Clinical Characteristics of Hemodialysis Patients on their Assessment of Activities of

Daily Living: Basis for a Structured Guidelines for CKD patients

A Thesis Paper Submitted in Partial Fulfillment of the Requirements for the Degree

Master of Arts in Nursing

Alexandra C. Torres

La Consolacion University Philippines

July 2021
 Approval Sheet

In partial fulfillment of the requirements for the degree of Master of Arts in

Nursing, this thesis entitled “Clinical Characteristics of Hemodialysis Patients on their

Assessment of Activities of Daily Living: Basis for a Structured Guidelines for CKD

patients” has been prepared and submitted by Alexandra C. Torres.

______________________
DR. CARLO VINCENT JORDAN
Adviser

June 2021

Approved in partial fulfillment of the requirements for the degree of Master of Arts
Nursing by the Panel of Examiners.

_________________________

Chairman

____________________________ ____________________________
DR. JOCELYN HIPONA
Member Member

Accepted and approved in partial fulfillment of the requirements for the degree Master of
Arts in Nursing.

____________________________
DR. ENRICO F. ROSALES
Dean, Graduate School

ii
 Acknowledgment

The researcher would like to thank the following people in the completion of this

study:

Dr. Carlo Vincent Jordan, the researcher’s adviser, for his advises, understanding,

and encouraging support in the preparation and improvement of the study.

The respondents who provided the data needed for the completion of this study

given the sensitivity issue of the topic.

The panel of examiners- Dr. Jocelyn Hipona and Dr. Enrico Rosales for their

suggestions for the improvement of this research study.

The researcher’s family for their faith, understanding and loving encouraging

support, that had helped her to go through the trials of this study. With them, giving up is

not an option but support and love will always be there through it all.

iii
 Abstract

The major concern of the study is to assess the effects of socio-demographic and

clinical factors on the quality of life of activities of daily Living of Hemodialysis

Patients.

This study made use of descriptive correlation method of research that utilized

standardized questionnaires as primary data gathering tool. The respondents of the study

were the Out Patient Hemodialysis Patients at a tertiary government hospital in Bulacan.

The results were processed using the Statistical Packages for Social Sciences Version 23

and Graph Pad InStat Version 3 and the data were presented using appropriate tables and

texts. Chronic Kidney Disease patients in Out Patient Hemodialysis Treatment are mostly

with an average of 1-3 years of treatment, with long term vascular access, and

unemployed. They have varying signs and symptoms experienced before, during, and

after hemodialysis with acceptable results of hemoglobin, potassium and creatinine

results intended for CKD patients. Though the activities of daily living of most

Hemodialysis Patients was assessed as good, some of the patients are already having

difficulties and are becoming dependent. Socio-demographic factors do not significantly

affect the activities of daily living of Hemodialysis Patients. Clinical factors significantly

do not significantly affect the activities of daily living of Hemodialysis Patients. A

number of implications may be considered by the hospital and its health care providers to

give holistic care to hemodialysis patients to aid in their activities of daily living.

iv
 Table of Contents

Page
List of Tables ……………………………………………………………………. vii
List of Figures …………………………………………………………………… viii
List of Appendices ………………………………………………………………. ix

Chapter 1: The Problem and Its Background

Introduction …………………………………………………………....... 1
Social-demographic Characteristics of Hemodialysis Patients………….. 3
Clinical Factors of Hemodialysis Patients ……………..………………... 5
Activities of Daily Living of Hemodialysis Patients ……………………. 11
Significance of the Study ……………………………………………….. 22
Theoretical/Conceptual Framework ………………….…………………. 23
Statement of the Problem ……………………………………………….. 26
Hypotheses of the Study…………………………………………………. 27
Definition of Terms ……………………………………………………... 28
Scope and Delimitation of the Study………..………….……………….. 30

