. (Capicchiano) Renal or kidney failure remains among the top 10 causes of morbidity and mortality in the country. Nephrologists and medical experts who were trained in the diagnosis and management of kidney disease, the renal failure at its final stage is on the ninth spot out of the top 10 causes of death in the country. Renal failure (formerly called renal insufficiency or chronic renal insufficiency) is a situation in which the kidneys fail to function adequately. (http://ihatedialysis.com/forum/index.php?PHPSESSID=dd493bbcefd7d58eb989 2c5b3534baa6&topic=19469.msg330200#msg330200) Each year an estimated 120 Filipinos per million populations (PMP) develop kidney failure. This means that about 10,000 Filipinos need to replace their kidney function each year. According to the Philippine Renal Disease Registry Annual Report in 2008, the leading cause of kidney failure in the Philippines is diabetes (41%) followed by an inflammation of the kidney (24%) and high blood pressure (22%). Patients were predominantly male (57%) with a mean age of 53 years. The best way to replace kidney function though is to transplant another kidney into the patient through a surgical procedure. Only another kidney can completely replace kidneys shrunken because of disease. Dialysis only provides about 15% of kidney function. It is enough to sustain life, but needs to be performed regularly, and for life. Acute kidney failure is a common problem. It affects approximately 5% of all hospitalized patients and up to 30% of patients admitted to Intensive Care areas. The mortality rate for AKF approaches 50% making it one of the leading causes of inpatient death. (Phipps, 2007) Nationwide, there are 8,708 patients who started their therapy in 2009, according to the Philippine Renal Registry in connection with the Department of Health (DOH). (2010)

Incidence of Renal Failure

The researchers foresee that the results of the study would extend its benefits not only to the researchers but also to the respondents in giving them precise information about renal failure. The product of this research would help the community by contributing knowledge and expounding their ideas about renal failure that would help in decreasing the incidence of renal failure through the use of the proposed program of the researchers. Objectives of the Study The researcher seeks to determine the demographic profile of the respondents in terms of age, gender, family income, ocuupation, and health related problems; it seeks to determine the factors contributing to the incidence of Renal Failure in terms of nutrition, lifestyle, medication and environment; and lastly, to propose a program on how to lessen or decrease the incidence of Renal Failure. Related Literature on Objective 1 Age Among Filipino children, ARF is common below two years; in contrast chronic renal failure is more common among adolescents 11 to 15 years old. In ARF the most common is prerenal particularly dehydration secondary to acute gastronephritis. (Fe del Mundo, etc.2000) The survival rate for acute renal failure has not improved, primarily because affected patients are now older and have more comorbid conditions.Infection accounts for 75 percent of deaths in patients with acute renal failure, and cardiorespiratory complications are the second most common cause of death. Depending on the severity of renal failure, the mortality rate can range from 7 percent to as high as 80 percent. In the general population, slightly more than 30 people in every 100,000 develop kidney failure each year. In the pediatric population-age 19 and underthe annual rate is only 1 or 2 new cases in every 100,000 children. In other words, adults are about 20 times more likely to develop kidney failure than children. The risk increases steadily with age. Pre-renal failure is the most common form of ARF in children. The main process in the development of pre-renal failure is hypoperfusion of the kidney, secondary to reduced effective plasma volume or heart failure. Numerous underlying conditions can lead to prerenal failure. In children, the most common causes are hypovolemia secondary to gastrointestinal losses, the state of shock, and postoperative conditions. For example, ARF may occur after heart surgery

Incidence of Renal Failure

when the aorta is cross-clamped or following prolonged cardiopulmonary bypass time. Postrenal failure is a less frequent cause of ARF in children. It presents as an abrupt decline in glomerular filtration rate (GFR) secondary to lower tract obstruction or bilateral upper tract obstructions, unless the patient has a single kidney. Clearly, the pediatrician must be alert to the possibility of renal obstruction. When a child presents with the signs of azotemia and a sudden decrease in urine output, the history and physical examination can help determine the location and cause of obstruction. The patient may have had frequent urinary tract infections, hematuria, trauma, underlying lesions, an alteration in the urinary pattern (decrease in urine stream, dribbling), and presence of lower abdominal or flank pain secondary to renal enlargement and dilatation of the collecting system. The physical examination may reveal a palpable suprapubic mass, such as in male newborns that have posterior urethral valves. This is the most common cause of postrenal failure in boys. (http://www.4shared.com/document/Lpb8h6qH/Acute_Renal_Failure_Dx.htm) According to Zaykoski (2010) Age and risk affect the chances of developing kidney failure, as well as longevity related to chronic kidney failure. MayoClinic.com reports that people age 65 or older have a higher risk of kidney disease than younger people. As a person ages, the kidney undergoes structural and functional changes. Renal blood flow is decreased by 1% per year after age 30. (Rosner, 2009). Renal function may decline by 50% or more by age 70. (Goldman, 2008). As person ages, tubular reception and renal concentrating ability decline because the size and number of functioning nephrons decrease. (Lippincott, 2008) Aging is known to cause predictable increases in both systolic and diastolic BP. This slow increase in blood pressure begins early in life and continuous through adulthood. Untreated hypertension accelerates the development of atherosclerosis, which leaks, to kidney failure. (Phipps, 2007) In the general population, slightly more than 30 people in every 100,000 develop kidney failure each year. In the pediatric population-age 19 and underthe annual rate is only 1 or 2 new cases in every 100,000 children. In other words, adults are about 20 times more likely to develop kidney failure than children. The risk increases steadily with age.

