https://doi.org/10.33698/NRF0203 Gurpreet Brar, Hemant Kumar Saini, Divya Soin
Abstract : Dialysis is the artificial process of eliminating waste materials from the blood through semi permeable membrane but an aggressive dialysis in grossly uremic patients can lead to disequilibrium syndrome. Nurses are the person who observes and give care to the patient from the beginning till the end of dialysis. So it is essential for the nurse to observe the early symptoms of dialysis induced disequilibrium syndrome (DIDS) and get it treated otherwise they may lead to life threatening complications.
A non-experimental quantitative research approach, using descriptive study was undertaken with the objectives to assess the knowledge and practices of staff nurses regarding the nursing management of dialysis induced disequilibrium. Sample size of 60 was selected by using convenient sampling technique and data was collected by using self-structured knowledge questionnaire and self-administered checklist. The knowledge score was categorized as good (21-30), average (11-20) and poor (0-10) and practices score was categorized as good practices (more than 78), average practices (52-78) and poor practices (less than 78). The findings of the present study revealed that most of (75%) staff nurses had average knowledge regarding dialysis induced disequilibrium syndrome. Regarding practices only 3.3% of study subjects scored good in practices regarding nursing management of dialysis induced disequilibrium whereas 76.6% of study subject scored average in practices, followed by poor accounting with 20% of study subjects. It was concluded that knowledge and practices were significantly related with each other as majority (82.2%) staff nurses with average knowledge about dialysis induced disequilibrium syndrome, scored average in practices regarding nursing management of dialysis induced disequilibrium syndrome.
Keywords
Dialysis Induced Disequilibrium Syndrome
Correspondence at
Gurpreet Brar Nursing Tutor CON DMC & H
Ludhaina
Introduction
Since more than 30 years dialysis therapy has provided successful long term life sustaining replacement for absent of renal functions. Dialysis is the artificial process of eliminating waste materials from the blood through semi permeable membrane. Hemodialysis is a highly efficient method of removing waste and solute from the body by mean of ultrafiltration, and ultrafiltration depends upon the presence of gradients across the semi-permeable membrane.
1 Dialysis induced disequilibrium syndrome is the most common complication of hemodialysis and the symptoms are the life threatening if not treated at its earliest. The clinical picture is caused by cerebral edema induced by Reverse urea effect. Kennedy AC et al (1962) were the first to suggest that Dialysis induced disequilibrium syndrome (DIDS) is related to ‘‘reverse urea effect”. The syndrome attributes to the delay in blood urea level, creating an osmotic gradient that favoured the shift of water into brain from the blood2. Kaze FF et al (2012) conducted a study on 129 patients over 4 months to assess the complication of hemodialysis in end stage chronic renal disease found overall complication of 41% out of which hypotension (25%), muscular cramps (22%), hypertensive crisis (14%), pruritus (10%), and fever (7%) were the most frequent complication arises during hemodialysis session.3 These complication can be prevented if nurse have knowledge on use of different preventive measures, early detection and management of Dialysis induced disequilibrium syndrome.
Risk assessment of patient before starting hemodialysis is of great help such as new patients and patients upto first 3 hemodialysis session are at greater risk of Dialysis induced disequilibrium syndrome. After that risk get decreased upto some extent as patient adapt to hemodialysis. Nurses can manage these patients by monitoring the vital signs of the patient every ½ hourly and continuously observe the patient from nursing station for the early detection of symptoms such as headache, nausea and vomiting and know the protocols regarding the management of these complications by prolonging the titration time and slow ultrafiltration time until the complications subsides.
For the individuals undergoing hemodialysis, it is important that nurse should establish interpersonal relationships, adherence to hemodialysis treatments protocol, identify and manage the complications of hemodialysis so that complications can be minimised and it in turn help in prolonging their life. Taking into account that Dialysis induced disequilibrium syndrome can be life threatening if it is not recognised at its earliest, this study may contribute to assess the knowledge in this area, as it promotes the adequate attention of policy makers towards the early recognition and management of Dialysis induced disequilibrium syndrome (DIDS)by staff nurses on their own to prevent life threatening complications. Therefore, the investigator has undertaken the present study with the objectives to assess the knowledge and practices of staff nurses regarding the nursing management of Dialysis induced disequilibrium syndrome.