Chapter 2: Methodology of the Study

Methods and Techniques Used …………………………………………. 32

Respondents of the Study……………………………………………....... 33
Instruments of the Study………………………………………………… 34
Data Gathering Procedure………………………………..……………… 37
Data Processing and Statistical Treatment………...…………………...... 37

Chapter 3: Presentation, Analysis, and Interpretation of Data

Socio-Demographic Factors of Hemodialysis Patients…………………. 39

Clinical Characteristics of Hemodialysis Patients ….…………………… 45
Activities of Daily Living of Hemodialysis Patients………………….. 54
Effects of Socio-Demographic and Clinical Characteristics on the
Activities of Daily Living……………………………………………….. 57
Nursing Implications Drawn from the Findings of the Study…………… 61

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Chapter 4: Summary, Conclusions and Recommendations

Summary of Findings…………………………………………………..... 63
Conclusions……………………………………………………………… 66
Recommendations……………………………………………………….. 68

References….………...………………………………………………………….. 69

Appendices……….……………………………………………………………… 79

Curriculum Vitae…………………..…………………………………………… 90

vi
 List of Tables

Page

1 Respondents of The Study………………………………………………... 33

2 Socio-Demographic Profile in terms of Age……………………………… 39
3 Socio-demographic Profile in terms of Civil Status ……………………... 41
4 Socio-demographic Profile in terms of Years of Hemodialysis Treatment 42
5 Socio-demographic Profile in terms of Number of Household Companions 43
Aged 18 and above …………………………………………
6 Socio-Demographic Profile in terms of Occupation……………………… 44
7 Clinical Profile in terms of Primary Disease Related to Chronic Kidney
Disease……………………………………………...…………………….. 45
8 Clinical Profile in terms of Access used during Hemodialysis ……… 48
9 Clinical Profile in terms of symptoms associated with Chronic Kidney 49
Disease- Current Physical State ……………..
10 Clinical Profile in terms of symptoms associated with Chronic Kidney 49
Disease- BEFORE hemodialysis ………………
11 Clinical Profile in terms of symptoms associated with Chronic Kidney 51
Disease- DURING AND AFTER hemodialysis
12 Clinical Profile in terms of Laboratory Result- Hemoglobin……….. 52
13 Clinical Profile in terms of Laboratory Result- Creatinine …………… 52
14 Clinical Profile in terms of Laboratory Result- Potassium………….. 54
15 Basic Activities of Daily Living…………………………………………… 54
16 Instrumental Activities of Daily Living…………………………………… 55
17 Composite Table of the Significant Relationship Between Socio
Demographic Profile and Activities of Daily Living and Instrumental
Activities of daily living of hemodialysis patients using Spearman’s rho
correlation analysis………………………………………………………… 58
18 Composite Table of the Significant Relationship Between Clinical
Characteristics and Activities of Daily Living and Instrumental Activities
of daily living of hemodialysis patients using Spearman’s rho correlation
analysis……………………………………………………………………... 60

vii
 List of Figure

Page

1 Diagram of the Roper-Logan Theory-Tierney Model of Nursing 24

Based on Activities of Living …………………………………...

2 Conceptual Model of the Study…………………………………. 26

viii
 List of Appendices

Page

A Permission Letter……………………………………………….. 79
B Letter to Respondents…………………………………………… 80
C Informed Consent……………………………………………….. 81
D Instrument of the Study…………………………………………. 83
E. Research Budget Proposal………………………………………. 89
F. Curriculum Vitae………………………………………………... 90

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 Chapter 1

The Problem and Its Background

Introduction

Chronic kidney disease (CKD)—or chronic renal failure (CRF)- is a term that

includes all levels of decreased renal function, from damaged–at risk through mild,

moderate, and severe chronic kidney failure. Patients with renal failure will show signs of

decreasing kidney function in the late stage (Stage 5) of Chronic Kidney Disease,

including peripheral edema, pulmonary edema, and hypertension. Most of these patients

experience anemia and may experience fatigue, reduced exercise capacity, impaired

cognitive and immune function. According to Arora (2020), Chronic Kidney Disease

occurs worldwide, and mostly the elderly are being affected. However, most younger

patients are now being diagnosed and staged accordingly. 30% of patients over 65 years

of age of those with kidney disease mostly have an increased risk of cardiovascular

disease and end-stage renal disease (ESRD). In the United States, it is the 9 th most fatal

disease. In the Philippines, according to the latest WHO data published in 2017, deaths

that are due to kidney failure have reached 22,772 or 3.68% of total deaths.