Incidence of Renal Failure Gender

According to Science Daily, Gender influences the prevalence and progression rate of many renal diseases, such as polycystic kidney disease (PKD). The physiology behind gender differences and renal disease is still uncertain, but the distinct characteristics of male and female kidney size, along with diet and the presence of hypertension, have all been thought to play a part. Thus, diabetic males in the most productive years of their lives comprise the population who received treatment for kidney failure in 2007. They require replacement of their kidney function to live. Without dialysis or kidney transplantation, patients with kidney failure die. (http://www.abscbnnews.com/node/14995). Kidney disease often affects the male population with 59 percent and common age population is between 41 to 70 years old with most suffering from Type 2 diabetes or obesity-related diabetes (Yu,2010). Several lines of evidence indicate that there are sex differences in the incidence and severity of cardiovascular and renal disease. Men are more prone to develop chronic kidney disease (CKD) and to progresses to end-stage renal disease than are women, when all-cause incidence rates are considered.When a primary diagnosis is taken into account, this assertion holds true for many causes of CKD, such as IgA or membranous nephropathy, hypertensive nephropathy, or polycystic kidney disease. However, in the case of diabetic renal disease, the sexual dimorphism favoring women is not as clear cut, and clinical data are conflicting (American Heart Association). Family Income Adequate dialysis costs from P25, 000 to P46, 000 per month or P300, 000 to P552, 000 annually. If one is able to afford this lifelong treatment then the patient will be well enough to return to his normal way of life, and just apportion time for dialysis treatment. However majority of Filipinos cannot afford this costly treatment for more than a year. A study at the National Kidney and Transplant Institute (NKTI), a tertiary government hospital providing services for kidney disease, showed that half the patients who start dialysis are dead within a year, presumably because they could not afford sufficient dialysis. On top of all that, transportation to and from treatment may be difficult to arrange and financial burdens may exist. While Medicare pays 80% of dialysis costs for most patients, and private health insurance or state medical assistance likely contributes funds, individuals could have co-pays for secondary insurance. Plus, Part D prescription coverage is rarely adequate for the high costs of oral medications. And individuals may need to limit their work hours, affecting take

Incidence of Renal Failure home pay, to accommodate appointments. (Martchev, 2008).

Financial burdenincreases, as treatment is expensive. The familys economic resources are strained to the maximum extent possible. It may cause a lot of stress not only for the individual but also on the family. If the individual is single, with no family support, the individual has to endure a high level of stress. (http://sofs.hubpages.com/hub/Kidney-failure-and-Dialysis-the-psychologicalaspects) Only 10 to 15 percent of people who suffer from kidney failure undergo dialysis because of financial constraints as one dialysis session costs between P1, 800 to P3, 500 while dialysis patients need to undergo dialysis two to three times a week (Yu, 2010). Occupation Incidence rates are also higher among steel plant coal oven workers. Exposure to heavy metals such as lead and cadmium may also raise risk levels. Exposure to asbestos and/or cadmium (a type of metal used in the production of batteries, plastics, and other industrial processes) can increase the risk of developing kidney cancer. (http://www.cancercenter.com/kidneycancer/kidney-cancer-risk-factors.cfm) So What Are The Main Sources of Cadmium? Cigarette smoke (inc. passive smoking), batteries (nickel-cadmium), paint, evaporated milk, ceramics, shellfish, electroplating (Electronics), drinking water (galvanised pipes), phosphate fertilisers, breathing contaminated air in the workplace, Fungicides, pesticides, tools, plumbing alloys, photographic chemicals. (http://www.kidneycoach.com/439/what-everybody-ought-to-know-aboutcadmium-toxicity-and-renal-failure/) Cadmium is also found in some industrial paints and may represent a hazard when sprayed. Operations involving removal of cadmium paints by scraping or blasting may pose a significant hazard. Artists who work with cadmium pigments, which are commonly used strong oranges, reds, and yellows, can easily accidentally ingest dangerous amounts, particularly if they use the pigments in dry form, as with chalk pastels, or in mixing their own paints. (http://en.wikipedia.org/wiki/Cadmium_poisoning) Heavy metals from the environment can also accumulate in the kidneys and can damage them. 4 We are exposed to heavy metals like cadmium, mercury and lead everyday from mercury in our fish, cadmium in our air, and lead in our pipes for example. (http://www.wellsphere.com/complementaryalternative-medicine-article/kidney-failure-the-unknown-epidemic/722242)

Incidence of Renal Failure Health Problems

Nephrologist Dr. Danny Yu and secretary of the Philippine Society of Nephrologists - Central and Eastern Visayas Chapter bared that more than 50 percent of those who have kidney problems is due to diabetes and 25 percent attributed to hypertension alone. In a few years time, such unhealthy lifestyle that goes with untreated hypertension will lead to organ damage, heart attack, kidney disease, and stroke.(Framelia V. Anonas, 2010) Uncontrolled hypertension increases the risk of stroke, heart failure, myocardial infarction and kidney diseases.(Rhoney D, Peacock WF., 2010) McCulloch (2006), the long-range study found that the obese have up to a seven times greater risk of kidney failure than normal weight people, suggesting that obesity should be considered a risk factor for the condition, and that kidney failure is yet another consequence of obesity. According to the United States Renal Data System, the causes of chronic renal failure are numerous, but diabetes mellitus and hypertension are by far the two most common, accounting for more than 30% and 20% of cases of ESRD respectively (2006). Other causes include glomerulonephritis (both primary and secondary systemic diseases), interstitial nephritis, congenital malformation, genetic disorders, neoplasms, hepatorenal syndrome, and obstructive neuropathy, microangiophic etiologist such as scleroderma and atheroembolic disease. (USRDS, 2006). Because of the extremely high prevalence if diabetes and hypertension as causes of chronic renal failure, an understanding of the renal pathophysiology specific to these entities and knowledge of interventions designed to slow down or even prevent progression to ESRD is imperative. Renal failure is a major complication of diabetes with an incidence of 40% in patients with type 1 diabetes mellitus and 40% - 63% in patients with type 2 diabetes mellitus. (Lancaster, 2007). In diabetes, the microvasculature in the organ systems of the body, including the kidneys, is damaged. In the kidneys, primarily the afferent and efferent arterioles and the glomerular capillaries are affected. Glomerular changes include thickening of the basement membrane, deposits of immunoglobulin and albumin and diffuse glomerulosclerosis. Late in diabetic neuropathy, tubular atrophy and interstitial fibrosis also occur. The exact

