http://doi.org/10.33698/NRF0299-Kochuthre siamma Thomas
Abstract: A descriptive study was conducted to identify the types and severity of stressors in fifty patients diagnosed to have chronic kidney disease, who are on long term hemodialysis. Physiological and psychosocial stressors were evaluated using the hemodialysis stressor scale developed by Baldree et at (1984). Patients were asked to rate the degree to which they were distressed by the physiological and psychosocial stressors. The highest ranking physiological stressors identified were fluid restriction, fatigue, muscle cramps and joint pain. Depression was reported as the most common psychosocial stressor. Results indicated that the psychosocial and physiological stressors have an equal impact on the patient. The finding of the study will help the nurses to plan specific interventions and individualized teaching the counseling session to deal with the stressors experienced by patients.
Key words: Chronic kidney disease, Hemodialysis, Stressors.
Introduction:Chronic Kidney disease has become one of the major health problems in our country. It is estimated that 100 new patients per million population develop end stage renal disease per year. Accordingly about 1 lakh patients need replacement therapy every year (Chung, 1996).1 Unfortunately in India we do not have the resources /facilities to cater to the needs of such a large number of patients. Out of the one lakh who need renal replacement therapy only one fourth of them receive transplantation every year. The rest of the patients need life saving support by dialysis.Any patient who is on long term hemodialysis will be taking a major unheaval in life. Patients will have various physiological and psychosocial stressors and have to make various adjustments in life. It is observed that patient teaching has a very low priority in the dialysis unit and the patients are deprived of the individualized care they need during dialysis. Many of the stressors can be minimized by individual counseling.The identification of specific stressors provide useful information for providing individualized care. Hence the present study was conducted to identify the specific stressors experienced by long term hemodialysis patients.
Materials and methods:The present study was conducted in the nephrology wards and dialysis units of a Medical College Hospital in the (Kerala) state. Patients with chronic kidney disease undergoing hemodialysis constituted the population of the study. The sample consisted of 50 patients. The patients in the population were on hemodialysis treatment at least for 3 months and had no other major illness including psychiatric problems.
The data collection instruments were the following.
- Socio demographic and illness related data sheet to measure the demographic characteristics like age, gender, religion, education, marital status and occupation. Illness related data was collected on the etiology of renal failure duration of dialysis.
- Hemodialysis stressor scale (HSS) In order to identify the nature and severity of stressors commonly encountered by patients on hemodialysis a stressor scale developed by Baldree et al (1982)2 was used. The scale consisted of 23 potential stressors which were classified as sixteen physiological and seven psychosocial stressors based on the distinction given by Monat & Lazarus (1987).3
Each stressor was rated according to Likert type format which utilized a 5 point scale. The end points of the scale ranged from ‘not at all’ to a ‘great deal’. Patients were asked to rate the extent to which they were troubled by each of the 23 stressors by circling a number from 1-5. The respondent completed the questionnaire during the dialysis treatment, in the presence of the investigator. A total stressor score as well as a psychosocial and physiological sub scores were derived by simple summation of ratings. The higher the score, the greater the degree of stress.
Results:About half (52%) of the patients were in the age group 41-50 years. The mean age was 42.55. Among the patients, 60% were males and 40% were females, 76% married, 56% were Hindus, 52% had high school education and 48 & were skilled workers (Table 1).
Table 1: Distribution according to socio demographic variables
| Sr.no. | Variables | No. | % |
| 1. | Age | ||
| <30 | 3 | 6 | |
| 31-40 | 9 | 18 | |
| 41-50 | 26 | 52 | |
| 51-60 | 12 | 24 | |
| 2. | Sex | ||
| Males | 30 | 60 | |
| Females | 20 | 40 | |
| 3. | Religion | ||
| Hindus | 28 | 56 | |
| Christian | 12 | 24 | |
| Muslims | 10 | 20 | |
| 4. | Marital status | ||
| Married | 38 | 76 | |
| Unmarried | 12 | 24 | |
| 5. | Education | ||
| Primary | 8 | 16 | |
| High school | 26 | 52 | |
| College | 12 | 24 | |
| Professional | 4 | 8 | |
| 6. | Occupation | ||
| Unskilled | 12 | 24 | |
| Skilled workers | 24 | 48 | |
| Govt. employees | 8 | 8 | |
| Business | 4 | 8 | |
| Others | 2 | 4 |
The etiology of developing chronic kidney disease was diabetic nephropathy in 48%patients followed by hypertension (30%) glomerulonephritis (20%) and other (10%).Half of the patient (50%) were undergoing dialysis for 13-24 years 30% for 7-12 months and 20% for 2-6 months. (Table 2)
Table 2: Distribution according illness related variables.
