Дисертації з теми "Program hemodialysis"

End stage renal failure refers to an irreversible kidney dysfunction in which the kidneys fail to remove toxins from the blood stream. Haemodialysis is an effective treatment modality to sustain the lives of patients with end stage renal failure by removing waste products like urea, creatinine, and excess fluid. It involves a challenging regimen including dietary restrictions to ensure long-term survival. Failure to adhere with the regimen can result in fatal consequences. Renal patient discomfort related to non-adherence is commonly seen in clinical settings; however, there is currently no evidence-based fluid or dietary education program available to haemodialysis patients. This dissertation aims to identify and evaluate current evidence for the effectiveness of dietary and fluid control programs in the treatment of haemodialysis patients, to assess the transferability and feasibility of implementing a nurse-led education program regarding dietary and fluid control in haemodialysis patients, and to develop an evidence-based, nurse-led fluid and dietary control program for haemodialysis patients. Four electronic bibliographical databases including PubMed, Cochrane library, PsycInfo and CINAHL and two searching engines including Google scholar and ProQuest were used to identify studies that examined the effectiveness of educational programs or interventions on fluid or dietary control for patients on haemodialysis. Forty-five unique studies were identified as potentially relevant. Eleven of those studies met the selection criteria and were evaluated in this dissertation. Appraisal instrument was used to evaluate the quality of the selected studies. Six studies and three studies showed statistically significant in reduction of serum phosphate level and interdialytic weight gain respectively after educational intervention. Critical evaluation of the available studies led to an evidence-based, nurse-led, fluid and dietary control program for haemodialysis patients that followed the guideline development process of the Scottish Intercollegiate Guideline Network. Comparison on the similarity of patient characteristics, staff competence, and organizational settings of the evaluated studies were similar to those of the target unit. Therefore, the proposed program may be transferable and feasible. Furthermore, a cost-benefit analysis showed that the benefit of the fluid and dietary control program to patients outweighs the cost needed to implement the program. This dissertation outlines a proposed twenty-week program including marketing of the program, training of staff in the targeted renal unit, pilot testing, and application of the proposed program. Evaluation of the program will focus on three categories: patient outcome, health care provider outcome, and organization outcome. Clinical effectiveness of the program is defined by an overall reduction in patients’ mean interdialytic weight gain and mean serum phosphate level, improvement in knowledge test scores by patients, satisfactory nurses’ attendance rate in the renal training sessions, high nurse satisfaction with the educational program, and reduction of admission rate related to non-adherence.
published_or_final_version
Nursing Studies
Master
Master of Nursing

Thesis: S.M. in Engineering and Management, Massachusetts Institute of Technology, System Design and Management Program, 2019
Cataloged from PDF version of thesis.
Includes bibliographical references (pages 75-77).
This thesis documents the process of invention and design of on-patient encoding of medical information. The work is demonstrated through the development of a prototype medical device system that addresses clinically observed issues associated with dialysis treatment for patients afflicted with kidney failure. Implemented as a temporary tattoo, the medical system is intended to be widely deployable in a variety of settings for a myriad of populations, including developed and emerging medical communities, in-clinic or at-home, and across a spectrum of human skin tones. Addressing hemodialysis challenges is important because, if one's kidneys fail, the ideal option is to receive a transplant, though for many patients (millions globally), the short-term and often long-term solution must be hemodialysis. Through this treatment, a patient regularly has large needles inserted into his or her arm through which the blood is pumped into an artificial kidney machine.
This must be done several times each week for four to eight hours at a time, often in a clinic though ideally (albeit uncommonly) at patients' homes. Presented is the development process of problem identification, concept generation, testing, and prototyping of image guidance systems for hemodialysis needle insertion. This serves to curb fear so patients and caregivers experience improved key performance indicators including: -- Less Pain - Fewer needle 'mis-sticks' -- Quicker Learning - Shortened treatment training time -- Simpler Treatment - Reduced dependence on one or more caregivers when cannulating -- Improved Access to Care - Designed for a broad range of patients. The project involves infrared illumination of hemoglobin, undistortion and mapping of vein images, and special ink chemistry based on temporary tattoos. The results of this project are intended to lay the engineering, business, and design groundwork for a Class 11 product and service suite consisting of: --
A vein mapper: a device consisting of an infrared vein illuminator (hardware) and real-time optical enhancement (software). -- An indelible dye: a mixture that stains immediately, resists clinical washing, and persists for days -- A cannulation key: a process by which an inkjet printer is used to produce a vein map guide that is then transferred onto a patient's arm.
by Jonathan Blair Miller.
S.M. in Engineering and Management
S.M.inEngineeringandManagement Massachusetts Institute of Technology, System Design and Management Program

Darbo tema – hemodializuojamų pacientų mokymo programos sukūrimas. Hemodializuojami pacientai turėtų būti mokomi taisyklingos mitybos, arterinio kraujo spaudimo (AKS) reguliavimo principų ir teisingos arterio – veninės (A-V) fistulės priežiūros. Sergantiesiems būtina suteikti psichologinę pagalbą, išmokyti juos pasinaudoti artimųjų parama. Galima daryti prielaidą, kad pradėjus mokyti hemodializuojamus pacientus, gydymo ir slaugos rezultatai bus geresni. Teiginį, kad pacientų mokymas yra nepakankamas, pagrindžia tai, kad nėra sukurtos mokymo programos. Darbo tikslas–ištirti hemodializuojamų pacientų mokymo poreikį ir sukurti hemodializuojamų pacientų mokymo programą. Tyrimo metodai: Mokslinės literatūros analizė; Anketinė apklausa; Statistinė duomenų analizė. Tyrimas buvo atliktas 2006m. gruodžio - balandžio mėnesiais. Tiriamųjų apklausa atlikta Klaipėdos Jūrininkų ligoninės nefrologijos ir hemodializių skyriuje ir UAB „Nefrida“ hemodializių skyriuje. Išvados: Hemodializuojamų pacientų mitybos mokymo poreikis yra didelis. Hemodializuojami pacientai informaciją mitybos apribojimų klausimais gavo, ta�����iau pavėluotai t. y. 29 pacientai (51 proc.) informaciją gavo mažiau nei pusė metų iki pirmos hemodializės procedūros. Dauguma pacientų net 47 pacientai (82 proc.) negavo iš šeimos gydytojo informacijos mitybos apribojimų klausimais. Iš dializės skyriaus slaugytojos daugiau nei pusė pacientų t. y. 34 pacientai (60 proc.) gavo informacijos mitybos apribojimų klausimais... [toliau žr. visą tekstą]
It is necessary to teach haemodialysed patients how to take health nourishment,how to regulate blood pressure (BP),how to take appropriate care about arterial-venal fistula. Patients need psychological help,to take family support. Possibly,this teaching will improve rezults of treatment and medical care.Statement,that teaching of such patients is insufficient, is based on the fact ,that there is no training program nowadays. Aims-to examine haemodialysed patient‘s demand of teaching,and to create training program.Methods- analysis of science terature,questionnaire,statistic data evaluation. Questionnaire took place in nefrology and haemodialysis department of Klaipeda Seamen hospital and in haemodialysis department of private clinic „Nefrida“. Conclusions-almost all patients (95 per cent)with chronic renal insufficiency were informed about nutrition limitation.More than half of them (51 per cent)were informed too late-less tan 6 month before first haemodialysis.The vast majority of patients(96,5)state that information about nutrition limitation they get mostly from nephrologist.17,5 of respondents state that such information they get from family doctor. The most of patients (92 per cent) were informed about A-V fistula imprtance and medical care during haemodialysis.Training program of haemodialysed patients was prepared.It consist of flyer,CD record,booklet about limitation in nutrition and A-V fistula care.The training program for haemodialysed patients are based... [to full text]