Incidence of Renal Failure

pathophysiological mechanism for these structural alterations is unclear, but hyperglycemia is a major contributor. (Lancaster, 2007). The effect of systemic hypertension on the kidneys results in a condition known as nephrosclerosis. Hypertensive nephrosclerosis involves the development of sclerotic lesions in the renal arterioles and glomerular cappilariesthar cause them to become thickened and narrowed, and eventually necrotic. Hypertensive nephrosclerosis can be benign or malignant. In benign nephrosclerosis, associated with chronic mild or moderate hypertension, renal impairment occurs every many years. Malignant nephrosclerosis, associated with malignant hypertension, can lead to permanent renal failure rapidly if blood pressure is not immediately reduced. Often symptoms like blurred vision and a severe headache accompany this crisis situation. Because hypertensive nephrosclerosis is directly caused by hypertension, its incidence is greater in populations with a higher incidence with primary hypertension.(Lancaster, 2006) Cardiovascular system can cause or accelerate acute and chronic renal failure. In addition, cardiovascular complications can arise as a result of renal failure. Common cardiovascular complications in acute and chronic renal failure include hypertension and hyperkalemia. Pericarditis, another cardiovascular disease of renal disease, is primarily seen with chronic renal failure. (D.Holcombe, 2006) Other gastrointestinal complications associated with renal failure primarily occur in chronic renal failure and include anorexia, nausea, vomiting, diarrhea, constipation, and oral cavity alterations such as: stomatitis, a metallic taste in the mouth, and fetor uremicus (the smell of urine and ammonia in the breath). (D.Holcombe, 2006) Other pulmonary complications in renal failure include pleural effusions, pleuritic inflammation and pain, uremic pneumonitis, and pulmonary infections. Pulmonary infections, on the other hand are common in both acute and chronic renal failure, especially in critically ill patients. Factors associated with renal failure that contribute to pulmonary infections include decreased pulmonary macrophage activity, a generalized immunocompromised state, tenacious sputum, and a depressed cough reflex. (D.Holcombe, 2006) Certain systemic diseases, such as diabetes mellitus, systemic lupus erythematosus (SLE), hypertension, sickle cell anemia. God pastures syndrome, acute glomerulonephritis, and acute pyelonephritis, may contribute to the development of acute renal failure. (Lippincott Williams, 2008). Obesity is an important and potentially preventable risk factor for chronic renal failure (CRF), according to a study in the June Journal of the American Society of Nephrology. "Our results confirm an accumulating body of clinical and experimental data implicating obesity as an important causative factor in kidney

Incidence of Renal Failure

disease," comments Dr. Elisabeth Ejerblad of Uppsala University, Sweden, lead author of the new study. Obesitydefined as a BMI of 30 or higherwas a strong risk factor for CRF. Subjects who met the definition of obesity at any age were three to four times more likely to develop CRF. For women, morbid obesityBMI 35 or higherwas also a risk factor for CRF. (http://www.sciencedaily.com/releases/2006/05/060513122553.htm) According to the National Kidney Foundation's Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease 2007, diabetes is the leading cause of CKD in developed countries, and is rapidly becoming the leading cause of CKD in developing countries. This is due to the global increase in type 2 diabetes and obesity. Diabetes accounts for 45 percent of prevalent kidney failure, up from 18 percent in 1980. When you have diabetes, your body fails to make enough insulin. Insulin is a hormone that regulates the amount of sugar in your blood. High blood sugar levels causes problems in many parts of your body. Your kidneys contain countless small blood vessels and filtering units, which become damaged as a result of high sugar levels. Untreated high blood pressure can damage your kidneys. This damage can lead to heart attacks, strokes and kidney failure. High blood pressure can reduce blood supply to the kidneys. It also damages the countless small blood vessels and filtering units in your kidneys. This can prevent the kidneys form removing waste products from the blood and extra fluids. The extra fluid in your blood vessels can build up and raise blood pressure even more. According to guidelines issued by the National Kidney Foundation, if you have kidney disease, your target blood pressure should be below 130/80 mm Hg. Polycystic kidney disease is the most common inherited kidney disease. It causes cyst formation in the kidneys that grows over time and can cause serious kidney damage. If left untreated, kidney stones can lead to CKD. If kidney stones are too large to pass, you can be treated by your doctor to remove the stones or bread them down into small bits so they will pass. If you have had one stone, you are at increased risk of having another one. Those who have developed one stone are at approximately 50 percent risk for developing another within five to seven years. Repeated urinary infections can lead to CKD. Urinary tract infections cause symptoms such as pain and/or burning during urination and the need to

Incidence of Renal Failure

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urinate more frequently. These infections most often affect the bladder, but they sometimes spread to the kidneys, and they may cause fever and pain in your back. (http://www.livestrong.com/article/97090-causes-nonfunctioningkidney/#ixzz1f9qH49tp) Polycystic kidney disease, PKD, is an inherited genetic disease that affects more than 12.5 million people worldwide. This disorders causes the formation of fluid-filled cysts, primarily in the kidneys. However, these cysts can form in many other organs. The National Kidney Foundation reports that approximately 50 percent of PKD patients have kidney failure by the time they reach 60.Alport's syndrome is another inherited condition that's a cause of kidney disease earlier in life. Alport's syndrome also affects hearing and vision. Although this disease affects men and women, men have a greater incidence of chronic kidney disease. Glomerulonephritis is inflammation of the membrane that acts as a filter in the kidney. The Kidney and Urology Foundation of America explains how an acute streptococcal infection can cause glomerulonephritis, inflammation of the glomeruli and kidney disease. Streptococcal infections don't directly affect the kidney, but the body's immune response to attack the invading streptococcal bacteria may overproduce antibodies. These antibodies get deposited in the filtering units of the kidney and cause damage. Although rare, acute poststreptococcal glomerulonephritis can cause permanent kidney damage. Bacterial endocarditis, a heart infection, and HIV infection can also lead to chronic renal failure. The exact mechanism of action is unclear, but it's believed that the immune response causes damage to the glomeruli and nephrons. Normally, the immune system can tell the difference between invading pathogens such as bacteria, viruses or cancer cells and the body's own cells and tissues. In the case of an autoimmune disorder, the immune system doesn't recognize the body's tissues and cells; the body literally attacks itself. Chronic autoimmune disorders such as systemic lupus erythematous result in kidney damage because of circulating antibodies that cause inflammation in the glomeruli and nephrons. Other autoimmune disorders that cause kidney disease are Goodpasture's syndrome, which directly targets the kidneys, and immuneglobulinA (IgA) nephropathy, which causes glomerulonephritis. (http://www.livestrong.com/article/106137-causes-kidneydisease/#ixzz1fACr0RB8) Literature on objective 2 Nutrition Acording to Zaykoski (2010), adhering to a renal diet can reduce the complications of end-stage renal failure and improve quality of life. The renal diet restricts the intake of protein, potassium, phosphorus and sodium. In patients