Methodology
This was a non experimental quantitative research approach using descriptive study conducted among 60 staff nurses working in dialysis unit at selected hospitals (Guru Gobind Singh Medical Hospital Faridkot, Christian Medical College and Hospital Ludhaina, Deep Hospital Ludhaina, Adesh Medical College and Hospital Bathinda) of Punjab. The researcher used the tool that was developed by keeping in mind the objectives of the study, reviewing literature, and discussion with the experts. Content validity of the tool was determined by expert’s opinion. The tool was given to the 10 experts in the field of Medicine (Nephrology) and Medical and Surgical Nursing and language experts in English to ascertain the content appropriateness, clarity and relevance. Tool consisted of three parts i.e. part 1: Demographic Profile (1-6) including code no. age, sex, professional qualification, total clinical experience, experience in dialysis unit and attend any in-service education program/workshop regarding hemodialysis. Part 2: Structured knowledge questionnaire containing 30 questions scored as 1 and 0 for correct and incorrect answer respectively which was broadly categorised into three main components as basic knowledge and principles behind hemodialysis, complications of hemodialysis and management of the complications of Dialysis induced disequilibrium syndrome was constructed for assessing the knowledge of staff nurses regarding dialysis induced disequilibrium syndrome. Interpretation of scores of self structured knowledge questionnaire to measure objective knowledge regarding Dialysis induced disequilibrium syndrome and its nursing management were as: Good (21 to 30) score, Average (11 to 20) score, Poor (0 to 10) score part 3: Self- Administered Checklist for practice assessment containing 8 symptoms for which 54 statements was made on a three- point scale of yes always done, sometimes done, and not done opportunity was missed scored as 2, 1 and 0 respectively. Interpretation of scores of self-administered checklist to know the practices regarding nursing management of Dialysis induced disequilibrium syndrome were as: Good practices (more than 78) score, Average practices (52 to 78) score, Poor practices (less than 52) score.
The initial pilot test done by researcher on 6 (10%) of the staff nurses working in dialysis unit indicated that the content of the instrument was adequate to meet the objectives with reliability coefficient was found to be 0.91 using test retest method and Karl Pearson coefficient of correlation. The tool was hence, found to be reliable and feasible.
For data collection self-introduction and establishment of rapport with subjects done. Staff nurses were explained about purpose of study. The subjects were assured about the confidentiality of their responses. During work-shift the tool was given to the staff nurses when they were free after putting the patient on hemodialysis. Tool was given to one staff nurse at a time and when she completed the tool, then tool was given to second staff nurse. The staff nurse was filling the tool under the observation in order to prevent biasness. An average 20 minutes was taken by each subject to fill the tool in which they tick the option of each item according to their knowledge and experience. Analysis of data was done using statistical package for the social sciences (SPSS) software.
Results
Table No.1 represented the demographic characteristics and showed that majority 53 (88.3%) of study subjects belonged to 22-27 years age groups. Regarding gender majority 43 (71.7%) of study subjects were females and 17 (28.3%) male study subjects. 44 (73.2%) of study subjects had professional qualification as B.Sc. Nursing and 16 (26.6%) of them were with Diploma in General Nursing Midwifery. Regarding clinical experience, majority 43 (71.6%) of study subjects were having clinical experience of 1 -3 years. Experience of 4 years and above was possessed by only 4 (6.6%) of study subjects. All study subjects had clinical experience in dialysis unit. Majority of study subjects did-not attend any kind of inservice training regarding hemodialysis while only 4 (6.6%) study subjects attended inservice training regarding hemodialysis.
Knowledge of Staff Nurses undergoing hemodialysis.