Диссертация на соискание ученой степени кандидата технических наук по специальности 05.11.17 – биологические и медицинские приборы и системы. – Национальный технический университет "Харьковский политехнический институт", Харьков, 2017. Диссертационная работа посвящена решению одной из актуальных научно-технических задач современного гемодиализа – контроля состояния гидратации пациента и разработке метода для своевременной остановки процедуры ультрафильтрации при достижении пациентом "сухого веса". В работе проведено анализ современных биофизических представлений про распределение и перемещение жидкостей в организме пациента, что позволило выявить высокий уровень сложности и многофакторности гидравлических процессов и установить необходимость создания математических моделей перемещения жидкостей и критерия остановки процедуры при достижении пациентом "сухого веса". Впервые получена математическая модель перемещения жидкости в организме пациента при ультрафильтрации, на основании теории неравновесной термодинамики, что позволило выявить взаимную функциональную зависимость наполнения жидкостных секторов при процедуре программного гемодиализа. Усовершенствована электрофизическая модель процессов в организме пациента при ультрафильтрации для метода биоимпедансометрии, за счет разделения жидкостных секторов, что позволило использовать его для определения состояния гидратации пациента при процедуре программного гемодиализа. По результатам теоретических исследований выбран параметр гематокрита, который характеризует состояние наполнения сосудистого русла, что дало возможность разделить объем внеклеточной жидкости на составляющие. Разработан метод определения "сухого веса", критерием в котором является распределение объема внеклеточной жидкости на две составляющие интерстициальную жидкость и плазму крови и сравнении значений объемов удаленного ультрафильтрата в этих составляющих во время гемодиализа. Разработанный на основе результатов моделирования метод определения "сухого веса" пациентов, позволил повысить достоверность определения момента достижения уровня нормогидратации пациентов при программном гемодиализе на (11-16) %. Разработана структурная схема системы для определения "сухого веса", которая позволяет объединить воедино серийно выпускаемые аппарат "искусственная почка", прибор биоимпедансометр и ПК, что дает возможность реализовать алгоритмические решения и обеспечить работу системы, без разработки дополнительных аппаратных средств. На основе клинических исследований и испытаний разработаны основные медико-технические требования для выбора или проектирования приборов биоимпедансометров, а также созданы практические рекомендации для применения метода определения "сухого веса" пациентов в гемодиализных клиниках. Сопоставление результатов проведенных клинических исследований с данными полученными с помощью традиционных методик, при ультрафильтрации, подтвердили эффективность разработанных моделей и метода для определения "сухого веса" пациента при программном гемодиализе. Основные результаты работы нашли внедрение в лечебный процесс отделения амбулаторного хронического гемодиализа №10, Харьковского областного клинического центра урологии и нефрологии им. В.И. Шаповала; в учебный процесс на кафедре промышленной и биомедицинской электроники НТУ "ХПИ"; при разработке нового варианта измерителя биоимпеданса человека в НТУ Украины "КПИ им. Игоря Сикорского".
The thesis for the degree of candidate of technical sciences, specialty 05.11.17 – biological and medical devices and systems. – National Technical University "Kharkiv Polytechnic Institute", Kharkiv, 2017. The thesis is devoted to one of actual scientific and technical problems of modern hemodialysis - monitoring of patient hydration and developing methods for timely stopping ultrafiltration procedure when reaching the patient "dry weight". The method of determining the "dry weight" criterion which is the distribution of extracellular fluid volume into two components interstitial fluid and blood plasma volume and value compared to the removed ultrafiltrate in these components during hemodialysis developed. The mathematical model of fluid movement in the patient received the first time. electro and model processes in the patient with ultrafiltration method for bioimpedancemetry improved. Based on simulation method for determining the "dry weight" patients developed first. It is possible to determine authenticity hung reaching state normohidratotsiyi at program hemodialysis. Also practical guidelines for the application of this method in clinics created.

Дисертація на здобуття наукового ступеня кандидата технічних наук за спеціальністю 05.11.17 – біологічні та медичні прилади і системи. – Національний технічний університет "Харківський політехнічний інститут", Харків, 2017. Дисертаційну роботу присвячено вирішенню однієї з актуальних науково-технічних задач сучасного гемодіалізу – контролю стану гідратації пацієнта та розробці методу для своєчасної зупинки процедури ультрафільтрації при досягненні пацієнтом "сухої ваги". Розроблено метод визначення "сухої ваги", критерієм у якому є розподіл об’єму позаклітинної рідини на дві складові інтерстиціальну рідину і плазму крові та порівнянні значень об'ємів видаленого ультрафільтрату у цих складових під час гемодіалізу. Вперше отримано математичну модель переміщення рідини в організмі пацієнта та удосконалено електрофізичну модель процесів в організмі пацієнта при ультрафільтрації для методу біоімпедансометрії. Вперше розроблено на основі результатів моделювання метод визначення "сухої ваги" пацієнтів, що дозволило підвищити достовірність визначення моменту досягнення стану нормогідратоції при програмному гемодіалізі на (11-16) %. Також створено практичні рекомендації для застосування даного методу у гемодіалізних клініках.
The thesis for the degree of candidate of technical sciences, specialty 05.11.17 – biological and medical devices and systems. – National Technical University "Kharkiv Polytechnic Institute", Kharkiv, 2017. The thesis is devoted to one of actual scientific and technical problems of modern hemodialysis - monitoring of patient hydration and developing methods for timely stopping ultrafiltration procedure when reaching the patient "dry weight". The method of determining the "dry weight" criterion which is the distribution of extracellular fluid volume into two components interstitial fluid and blood plasma volume and value compared to the removed ultrafiltrate in these components during hemodialysis developed. The mathematical model of fluid movement in the patient received the first time. electro and model processes in the patient with ultrafiltration method for bioimpedancemetry improved. Based on simulation method for determining the "dry weight" patients developed first. It is possible to determine authenticity hung reaching state normohidratotsiyi at program hemodialysis. Also practical guidelines for the application of this method in clinics created.

Objetivo: Estudar os efeitos de um programa de exercício comunitário de 16 semanas na composição corporal e aptidão física em indivíduos com doença renal crónica em hemodiálise. Metodologia: A amostra era composta por um grupo indivíduos do sexo masculino (n=3), com doença renal crónica em hemodiálise que realizou o programa de exercício físico durante 16 semanas, nos dias em que não realizavam sessões de hemodiálise. Avaliou-se a massa corporal, a altura, a capacidade aeróbia, agilidade, força muscular de membros inferiores, controlo postural, eletromiografia e a qualidade de vida. Resultados: Não se registaram diferenças significativas, mas houve melhorias em alguns domínios da qualidade de vida, no equilíbrio, no teste de caminhada de 6 minutos, no teste de levantar, caminhar e sentar. Na composição corporal e na força muscular de membros inferiores verificou-se melhorias apenas em algumas variáveis Conclusão: O programa de exercício físico teve impacto positivo na aptidão física funcional dos doentes renais crónicos em hemodiálise; ABSTRACT: Effect of a Physical Exercise Program on Hemodialysis Patients Objetive: To study the effects of a 16-week community exercise program on body composition and physical fitness in individuals with chronic kidney disease on hemodialysis. Methodology: The sample consisted of a group of male individuals (n = 3) with chronic kidney disease on hemodialysis who underwent the physical exercise program for 16 weeks, on days when they did not have hemodialysis sessions. Body mass, height, aerobic capacity, agility, lower limb muscle strength, postural control, electromyography and quality of life were evaluated. Results: There were no significant differences, but there were improvements in some domains of quality of life, balance, the 6-minute walk test, the stand up, walk and sit test. In body composition and muscle strength of the lower limbs there were improvements only in some variables. Conclusion: The exercise program had a positive impact on the functional fitness of chronic renal patients on hemodialysis.

