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Perit Dial Int 2003 Leung S90 4

Perit Dial Int 2003 Leung S90 4

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Published by Roberto Manuel II

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Published by: Roberto Manuel II on Jun 24, 2012
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0896-8608/03 $3.00 + .00Copyright © 2003 International Society for Peritoneal DialysisPrinted in Canada. All rights reserved.Proceedings of the First Asian Chapter Meeting — ISPDDecember 13 – 15, 2002, Hong Kong
Peritoneal Dialysis International,
Vol. 23 (2003), Supplement 2
It is not uncommon for renal patients to present withpsychosocial problems and behavioral problems. Thispaper briefly discusses some of the psychosocial factorsassociated with renal disease and peritoneal dialysis,considers the role that those factors play in relation toclinical treatment, and suggests nursing interventions thatinvolve problem-solving with patients and providing sup-port to caregivers. Because nurses are on the front line inencounters with patients, their contribution can facilitatesupport for the psychosocial situations of their patientsthrough effective communication within a committedmultidisciplinary team that share a vision of the signifi-cance of psychosocial intervention.
Perit Dial Int 
2003; 23(S2):S90–S94www.PDIConnect.com
KEY WORDS: Chronic disease; stressors; assess-ment; encouragement; life enhancement; support tocaregivers; multidisciplinary team.
ny illness that occurs within the context of anindividual’s life is likely to have effects at thepsychological and social levels. However, health careproviders often tend to separate the biologic andpathologic elements of illness from the psychosocialelements (1).End-stage renal disease (ESRD) is a chronic ill-ness that results from a number of pathologic pro-cesses, with subsequent physiologic upsets. Thecondition cannot be managed by medical interven-tion alone. Periodic monitoring and supportive careare required to reduce the degree of illness and tomaximize physical function and self-care.A diagnosis of ESRD creates turmoil that reachesinto all aspects of a person’s life. The diagnosis pre-cipitates a rollercoaster ride of emotions, includingfear and anger, despair and hope. Life with kidneyfailure becomes challenging. The person is forced toconfront, in a very personal way, the frailty and vul-nerability of the human condition.Research by professionals has found that the psy-chosocial environment in which an ESRD patient livesaffects the course of the disease and the patientsphysical well-being (2). Medical technology has maderenal replacement therapies available to adjust thephysiologic upsets in ESRD patients. In various coun-tries, differences occur in the use of the various dialy-sis modalities, reflecting the effects of medical andeconomic factors, of resource issues, and of profes-sional preferences (3).Peritoneal dialysis (PD) is one treatment option. Apatient with ESRD who uses PD faces, in addition toa debilitating and disruptive chronic illness, a treat-ment regime that is itself complex, demanding, andincessantly intrusive on personal and social life (4).Estimates suggest that 25% or more of people withchronic renal failure present with depressive symp-toms, and one third of them may be suffering from amajor depression that requires treatment (5,6).Numerous psychosocial stressors affect ESRD pa-tients and their families. Some of the stressors aredependency, role loss, changed body image, financialconcerns, vocational concerns, and changes in socialand marital relationships. The response by patients—and other involved persons—to those stressors affectsadjustment to treatment and response to treatmentregimes.By reaching a better understanding of the day-today stresses and concerns of patients, staff in renalunits can respond with appropriate support (6). Thepresent article briefly discusses some of the psycho-social factors associated with ESRD and PD, consid-ers the roles that those factors play in relation toclinical treatment, and suggests nursing interventionsthat use problem-solving with the patient for opti-mal treatment outcome.
End-stage renal disease results from irreversibledamage to kidney tissue. Clinical manifestationsinclude edema, uremia, anemia, gastrointestinal dis-orders, dermatologic symptoms, and renal osteodys-
Correspondence to: D.K.C. Leung, Renal Unit, Tuen MunHospital, Tsing Chung Koon Road, New Territories, HongKong SAR, China.galaxy97@netvigator.com
Dora K.C. Leung
Renal Unit, Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China 
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 DECEMBER 2003 – VOL. 23, SUPPL 2
trophy. Physical disturbances may present as gener-alized discomfort, nausea, insomnia, diminished tol-erance for exercise, pallor, and pain. In addition,complications attributable to comorbid conditions suchas diabetes and cardiovascular problems magnify thephysiologic and physical disturbances. As a result, pre-viously normal lives are disrupted by varying degreesof physical limitation, and patients follow a trajectoryof perceivable alterations in ability to function physi-cally and to engage in social activities.
