CNA576 Self Management In Renal Nursing

Introduction

Hyperkalemia is a common clinical condition in patients suffering from end stage renal diseases. Due to the impact on the cardiac conductivity, hyperkalemia has become a topic of concern among the physicians. This condition is mainly caused by the overabundance of the potassium in the extracellular compartments. It occurs when the serum potassium concentration goes above 5.5 mm (Putcha and Allon 2007). Some of the common cause of the hyperkalemia in patients involve the excessive uptake of the potassium through dietary supplements and occasionally via intravenous fluids. Treatment of Hyperkalemia involves stabilization of the myocardium, hemodialysis, administration of the intravenous insulin or albuterol, bicarbonate and epinephrine (Putcha and Allon 2007). Removal of the potassium can be done by the cation exchange resins, bicarbonate infusion and dialysis. The prevention of hyperkalemia involves dietary restrictions and adherence to medications.

Exploration of the self-management of the end stage renal diseases is important as they are faced with a number of complex treatments, restrictions, dependency on the technology and uncertainty about life (Reid et al. 2011). Through the stages of renal diseases, people have to modify their diets and life style managing with medications and appointments, including dialysis. The burden of the renal replacement therapies also have considerable demands on the health care resources. Hence self-management of the disease is necessary. But several barriers restrict the slef management of Hyperkalemia.

Self-management education and promotion

Although education about hyperkalemia is provided to the patients at the time of the short clinical interactions but interactions and normally the patients are left to take their own day to day decisions and hence self-management is necessary. Health education regarding the hyperkalemia can be provided by conducting health promotion programs with proper target audiences and health promotion strategies. However there are certain barriers to the education and promotion of the self-management of the disease.

Patient barriers to education and the promotion of the self- management of hyperkalemia

Barriers to patient education and promotion about the self-management are the low line awareness about hyperkalemia, health literacy and access to information on hyperkalemia.

Low understanding about the disease

The general population have a very low level of understanding of the role of the kidney in the relative health of the person as well as other organs. In patients having hypertension, the concerns about end stage renal disease is much less as compared with the concerns about cancer or cardiovascular problems (Kovesdy 2017).

Selection of dialysis modality is also dependable on the patient. In spite of the cost and time savings, flexibility schedules and control over the treatment the use of the home dialysis is low due to factors like difficulties in reimbursement of the finance with the medical insurers and social concerns like non adherence to the treatment regimen, lack of suitable housing (Harwood and Clark 2012). Furthermore the family members of the patient might not have that cognitive capability to carry out a home based dialysis.

Lack of motivation

Patients who are receiving hemodialysis have to restrict their fluid for ensuring appropriate interdialytic weight gains. The ability of the patient to manage the fluid gain depends upon the understanding of the patient. In many cases the patients are not willing to self-manage their fluid restrictions (Crown and Vogel 2017). Hence lack of motivation can be perceived as a barrier in education and promotion of the patient undergoing hemodialysis.

Limited health literacy

In most of the patients suffering from hyperkalemia the health literacy is limited. A systematic review has suggested that the 18% of about 400 patients in a cohort have been found to have restricted health literacy (Jain & Green, 2016). Low health literacy is related to low level dialysis patient self-management. Low level of health numeracy. According to a study, more than half of the patient with hyperkalemia could answer one or fewer numeracy assessment.

Provider barriers

Other provider barriers are less prioritization of hyperkalemia, restrictions on time, lack of confidence, the competing demands, lack of consensus about the time and the suitability for starting hyperkalemia education.

Poor prioritization and time constraints

Some of the barriers to health promotion about hyperkalemia self-management is that, the health service providers might not consider hyperkalemia as the priority health concern (Harwood and Clark 2012). Primary care sector clinicians get very little time to address such a wide array of the patient problems.

Lack of confidence

Many of the health service care providers may feel that they do not have sufficient training in explaining the kidney diseases. The non-kidney specialist might get confused and intimidated by the lengthy and evolving kidney disease guidelines on the content and the timing of the education (Bonner et al. 2014). Absence of collaborative management and communication between the nephrologists and the primary care physicians leave an educational gap in the patients, as both of them think that the other person had provided the education.