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Introdução: As complicações da doença renal crônica e do próprio processo de diálise são condições que aumentam o grau de dependência nesses pacientes e podem gerar um maior nível de sobrecarga em seus cuidadores. Objetivo: Comparar os níveis de sobrecarga, qualidade de vida, ansiedade e depressão de cuidadores familiares de pacientes dependentes de hemodiálise submetidos a um programa de exercícios com os cuidadores de pacientes submetidos ao tratamento usual de hemodiálise sem exercício. Métodos: Foram estudados cuidadores familiares de pacientes em hemodiálise da Clínica Pró-Renal-Barbacena-MG que participavam regularmente de um programa de exercícios durante as sessões de hemodiálise e cuidadores familiares de pacientes da Clínica RenalClin-São João Del Rey-MG submetidos ao tratamento de hemodiálise usual. Inicialmente, 60 pacientes foram recrutados em cada clínica para avaliar o grau de dependência pela escala de Lawton e Brody. Quando foram classificados como dependentes, 30 pacientes foram selecionados aleatoriamente em cada clínica e seus cuidadores familiares foram avaliados. Os cuidadores foram submetidos a uma entrevista para avaliar a sobrecarga dos cuidadores (CB escala), qualidade de vida e níveis de ansiedade e depressão. O projeto foi aprovado pelo Comitê de Ética e Pesquisa da FHEMIG-MG (CAEE nº 62917516.7.0000.5119). Os dados foram expressos como média ± desvio padrão ou mediana (intervalo interquartil), quando apropriado. Resultados: O escore geral [1,2 (0,2) vs. 1,9 (0,7)] e todas as dimensões da escala de sobrecarga de cuidadores foram significativamente menores nos cuidadores do grupo exercício quando comparados aos do grupo tratamento usual (p<0,05), exceto a dimensão envolvimento emocional. Os cuidadores do grupo exercício, quando comparados aos do grupo tratamento usual, apresentaram maiores escores do questionário de qualidade de vida nos domínios capacidade funcional [100,0 (11,3) vs. 85,0 (30,0)], limitação por aspectos físicos [100,0 (31,3) vs. 62,5 (75,0)], dor [72,0 (32,0) vs. 61,5 (41,3)], estado geral de saúde (77,3 ± 16,9 vs. 63,9 ± 19,0), vitalidade (75,4 ± 15,1 vs. 58,5 ± 23,0), aspectos sociais [100,0 (25,0) vs. 62,5 (37,5)], limitação por aspectos emocionais [100,0 (33,3) vs. 33,3 (100,0)] e saúde mental [80,0 (26,0) vs. 66,0 (41,0)], respectivamente, e menores índices de ansiedade e depressão (p<0,05). Conclusão: Os familiares cuidadores de pacientes em hemodiálise submetidos a um programa de exercícios apresentaram menor sobrecarga do cuidador, melhor qualidade de vida e menores níveis de ansiedade e depressão quando comparados aos cuidadores do grupo de tratamento usual.
Introduction: The complications of chronic kidney disease and the dialysis process itself are conditions that increase the level of dependence in these patients and may generate greater overload in their caregivers. Objective: Compare the burden, quality of life, anxiety and depression levels of family caregivers of dependent hemodialysis patients submitted to an exercise program with the caregivers of patients undergoing usual hemodialysis treatment without exercise. Methods: We studied family caregivers of patients undergoing hemodialysis at the Pró-Renal-Barbacena-MG Clinic who regularly participated in an exercise program during hemodialysis sessions and family caregivers of patients at the RenalClin-São João Del Rey-MG Clinic receiving hemodialysis treatment usual. Initially, 60 patients were recruited at each clinic to assess the degree of dependence by the Lawton and Brody scale. When they were classified as dependents, 30 patients were randomly selected at each clinic and their family caregivers were evaluated. Caregivers were submitted to an interview to assess the overload in caregivers (CB scale), quality of life and levels of anxiety and depression. The project was approved by the Ethics and Research Committee of FHEMIG-MG (CAEE no 62917516.7.0000.5119). Data were expressed as mean ± standard deviation or median (interquartile range), where appropriate. Results: The global score [1.2 (0.2) vs. 1.9 (0.7)] and all dimensions of the CBS were significantly lower in caregivers from the exercise group in relation to those in the usual treatment group (p<0.05), except for the emotional involvement dimension. When compared to caregivers from the usual treatment group, those from the exercise group exhibited higher scores in the quality of life questionnaire for the domains physical functioning [100.0 (11.3) vs. 85.0 (30.0)], role physical [100.0 (31.3) vs. 62.5 (75.0)], pain [72.0 (32.0) vs. 61.5 (41.3)], general health (77.3 ± 16.9 vs. 63.9 ± 19.0), vitality (75.4 ± 15.1 vs. 58.5 ± 23.0), social functioning [100.0 (25.0) vs. 62.5 (37.5)], role emotional [100.0 (33.3) vs. 33.3 (100.0)] and mental health [80.0 (26.0) vs. 66.0 (41.0)], respectively, in addition to lower anxiety and depression levels (p<0.05). Conclusion: The family caregivers of hemodialysis patients submitted to an exercise program showed less caregiver burden, better quality of life and lower levels of anxiety and depression when compared to caregivers from the usual treatment group.

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patients in hemodialysis (HD) present low exercise capacity, low perception of quality of life (QOL), and reduction of daily activities. These facts can be softened through a regular practice of physical exercises. Objective: To analyze the effects of cardiovascular and muscle training on the physical fitness and perception of QOL of patients in HD. Methodology: This study is characterized as randomized clinical trial. The population will be determined from 72 patients included the treatment of HD. The patients will be divided into control group (CG) and experimental group (GE) and evaluated through a questionnaire for the demographic variables (gender, age, skin color), socioeconomic variables (civil status, schooling and socioeconomic level) and the time of HD. To evaluate the physical fitness, it were used, for T6 sub max effort; The test seat and stand, for RML of MU; the abdominal test, for RML abdominal; the test inspiratory and pressure test and maximal expiratory, respiratory muscle strength; and the test seat and reach, for flexibility. The perception of QOL was evaluated through the SF-36. The program of physical exercises will be carried out during the HD, three times a week, consisting of stretching active, aerobic resistance, muscle resistance located and liabilities stretching. Key-words: Hemodialysis, Physical Training. Quality of life. Physical
Pacientes em hemodiálise (HD) apresentam baixa capacidade de exercício, baixa percepção de qualidade de vida (QV), e diminuição das suas atividades cotidianas. Estes fatos podem ser amenizados através de uma prática regular de exercícios fisco. Objetivo: Analisar os efeitos do treinamento diovascular e muscular sobre a aptidão física e a percepção da QV de pacientes em HD. Metodologia: Esse estudo se caracterizará como ensaio clínico randomizado. A população será determinada a partir de 72 pacientes inseridos ao tratamento de HD. Os pacientes serão divididos em grupo controle (GC) e grupo experimental (GE) e avaliados através de um questionário para as variáveis demográficas (gênero, idade, cor da pele), socioeconômicas (estado civil, escolaridade e nível socioeconômico) e tempo de HD. Para avaliar a aptidão física, foram utilizados o T6, para esforço submáximo; o teste de sentar e levantar, para RML de MI; o teste de abdominal, para RML de abdome; o teste de pressão inspiratória e expiratória máxima, para força muscular respiratória; e o teste de sentar e alcançar, para flexibilidade. A percepção de QV foi avaliada através do SF-36. O programa de exercícios físicos será realizado durante a HD, três vezes na semana, sendo constituído por alongamentos ativos, resistência aeróbia, resistência muscular localizada e alongamentos passivos.

碩士
國立陽明大學
臨床護理研究所
94
The purpose of this study was to examine the effects of exercise program during hemodialysis on fatigue, physical activity and physical capacity in hemodialysis patient. This research is a quasi-experimental design. 45 Patients were selected using purposive sampling at hemodialysis unit of a major medical center in northern Taiwan. They were assigned 19 patients into the experimental group and 26 patients into the control group. For 8weeks ,the experimental group received exercise program during hemodialysis three times a week and 30 minutes each times, the control group didn’t receive any instruction related to exercise。Before and after 4weeks、8weeks of exercise program ,each subject was required to complete the questionnaire of fatigue and scale of physical activity. Seven patients of experimental group also received graded exercise tolerance test. The data were coded and analyzed by using the SPSS for Windows 11.5 version software. The statistical methods included frequency distribution, percentage, mean, standard deviation, chi-square, t-test,Mann-Whitney U test、Wilcoxon signed ranks test、Spearman Rank-order correlation. The results of this study demonstrated that patients in the experimental group significantly improved their levels of fatigue(p<.05),physical activity(p<.05)and exercise capacity(p<.05)more than patients in the control group. Fatigue was significantly and negatively associated with physical activity. The findings may serve as a reference for clinical care and providing suggestions for the exercise training therapy for hemodialysis patients. It is hope that the intervention can enhance patient’s motivate to perform and improve quality of life.

碩士
中原大學
醫學工程學系
82
Since hemodialysis has applied to chronic renal failure patients,it is still a goal to assess the completeness and adequacy of hemodialysis.This paper is to develop software program to evaluate urea kinetics for quantifying hemodialysis therapy. In the software program system, one-pool model and two- pool model are used for analysis of urea kinetics. Both constant and variable volumes dialysis are also considered; model para- meters can be determined with a two BUN or a three BUN methods; during dialysis, the operation mode can follow a conventional or a optimal schemes; the dialysis frequency of the patient can be taken with a two times or a three times per week. The optimal dialysis is the main feature of the program system. The time-average blood urea nitrogen (TAC) and the protein catabolic rate (PCR) are selected as the measures of prescription effectiveness. The TAC was suggested by the National Cooperative Dialysis Study (NCDS,USA) as the major outcome parameter.The pro- gram estabilished in the paper can provide the clinicians pre- scribing dialysis to achieve ideal TAC and ideal PCR for improve- ment of patient care. The results of theoretical calculation and clinical data applications depict that the system developed in this paper is available clinically. Besides talking above,we can find the correlation coefficients are very high for useing one- pool model and two-pool model、a two BUN and a three BUN methods to calculate any one of these parameters, which are production rate of BUN (G), BUN distribution volume V and TAC by statistical analysis. It means that these methods are consistency. In the beta-2-microglobulin(β2-M) simulation, we can calcul- ate the production rate of β2-M (Gb) by a two BUN method or a three BUN method. The Gb not only include production rate of cellular catabolism (Gc), but also include production rate of immunological response (Gi).