With the occurrence of such signs and symptoms, if not intervened immediately,

patients with Chronic Kidney Disease, therefore, will have an increased chance of

reduced quality of life, development of cardiovascular disease, new onset of heart failure,

or the result of more severe heart failure and Increased cardiovascular mortality (Arora,

1
2020). These risk factors contributes to the ability to perform activities of daily living

within these patients.

Patients undergoing hemodialysis with Chronic Kidney Disease have difficulty

performing activities of daily living compared to those who do not have this ailment.

Activities of daily living, when done with difficulty, is an early predictor of loss of

independence and mortality in older community-living people. However, determinants of

ADL difficulty in HD patients have not been clarified (Kindly Care, n.d.) Furthermore,

Not much information is known on the functional status of patients

receiving hemodialysis from developing countries where the cause of Chronic Kidney

Disease and demographic profile varies according to Viswanath., Kumar, Haridasan, and

Parameswaran (2019). Only few studies have been conducted in the Philippines which

indicates the need for further research in the country,

This study aims to explore further knowledge by studying the patients receiving

hemodialysis treatment – their demographic data, their cinical characteristics and how

can these factors affect their basic and instrumental activities of daily living. Upon

learning these factors, health care providers may be able to provide inetrventions to

prevent further deterioration, morbidity, and death among these patients. This study also

aims that further studies may be reproduced with the outcome of this research since few

researches about Chronic Kidney Disease and Hemodialysis Patients were conducted in

the country.

2
REVIEW OF RELATED LITERATURE

Socio Demographic Factors of Hemodialysis Patients

Torino (2018) states that the physical function is the highest predictor of power of

patients with deteriorating disease. Its forecast value can define what is can happen in

very old dialysis patients. Old patients with Chronic Kidney Disease represent a likely

course of decreasing physical function in comparison with younger patients. Quality of

life, in his study, was measured by the Rand- QoL Short Form 36 questionnaires in a

multi-center, perspective cohort study including 253 very old patients above 75 years old

in long term dialysis.

Viswanath., Kumar, Haridasan, and Parameswaran (2019) measured functional

status using three generic tools -- Functional Independence Measure (FIM) (scores 18-

126), Seven domains and five levels (7D5L) (scores 0-28),

and Activities of Daily Living Questionnaire (ADLQ) (scores 0-6) scales. In their study,

results showed that more than 80% showed full functional independence with ADLQ

instrument.

Hall and McAdams-De Marco (2018) stated that one third of patients in dialysis

in the United States is composed of the elderly and as the years progress. This number,

according to him, will continue to increase in time. Most of these patients will experience

3
more symptoms and sickness and even death than those in dialysis in the younger groups.

The decrease of progressive functions is shown by need for assistance with more than

two activities of daily living, contributes to risk of hospitalization, further functional

decline, and subsequent nursing home placement when a patient can no longer do

activities for himself alone.

Ulutas and Farragher (2018) studied older adults that is on Peritoneal Dialysis

using Barthel and Lawton Scales as their instruments in their study to determine the

relationship between disability to demographics, clinical characteristics, and physical

performance. In their study, 162 participants, mostly male, at around 75 years old of age,

8 had no disability, 69 had only instrumental dependence, and 85 had combined

disability. Those who needed multiple prescription drug needs, poor timing in 'up-and-go'

mobility performance, and education level were associated with the need for further

assistance. The study shows that the inability to do self-care is common among older

patients on hemodialysis. As a result of this study, it was then concluded that thorough

planning is needed to routinely identify those older dialysis patients at risk of functional

impairment and to prevent further injuries.