Table-1: Percentage Distribution of sample characteristics
|
N=30
Figure no.1 shows that maximum distribution of knowledge score lies in class interval of average (11 to 20) i.e. 45(75%)subjects, followed 10(16.7) subjects in class interval of good score (21 to 30) and only 8.3% subjects scored poor(1to10). The score ranged from 9 to 24.
Figure No: 1 Distribution of knowledge score
Findings regarding Table-2 revealed that all the subjects responded correct about principle diffusion behind dialysis; In human beings nephrons act as filter that separates the larger substance from smaller substance; during hemodialysis, mostly single lumen venous catheter is used; slow flow & shortened dialysis can aggravate the condition of DIDS. More than 90 % nurses knew that filtration occurs through glomerulus basement membrane; DIDS is a central nervous system disorder, occurring due to cerebral edema; DIDS develops immediately after dialysis; early manifestations of DIDS are diarrhoea, polyuria, hypotension, blurred vision, cardiac arrest, tremors . There were some components for which less than 30 % nurses could give correct answers i.e. DIDS is a complication of haemodialysis; metabolic alkalosis is one of the causative factors of the DIDS; diffusion of bicarbonate from dialysate is also responsible for DIDS; adding urea to dialysate solution can aggravate the condition of DIDS; profuse diarrhoea is not a symptom of Dialysis induced disequilibrium syndrome.
Table–2: Knowledge of subjects regarding Dialysis induced disequilibrium syndrome (DIDS)
| S.
No. |
Questions | Correct response f(%) |
|
1. |
Basic knowledge and principle behind hemodialysis
Dialysis works on the principle of diffusion of solutes. |
60 (100) |
| 2. | In human beings nephrons act as filter that separates the larger substance from smaller substance. | 60 (100) |
| 3. | There are about one lakh nephrons that are present in human kidney. | 33 (55.0) |
| 4. | Normal glomerular filtration rate is 60ml/min/ 1.73m2 | 20 (33.3) |
| 5. | Filtration occurs through glomerulus basement membrane | 55 (91.6) |
| 6. | Albumin-urea is positive indicator of End Stage Kidney Disease | 29 (48.3) |
| 7. | During hemodialysis, mostly single lumen venous catheter is used | 60 (100.0) |
| 8. | DIDS is a complication of hemodialysis. | 12 (20.0) |
| 9. | DIDS is a central nervous system disorder, occurring due to cerebral edema. | 55 (91.6) |
| 10. | New patients just being started on hemodialysis are at greater risk of developing DIDS. | 35 (58.3) |
| 11. | Patient having history of meningitis, sepsis are at greater risk of developing DIDS. | 27 (45.0) |
| 12. | Peritoneal dialysis does not alter the osmotic gradient in brain which act as an indicator of Dialysis induced disequilibrium syndrome | 41 (68.0) |
| 13. | DIDS develops immediately after hemodialysis. | 57 (95.0) |
| 14. | Metabolic alkalosis is one of the causative factors of the DIDS | 8 (13.3) |
| 15. | Rapid removal of urea and creatinine from plasma creates an osmotic gradient which causes DIDS. | 51 (85.0) |
| 16. | Diffusion of bicarbonate from dialysate is also responsible for DIDS | 11 (18.3) |
|
17. |
Complications of dialysis induced disequilibrium syndrome (DIDS)
Early manifestations of DIDS are diarrhoea, polyuria, hypotension, blurred vision, cardiac arrest, tremors. |
59 (98.3) |
| 18. | In Dialysis induced disequilibrium syndrome there is no profuse diarrhoea. | 6 (10.0) |
| 19. | Cardiac changes do not play significant role in detecting DIDS | 29 (48.3) |
| 20. | Dialysis induced disequilibrium syndrome does not lead to heart failure. | 46 (76.6) |
| 21. | Dialysis induced disequilibrium syndrome is a life threatening condition | 19 (31.6) |
|
22. |
Management of dialysis induced disequilbrium syndrome
Blood samples are drawn 2to 3 hours after hemodialysis to assess the degree to which electrolyte and acid base balance have been corrected |
59 (98.3) |
| 23. | Slow flow & long titration time can aggravate the condition of DIDS | 60 (100) |
| 24. | Adding urea to dialysate solution can aggravate the condition of DIDS | 4 (6.0) |
| 25. | In a patient, who develop seizures or coma, dialysis should be slow. | 25 (41.6) |
| 26. | Intravenous infusion of mannitol may reduce DIDS. | 19 (31.6) |
| 27. | Continuous renal replacement is an alternative option to prevent DIDS | 17 (28.3) |
| 28. | Renal transplant is last option to prevent DIDS | 19 (31.6) |
| 29. | Patient with fluid overload can be treated with ultrafiltration followed by short period of hemodialysis. | 47 (80.0) |
| 30. | To prevent DIDS patient should be advised to take meal immediately before dialysis. | 54 (90.0) |
Practices of staff nurses regarding nursing management of Dialysis induced disequilibrium syndrome.