碩士
國立陽明大學
護理學系
100
Background: Fatigue is one of the most common symptoms among patients with end-stage renal failure (ESRD). The experience of fatigue became worse after hemodialysis, and acupressure was reported to reduce hemodialysis related fatigue. We performed a randomized trial to compare the efficacy of acupressure with that of sham for fatigue in patients with ESRD undergoing maintenance dialysis therapy. Methods: A total of 53 patients with ESRD undergoing maintenance dialysis therapy were recruited from the Taipei City Hospital. The participants were instructed to receive either acupressure (n=27) or sham treatment (n=23) after hemodialysis for a period of 6 weeks. The primary outcome measures were the mean visual analogue scale fatigue score. Secondary outcome parameter was the global score on the World Health Organization Quality of Life questionnaire – Taiwan brief version. Results: Of the initial 53 intent-to-treat participants, 50 completed the 6-week study. The mean visual analogue scale fatigue scores decreased significantly in acupressure group. Mixed model analysis showed that acupressure was more effective in improving fatigue and promote quality of life than sham group. Conclusion: Acupressure may be worth further investigation as a treatment for fatigue among patients with ESRD undergoing maintenance dialysis therapy.

Objective We sought to analyze the effect of a structured, dietitian-led education program on patients' general knowledge of phosphate and phosphate binders, and its impact on serum phosphate concentrations in a single-center hemodialysis population. Design We compared subjects before and after intervention. Setting This study involved two dialysis units operated by a single center. Patients One hundred and fifteen hemodialysis patients consented to participate in this study (54% male; mean age, 61.1 years; 32% Asian). Patients acted as their own controls. One hundred and eight patients completed the study. Intervention All patients completed a questionnaire to assess their knowledge of phosphate and phosphate-binder therapy. Small group teaching sessions were then delivered to patients by a single dietitian, with the aid of a hospital interpreter as required. Patients also received information booklets or audio cassettes translated into Urdu. A second identical questionnaire was completed a month later. Main Outcome Measures Outcome measures involved pre-education and posteducation knowledge scores, monthly measurements of serum phosphate, calcium, and mean Kt/V, and parathyroid hormone concentrations every 3 months during the 5 month run-in period and subsequent 5-month study period. Results The education program significantly improved patients' general knowledge of phosphate and of phosphate-binders (P < .001), especially in patients with a low pretest score and those of South Asian origin. This result was associated with a significant reduction in serum phosphate in patients with hyperphosphatemia (P = .032). Conclusions These findings suggest that a combination of educational initiatives is effective in enhancing patients' knowledge of phosphate and phosphate-binders, and consequently in improving serum phosphate levels in patients with hyperphosphatemia.

Background: Levels of physical activity are significantly lower among individuals with end-stage renal disease (ESRD) compared to their healthy sedentary counterparts. Low levels of self-efficacy (SE) with respect to exercise may contribute to a sedentary lifestyle in the ESRD population. Therefore, in a pilot investigation we examined the effects of an 8-week intra-dialytic (ID) exercise program on SE and physical activity (PA) in hemodialysis (HD) patients and determined the appropriateness and sensitivity of the selected outcome measures and proposed intervention. Methods: HD patients were randomized into an Exercise group (EX, n=4) or a Control group (CON, n=4). The EX group cycled for approximately 60 min during HD, thrice weekly for 8 weeks. The CON group continued with their usual activity. At 8 weeks, participants in both groups had the option to participate in the exercise program. Physical Activity was determined using the Human Activity Profile (Maximal Activity Score, MAS; Adjusted Activity Score, AAS) and SE was evaluated using the Chronic Disease Self-Efficacy Scale (CDSES) and Exercise Self-Efficacy Scale (ESES). Measures were obtained at pre, post and 8 weeks following the intervention. Results: No significant changes in PA or SE occurred between or within groups at any time point. Limited statistical power due to the small sample size and a ceiling effect due to initial high-function levels of the participants may have contributed to the lack of significant changes. MAS and AAS were generally lower in the CON group. Age was significantly associated with the AAS, MAS, and the Perform Social/Recreational Activities sub-scale of the CDSES. Serum albumin was significantly related to the AAS and the Exercise Regularly and Do Chores sub-scales of the CDSES. Conclusions: Age and albumin should be taken into account when assessing physical activity in HD patients. Recruitment of additional participants is required to more clearly define the role of intra-dialytic exercise in enhancing exercise self-efficacy and physical activity in HD patients.
Thesis (Master, Rehabilitation Science) -- Queen's University, 2010-07-27 09:51:11.297

Patient-related barriers may reduce the effectiveness of screening for depression. This study aimed to explore perceived barriers to participation in a Screening Program for Depression by hemodialysis patients. In a cross-sectional study of hemodialysis patients, the Perceived Barriers to Psychological Treatment questionnaire was used to measure barriers to the Screening Program. Of 160 participants, 73.1% perceived at least one barrier (95% CI, 66.2% to 80.0%). The most common barriers were concerns about the side effects of antidepressant medications (40%), concerns about having more medications (32%), feeling that the problem is not severe enough (23%), and perceiving no risk of depression (23%). A high depression score was an independent predictor of barriers related to perceiving no benefit of the Screening Program and psychological, social, and practical barriers. We believe that patient-related barriers need to be addressed before implementing any case identification and treatment program for depression.

碩士
國立中山大學
傳播管理研究所
99
Due to high frequency and occurrence of chronic kidney diseases in Taiwan, as well as the low public awareness, this research aims to explore the knowledge construction process of Hemodialysis in health broadcasting programs from a health communication point of view. This research intended to answer the following questions: 1) What are health radio program audience types? 2) How does the knowledge on hemodialysis differ among audiences? 3) What is the knowledge construction process among audience in regards to hemodialysis? Data were collected by ten episodes of the Kaohsiung Police Ration Station’s “Medical Network” program for a six month period (January ~ June 2011). This research has utilized content analysis method on the audience type, quantitative description on questions identified by the audience and qualitative methods to summarize and interpret the audience’s knowledge construction process on hemodialysis. The results showed that the main audiences for health broadcast programs are mostly male, age 31 to 50 years, holding profession as drivers, service personnel and potential patients. Among them, the potential patients and their family members most often times ask diagnostic questions, falling into the compelled group in seek of knowledge. Those who have not been diagnosed with the disease often times bring up knowledge confirmation questions, belonging to the proactive knowledge chaser group. These two groups also demonstrated different hemodialysis knowledge construction processes. While the radio program host plays the role of knowledge enhancer to the diagnostic-need group (potential patients), the role transfers to a knowledge transformation model for the knowledge confirmation group (non-patients). Participating physicians follow the treatment process of – examination, diagnosis and treatment to deliver information. The research process shall provide broadcasters or other media professionals a best practice on how the audience absorbs information - to study the distribution and motives of the audience and to deliver the knowledge of health and illnesses.

碩士
臺北醫學大學
護理學研究所
97
The purpose of this experimental study was to explore the effects of a home-based exercise training program on sleep quality and physical function in hemodialysis patients . A total of 61 eligible subjects were recruited by purposive sampling from two hemodialysis units from a medical center in Taipei. They were randomly assigned into exercise training group (n=30) or control group (n=31). The exercise training group received fast walking exercise training on non-dialysis day, 30 minutes each time, three times a week, and for eight weeks. The control group received regular nursing care. Each subject in both groups completed the 6-minute walk test, The Chinese version of the Pittsburgh Sleep Quality Index and Functional Status Questionnaires before and after the eight-week study. The collected data were analyzed by descriptive statistics using percentage, mean±SD, Chi-square, Pearson correlation, inferential statistics using independent t-test and paired t test by statistics software. The results showed that there are not significant difference in characteristic data, sleeping quality and physical function at baseline between the two groups (p＞.05). However, there are significant improvement in sleeping quality (t=5.95, p＜.01), total physical functional score (t=-3.34, p=.02) and the 6-minute walk test (t=-10.62, p＜.01) in exercise group after the 8-weeks training, but all the indicators of the control team are not significant difference. The results showed that the home-based exercise program significantly improved the subjects sleep quality, physical function and the distance covered in the 6-minute walk test among hemodialysis patients. Results of this study, provide as a reference for patients receiving hemodialysis in the clinical practice. Based upon the study findings, we suggest that a home-based exercise training program could be infused in future home care plan.