Integration of dialysis treatment into daily life fre-quently undermines the usual patterns and activi-ties of daily living. Care of the chronically ill patientmust therefore focus not only on primary physicalinterventions, but also on mitigating the psychoso-cial impact of the illness on daily life (5). The majorpsychosocial factors for patients with ESRD on PDare emotion, self-esteem, lifestyle, personal values,social culture and beliefs, and sexual function.
The physical effects of ESRD are appar-ent. Emotional effects relating to the illness and itstreatment also exist. They include fear (“What doesthe future hold with an implanted catheter?”), anger(“Why me?”), grief (for loss of a former image of capa-bility before becoming dependent on dialysis), anddepression (owing to the threat of PD complications).Those emotions cannot be avoided. Fear of the un-known—the course of the illness, partial resumptionof previous life—threatens the patient and motivatesa search for assistance in biopsychosocial adaptation.Grief for a former self-image drives the patient to in-tegrate the illness and its treatment as a permanentpart of personal identity. Depression may provide timefor the long-term reality to sink in, with eventual long-term adaptation. Acceptance of the illness and itstreatment is a recognition that the unwelcome in-truder is here to stay.Sometimes the patient directs the emotional effectsat inappropriate targets: anger at a spouse, an em-ployer, or a health care provider, for example. At othertimes, suicidal thoughts may emerge. Everyone in-volved with the patient must understand what ishappening and must communicate care and support.
Self-esteemrefers to personal judg-ment of one’s own worth. It is rooted in an individual’spersonal perception of goal attainment with regardto a personal ideal.Patients on PD may experience a feeling of lack of control over their destiny. They may have to compro-mise or to abandon long-range goals. It takes time forthe patient to adjust and adapt. Altered self-esteemcan be triggered by role changes. For example, a bread-winner becomes, in personal perception, a burden tothe family; the debilitating effects of illness causesdependence on PD; unemployment leads to financialhardship.Body image is the mental picture that people haveof their own bodies and bodily functions, includingassociated external and internal sensations. It alsoincludes a personal perception of the way others seeoneself. The physical “imperfections” of the patienton PD—a permanent peritoneal catheter, skin lesions,uremic breath, distended abdomen—can contributeto stress or even lead to distortions in the deeper senseof self. Not uncommonly, anger and frustration esca-late. A group environment—with peer support, shar-ing of personal experiences, exchange of successfulstrategies—can provide opportunities to create sup-portive interpersonal relationships.
The pervasiveness of uremic symptomsand the commitment of time and energy necessary fora PD treatment regime disturb virtually every aspectof a patient’s lifestyle. The intrusiveness of the illnesson certain activities and interests that are valued bythe patient (such as travel or sports) changes life pat-terns. Enjoying a tub bath becomes a luxury for thepatient with a peritoneal catheter. Eating preferencesor cooking patterns may have to be adapted to meetthe nutritional requirements of the illness and to ob-serve restrictions on fluid and diet. Follow-up appoint-ments and treatment times may clash with the dailywork schedule. The debilitating nature of the illnessmay restrict the number of working hours or requirethe patient to quit a job. A distorted bodily shape mayrequire a change in clothing style. A positive adjust-ment can be encouraged by the provision of opportu-nities for patient-to-patient communication.
Personal Values:
“Personal values” refers to anysituation valued by the patient. A particular indi-vidual may be concerned with diminishing urine out-put or other decline in bodily function as the illnessprogresses. The person may also worry about an in-ability to attain a desired goal or a failure to sustaina previously harmonious relationship with the fam-ily because of inadequate support or understandingfrom other family members (as perceived by the pa-tient). Employment may be lost due to lack of socialrecognition of the person’s work capacity.Disturbance in self-concept may lead to depres-sion—sometimes associated with suicidal thoughts.Poor self-esteem may be manifested by poor self-hy-giene, by excessive dependency, or, not uncommonly,by lack of adherence to treatment requirements.Rehabilitation management can help to restore thepatient’s functional strengths and optimal well-being.Some patients make secondary gains from the illness,because they discover a potential that was not previ-ously recognized: intelligence for self-management of health care, closer family relationships, or better so-cial supports.