Figure no. 2 inferred that only 3.3% of study subjects scored good in practices regarding nursing management of dialysis induced disequilibrium whereas 76.6% of study subject scored average in practices, followed by 20% scored poor.
Figure No: 2 practice score of nurses regarding nursing management of DIDS
Table 3 indicate that all the nurses always observed the level of consciousness and recorded weight of patient before starting hemodialysis; put the patient in semi fowlers position and turn the patient to side whenever they observe the symptoms of nausea and vomiting. Some of the practices were reported to be done sometimes by all the nurses such slow the pump speed, readjusting ultrafiltration rate; administer prescribed medication for headache, nausea and vomiting; prevented aspiration in case of vomiting. In case of muscular cramps 98% slowed down pump speed; 46% give sometimes I/V saline bolus as they were having difficulty in adjusting the ultrafiltration rate and speed on their own; 86% always provided calf muscle massage and 85% advised stretching exercises.
In case of hypotension most of them Give I/V Normal Saline bolus (65%); Reduce ultrafiltration rate (86%); If not corrected discontinue ultrafiltration rate (48%) and Educate patient on fluid and dietary restriction(70%). In case patient goes in Coma a 56% nurses always readjust the blood flow rate and 46% always observed the condition and If condition still not improved than stop the dialysis and re- infuse the blood to the patient. More that half (53%) nurses responded that sometimes they observe for cheyne-stroke respiration, Maintain the airway of the patient and Readjust the dose of heparin used for dialysis.
43.3% nurses checked sometimes kitone bodies and blood sugar levels. None of the nurse observed the patient for venticular techycardis which was followed by defibrillation. This opportunity was missed by all the nurses.
Table- 3: Practices of nurses regarding management of DIDS
N=60
| Nursing management Practices | Always done
f(%) |
Sometimes done f(%) | Not done, opportunity was missed
f(%) |
| Headache
Check the Blood pressure of the patient every 15min |
39 (65.0) |
20 (33) |
1 (1.6) |
| Observe for the level of consciousness | 60 (100) | ||
| Slow down the pump speed and ultra filtration rate | 60 (100) | ||
| Administer hypertonic saline to the patient | 19 (31.6) | 41 (68.3) | |
| Administer prescribed medication for headache | 60 (100) | ||
| Nausea/ Vomiting
Put the patient in semi-fowler position |
60 (100) |
||
| Turn the head to the side | 60 (100) | ||
| Prevent aspiration | 60 (100) | ||
| Readjust the ultrafiltration rate | 60 (100) | ||
| Administer prescribed medication for nausea and vomiting | 60 (100) | ||
| Keep dialysis session, slow flow and for shorter time initially | 25 (41.6) | 7 (11.6) | 28 (46.6) |
| Muscular Cramps
Slow down the pump speed. |
1 (1.6) |
59 (98.3) |
|
| Give I/V Normal Saline bolus | 28 (46) | 32 (53.3) | |
| Administer hypertonic saline/ Dextrose as prescribed | 32 (53.3) | 28 (46) | |
| Application of warm compression to calf muscles | 29 (48.3) | 2 (3.3) | 29 (48.3) |
| Provide calf muscle massage | 52 (86.6) | 2 (3.3) | 6 (10) |
| Advise stretching exercises | 51 (85) | 3 (5) | 6 (10) |
| Hypotension
Assess body weight before dialysis |
60 (100) |
||
| Place the patient in Trendelenberg position | 60 (100) | ||
| Give I/V Normal Saline bolus | 20 (35) | 39 (65) | 1 (1.6) |
| Cool the diaysate solution till 8 degree. | 60 (100) | ||
| Reduce ultrafiltration rate | 8 (13.3) | 52 (86.6) | |
| If not corrected discontinue ultrafiltration rate | 29 (48.3) | 31 (51.6) | |
| Educate patient on fluid and dietary restriction | 42 (70.0) | 18 (30.0) | |