In another study, basic tools to assess and study the sociodemographic

characteristics, neurosensory deficits, pain, falls, polypharmacy,

basic activities of daily living capabilities of patients 70 years old above were used during

the interview - The Timed Up and Go, Nutritional Health Checklist, Two Question

Instrument for depression and Charlson comorbidity index (CCI). Results showed that

4
these patients had significantly worst ADL score, reported more frequent falls, depression

and impaired vision than younger patients. (Račić, Petković , & Koviljka, p. 2017)

In the Philippines, one Filipino develops Chronic Kidney Disease every hour or

about 120 Filipinos per million population per year according to the National Kidney and

Transplant Institute. In the Philippines, there are more than 5,000 dialysis patients and

around 1.1 million people are on renal replacement therapy around the globe. In the

province of Bulacan, most specifically in Bulacan Medical Center, the total number of

patients in maintenance Hemodialysis is 163 (February 2021).

Clinical Factors of Hemodialysis Patients

The current access used for dialysis may also interfere with their daily activities.

A study by Robbins (2018) discusses the influence of arteriovenous fistula's effects on

activities of daily living using an open answer questionnaire to describe behaviors that

was changed while on hemodialysis. Limited movements of their arms and shoulders due

to AV fistula has decreased their ability to do routine activities by themselves.

Adib-hajbagheri (2018) used questionnaires and three kinds of checklists. This

research aims to assess the effects of the complications of vascular access to the self care

needs of hemodialysis patients. The studied concluded that Nurses and their skills are

related with the complications associated with vascular access problems and the effects

on the activties of daily living of hemodialysis patients.

According to the study of Morishita (2017) body function is related with death in

patients with Chronic Kidney Disease in dialysis. When there is an increase in activities,

5
according to the authors, there is a decrease chanced of death. The health care team

should be able to assess the functions of their patients undergoing dialysis. In addition,

exercise is related with reduced mortality among patients with CKD and dialysis.

Prolonged ICU stay with mechanical ventilation and resuscitation will increase

the chance of body deterioration in Chronic Kidney Disease patients. This was found

during the study of Kuwabara et al (2017) using the Japanese administrative database

including the Barthel Index at admission and discharge. Health care workers, according

to their study, should be aware of the effects of critical care procedures on functional

deterioration and advance the appropriate use of functional support according to each

patient's condition.

A recent study (Oh 2019), the factors of cognitive impairment in patients with

Chronic Kidney Disease on hemodialysis were reviewed and identified. The study used

primarily nonexperimental correlational studies and studies with experimental, quasi‐

experimental, or pre–post cohort designs. Age, gender, stroke history, difficulties

in activities of daily life, hemoglobin levels, pain, sleep difficulties, and depression were

found to be important factors of cognitive impairment. Nurses should be aware that the

risk of cognitive impairment in patients with Chronic Kidney Disease

on hemodialysis can be significantly higher for elders, women and in patients with

history of stroke, increased difficulties in activities of daily living, lower hemoglobin

concentrations, higher pain levels, sleep difficulties, or depression.

6
 A study by Reboredo (2018) discussed the different factors can contribute to a

sedentary lifestyle among hemodialysis patients, including the period they spend on

dialysis. Dialysis patients were evaluated using the DynaPort accelerometer and

compared to nineteen control individuals, regarding the time spent in

different activities and positions of daily life and the number of steps taken. The patient's

Hemoglobin results, lower extremity muscle function, and physical strength of SF-36

questionnaire affects the walking time and active time. Looking accurately at the patterns

of activity in daily life, dialysis patients are more sedentary, especially on dialysis days.

These patients should be encouraged to enhance the physical activity.