 Health Beliefs and Culture:
It is not uncommon toencounter patients with attitudes such as “Kidney
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 DECEMBER 2003 – VOL. 23, SUPPL 2
disease is a consequence of overwork,” “Chronic ill-ness is the penalty imposed by supernatural forcesfor having broken moral codes,” “The role of ‘patient’is a burden to family and to self,” The role of patientdenotes inferiority among peers,” “Laypeople can’tpractice self-care in health matters.” Health beliefsand culture influence how a patient adapts to treat-ment requirements. For example, perceptions aboutnutrition play an important role in patients on PD.Nutritionists can provide good advice about a low-phosphate diet; however, the patient may believe thatfood is the greatest gift” and that there should be norestrictions. Perceptions about the body, ideas aboutself and about illness, and social attitudes toward ill-ness vary and may be very different between ethnicgroups, countries, or even families.Care should focus on the patient’s personal andcultural realities and should not impose beliefs andculture from outside. Nurses require the sensitivityto avoid poor interpersonal contacts, distorted social-ization, and negative influences on the patient’s mo-tivation that will cause grief in the patient about self or others. The establishment of supportive social en-vironments has been shown to have a positiveimpact (7).
Sexual Function:
Renal disease may affect sexualperformance in both men and women. The cause orcauses may be organic (hormonal change attributableto uremia, or vascular insufficiency in diabetes), psy-chosocial (changes in self-esteem from alteration inbody image due to the presence of the PD catheter,leading to feelings of sexual unattractiveness), orphysical (distention and discomfort due to intraperi-toneal fluid, uremic symptoms that decondition thepatient on PD treatment). The role of patient” andthe accompanying stress on the partner can furtheralter role perceptions and affect sexual performancein some patients. The effects of drugs prescribed aspart of the treatment regime can cause sexualdysfunction.The knowledge that help is available if problemsoccur is all that is needed until a specific problemarises. The patient may reflect sexual difficulties in aloss of physical function. Referral to a sex therapistor counselor is appropriate so that specific strategiescan be developed to improve sexual function and toallay the frustrations of the patient and the partner.
End-stage renal disease is progressive, and the dis-turbances it brings are progressive. Any interventionhas to be tailored to the progress of the disease itself,with the individual’s level of physical, psychological,and social functioning as the central focus. The con-current physiologic, psychological, and social stressesdemand cognitive effort from the patient in coping.Researchers suggest that patient adherence to a medi-cal regime is significantly related to high social de-sirability and a shorter length of time on dialysis (8).Patients with ESRD are empowered for self-care inmatters of drug administration and PD management,but adherence to treatment requirements must be avoluntary act of submission, with consent for the ad- justment and adaptation to the illness and treatment.Psychosocial intervention is best started as early (atdiagnosis) and demands continuous effort.
 Nursing Implications:
End-stage renal disease hasa characteristically downward trajectory. Patientshave to come to terms with their current physical con-dition. Psychosocial nursing interventions should at-tempt to facilitate adjustment to changes in the courseof the illness and to normalize social interaction andlifestyle by preventing medical crises, controllingsymptoms, and incorporating the PD treatment re-gimes into daily living (9). Knowledge can significantlyminimize a patient’s anxiety. It is crucial that nurseshave the skills to provide clear information, to helppatients identify their goals in the course of treat-ment, and to assist with problem-solving for optimalphysical functioning.
Assessment determines the patient’sneeds, identifies problems and potential problems,and collects information for a treatment plan so thatappropriate support can be rendered. The assessmenttherefore focuses on the effect of the illness on thepatient. Useful information includes the patient’slifestyle, patterns of daily living, personality,strengths and interests, normal coping patterns, un-derstanding of the current illness, perception of treat-ment regimes, recent life stresses or changes, andmajor issues raised by the disease. By listening tothe patient and the family in the course of discus-sion, nurses can identify the observable psychoso-cial interferences consequent to the disease and theneeds for assistance. At the same time, informationon the expected course and likely outcome of the dis-ease can be provided.
The role of the health care profes-sional is to encourage and, where possible, to enablepatients to accept responsibility for their health andwell-being and to fulfill their obligations within thefamily and society. As well as providing knowledgeand clarifying misconceptions, nurses can encouragepatients to accept the personal limitations consequentto the illness and its treatment. When a patient isencouraged to perform self-care, better self-esteemand power to maintain health are established. Whenopen discussion and awareness of the mutual situa-tion is encouraged between patients and their part-ners, positive and understanding attitudes arereinforced. The perception of emotional support has
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