| Coma
Observe for cheyne-stroke respiration |
32 (53.3) |
28 (46.6) |
|
| Maintain the airway of the patient | 32(53.3) | 28(46.6) | |
| Observe for CVP | 19 (31.6) | 34 (56.6) | |
| Readjust the blood flow rate | 16 (56.6) | 44(73.3) | |
| Readjust the dose of heparin used for dialysis | 32(53.3) | ||
| If condition still not improved than stop the dialysis and re-infuse the blood to the patient | 29(48.3) | 31(51.6) | |
| Check for ketone bodies and blood sugar level | 26(43.3) | 34(56.6) | |
| Observe the patient for Ventricular Tachycardia followed by defibrillation. | 60(100) |
Table 4 depicts that in case of convulsions 45% of the staff nurses always administered hypertonic normal saline, glucose and kept patient nil orally to relieve the patient from convulsive attack. All the staff nurses put the patient on maintenance dose of anticonvulsant drugs during next session of hemodialysis. More than 80% of nurses sometimes raise the side rails of the patient; maintain the airway of the patient; prevent aspiration ; turn the head to the side; administer antiedema drug like I/V mannitol; administer anticonvulsant drug as prescribed by physician.
Table-4: Practices of nurses regarding management of DIDS
N=60
| Nursing management Practices | Always done
f(%) |
Sometimes done f(%) | Not done, opportunity was missed
f(%) |
| Convulsion
Raise the side rails of the patient |
50 (83.3) |
10 (16.6) |
|
| Maintain the airway of the patient. | 50 (83.3) | 10 (16.6) | |
| Prevent aspiration | 48 (80.0) | 12 (20.0) | |
| Turn the head to the side | 48 (80.0) | 12 (20.0) | |
| Administer hypertonic Nacl (3%), glucose. | 27 (45.0) | 33 (55.0) | |
| Administer antiedema drug like I/V mannitol | 48 (80.0) | 12 (20.0) | |
| Administer anticonvulsant drug as prescribed by physician | 48 (80.0) | 12 (20.0) | |
| Put the patient on NPO. | 27 (45.0) | 10 (16.6) | 13 (21.6) |
| If condition still deteriorates stop the dialysis. | 37 (61.6) | 14 (23.3) | |
| Send the samples of the patient to lab for assessing the electrolyte imbalance (like glucose, serum Ca, Mg, RFT , LFT and fibrinogen level) | 6 (10.0) | 54 (90.0) | |
| Ask from the patient related to precipitating factors of convulsions
like sleep deprivation, history of alcohol consumption, migraine attacks. |
60 (100) | ||
| When patient returns to conscious level, educate regarding LP who are infected with HIV or viral infections. | 38 (63.3) | 22 (36.6) | |
| Put the patient on maintenance dose of anticonvulsant drugs during next session of dialysis. | 60 (100) | ||
| Nervous Irritability
Assess for level of consciousness |
31 (51.6) |
29 (48.3) |
|
| Provide conducive environment to the patient (noise free and dim light) | 8 (13.3) | 42 (70.0) | |
| Talk to the patient | 16 (26.6) | 44 (73.3) | |
| Administer Mannitol as prescribed by physician | 60 (100) | ||
| Fatigue
Provide calm environment |
60 (100) |
||
| Restrict visitors | 27 (45.0) | 33 (55) | |
| Administer 5 dextrose as prescribed | 54 (90) | 6(10.0) | |
| Provide foot massage and lower back massage | 60 (100) | ||
| Provide fruit juices and high protein containing shake to the patient at the end of dialysis | 60 (100) |
In case of nervous irritability half of nurses always assessed for level of consciousness and 13% provided conducive environment to the patient (noise free and dim light) . All of them sometimes Administer Mannitol as prescribed by physician. For fatigue all staff nurses sometimes practiced to relieve fatigue of patients by providing foot and lower back massage and providing calm and quiet environment. 90% of the staff nurses administer 5% of dextrose as per physician prescription.