In South Korea, Yeung (2017) made a study that used a Descriptive Survey in

hemodialysis patients. They also completed self‐administered questionnaires of Dialysis

Symptom Index and Kidney Disease Quality of Life Instrument‐Short Form. The results

of this study may further address the symptoms experienced by hemodialysis patients.

They also provide basic information for developing nursing interventions to manage

these symptoms and improve the quality of life of these patients.

Johansen (2018) studied about the prevalence of frailty among Chronic Kidney

Disease patients and have found frailty to be more common among individuals with CKD

than among those without. Studies have shown that frail patients are started dialysis

earlier at a higher estimated glomerular filtration rate on average than non-frail patients,

7
but it studies will still have to be made if whether these patients' frailty is a result of

uremia or is independent of CKD.

The aim of the study by Ortega-Pérez de Villar (2018) is to assess the relative and

absolute reliability of the Short Physical Performance Battery (SPPB), One-Legged

Stance Test (OLST), and Timed Up and Go (TUG) test, as well as the minimal detectable

change (MDC) scores for these tests in Chronic Kidney Disease patients on maintenance

dialysis. The MDC data generated by these tests can be used to assess changes in the

capability of patients to do ADL.

A study by Segura, Gordon, Doyle, and Johansen (2018) determined the extent to

which poor physical functioning, low participation in physical activity, and muscle

atrophy observed among patients on hemodialysis are evident in the earlier stages of

chronic kidney disease. It is then concluded that interventions aimed to increase muscle

mass and energy expenditure might have an impact on improving physical function of

CKD patients.

Bossola (2017) did a study in which results showed that patients with Post

Dialysis Fatigue (PDF) were older and has a lower ADL score and dialytic variables

seem unrelated to PDF. Two tools that were identified due to their simplicity are the

Fatigue Severity Scale (FSS) and the Functional Assessment of Chronic Illness Therapy-

Fatigue (FACIT-Fatigue). They both also demonstrated the ability to measure how

fatigue impacts patients. This measures a patient's fatigue over the previous week and the

8
lower the score the higher the level of fatigue. Both of these tools can assist the health

care team to identify what their patients are experiencing as a result of fatigue and how

they can help their patients best manage their fatigue. It is included in the study that while

managing fatigue in hemodialysis patients can be a challenge, nurses have the ability to

influence their patients on how to best manage their fatigue.

Recognizing that a patient as "frail" may be useful in assessing the prognosis and

therapeutic approach (Fredzzia 2017). In his study, a total of 320 patients with stage V

chronic kidney disease who were on hemodialysis between September 2014 and

September 2015 was analyzed using the Fried phenotype model resulting in 5.6% of the

study population were frail, with lower BMI, serum albumin, and hemoglobin, lower

capabilities for basic activities of daily living, ambulation, and transference, as well as

high morbidity and mortality.

Seung (2017) compared overall physical function, including gait speed and

peripheral nerve function, between diabetic chronic kidney disease (CKD) patients and

nondiabetic CKD patients and to investigate the association between walking speed and

peripheral neural function in CKD patients. The study found out that In CKD patients

with maintenance HD, their gait speed, sensory functions, and peripheral nerve functions

were all significantly impaired when they have diabetes, and the severity of PN

(Peripheral Neuropathy) was negatively correlated with their gait speed, sensory function,

and ADL function. The complications of diabetes impacted physical performance of

9
CKD patients. The physical disability of those patients may also be a result of peripheral

neuropathy.

Horigan (2018) explained that there are a number of causes for fatigue which

include anemia, uremia, malnutrition, poor dialysis, insomnia, and inflammatory

response. Fatigue, in CKD patients, according to the author, is a common and

debilitating symptom for adult patients with end stage renal disease on hemodialysis and

has been associated with decreased survival and quality of life. 