Challenges to communicate the complexity of the disease in education and promotion

According to studies, the primary care clinicians have admitted that the potential barriers in educating these patient is the complexity of the pathophysiology and it also becomes difficult for them to explain about hyperkalemia in short clinic visits (Narva et al. 2016). Furthermore the nephrology community have confusion as whether the advanced aged patient who meet the eGFR criteria for hyperkalemia should be screened and educated or all patient who meet the criteria for hyperkalemia should be educated. Again heightening awareness may lead to generation of unnecessary concern among the patient about the renal disease progression.

System barriers: Less incentives to education and health promotion

The existing quality improvement initiatives for revamping the reimbursement structures have failed to incentivize education for hyperkalemia. The recent health systems of Australia omits the education specific objectives. Accordingly most of the Australian clinical system fail to prioritize the patient education. The assistance that the government is providing to fund home dialysis is not adequate (Narva et al. 2016). Furthermore, the Australian policy to lift hyperkalemia education rates by revising the reimbursement policies have been less successful.

Low decision support tools in health promotion

Although the automation of the eGFR reporting have improved the awareness among the health care professionals, the extent to which it has helped the understanding of the patient is still questionable. The primary health care providers who can spot the presence of hyperkalemia to the patient can refer him/ her to the nephrologists but are less likely to educate the patients. Health promotion program for the self-management of hyperkalemia requires proper funding from the government. Health promotion program would require dissemination of the information via online sources of newsletters. The target audiences should be identified and informed about the health promotion program. All these would require training of the health care staffs. As in most of the cases the health care workers do not have proper education to promote self-awareness and self-management.  Hence lack of proper funding is another barriers to the health promotion program about the self-management of hyperkalemia.

Conclusion

In conclusion it can be said that Hyperkalemia is a mounting problem and it is important the patients are educated to self-manage in the early stages of the disease. However although some barriers have been identified in the self-management of the disease, robust training and revised funding may improve the problems related to self-management.

References

Bonner, A., Havas, K., Douglas, C., Thepha, T., Bennett, P. and Clark, R., 2014. Self?management programmes in stages 1–4 chronic kidney disease: a literature review. Journal of renal care, 40(3), pp.194-204.

Burke, M.T., Kapojos, J., Sammartino, C. and Gray, N.A., 2014. Kidney disease health literacy among new patients referred to a nephrology outpatient clinic. Internal medicine journal, 44(11), pp.1080-1086.

Crown, S. and Vogel, J.A., 2017. Enhancing Self-Care Management of Interdialytic Fluid Weight Gain in Patients on Hemodialysis: A Pilot Study Using Motivational Interviewing. Nephrology Nursing Journal, 44(1).

Harwood, L. and Clark, A.M., 2012. Understanding health decisions using critical realism: home?dialysis decision?making during chronic kidney disease. Nursing inquiry, 19(1), pp.29-38.

Jain, D., and Green, J. A. 2016. Health literacy in kidney disease: Review of the literature and implications for clinical practice. World Journal of Nephrology, 5(2), pp.147–151.

Kovesdy, C.P., 2017. Updates in hyperkalemia: Outcomes and therapeutic strategies. Reviews in Endocrine and Metabolic Disorders, 18(1), pp.41-47.

Narva, A. S., Norton, J. M., and Boulware, L. E. 2016. Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care. Clinical Journal of the American Society of Nephrology?: CJASN, 11(4), pp. 694–703.

Putcha, N. and Allon, M., 2007, September. Management of hyperkalemia in dialysis patients. In Seminars in dialysis (Vol. 20, No. 5, pp. 431-439). Oxford, UK: Blackwell Publishing Ltd.

Reid, C., Hall, J., Boys, J., Lewis, S. and Chang, A., 2011. Self-management of haemodialysis for End Stage Renal Disease: a systematic review. JBI Database of Systematic Reviews and Implementation Reports, 9(3), pp.69-103.