The third objective was to find out the association between knowledge and practices of staff nurses regarding the nursing management of Dialysis induced disequilibrium syndrome. Findings revealed that majority (82.2%) staff nurses with average knowledge about dialysis induced disequilibrium syndrome, used average practices, followed by 2.2% had average knowledge used good practices, 15.5% of the study subjects that had average knowledge used poor practices regarding nursing management of dialysis induced disequilibrium syndrome. (p=0.05)
Discussion
Hemodialysis is a highly efficient method of removing waste and solute from the body. The patient’s blood is passed across semi-permeable membrane contained in dialysis. Water is removed during hemodialysis by mean of ultrafiltration, and ultrafiltration depends upon the presence of gradients across the semi-permeable membrane. An aggressive dialysis in grossly uremic patients can lead to disequilibrium syndrome. Dialysis induced disequilibrium syndrome based upon two important components that are Blood Brain Barrier and Reverse Urea Effect.
Present study conjectured that three fourth (75%) of staff nurses had average knowledge regarding dialysis induced disequilibrium syndrome and in case of practice almost same percentage of staff nurses (76.6%) had average practice score regarding the nursing management of various complications of Dialysis induced disequilibrium syndrome.
All the staff nurses reported that they can slow the ultrafiltration rate to reduce the severity of Dialysis induced disequilibrium syndrome symptoms like headache, nausea and vomiting and muscular cramps. These findings are supported by R Saran et al (2005), who concluded that longer titration time and slow ultrafiltration time decrease the incidence of Dialysis induced disequilibrium syndrome either combined or separately.4 majority (89%) of staff nurses reported that they intravenously infuse mannitol to treat complications like convulsions and hypotension. These findings are supported by Franciso Rodrigo et al (2007) who revealed that combination of dialysate glucose and intravenous mannitol was effective in treating the symptoms of Dialysis i nduced disequilibrium syndrome.5 All staff nurses reported the use of I/V saline administration in reducing the severity of muscular cramps and hypotension. These findings are supported by Stewart et al (2006) who concluded that high concentration of sodium dialysate was effective in reducing the frequency of muscular cramps.6 It is concluded that majority of staff nurses has above average knowledge and average practice score regarding nursing management of Dialysis induced disequilibrium syndrome, which poses need for conducting seminars, workshop for enhancing their knowledge about hemodialysis and its further complications like Dialysis induced disequilibrium syndrome, hemodialysis induced anaemia. Nurses should know that how to put the patient on hemodialysis and assess the risk especially in new patients and patients upto first 3 hemodialysis session, after that risk get decreased upto some extent as patient adapt to hemodialysis and taking the vital signs of the patient every ½ hourly and continuously observe the patient so as to recognise the symptom of Dialysis induced disequilibrium syndrome at its earliest stage before it get converted into chronic complication. It is recommended that guidelines, protocols and standards related to hemodialysis can be developed with the clear cut instructions on identification of its complications and their management so that nurses can prevent the patient’s from developing life threatening complication.
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