Incidence of Renal Failure

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with advanced renal failure, the diet also restricts the amount of fluid consumed on a daily basis. Because damaged kidneys cannot filter waste products, reducing protein intake reduces the amount of creatinine consumed during protein metabolism. The less creatinine in the blood, the less work the kidney has to do to filter wastes. Since the kidneys also control fluid and mineral balances, reducing sodium, phosphorus, potassium and fluid intake reduces the workload of the kidneys and reduces the risk of complications. Excessive salt intake makes a person retain water. Retaining water can be very dangerous for people with kidney failure, as they cannot get rid of extra fluid through urinating. Excessive salt can also lead to high blood pressure, a problem often associated with kidney failure. Chronic high blood pressure can lead to worsening of kidney failure. It is also seen that dairy products also cause formation of kidney stones. There are very small amount of nutrients extracted by our body from the dairy products, and there are more amounts of waste products, which gets converted into kidney stones. It is also recommended that the food, which contains high protein content, should also be avoided. The protein rich food is difficult on kidneys. The high protein diet includes meat, eggs etc. Food with high sodium content should also be avoided as it helps in more calcium formation in urine and can thus cause kidney stones. Food with high sugar content should also not be taken as a sugary food helps in formation of kidney stones. It is seen if all these food items are avoided from the diet then the chances of having kidney stones decreases to a great extent. On the other hand there are some foods which if consumed can decrease the chances of kidney stones, citrus fruits is one such option. If you include plenty of citrus fruits in your diet then you can be saved from kidney stones. You should consume lots and fruits and vegetables to avoid kidney stones. Water is one wonderful option; you should drink plenty of water. Your body can get rid of toxins if you drink plenty of water. Although we have discussed certain food items in the above paragraphs, as the ones which can cause kidney stones. This certainly does not mean that you should eliminate all these foods from your diet. The important thing to know here is moderation. Every food should be had in moderation until or unless advised by the doctor, not to have it. (http://www.kidney-stones.net/foods-toavoid-with-kidney-stones/) A new study linked drinking two or more cola drinks (either diet or regular) each day with an increased risk for chronic kidney disease. Other kinds of sodas did not increase the risk for chronic kidney disease. When your kidneys are functioning improperly, your ability to balance salt levels in the body diminishes. Salt accumulation can cause edema or swelling of

Incidence of Renal Failure

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the face, feet and hands. Salts also contain potassium, a nutrient that has certain roles in muscle contractions, especially those of the heart. Altered potassium levels may cause arrhythmia or abnormal heart rhythm. Chocolate, oranges, bananas, prunes, tomatoes, beans, peas and dried nuts should be avoided because of their high potassium level. Foods with added salts include soy sauce, table salt, pickles, pizza, cheese, french fries, potato chips, bacon, ham and canned goods, all of which should be limited or restricted if you have or develop kidney disease Protein, an important nutrient, helps your body maintain muscle strength and cellular functions. However, it can also worsen kidney disease. When you consume protein-rich foods, your body releases a chemical agent called uric acid after the protein is broken down. In patients with diseased kidneys, this toxic substance causes conditions such as muscle weakness, heart disorders and joint pain. High-protein animal products are more harmful to your body than lower protein plant foods if you have kidney disease. Eggs, pork, beef, tuna and dairy sources such as creams and cheese should be limited or restricted. With the onset of disease, your kidneys may fail to perform their normal functions. This can cause increased weight gain and edema in parts of your body in response to excess fluid buildup. Fluid accumulation can affect your heart by prompting it to pump large blood volumes, exerting unnecessary pressure on your heart. Although consuming at least 64 oz. of water daily is a standard target, your physician may recommend that you adjust your fluid intake to improve your kidney condition. Certain foods, such as oranges, lemons, tomatoes, lettuce, celery, grapes, ice creams, juices and soups, should also be avoided to lower or decrease fluid levels in your body. For best results, seek individualized advice from your doctor. Foods such as strawberries, rhubarb, spinach, beets, chocolate, tea, wheat bran, nuts and most dry beans contain large amounts of oxalate, a chemical compound that is stored in your kidneys and can cause kidney stones if it is not excreted. This can cause damage if you are suffering from kidney disease. Your physician is likely to adjust your daily diet to allow only minimal amounts of these foods until your kidney health has improved. In addition to the total amount of fluid consumed, the type of beverage might also play a role. In a study of middle- aged women, coffee, tea and wine were independently protective, whereas grapefruit juice promoted incident kidney stone disease. These findings were also confirmed in men; however, in this cohort, beer consumption reduced, and apple juice increased the risk of kidney stones. Some beverages, for example stronger hopped beers such as European