A study by Bossola, Di Stasio, Giungi, and Tazza (2019) states the relationship of

activated immune-inflammatory pathways and interleukin-6 (IL-6) in the development of

fatigue and/or depression in patients with end-stage renal disease on hemodialysis. The

study used the Beck Depression Inventory (BDI), the Hamilton Anxiety Rating Scale

(HARS), the Mini-Mental State Examination (MMSE), the activities of daily

living (ADL), and the instrumental activities of daily living (IADL). It revealed that

fatigue correlates with symptoms of depression and serum IL-6 levels in patients

receiving chronic dialysis.

Patients with Sarcopenia with Chronic Kidney Disease were studied by Souza, V.

in 2017. In her study, Sarcopenia was defined using the criteria of the European Working

Group on Sarcopenia in Older People (EWGSOP) and of the Foundation for the National

Institutes of Health (FNIH) Sarcopenia Project. Sociodemographic data, clinical

characteristics, the ability to do activities of daily living, functional capacity, and

10
physical activity were also evaluated. It is concluded in this study that Sarcopenia is

common in patients with Chronic Kidney Disease, particularly in the most advanced

stages of the disease. The author observed an association between the levels of

inflammatory markers and peripheral lean body mass, physical performance, and BMI.

This relationship between sarcopenia and the dependent factors determines the

importance of early diagnosis and the implementation of therapeutic measures to

minimize adverse outcomes in patients with CKD.

In a study by Yazawa (2018), he used the Japanese National Registry data in 2007

to determine if health conditions such as functional status (FS) at initiation of dialysis

influence prognosis. There are different levels of functional disability, according to the

author: severe (bedridden), moderate (overt difficulties in exerting

basic activities of daily living), or mild/none (none or some functional disabilities). It is

concluded in the study that early death after starting dialysis was relatively common,

especially among the elderly, even in Japanese patients. Mortality was significantly

associated with impaired FS at initiation of HD.

Activities of Daily Living of Hemodialysis Patients

Needing assistance with activities of daily living is an early indicator of functional

decline and has important implications for individuals' quality of life according to Kutner,

Xhang, Allman, and Bowling (2017). A multicenter cohort of 742 prevalent dialysis

11
patients was assessed in 2009-2011 and classified as frail, prefrail and nonfragile by the

Fried frailty index (recent unintentional weight loss, fatigue, lower arm weakness, slow

walk speed, low physical activity). While increasing the number of physical activity that

might delay or reverse the process of frailty, the immediate symptoms/conditions to

which individuals attribute their ADL difficulty may have clinical relevance for

developing targeted management and/or treatment approaches.

A study by Caltabiano and Bonner (2018) revealed that renal nurses are ideally

positioned to engage in early identification and regular monitoring of both fatigue

and activity levels in people with chronic kidney disease. Individual care plans can be

developed to incorporate supportive rehabilitative strategies which aim to reduce fatigue

and maximize activity level using a sample of 112 people who completed the fatigue

severity scale and Human Activity Profile Scale.

Mollaoglu (2017) wrote a study to assess patients'

disability, activities of daily living and self-efficacy in patients with Chronic Kidney

Disease undergoing hemodialysis to study the relationship between them. The study

results demonstrate that while there is a relationship between self-care ability and age,

education level, marital status and additional health problems, factors such as age,

gender, education attainment, job employment, income, social insurance status and

frequency of hemodialysis application determine self-efficacy. The author used these

instruments: Personal Information Form, Brief Disability Questionnaire,

12
Katz's Activities of Daily Living Index and Lawton and Brody's

Instrumental Activities of Daily Living Index and Self-efficacy Assessment Form.

A study by Han, Ye, Preciado, and Williams (2018) explored the association

between neighborhood walkability and daily steps in hemodialysis patients. This was first

studied among dialysis patients to indicate a direct relationship between neighborhood

walkability and the actual steps taken. The findings of this study should be considered

when designing initiatives to increase and improvise exercise routines in dialysis

populations.

Clarkson, Bennet, Fraser, and Warmington, (2019) wrote a study to determine

whether exercise programs improve objective measures of physical function indicative

of activities of daily living for patients with end-stage kidney disease on dialysis. From

the results given, physical activity, regardless of the method, improved objective

measures of physical function for end-stage kidney disease patients undergoing dialysis.