博士
國立臺灣大學
護理學研究所
97
【Background】 Taiwan has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world. The numbers of people receiving dialysis continue to increase, and dialysis patients are getting older, as well. Hemodialysis is the most common form of treatment for ESRD in Taiwan. Both the disease and the treatment have a great impact upon patients mentally and physically, as well as upon society at large. As such, improving physical functioning and quality of life for dialysis patients through superior medical treatment and care is an important issue. Exercise is effective for maintaining bone mass, and is also mentally and physically beneficial for dialysis patients. In terms of caring for patients, exercise is also a feasible option for promoting the health of those undergoing hemodialysis. 【Aims】 The main purpose of the present study was to examine the effects of an exercise program on hemodialysis patients in terms of their physiological responses, physical functioning and quality of life. 【Methods】 This was a quasi-experimental study in which data were collected from hemodialysis units at a medical center in northern Taiwan. Purposive sampling was used to recruit participants who were assigned to an experimental group (participating in exercise sessions lasting from 20 to 30 minutes or more, three times per week for twelve weeks, for a total of 36 sessions) and a comparison group (who continued with existing medical care and life style) according to their individual preferences. Outcome indicators included bone mineral density (BMD), blood biochemistry values, time to complete 5 sit-to-stand cycles (STS-5), time to complete 10 sit-to-stand cycles (STS-10), repetition of sit-to-stand cycles in one minute (STS-60), 6-minute walk distance (6-MW), gait speed and IQOLA Short Form-36 Taiwan version (SF-36). Tests were performed at two time points: one prior to the intervention, and one following the intervention. Data analysis consisted of basic characteristics and outcome indicators presented in terms of descriptive statistics; inferential statistics were used to investigate correlation between the variables; and one-way ANCOVA was used to test the response to exercise. 【Results】 Participants in the present study numbered 28 in the experimental group and 31 in the comparison group. The two groups were homogeneous to each other. The mean age was 54.98 years, with the majority between the age of 50 and 69 (54%); there were slightly more males (54%); 25% were employed; 56% exercised regularly, though only 34% exercised to a point where it was effective; and the leading primary causes of ESRD included chronic glomerulonephritis (27%) and diabetes mellitis (17%). The duration of dialysis treatment for participants was between 6 and 202 months. The prevalence of low bone mass (including osteoporosis and osteopenia) was 73% in the femoral neck (FN) and 42% in the lumbar spine (LS). Serum albumin level and an effective exercise time were positively correlated with FN-BMD, and the exercise program was effective for slowing bone loss. Changes to FN-BMD and LS-BMD were measured both before and after the intervention, and even though a significant difference was seen only in the FN site, the rate of bone loss for the experimental group was slower than for the comparison group both for the FN and LS sites. In addition to significant increases in albumin, the exercise intervention did not result in significant changes in other physiological responses for participants in the experimental group. Changes in alkaline phosphatase (ALP) and intact parathyroid hormone (iPTH) in the experimental group were beneficial to bone formation, while in the comparison group these values were comparatively higher, showing that bone resorption was more severe. In terms of STS-5, STS-10, STS-60, 6-MW and gait speed, the experimental group showed significant reductions in time (–22% and –21%), along with increases in repetitions (+25%), distance (+11%) and speed (+19%), respectively. Slight improvements were seen in the comparison group in duration (–9% and –4%), repetitions (+6%) and speed (+5%), respectively, though distance decreased (–1%). In addition to physical functioning (PF), the exercise program resulted in significant improvements in the quality of life for the participants in every dimension of SF-36. In a comparison of the measurements taken before and after the intervention in the experimental group, improvements were seen in eight dimensions of quality of life (+13% to 39%). By contrast, PF (+3%) and social functioning (SF) (+2%) went up in the comparison group, while the other six dimensions dropped, role-physical (RP) (–24%) and role-emotion (RE) (–15%) particularly so. 【Conclusion】 The results of the present study confirm the effectiveness of this exercise program as an intervention modality. It may be assumed that an exercise program of weight bearing training (fast walking on a running machine) can help hemodialysis patients to partly improve the stability of their physiological responses, to effectively decelerate bone loss, strengthen physical functioning and enhance their quality of life. The results of the present study can be used as a reference for domestic health organizations and medical hospitals when formulating policies for dialysis treatment and guides for clinical therapy and care. However, generalizablity from the present study should be conservative owing to the limitations of its research design and sampling method.

Submitted in fulfillment of the requirements for the degree of Master of Clinical Technology (Nephrology), Durban University of Technology, Durban, South Africa, 2013.
Diabetic nephropathy is a serious complication of diabetes that can lead to end stage renal failure (ESRF). It is now the most common cause of ESRF in patients accepted onto renal replacement therapy (RRT) programmes. Kidney disease is common in South Africa. 60-65% is due to inherited hypertension and 20-25% due to Type 2 diabetes (National Kidney Foundation of South Africa, 2002). The renal replacement therapies include haemodialysis, peritoneal dialysis and transplantation. Successful long-term haemodialysis in patients with end stage renal disease (ESRD) depends to a large extent upon a trouble- free vascular access. Achieving a successful vascular access remains a challenge especially in the diabetic population. Current Kidney Dialysis Outcome Quality Initiative (KDOQI) guidelines encourage placing Arterio-Venous Fistula (AVF) in more haemodialysis patients. While the upper limb is the preferred site for AVF creation, researchers are undecided on which is the ideal location (distal or proximal arm) in the diabetic population. Many new fistulae fail to mature sufficiently to be usable for haemodialysis. Pre-insertion work-up with regard to haemodialysis access is important in maintaining the most appropriate access in the growing diabetic population requiring haemodialysis. Pre-operative vascular mapping to identify suitable vessels has been reported to improve vascular access outcomes . In South Africa, duplex scanning is not routinely done, and a clinical judgement by the surgeon remains in most instances the deciding factor on the site of the AVF. Whilst conducting this research, it has been found that while diabetic patients may have AVF created, the maturation time is of a much extended period, and a challenge to achieve the desired dose of dialysis. This is a prospective, quantitative and qualitative study of 21 diabetic patients. These included patients that were starting on the chronic haemodialysis program and limited to patients that were having first attempt of AVF creation and aims to establish if sonogram testing provides a more accurate measure of the ideal location for the AVF, or if a clinical evaluation alone by the surgeon is sufficient. Surgical techniques are different amongst surgeons and clinical evaluation is more a subjective decision. By limiting the surgeons performing the AVF, a standardized surgical procedure was established. If an ideal AVF access for the patient is created, haemodialysis efficiency is increased and ultimately patient outcome improved. The AVF was created according to the clinical evaluation as is the current process, and the surgeons were not aware of the duplex sonogram results. Failure and success of AVF were analysed according to primary patency and functional success. A primary patency success of the AVF does not guarantee functional success. If an AVF is not able to complete an entire haemodialysis session trouble free at the prescribed dialysis dose, the AVF is considered a failure irrespective of primary patency success. This was evident with 10% of patients who had primary patency but functional success was not achieved. With a 55% functional success in this study with AVF created on clinical evaluation, there was no significance difference (p=0.795) if AVFs were based on duplex sonogram findings. However, there was evidence of increased AVF success in 33% of the failed AVFs when the new AVFs were created at the duplex sonogram site. 95% of patients in this study had commenced haemodialysis with a Central Venous Catheter (CVC). AVF success could be increased if early referral of diabetic patients for permanent access to the surgeon occurred. Maturation rate of AVF differed from KDOQI guidelines with AVF first cannulation only after 17 weeks, and not after the recommended time of 6 weeks. Blood flow rates on dialysis also varied with international standards, with only maximum of 400mls/min reached after one year. With distal arm AVF, diameter of radial artery of less than 2mm and cephalic vein less than 3mm was associated with AVF failure. This research study represents the first of its kind in Kwazulu Natal looking at vascular access sites in diabetic patients with End Stage Renal Disease on haemodialysis.
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碩士
高雄醫學大學
醫務管理學研究所碩士在職專班
94
An Evidence-based Research of Integrated CKD Care Program Impacts on the medical effectiveness of Incident ESRD Patients on Hemodialysis Background and objectives: End-stage renal disease (ESRD) is epidemic worldwide. The medical expenditure of ESRD was increasing rapidly in last decade in Taiwan , due to the high annual incidence of ESRD rising from 257 pmp (per million population) in 1996 to 352 pmp in 2004. The integrated chronic kidney disease (CKD) care program was implemented since 2003 in Taiwan. The purpose of this study was to evaluate the effectiveness of 「Integrated CKD Care Program」. Methods and materials: The study subjects were divided as: (1) intervention group: 74 patients with intervention; (2) control groups: 117 patients without intervention after CKD care program and 194 incident ESRD patients before CKD care program implementation. We collected and compared the data and outcomes between intervention and control groups about demographic characteristics, underlying disease, and cormobidity. The outcome variables included clinical, quality outcome, medical expenditure and service utilization. The different predictive models of medical expenditure during pre-hemodialysis 6 months to initial HD were established. The statistical analysis were performed by independent- t test, Chi-square test, one-way ANOVA test, simple regression and multiple regression analysis. Results: The results of the intervention group vs. control group were as follows: hematocrit 24.19 vs. 22.78 %, p=0.018; albumin 3.28 vs. 3.11 g/dl, p=0.032; quality outcome grade 1：59.46 vs. 15.38 %; grade 2~ 4：48.54 vs. 84.62 %, p <0.001; medical service utilization: freguency of outpatient visit on 6 months before hemodialysis (HD) average 1.58 vs.0.83 times per patient-month, p<0.001; length of stay on initial HD through hospitalization: average 6.58 vs. 16.15 days, p<0.001 per patient; total dosage of rHuEPO on 6 months before HD: 4790.54 vs. 2361.82U per patient-month, p=0.003; medical expenditure: outpatient cost on 6 months before HD: average 5546.52 vs. 1759.02 NT dollars per patient- month, p=0.001; inpatient cost on initial HD : 40924.89 vs. 114622.10 NT dollars, p<0.001; overall expense ( dialysis cost excluded) during 6 months before HD to initial HD：77304.69 vs 115035.70 NT dollars per patient, p＝0.006. By stepwise multiple regression analysis, the significant risk factors of predictive model of overall medical expenditure were as follows: length of stay on initial HD via hospitalization, days of hospitalization before HD, hospital level, gender and albumin (p<0.05). Conclusion: Our results revealed the evidences that the integrated CKD care program significantly reduces medical expenditure, ultilization and improves quality of care on incident ESRD patients on hemodilysis.