Incidence of Renal Failure

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lagers, might contain significant amounts of oxalate but their consumption also increases urinary flow and dilution, which likely explains their neutral or even beneficial effects in observational studies. A general recommendation for the consumption of alcoholic beverages to reduce the risk of stone disease cannot be given at the present time. In addition, coffee, as opposed to tea consumption, has repeatedly been shown to be protective in a dose- dependent fashion, which likely relates to its effects on urine flow. Lifestyle Psychological and sociological factors can affect the patients health. (Lippincott, 2008) Exposure to any form of stress triggers activity within the hypothalamicpituitary-adrenal axis. The key aspect of stress response is adrenal release of norepinephrine, epinephrine and cortisol. These hormones affect multiple physiological functions, including those of kidneys. (http://www.ehow.com/facts_5929145_effect-stress-hormones-kidneyfunction.html) When it comes to drinking alcohol, for anyone who can drink it safely, moderation is the key. Drinking too much alcoholeven for a completely healthy personcan cause kidney disease. (http://www.davita.com/kidney-disease/dietand-nutrition/lifestyle/alcohol-and-chronic-kidney-disease/e/5330) Drinking alcohol can cause the kidneys to increase urinary output. This can lead to dehydration. More than two drinks a day can cause a rise in blood pressure. The carbohydrate load from drinking can cause obesity. This could increase the risk of diabetes and diabetic kidney disease. Drinking can interfere with the blood chemistries and increase the ability of the body to protect the kidneys. Many people who drink are more likely to smoke. Smoking also causes kidney disease. (Vamvakas, 2006). Exercise causes you to sweat. The more intense the physical activity, the more fluids are lost through sweat. If you fail to replenish these fluids, it can ultimately lead to dehydration. It isn't until dehydration becomes severe that it can slow blood flow to the kidneys. This can affect their functioning, leading to what the American Urological Foundation calls pre-renal failure. The reduction in blood flow inhibits the kidneys' ability to filter waste, causing a buildup of not only toxins but fluids. (George, 2011). Both depression and anxiety may predispose patients to worsening of congestive heart failure. One source found depression to be a fairly strong predictor of repeated hospital admission, independent of the initial severity of

Incidence of Renal Failure

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heart failure. Another source states that CHF patients with severe depression are 4 times more likely to die within 2 years compared to those without depression. The mental stress of anxiety and depression is associated with excess activation of the sympathetic nervous system (SNS). This increased activity in the SNS is strongly associated with increased mortality and morbidity in CHF. Studies also show that depression and anxiety predispose to poor compliance with heart failure treatment plans, leading to worsening heart failure. Peer pressure, development of identity, preoccupation with appearance, the joy of the moment, aspirations and dreams for the future. Add to this a serious medical condition. There may be poor self-image, depression and anger displaced onto the disease or treatment. Adolescent risk taking, magical thinking and denial can all contribute to poor treatment adherence. Increased authority from parents and professionals, overprotection and the sick role may lead to learned dependency. In addition to the challenges faced by every teenager, adolescents with chronic kidney disease must rely on drugs or machines for their health or survival, with little margin for acting out or error. Missed treatments can lead to irreversible injury, or even death. (Bell) Control Your Blood Pressure keep your blood pressure below 130/85 (adults) with weight loss and exercise, a low sodium/low fat diet, reducing stress, and taking your blood pressure medication correctly. For some patients, the target blood pressure is lower (125/75). Controlling high blood pressure may delay the progression of kidney disease by slowing damage to the kidneys. Smoking can interfere with the medicines used to treat high blood pressure. If you have high blood pressure and you smoke, your medicines may not control your blood pressure well enough. Uncontrolled or poorly controlled high blood pressure is a leading cause of chronic kidney disease. Smoking can also be a problem for people who already have kidney disease. Smoking slows blood flow and can worsen existing heart, blood vessel and kidney problems. In addition, bladder cancer and kidney cancer are more common in smokers. A research has found anger and hostility to be positively correlated with hypertension, a major risk factor for CKD and its progression to ESRD. Individuals who live alone or have minimal contact with friends, relatives, or acquaintances have been found to have higher rates of cardiovascular disease morbidity and mortality than persons who are integrated in social networks. ( Bruce, 2010) Kidney failure occurs after prolonged stress on the system due to heroin use. Loss of a function kidney puts the heroin user at greater risk of serious illness or death. Kidney disease is one of the less talked about consequences of

Incidence of Renal Failure

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heroin use, but remains a great risk for those who use the drug over months and years. (http://www.michaelshouse.com/heroin-addiction/effects-of-heroin/) Medication According to Zaykoski (2010), prescription and over-the-counter medications are designed to treat the symptoms or underlying causes of many diseases and medical conditions. While many are effective, some have severe side effects that can be life-threatening. One possible side effect of prescription and OTC medications is kidney failure. Many medications are associated with acute kidney injury. Some of the most common culprits are non-steroidal anti-inflammatory drugs (NSAIDs); antimicrobials such as aminoglycosides, amphotericin B and acyclovir; cardiovascular drugs such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs); diuretics; antidepressants; and intravascular contrast media. (Naughton, 2008). Heavy use of painkillers containing ibuprofen (Advil, Motrin), naproxen (Aleve), or acetaminophen (Tylenol) have been linked to interstitial nephritis, a kidney inflammation that can lead to kidney failure. A new study suggests that ordinary use of painkillers (e.g., one pill per day) is not harmful in men who are not at risk for kidney disease. Allergic reactions toor side effects ofantibiotics like penicillin and vancomycin may also cause nephritis and kidney damage. Use of certain nonprescription drugs, such as heroin or cocaine, can damage the kidneys, and may lead to kidney failure and the need for dialysis. In patients who are at high risk for kidney problems, several other medications can cause problems. Diuretics taken alone can cause dehydration which can lead to kidney failure. Antibiotics, specific antiviral medications and antifungal agents like amphotericin B can cause kidney problems and may need to be discontinued. It is important to alert the physician to all of the medications a person is taking because a combination of drugs or procedures may cause problems when used together. The physician will monitor kidney function closely when prescribing any of these treatments to minimize the risk of kidney failure.

Patients who have other health problems such as diabetes combined with kidney disease may be at higher risk for kidney failure after a radiologic procedure that uses contrast dye. Patients who receive large amounts of dye or who suffer from dehydration can also develop kidney failure after a procedure. As with other medications and agents that can cause kidney failure, there is often an initial decrease in kidney function that stabilizes over a few days, but in patients with previous risk factors, this may not improve (Brooks).