| Sr.no. | Variables | No. | % |
| 1. | Etiology | ||
| Diabetic nephropathy | 20 | 40 | |
| Hypertension | 15 | 30 | |
| Glomerulo nephritis | 10 | 20 | |
| Others | 5 | 10 | |
| 2. | Duration of dialysis | ||
| 13-24 months | 25 | 50 | |
| 7-12 months | 15 | 30 | |
| 2-6 months | 10 | 20 |
About two third of the patients (62%) experienced severe stress due to physiological stressors and 66% of patients had severe psychological stress. There was no significant difference between the physiological stressors (p value >0.05). Both type of stressors had an equal impact on the patient (Table 3)
Table 3: Distribution according to severity of stressors
| Types of stressors | Mild | Moderate | Severe | |||
| No | % | No | % | No | % | |
| Physiology | 5 | 10 | 14 | 28 | 31 | 62 |
| Psychology | 5 | 10 | 12 | 24 | 33 | 66 |
While rank ordering of physiological stressors according to severity it was noted that limitation of fluid was the most frequently reported physiological problem. Muscle cramps and fatigue were on second and third rank order respectively. (Table 4)
Table 4: Rank ordering of physiological stressors according to the severity of occurrence
| SI.NO. | Stressors | Mean score |
| 1 | Limitation of fluid | 4.25 |
| 2 | Muscle cramps | 4.01 |
| 3 | Fatigue | 4.00 |
| 4 | Dryness of mouth | 3.88 |
| 5 | Thirst | 3.71 |
| SI.NO. | Stressors | Mean score |
| 6 | Limitation of food | 3.60 |
| 7 | Nausea & vomiting | 3.58 |
| 8 | Limitation of physical activity | 3.30 |
| 9 | Pain at the access site | 3.01 |
| 10 | Itching | 2.90 |
| 11 | Headache | 2.78 |
| 12 | Dizziness | 2.40 |
| 13 | Backache | 2.18 |
| 14 | Joint pain | 2.01 |
| 15 | Chest pain | 1.88 |
| 16 | Shortness of breath | 1.66 |
Among the psychosocial stressors, depression, sadness and irritability were found to be major ones. (Table5).
Table 5: Rank ordering of physiological stressors according to the severity
| SI.NO. | Stressors | Mean score |
| 1 | Depression | 4.01 |
| 2 | Sadness | 3.89 |
| 3 | Irritability | 3.71 |
| 4 | Dependency on other | 3.40 |
| 5 | Uncertainty about future | 3.04 |
| 6 | Fear of being alone | 2.38 |
| 7 | Change in family responsibility | 2.08 |
Discussion: Gurklis and Edna (1988)4 identified the stressors in chronic Hemodialysis patients. Results showed that feeling tired was the most frequently reported stressor. But the findings of present study showed that fatigue was the 3rd major stress reported by the patients. Smith and Murphy (1982)5 assessed the type and severity of stressors and methods of coping with stress in 35 patients on hemodialysis. Fluid restriction was ranked as the highest stressor. The findings are comparable with that of the present study.The results of the study are highly relevant to nursing practice as they provide more detailed description of the nature of patient’s perception of stressors that are specific to hemodialysis patients. There information help the nurse to strengthen their assessment of patient’s physiological problem.The nurses can assist patients to adjust to the hemodialysis experience by individual counseling and teaching which are useful interventions in reducing the stressors and improving the quality of life of hemodialysis patients.
References
- Chung K. S. Commerce in Transplantation in third world countries. Kidney international 1996; 49:1181
- Baldree et at. Stress identification and coping pattern in patients on Hemodialysis. Nursing Research 1984; 31:107-112.
- Monat and Lazarus. Stress and coping. An Anthology, New York, Columbia University press, 1977.
- Gurkhis & Endo (1988)
- Smith & Murphy (1982)