碩士
臺北醫學大學
護理學研究所
95
The advantage of exercise for dialysis patients has been widely appoven. This study was to verify the efficacy of home-based exercise program on physical fitness, bone mineral density, and fatigue among dialysis patients. This study was a quasi-experimental design, taking objects themselves as the control group. The measurement was done at the started of study, 8th, and 16th week. During the first 8 weeks, no exercise intervention occured. During the second 8 weeks, home-based exercise program was intervened. Each measurement included physical fitness, bone mineral density, and fatigue.The objects were recruited from 2 medical centers and 3 dialysis clinics in the Northern Taiwan by purposive sampling. Home-based exercise program was brisk walk 3days per week lasting for 8 weeks, duration of each brisk walk from 15 minutes gradually increased to 40 minutes. The collected data were analysed by chi-square test, t-test, and pair-t test by statistic software. The results indicated that home-based exercise program could significantly increase the number of 30s chair stand test, extend the distance covered in the 6-minute walk test, improve bone mineral density, alleviate fatigue. In addition, the efficacy of home-based exercise program in hemodialysis patients was similar in peritoneal dialysis. The results implied that home-based exercise program can be a model for clinical dialysis patients to improve their health.

碩士
國防醫學院
護理研究所
106
Background Insomnia, fatigue and hypersomnia are the physical symptoms of the lack of energy which experienced by most hemodialysis patients. Evidence has proven that effects of interventions on sleep quality also validate on depressive symptoms and heart rate variability. Considering the unique pathophysiology of sleep disorders in patients with uremia, evidence-based interventions are necessary. However, there is no clinical guideline for sleep improvement in patients with hemodialysis. Purpose Base on the systematic literature reviews, this research establishes and investigates the effect of the evidence-based patient education program of non-pharmacological intervention on sleep quality, depressive symptoms, and heart rate variability in patients with hemodialysis. Method This research adopts quasi-experimental design of single group longitudinal study with repeated measurements that involved fifty-nine qualified patients with hemodialysis at a medical center of north Taiwan. The duration of this trail has conducted for 13 weeks. Patients received the evidence-based patient education program of non-pharmacological intervention at the 5th -8th weeks of the trail. Questionnaires of Chinese version of Pittsburgh Sleep Quality Inventory (PSQI), Chinese version of Epworth Sleepiness Scale (ESS), and Chinese version of Beck Depression Inventory-II (BDI-II), and heart rate variability (HRV) measurements were used as measurement tools in the following periods︰one month prior to the intervention period, the eve of the intervention period, one week after the intervention period, and one month after the intervention period. Results The duration of this study began from January 2nd , 2018 to April 30th , 2018. All fifty-five patients conducted the intervention and completed the questionnaires. The statistical analysis of results was using generalized estimatiog equation (GEE). This study results present that (1) PSQI, ESS, and BDI-II are significantly improved both at one week after the intervention period (p<0.001, p<0.001, p<0.008) and one month after the intervention period (p<0.001, p<0.001, p<0.007) compared to the eve of the intervention period. (2) High frequency (HF) continues to rise and low frequency (LF) is being inhibited, result in the LF/HF ratio declines at one week after the intervention period. At one month after the intervention period, HF decreases and LF increases, causes the LF/HF ratio increased. However, there are no significant differences in the HRV parameters both at one week after the intervention period (p=0.851, p=0.815, p=0.885) and one month after the intervention period (p=0.163, p=0.181, p=0.289) compared to the eve of the intervention period. Conclusion The evidence-based patient education program of non-pharmacological intervention significantly improves sleep quality and depressive symptoms in patients with hemodialysis. It also temporarily improves the HRV parameters but not maintains for the long-term. Although there are no significant differences in the HRV parameters, there still are clinical values.

碩士
國立臺灣大學
護理學研究所
94
The major purpose of our study is to explore the effectiveness of the emotional problem education program on the knowledge, attitude, and behavior of the hemodialysis nursing personnel who care the hemodialysis patients with emotional disorders and mental problem. We use the Quasi-experimental designs. Under the purposive sampling, the objects are the hemodialysis nursing care personnel working at two medical centers and one district center in the northern Taiwan. They are classified into three groups: experimental group-I, experimental group-II and control group. We use the Emotional Problem Education Program as intervention tool by which we also try to understand its effectiveness. After the pretest, Exp-I received five 60-minute courses and Exp-II received only one 60-minute course. Then we give the posttest for both groups on the end of education course. The control group does not receive any education program after the pretest. The timing of the pretest and posttest for these three groups tests at the same. Using three questionnaires which are : Individual Basic Data Questionnaire, Emotional Problem Knowledge Questionnaire, Depression Attitude Questionnaire, Emotional Problem Practice Skills and Performance Behavior Questionnaire. The effective questionnaire is 53(response rate 61％). The results shown: (1)There is significant difference on the total working career and age in the three groups, the nursing personnel of Exp-I group are senior. (2)On the aspect of the experience about contact with hemodialysis patients with mental problem, there are much more experiences for Exp-I group to contact the schizophrenic patients. (3)The total hours of mental health education are given more to the Exp-I group. (4)Among 3 groups, there is no significant difference on the pretest result about knowledge, attitude, and behaviors. (5)Analyzed with Repeated Measures as Mixed effects GLMs, experimental intervention is a fixed effect, three groups are in different ages, total work year , look after schizophrenia patient and mental health educate participate in the hours as a covariance, the knowledge shows no significant difference among all three groups. (6)The scores of the posttest on attitude are all increased in three groups. It shows that there is a positive upgrade of the attitude of nursing personnel to the depressive disorders. (7) On the aspect of nursing behavior, the average value of execution of nursing behavior will increase 0.51 score as the increase by one year of age. (8)After the analysis with the Pearson Correlation Coefficient, there is no correlation between the attendance times of emotional problem education and knowledge, attitude or behavior, but the age is related with nursing behavior. According to our study, there is no significant difference in knowledge ，depressive attitude and in behavior of caring about emotional problem, but it’s result and process can be used as a reference tool of continuing education for the hemodialysis nursing personnel.

碩士
南華大學
環境管理研究所
95
There are approximately forty-five thousand dialysis patients in Taiwan and the annually increasing rate is 7%, ranked top second in the world. Except artificial kidney which can be reused, other consumption materials are used one time only then discarded. As a result, medically infectious wastes increase continually. After implementing national medical care, the hospital income is significantly reduced. Considering the cost and regulation, it is important for the hospital to carry out infectious wastes reduction. The purpose of this study is to set up infectious wastes reduction program to effectively reduce such wastes. 　 　　This research is a case study in the Da-Lin Tsuchi Hospital. The associated administrative office director and nursing staff are interviewed and directly observed and asked to write questionnaires. 　　　 　　The results show that the increase of infectious wastes can be attributed to the following factors: (1) unbuilt habit of classification, (2) confusion of classification from nursing staff, patients and their family members, (3) operation mistakes, (4) too many trash cans, (4) unclear indication signs on trash cans, (5) high water contents of artificial kidney, and (6) dirty water of IV bags and IV sets. This study focuses on these six factors to propose several infectious wastes reduction programs. The experiment period is performed from November 2006 to January 2007.After increasing times of audit and classified guidance, posters and slogans manufacture, decreasing operation mistakes as well as designing specialized sewage collectors for the hemodialysis room, the weight of infectious wastes is reduced from 0.9 to 0.778kg per person per bed. In the average, the amount of infectious wastes is reduced 0.122 kg per person per bed, about 14% relative to previous amount of infectious wastes. The average monthly processing expense is also reduced, from NT$ 54,690 to NT$ 48,395, which creates the savage of NT$ 6,295 per month. Moreover, after the education training, the achievement test of nursing staff for infectious wastes recognition questionnaire indicates 98.95% of questions can be answered correctly. It implies the efficiency of our wastes reduction program on increasing recognition of infectious wastes for nursing staff. 　 　　By our wastes reduction program, infectious wastes and environmental impact are both lowered, the service quality for patients is raised, as well as the hospital environment is secured.