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Kidney trauma can occur as the result of an accident or overuse or abuse of over-the-counter and prescription drugs. Ibuprofen and acetaminophen have been known to lead to kidney inflammation that can increase the risk for renal disease. Allergic reactions to antibiotics can also lead to inflammation of the kidneys and eventual kidney disease. Physical trauma includes injuries sustained in auto accidents and during surgical procedures. This type of trauma can reduce the flow of blood to the kidneys and result in renal disease. Nephrotoxic drugs. Drugs causing prerenal damage. Drugs that cause excessive gastrointestinal losses, either through diarrhea or vomiting, also cause volume depletion and may precipitate acute renal failure. NSAIDs, even in short courses, can cause acute renal failure as a result of renal under perfusion. ACE inhibitors can also cause deterioration in renal function. However, this is a problem only in patients with compromised renal perfusion, particularly those with renal artery stenosis. Care should be taken when an ACE inhibitor and NSAID are prescribed together as this combination may precipitate an acute deterioration in renal function. Drugs causing intrarenal damage. Intrarenal damage may result a direct toxic effect on the kidneys or hypersensitivity reactions. Most drugs that cause damage within the kidneys do so as a result of hypersensitivity reactions, which involve either glomerular or interstitial damage. Drugs that have been reported to cause glomerulonephritis include penicillamine, gold, captopril, phenytoin and some antibiotics, including penicillins, sulphonamides and rifampicin. Drugs that may cause interstitial nephritis include penicillins, cephalosporins, sulphonamides, thiazide diuretics, furosemide, NSAIDs and rifampicin. There are a number of drugs that cause direct toxicity to the renal tubules (acute tubular necrosis), e.g. aminoglycosides, amphotericin and ciclosporin. Drugs causing postrenal damage (urinary tract obstruction). High-dose sulphonamides, acetazolamide or methotrexate may cause crystalluria and could therefore cause obstruction. nticholinergics, e.g. tricyclic antidepressants, and alcohol may cause urinary tract obstruction due to retention of urine in the bladder. Other nephrotoxic drugs.Cephalosporins: cephaloridine, one of the first cephalosporins introduced, has been associated with direct renal toxicity and is no longer in clinical use. Other cephalosporins are much less likely to produce renal damage but third generation cephalosporins, e.g. cefixime, have very rarely been reported to cause nephrotoxicity. Analgesics: NSAIDs may cause acute renal failure due to hypoperfusion and interstitial nephritis, as well as analgesic nephropathy (chronic interstitial nephritis and papillary necrosis). Analgesic nephropathy has been most commonly seen with combination analgesic products that contain aspirin and/or paracetamol. Analgesic nephropathy is one of the few preventable causes of chronic renal failure. Discontinuation of the abused drugs often results in stabilisation or even improvement in renal function

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but continued abuse leads to further renal damage. Lithium: serum levels of lithium consistently above the therapeutic range have been associated with development of a nephrogenic diabetes insipidus. Over-the-counter analgesics. Analgesic nephropathy. Classic analgesic nephropathy is a slowly progressive interstitial nephritis characterized by small, irregularly shaped kidneys with renal papillary necrosis. Analgesic nephropathy results from the daily use for many years of antipyretics such as phenacetin, acetaminophen, and aspirin, usually in combination with caffeine or codeine. In most studies, analgesic abuse is defined as the daily consumption of analgesics for at least 5 years with a minimum of 3000 doses. Early clinical symptoms of analgesic nephropathy include polyuria, sterile leukocyturia, and microscopic hematuria. Progression is insidious, and clinical findings in later stages are related to advanced renal failure. Diagnosis can be made by ultrasound, but a CT finding of irregular kidneys with papillary necrosis and calcifications is the most sensitive and specific method of diagnosing analgesic nephropathy. Because of the requirement of prolonged analgesic consumption (ie, N 5 years), it is not likely that analgesic nephropathy will present during adolescence. However, the habitual use of analgesics may begin in adolescence, and practitioners should inquire about chronic analgesic use and provide counseling on the potential adverse renal effects. Nonsteroidal anti-inflammatory drugs. No convincing evidence indicates that the habitual, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) results in the development of classic analgesic nephropathy. Nonetheless, NSAIDs, including the newer cyclo-oxygenase 2 inhibitors , are associated with a wide variety ofadverse renal effects. All NSAIDs have the potential to induce an acute,but usually reversible, decline in renal function. Although acute renalfailure can occur in healthy individuals, most cases of acute renal failuremanifest in individuals at high risk, such as the aged and those with congestiveheart failure, pre-existing renal disease, volume depletion (eg, dehydration), orconcosmitant therapy with diuretics or other agents with nephrotoxic potential (eg, cyclosporine).Typically, high-risk patients have conditions that result in increased vasoconstrictor activity, and renal prostaglandins maintaineffective renal blood flow and glomerular filtration rate by attenuating the effectsof the vasoconstrictors (eg, angiotensin II, vasopressin) through the vasodilatationof the renal vasculature. Inhibition of renal prostaglandin production by NSAIDsresults in unopposed vasoconstrictor activity and a reduction in renal blood flowand renal function. Other less common untoward effects of NSAIDs on thekidney include the nephroticsyndrome , papillary necrosis, andinterstitial nephritis. Natural medicines and dietary supplements.About 40% of Americans use dietary supplements. Many consumers assume that, because dietary supplements are regulated as food and not as drugs, they are harmless. However, natural does not necessarily mean safe, as many 32 bloweydietary