Erdly-Kass, Kass, Gellis, Bogner, Berger, and Perkins (2018) did a study to

determine the effectiveness of Problem-Solving Therapy (PST) in

older hemodialysis (HD) patients by assessing changes in health-related quality of life

and problem-solving skills where 33 HD patients received PST from a licensed social

worker for 6 weeks. Results showed PST is an effective, efficient, and easy to implement

intervention that can benefit problem-solving abilities and mental health-related quality

13
of life in older HD patients. The results may help patients manage

their daily living activities related to their medical condition and reduce daily stressors.

Painter and Marcus (2018) concluded that Gait speed is low in patients with CKD,

and those treated with hemodialysis average below cut-points known to indicate

increased risk of reduced survival and adverse health events. The level of measurements

of walking speed in patients with CKD may be valuable in identifying those at risk for

adverse events, including disability and mortality.

In the article by Canaud (2019) discusses issues related to Renal Replacement

Therapy by hemodialysis is a life sustaining treatment and maintaining daily activities of

living. The healthcare workers, according to him, must have not only better

understanding of uremic pathophysiology, improvement in dialysis tolerance, and better

management of anemia and other comorbidities but also understanding of appropriate

care of patients with end-stage renal disease alongside with their quality of life.

Procópio (2019) showed that fatigue is directly related to the level

of activities of daily living, causing less ability to perform activities in the higher level of

fatigue, after the operation and procedures and only settling fully on the 9th postoperative

day. The studied used descriptive statistical analysis.

14
 Song, Mi-Kyung, Ward, Sandra, Bair, Eric, Weiner, Lia, Bridgman, Jessica,

Hadik, Gerald, Gilet, and Constance (2018) used telephone-based neuropsychological

battery that is a Brief Test of Adult Cognition by Telephone, a measure of objective

cognitive functioning or a measure of subjective cognitive functioning and measures of

everyday functioning on135 patients. The results showed the potential clinical value of

subjective measures of cognitive functioning, not to replace objective measures or

diagnostic tests, but rather to optimize the meaningfulness of clinical assessment and

management

A study by Saby (2018) believed that functional impairments can be addressed

with referrals to physical therapy for gross motor issues, occupational therapy for self-

care problems, psychiatry for mental disorders, and neurology for cognitive deficits. The

more accurate the assessments over time, the more targeted and effective the therapies

become. According to him, proper assessment can address impairments that can identify

the needs suitable for each patient.

Liu (2017) made a study that showed that the prevalence of depressive symptoms

among hemodialysis patients was 29.1%. Patients with a depressed mood have lower

physical function and quality of life than patients with better mood which also have less

social support than patients with better mood, including both family support and outside

family support.

15
 Rambod (2018) used also the Instrumental Daily Living Activity scale in both

groups (Control Group and Relaxation Group) as baseline at 8 weeks. The results of the

study suggest good outcomes of Benson's relaxation technique on the improvement of

physical activity in hemodialysis patients. The results of his study showed that teaching

relaxation techniques could serve as a resource for improving the levels of

physical activity.

Shaoqing (2018) used randomized controlled trial to select participants and were

instructed to perform auricular acupressure 3-5 times per day for 3 months. Participants

in the control group received the regular treatments only. Diabetic patients with chronic

kidney diseases receiving hemodialysis tolerated Auricular acupressure. Future research

is needed to confirm these results.

Mendonça, Antera, Aparecido , Marques, and Kusumota (2017) made a study that

describes and analyzed the functional independence of the patients served in

the hemodialysis services of a countryside town in the State of Sâo Paulo, Brazil, using

the Functional Independence Measure (FIM). The study concluded that the awareness of

the level of functional independence of the patients being subjected to hemodialysis is

necessary in order to back up necessary interventions for the enhancement of nursing

assistance provided to this population.