A presente dissertação de mestrado, em cuidados paliativos, situa-se na temática da doença renal crónica e as suas implicações na pessoa em hemodiálise. O objetivo desta dissertação de mestrado, é conhecer o que a evidência científica apresenta sobre as vivências do doente crónico em programa de hemodiálise. O corpo do trabalho apresenta uma contextualização histórica da doença renal crónica, seguindo-se a clarificação do tipo de estudo selecionado baseado no Protocolo de Revisão de Literatura do Instituto Joanna Briggs (2014) e, por fim, os resultados obtidos através da análise de conteúdo, segundo Jorge Vala (2014), num total de vinte e sete documentos, publicados em Portugal, Brasil, Estados Unidos da América, França e Tailândia de 1999 a 2017. O resultado fundamental desta revisão sistemática da literatura prende-se com o facto de se ter constatado que, independentemente do ponto geográfico onde a pessoa/família resida e trabalhe, as vivências associadas ao programa de hemodiálise são semelhantes. Verificamos ainda que a amostragem populacional utilizada nos estudos analisados não é muito extensa, o que nos impele a continuar a investigar sobre esta temática. Contudo concluímos que as vivências do doente crónico em programa de hemodiálise são diferenciadas tendo sempre como elo de ligação as necessidades básicas do ser humano no campo psico-espiritual e sociofamiliar enquanto domínios prioritários da nossa vida.
The present master's degree dissertation on palliative care is based on the theme of chronic renal disease and its implications in the person undergoing hemodialysis. The purpose of this Master's thesis is to know what the scientific evidence presents about the experiences of the chronic patient in a hemodialysis program. The body of the study presents a historical context of chronic kidney disease, followed by clarification of the type of study selected based on the Literature Review Protocol of the Joanna Briggs Institute (2014) and, finally, the results obtained through content analysis, according to Jorge Vala (2014), in a total of twenty-seven documents written in Portugal, Brazil, the United States of America, France and Thailand from 1999 to 2017. The fundamental result of this Systematic Review of Literature is that it has been found that, irrespective of the geographic location where the person / family resides and works the experiences of the hemodialysis program are similares. In the studies that we analyze, we verified that the population sampling used Bis not very extensive, which impels us to continue to investigate this issue. However, we conclude that the experiences of the chronic patient in a hemodialysis program are differentiated, always having as a link between the basic needs of the human being in the psycho-spiritual and socio-family field as priority areas of our life.

Introdução: A Doença Renal Crônica (DRC) é um problema de saúde pública emergente a nível mundial. Alterações na cavidade oral, tais como a periodontite, xerostomia e outras manifestações de saúde oral fraca, são comuns em doentes com doença renal crónica (DRC) e podem contribuir para o aumento da morbilidade e mortalidade. A prevalência de DRC em Portugal é das maiores da Europa. Existe pouca evidencia publicada sobre o estado de saúde oral de doentes com DRC em Portugal. Objetivos: Este estudo pretende avaliar a saúde dentária e periodontal de doentes com DRC em hemodiálise no Serviço de Nefrologia do Centro Hospitalar Tondela- Viseu. Os objetivos foram determinar a prevalência de cárie dentária, o estado periodontal e averiguar os seus comportamentos de saúde oral tais como a última vez que foi ao dentista e a forma como realizam a higiene oral. Métodos: Foi realizado um estudo epidemiológico observacional transversal obtendo uma amostra final de 30 doentes. Os dados foram adquiridos através de um questionário estruturado com foco em informações demográficas, histórico médico e sobre a cavidade oral. Isto foi procedido por um exame oral usando dois índices: Dentes Cariados, Perdidos e Obturados (CPOD) e o Índice Periodontal Comunitário (CPI). Resultados: O Índice CPOD médio foi de 22,1. Os resultados do CPI mostraram que a maioria dos participantes (72,4%) pontuou 4, indicando a presença de bolsas iguais ou superiores a 6mm. Quanto a data da última consulta de medicina dentária apenas 36,7% destes doentes a realizaram há 1 ano ou menos, em termos de escovagem dentária só 43,4% é que a realiza pelo menos 2 vezes por dia. Conclusões: Os resultados obtidos demonstram que os doentes com DRC em hemodiálise no Serviço de Nefrologia do Centro Hospitalar Tondela-Viseu, apresentam um estado de saúde oral bastante precário e que necessitam de adquirir informação e conhecimentos sobre medidas preventivas primárias.
Introduction: Chronic Kidney Disease (CKD) is an emerging public health problem worldwide. Changes in the oral cavity, such as periodontitis, xerostomia and other manifestations of poor oral health, are common in patients with chronic kidney disease (CKD) and may contribute to increased morbidity and mortality. The prevalence of CKD in Portugal is the highest in Europe. There is little published evidence on the oral health status of patients with CKD in Portugal. Objectives: This study aims to evaluate the dental and periodontal health of patients with CKD on hemodialysis at the Nephrology Service of the Tondela-Viseu Hospital Center. The objectives were to determine the prevalence of dental caries, periodontal status and to ascertain their oral health behaviors such as the last time they went to the dentist and the way they perform oral hygiene. Methods: A cross-sectional observational epidemiological study was performed, obtaining a final sample of 30 patients. The data were acquired through a structured questionnaire focusing on demographic information, medical history and the oral cavity. This was done by an oral examination using two indexes: Decayed, Missing, Filled Teeth(DMFT) and the Community Periodontal Index (CPI). Results: The average DMFT index was 22.1. The CPI results showed that the majority of participants (72.4%) scored 4, indicating the presence of pockets equal to or greater than 6 mm. As for the date of the last dental clinic visit, only 36.7% of these patients performed it for 1 year or less, in terms of dental brushing only 43.4% performed it at least 2 times a day. Conclusions: The results obtained demonstrate that patients with CKD on hemodialysis at the Nephrology Service of the Tondela-Viseu Hospital Center present a very precarious state of oral health and who need to acquire information and knowledge about primary preventive measures.