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supplements contain compounds potentially toxic to humans and the human kidney. According to the Dietary Supplement Health and Education Act of 1994, a dietary supplement is an oral product that is intended as a supplement to the diet, is labeled as such, and contains at least one of the following dietary ingredients: vitamin, mineral, enzyme, amino acid, herb, or botanical product. No premarket approval requirement exists for dietary supplements, and the manufacturer has no obligation to provide evidence of product safety unless the product is considered a new dietary product. Furthermore, there are no postmarket adverse event reporting requirements for dietary supplements. A product is considered a new dietary supplement when the ingredient was notmarketed before October 15, 1994 or the ingredient is currently not present in the food supply. The manufacturer must show the US Food and Drug Administration (FDA) that a new dietary supplement can reasonably be expected to be safe but is not required to have a premarket evaluation of safety and efficacy, in contrast to the stringent requirements for new drugs. The FDA can bring enforcement action against an existing supplement if it presents an unreasonable or significant risk of harm, if the manufacturer makes false or misleading claims, or if the product is adulterated or misbranded. Recent events associated with dietary supplements containing ephedrine alkaloids and steroid precursors illustrate these safety and enforcement concerns. Chinese herbs nephropathy.In 1993, a rapidly progressive interstitial renal fibrosis was reported in a group of young women who ingested pills containing Chinese herbs while attending a slimming clinic in Brussels. Subsequent investigation found that one of the prescribed Chinese herbs had been inadvertently replaced by other Chinese herbs containing the nephrotoxinaristolochic acid. Since the original description, there have been several reports worldwide of nephropathy associated with the inadvertent adulteration of herbal remedies taken for a variety of conditions with herbs containing aristolochic acid. Interestingly, the pathologic findings in Chinese herbs nephropathy bear a striking resemblance to those observed in the illdefined Balkan nephropathy, suggesting that the latter might represent a chronic exposure to aristolochicacids. The cardinal pathologic features of Chinese herbs nephropathy are an acellular, extensive interstitial fibrosis and tubular atrophy with preserved glomerular structures. Consistent with the predominant tubular interstitial damage, most patients present with tubular dysfunction manifested as lowmolecular-weight (tubular) proteinuria, glycosuria, aseptic leukocyturia, and Fanconi syndrome. Other common clinical findings include renal failure, mild to moderate hypertension, and anemia. The onset of renal failure is often delayed for several years after the exposure to Chinese herbs, but once it is present, progression to end-stage renal disease is more rapid than that noted in other interstitial nephropathies. Extrarenal manifestations of Chinese herbs nephropathy include nephrotoxicity of drugs 33fibrosis of the salivary gland, periureter, and peritoneal membrane, aortic insufficiency, and a predisposition to

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urothelial malignancies. The delay in the development of renal damage for several years after exposure suggests that the mechanism by which aristolochic acids cause fibrosis and a predisposition to urothelial malignancies is related to DNA modifications rather than to a direct cytotoxic effect. Cocaine is a stimulant extracted from the leaf of the Erythroxylon coca bush and available as a hydrochloride salt for intravenous or intranasal administration or as freebase for smoking. The euphoric effect associated with cocaine is caused by an inhibition of dopamine reuptake in the neural cells. Cardiovascular effects, such as hypertension, cardiac arrhythmias, and heart attacks, are the most common medical consequences of cocaine abuse. A variety of renal complications have been reported. Acute renal failure is well described in patients presenting with acute cocaine intoxication. The cause is probably multifactorial and involves a direct vasoconstrictive effect of cocaine on the renal vasculature, altered systemic hemodynamics, and myoglobin-induced renal failure due to rhabdomyolysis. A report from an emergency department found that 24% of patients evaluated for cocainerelated issues had evidence of rhabdomyolysis in the form of a CPK greater than 1000 IU/L. A retrospective study of 39 patients admitted with cocaine intoxication and rhabdomyolysis found that 13 (33%) developed renal failure for which eight required dialysis [56]. Cocaine use has been linked to renal infarction, and an autopsy study found an increased incidence of glomerular sclerosis, periglomerular sclerosis, and atherosclerotic changes in cocainerelated deaths. Inhalants are volatile substances that can be inhaled to induce a psychotropic response. Inhalants are generally classified as volatile solvents (eg, glue, paint thinners, gasoline), aerosols, gases, or nitrites. Although several chemical substances are found in abused solvents, the most commonly abused compound is toluene. Inhalants produce a euphoric high that resembles the effect of alcohol followed by drowsiness and disinhibition. A significant amount of inhalation can result in loss of consciousness. Chronic exposure to inhalants can produce neurologic, hematologic, hepatic, and a variety of kidney toxic effects. The chronic inhalation of solvents has been associated with varied kidney abnormalities, including acute and chronic renal failure, renal tubular acidosis, Fanconi syndrome, urolithiasis, hematuria,pyuria, and proteinuria. The tubular manifestations arising from solvent abuse probably result from the interference with intracellular metabolic processes involved with membrane transport. Often the tubular abnormalities resolve with avoidance of the suspected solvent. Rarely, antiglomerular basement membrane antibodymediated glomerulonephritis is observed with gluesniffing.nephrotoxicity of drugs 39Amphetamines. Ecstasy (ie, MDMA; 3, 4-methylenedioxymethamphetamine) is a close

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structural analogue of amphetamine with both stimulant and hallucinogenic effects in humans. Ecstasy is a popular drug of abuse, particularly among adolescents who frequent rave or techno parties, and is used to prolong dancing time and mood enhancement. Toxicity includes convulsions, fulminate hyperthermia, hepatic dysfunction, rhabdomyolysis, disseminated intravascular coagulation, and acute renal failure. Some of the toxic effects probably result from the combination of direct drug effect and the environmental circumstances associated with the abuse of Ecstasy. The sustained physical exertion (eg, dancing) associated with a high ambient temperature and inadequate fluid intake may result in severe hyperpyrexia, rhabdomyolysis, and acute renal failure. Ecstasy has been shown to stimulate the release of antidiuretic hormone, and cases ofhyponatremia and stupor have been reported with aggressive hydration. Acute renal failure has been associated with the intravenous administration of cannabis, and urinary retention has been reported with cannabis ingestion. Several cases of acute renal failure have been reported in individualsingesting wild mushrooms with the intent of producing hallucinations.Inexperienced collectors inadvertently collected and ingested Cortinarius mushrooms or other nephrotoxic species. Finally, the overdose of a variety ofdrugs has led to a prolonged coma, pressure-induced muscle necrosis, and acuterenal failure from the muscle breakdown products (eg, myoglobin Environment The economic and social standing of communities and families often provides access to important social, emotional, and material resources that help individuals care for themselves and others. Race, sex, and socioeconomic status have important implications for individuals, families, and communities because they can play a critical role in the formation and navigation of difficult social and economic environments where opportunities for upward mobility are scarce. Three important components of the distressing or unhealthy social environments are (a) poor residential conditions, (b) economic deprivation at the household level, and (c) social stressors such as racism or discrimination. (Bruce, 2010). Social scientists have noted that living in economically and socially challenging environments can be psychologically harmful. Constant exposure to distressing environments can reinforce constraints on ones existence and lead to higher levels of anger, anxiety, depression, and/or stress. The number of studies examining the relationship between psychosocial factors and kidney disease has grown in recent years, as a larger segment of the nephrologic community has become interested in identifying and addressing modifiable risk factors. However, the study of the psychosocial aspect of nephrology is still relatively new and requires scientists to devote considerable attention to nontraditional risk factors such as anxiety, stress, and social support.We believe that this line of research, referred to as psychonephrology, may provide unique insights into the development and progression of kidney disease.

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Classic social science asserts that social relationships affect an individuals well being. It has been well established that patients with sparse social networks and low levels of social support have an increased risk for death. Individuals who live alone or have minimal contact with friends, relatives, or acquaintances have been found to have higher rates of cardiovascular disease morbidity and mortality than persons who are integrated in social networks. The relationship between social relations and kidney disease has not been pursued extensively. A few studies have examined the relationship between social support and depression, quality of life, compliance, and survival rates among patients undergoing hemodialysis, and they determined that social support is inversely related to morbidity and mortality risk. These studies provide evidence that positive social support can be a protective factor for individuals dealing with time-consuming, long-term therapy associated with ESRD. The existing literature suggests that involvement in dense social networks and emotionally supportive relationships can be a protective factor against environmental threats to psychological and physiological health. However, the impact of social support has been assessed primarily in patient populations. Research has not determined the degree to which social support has implications for the development and progression of CKD. It is not clear how social support interacts with environmental factors or other psychosocial factors to affect the health of individuals at risk for CKD or who are in the early stages of CKD. This suggests that future studies should examine the relationship between social support and the development and progression of CKD while also considering social and psychological challenges that at-risk individuals (eg, racial/ethnic minorities and the poor) confront on a regular basis. (J Investig Med. 2009 April; 57(4): 583 589). Theoretical Framework Hall believed patients should receive care ONLY from professional nurses. Nursing involves interacting with a patient in a complex process of teaching and learning. Hall was not pleased with the concept of team nursing--she said that "any career that is defined around the work that has to be done, and how it is divided to get it done, is a "trade" (rather than a profession). Nursing functions in all three of the circles (core, care, and cure) but shares them to different degrees with other disciplines. For example, the nurse's function in the cure circle is limited to helping patients/families deal with the measures instituted by the physician. She felt that the care circle was exclusive to nursing. The core circle was shared with social workers, psychologists, clergy, etc. Care focuses on hands-on bodily care and the belief that a caring touch and thorough assessment is therapeutic. This nurturing component also referred to

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as "mothering" the patient, was done with the goal of comforting the patient and helping them meets their needs. Hall believed this was an aspect of care that was exclusive to nurses. In Hall's theory, "core" refers to using therapeutic communication to help the patient understand not only his condition, but also his life. In this aspect, patient care was based on social sciences and shared with other parts of the community, such as psychologists and clergy. The goal is to help patients learn their roles in the healing process, maintain who they are, and learn to use the nurse as a sounding board. Cure refers to nurses applying their medical knowledge of the disease to assist with a plan of care. Patient care in this section is based on pathological science. In this aspect, the function of the nurse is to assist the patient and her family in coping with treatment ordered by a physician. It is also here that a nurse's role as a patient advocate comes into play; she must advocate her plan of care for the best interest of the patient.

Conceptual Framework

Demographic profile of the Respondents y y y y Age Gender Family income Health related problems

Factors contributing to the incidence of Renal Failure y y y

y

Nutrition Lifestyle Medication Environment

Proposed Program on how to lessen or decrease the incidence of Renal Failure

Figure 1 Figure 1 shows the demographic profile of the respondents in terms of age, gender, family income and health related problems. Then the next box is the factors contributing to the incidence of Renal Failure in terms of nutrition, lifestyle, peer group and environment. Through these, the researchers can propose program on lessening/decreasing the incidence of Renal Failure.

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Methods Research Design The researchers utilized the purposive sampling method in the research. This type of research tends to observe, describe and document aspects of a situation as it naturally occurs. The descriptive method seeks what is rather than predicts relations to be found. It is concerned with describing the characteristics of the population as well as finding out the association of certain characteristics in the population. (Polit& Beck, 2008).

Study Locale The students will conduct study in selected adopted communities of Lyceum of the Philippines University Batangas. The researchers chose these particular adopted communities because of the accessibility and familiarity of the researchers. Participants The researchers selected 3 adopted communities of LPU Batangas. Instruments The researchers used questionnaires as a data gathering tool. It is a selfmade questionnaire that was made through the hard works and collaboration of the researchers and was also guided with the help of other experts. The questions were easily comprehendible and were formulated in a way that the respondents can easily understand. The first part of the questionnaire comprises of the demographic profile of the respondent. The second part was about the factors contributing to the incidence of Renal Failure. The researcher utilized purposive sampling which the researchers select participants based on personal judgement about which one will be most informative. (Polit& Beck, 2008). Procedures The researchers started the research study from the time the titles was constructed together with its particular objectives. Then it was presented to the

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adviser for approval and validation. From the approved title and objectives, the research study was then started entitled Incidence of Renal failure in Adopted communities of LPU Batangas. And it was followed by the formation of questionnaires that was based from the literature of every objective. Afterwards it was again presented to the adviser and other chairperson for consultation and approval. Receiving the endowment and approval from the Dean of the College of Nursing, the research study was conducted, allowed by the hospital administrators. The participants were given consent to sign for cooperation in answering the questionnaires and it was treated with highest confidentiality.