SUMÁRIO - O desafio atual da Saúde Pública é assegurar a sustentabilidade financeira do sistema de saúde. Em ambiente de recursos escassos, as análises económicas aplicadas à prestação dos cuidados de saúde são um contributo para a tomada de decisão que visa a maximização do bem-estar social sujeita a restrição orçamental. Portugal é um país com 10,6 milhões de habitantes (2011) com uma incidência e prevalência elevadas de doença renal crónica estadio 5 (DRC5), respetivamente, 234 doentes por milhão de habitantes (pmh) e 1.600 doentes/pmh. O crescimento de doenças associadas às causas de DRC, nomeadamente, diabetes Mellitus e hipertensão arterial, antecipam uma tendência para o aumento do número de doentes. Em 2011, dos 17.553 doentes em tratamento substitutivo renal, 59% encontrava-se em programa de hemodiálise (Hd) em centros de diálise extra-hospitalares, 37% viviam com um enxerto renal funcionante e 4% estavam em diálise peritoneal (SPN, 2011). A lista ativa para transplante (Tx) renal registava 2.500 doentes (SPN 2009). O Tx renal é a melhor modalidade terapêutica pela melhoria da sobrevida, qualidade de vida e relação custo-efetividade, mas a elegibilidade para Tx e a oferta de órgãos condicionam esta opção. Esta investigação desenvolveu-se em duas vertentes: i) determinar o rácio custo-utilidade incremental do Tx renal comparado com a Hd; ii) avaliar a capacidade máxima de dadores de cadáver em Portugal, as características e as causas de morte dos dadores potenciais a nível nacional, por hospital e por Gabinete Coordenador de Colheita e Transplantação (GCCT), e analisar o desempenho da rede de colheita de órgãos para Tx. Realizou-se um estudo observacional/não interventivo, prospetivo e analítico que incidiu sobre uma coorte de doentes em Hd que foi submetida a Tx renal. O tempo de seguimento mínimo foi de um ano e máximo de três anos. No início do estudo, colheram-se dados sociodemográficos e clínicos em 386 doentes em Hd, elegíveis para Tx renal. A qualidade de vida relacionada com a saúde (QVRS) foi avaliada nos doentes em Hd (tempo 0) e nos transplantados, aos três, seis, 12 meses, e depois, anualmente. Incluíram-se os doentes que por falência do enxerto renal transitaram para Hd. Na sua medição, utilizou-se um instrumento baseado em preferências da população, o EuroQol-5D, que permite o posterior cálculo dos QALY. Num grupo de 82 doentes, a QVRS em Hd foi avaliada em dois tempos de resposta o que permitiu a análise da sua evolução. Realizou-se uma análise custo-utilidade do Tx renal comparado com a Hd na perspetiva da sociedade. Identificaram-se os custos diretos, médicos e não médicos, e as alterações de produtividade em Hd e Tx renal. Incluíram-se os custos da colheita de órgãos, seleção dos candidatos a Tx renal e follow-up dos dadores vivos. Cada doente transplantado foi utilizado como controle de si próprio em diálise. Avaliou-se o custo médio anual em programa de Hd crónica relativo ao ano anterior à Tx renal. Os custos do Tx foram avaliados prospetivamente. Considerou-se como horizonte temporal o ciclo de vida nas duas modalidades. Usaram-se taxas de atualização de 0%, 3% e 5% na atualização dos custos e QALY e efetuaram-se análises de sensibilidade one way. Entre 2008 e 2010, 65 doentes foram submetidos a Tx renal. Registaram-se, prospetivamente, os resultados em saúde incluíndo os internamentos e os efeitos adversos da imunossupressão, e o consumo dos recursos em saúde. Utilizaram-se modelos de medidas repetidas na avaliação da evolução da QVRS e modelos de regressão múltipla na análise da associação da QVRS e dos custos do transplante com as características basais dos doentes e os eventos clínicos. Comparativamente à Hd, observou-se melhoria da utilidade ao 3º mês de Tx e a qualidade de vida aferida pela escala EQ-VAS melhorou em todos os tempos de observação após o Tx renal. O custo médio da Hd foi de 32.567,57€, considerado uniforme ao longo do tempo. O custo médio do Tx renal foi de 60.210,09€ no 1º ano e 12.956,77€ nos anos seguintes. O rácio custo-utilidade do Tx renal vs Hd crónica foi de 2.004,75€/QALY. A partir de uma sobrevivência do enxerto de dois anos e cinco meses, o Tx associou-se a poupança dos custos. Utilizaram-se os dados nacionais dos Grupos de Diagnóstico Homogéneos e realizou-se um estudo retrospectivo que abrangeu as mortes ocorridas em 34 hospitais com colheita de órgãos, em 2006. Considerou-se como dador potencial o indivíduo com idade entre 1-70 anos cuja morte ocorrera a nível hospitalar, e que apresentasse critérios de adequação à doação de rim. Analisou-se a associação dos dadores potenciais com características populacionais e hospitalares. O desempenho das organizações de colheita de órgãos foi avaliado pela taxa de conversão (rácio entre os dadores potenciais e efetivos) e pelo número de dadores potenciais por milhão de habitantes a nível nacional, regional e por Gabinete Coordenador de Colheita e Transplantação (GCCT). Identificaram-se 3.838 dadores potenciais dos quais 608 apresentaram códigos da Classificação Internacional de Doenças, 9.ª Revisão, Modificações Clínicas (CID- 9-MC) que, com maior frequência, evoluem para a morte cerebral. O modelo logit para dados agrupados identificou a idade, o rácio da lotação em Unidades de Cuidados Intensivos e lotação de agudos, existência de GCCT e de Unidade de Transplantação, e mortalidade por acidente de trabalho como fatores preditivos da conversão dum dador potencial em efetivo e através das estimativas do modelo logit quantificou-se a probabilidade dessa conversão. A doação de órgãos deve ser assumida como uma prioridade e as autoridades em saúde devem assegurar o financiamento dos hospitais com programas de doação, evitando o desperdício de órgãos para transplantação, enquanto um bem público e escasso. A colheita de órgãos deve ser considerada uma opção estratégica da atividade hospitalar orientada para a organização e planeamento de serviços que maximizem a conversão de dadores potenciais em efetivos incluindo esse critério como medida de qualidade e efetividade do desempenho hospitalar. Os resultados deste estudo demonstram que: 1) o Tx renal proporciona ganhos em saúde, aumento da sobrevida e qualidade de vida, e poupança de custos; 2) em Portugal, a taxa máxima de eficácia da conversão dos dadores cadavéricos em dadores potenciais está longe de ser atingida. O investimento na rede de colheita de órgãos para Tx é essencial para assegurar a sustentabilidade financeira e promover a qualidade, eficiência e equidade dos cuidados em saúde prestados na DRC5.
ABSTRACT - The current challenge of Public Health is to ensure the financial sustainability of the health system. Economic evaluations help health authorities facing budget constraints and inform about the allocation of scarce resources aiming to maximize societal utility. Portugal is a country with 10.6 millions inhabitants with an annual incidence of 234 per million population (pmp) and a prevalence of 1,600 pmp of end stage renal disease (ESRD). Worldwide, the ageing population and the increasing rates of Diabetes Mellitus and arterial hypertension anticipates that chronic kidney disease (CKD) is growing. During 2011, 17,533 patients received renal replacement therapy. About 59% were on hemodialysis (Hd) in private for-profit dialysis centers, 37% had a kidney transplant (KT) and 4% were on peritoneal dialysis (SPN, 2011). There were 2,500 patients on the KT wait-list (Portuguese Society of Nephrology, 2009). KT is a better treatment modality, improving survival and health related quality of life (HRQOL), and having a favourable cost-effectiveness ratio. However, transplant eligibility and the availability of organs for transplantation constrain this treatment option. This research aims to: i) assess the incremental cost utility ratio of KT compared to Hd ii) assess the number, characteristics and causes of death of potential donors compared with effective donors, nationally and at the level of the five Office Coordinator of Procurement and Transplantation (OCPT) and to evaluate the performance of organ procurement organizations. We conducted an analytical longitudinal prospective study of 65 patients who underwent KT during follow-up of 1-3 years. At enrollment, we collected demographic and clinical data of 386 dialysis patients, wait-listed for KT. HRQOL was assessed in Hd (baseline) and two years after in those remaining on the transplant list. The second evaluation was obtained in 82 patients to analyze the evolution of HRQOL in Hd. Follow-up interviews were scheduled at 3, 6, 12, 24 and 36 months after KT. Patients who had lost their graft were included. We used the EuroQol 5-D (EQ-5D), a preference-based questionnaire that allows the calculation of QALYs. A cost-utility analysis of KT vs Hd was performed. A societal perspective was taken. Direct costs, medical and non-medical, and productivity changes on Hd and KT were identified. Costs related to cadaveric and living kidney donation, selection of candidates for KT in the year of acceptance on the transplant list and in subsequent years were included. Each transplant recipient acted as his/her own control on Hd. Resource consumption on Hd was reported to the year prior to KT and assumed to be constant, annually. Costs allocated to KT were prospectively measured. Future life-years on Hd and KT were considered. Costs and QALY were discounted at 0%, 3% and 5% and sensitivity analyses were undertaken. From 2008 to 2010, 65 patients underwent KT. Clinical events, causes of hospital readmissions, adverse effects of immunosupression and health resource consumption were collected from medical records. We used multiple linear regression models to identify significant predictors of costs. We used repeated measures models to evaluate HRQOL over time. Multiple linear regression models were used to investigate the relationships between HRQOL changes and baseline characteristics and clinical outcomes. Compared to HD, there was a positive change of EQ-VAS in all observation times after KT and a positive change of EQ-5D utility scores at 3 months. The average annual cost of HD was 32,567.57€, assumed constant over time. Total costs during the first year and subsequent years averaged 60,210.09€ and 12,956.77€, respectively. The incremental cost utility ratio was 2.004,75€/QALY. KT was more effective and less expensive if the survival of the graft surpassed two years and five months compared to Hd. Using the national diagnosis related groups (DRG) database, we conducted a retrospective study to analyze mortality in the 34 hospitals where organ recovery had occurred. Potential donors were defined as patients aged over one year and less than 70 years who died in hospital, and were deemed medically suitable for organ donation. Demographic data and characteristics of the hospitals were collected. The performance of Organ Procurement Organizations (OPO) was evaluated by the conversion rate and the potential donors/pmp stratified at three levels: national, regional, and by Office Coordinator of Procurement and Transplantation (OCPT). We identified 3,838 potential donors and 608 patients presented ICD - 9 MC codes that frequently evolve to brain death. Logit regression revealed that the ratio between Intensive Care Units and acute beds of hospital, age, existence of transplant centre and OCPT and mortality from labour accidents in the geographical location of hospitals were significant predictors for a potential donor to be converted into an effective donor. Health authorities should consider organ donation as a priority area of healthcare. Securing sustainable financing for the hospitals with donor programmes should avoid the wasting of organs for transplantation, a public and scarce resource. Organ donation must be assumed as one of the core activities of clinical practice. The hospital performance should be evaluated according to the achievement of defined indicators. The effectiveness of measurement strategies should include organizational processes to ensure that potential donors are identified and, as many as possible, converted into effective donors. This study shows that: 1) renal transplantation provides health benefits, both survival and quality of life, and cost savings compared to dialysis; 2) the optimal conversion rate of potential donor into an effective donor has not been achieved in Portugal. The investment in the organisational structure of organ donation is essential to ensure financial sustainability, quality, efficiency and equity of health care in ESRD patients.