16
 Fiaccadori, Enrico, Sabatino, Alice, Schito, Franco, Angela, Francesca, Malagoli,

Martina, Tucci, Marco, Cupisti, Adamasco, Capitanini and Regolisti (2018) made a study

in an Italian Dialysis Facility that identified a number of barriers that is patient-related

and health personnel-related to physical activity in patients on hemodialysis. Future

studies should address these barriers and should aim at increasing the level of

physical activity in this population. The study used different questionnaires exploring

participation in physical activity, physical functioning, patient attitudes and preferences,

and barriers to physical activity perceived by either patients or dialysis doctors and

nurses.

Turgay (2017) made a study and the data was collected using instruments such as

the Patient Identification Form, the Katz ADL Scale, Lawton and Brody

Instrumental ADL Scale, Brief Disability Questionnaire, Charlson Comorbidity Score

and Beck Depression Inventory. The patients were categorized into two groups: the 50-64

years age group and the 65-plus age group. His study concluded that slow walking speed

and age are associated with activities of daily living in dialysis patients who can walk.

This can also be associated with patients' depressive symptoms.

Kalfoss, Schick-Makaroff, and Molzahn, (2019) explored how illness perceptions,

specifically intrusiveness, impact individuals with chronic kidney disease living with

dialysis therapy and kidney transplants, and to determine the relationships among their

perception of their illness, symptoms, dealing with sickness, and quality of life (QoL). As

17
health workers, according to the author, they can solve symptom burdens and help with

coping strategies to enhance quality of life.

DePasquale (2019) wrote a study to understand the process of illness of an adult

person with terminal renal disease in dialysis and their families. The correlations of

alterity, commitment, respect and concern were established between researchers and

researched, allowing a deep understanding of the dimensions that make up the experience

of becoming ill, especially the relationship with the family of the patient that needs the

care. The study used an analytical approach with stratified focus groups comprising of 49

family members of dialysis patients.

Jonasson (2017) made a study about the experience of patients living with

hemodialysis. Adjustments in their daily lives that patients may experience because

of hemodialysis are major and also essential so they can stay alive. The main objective of

this research was to describe changes in life for patients with renal failure

undergoing hemodialysis. The study used a qualitative descriptive with a qualitative

research content analysis based on in-depth interviews with patients

undergoing hemodialysis. Results show that life in hemodialysis is will mean that the

patient will have to adjust to the new life, and the new life moving towards reconciliation.

The results of this study shows that support towards reconciliation is crucial for patient

health.

18
 Watanabe (2018) demonstrated that patients who undergo hemodialysis encounter

challenges including role changes, physical degeneration, and difficulty in

performing activities of daily living and self-care. High resilience and social support can

alleviate stress and depression. This study evaluated the importance of high resilience and

social support in managing depression in elderly patients undergoing

maintenance hemodialysis.

Painter (2018) revealed that greater effort to incorporate education and motivation

into the routine care is warranted to increase physical activity to levels that may result in

health benefits. 1323 respondents used questionnaires on which 57% of respondents

reported participation in regular physical activity; however, only 13.2% achieved

recommended levels based on frequency, duration, and intensity. The primary reasons for

no physical activity were "too tired" and "not motivated."

A study by Kavanagh, Schiller, Saxena, Thomas, and, Kurella (2017) discussed

about Functional dependence as an important determinant of longevity and quality of life.

Using validated questionnaires, it is revealed that no significant association between

demographic characteristics, chronic health conditions, depressive symptoms or

laboratory measurements, and functional dependence. Difficulty in physical function was

more strongly associated with functional dependence than memory impairment.

Functional dependence is common among Chronic Kidney Disease patients and

independently associated with stroke, systolic blood pressure, and executive function

impairment.

19
 A study by Orcy, Dias, Sues, Barcellos, and Bohlke, (2017) revealed that Chronic

Kidney Disease patients that uses the combination of aerobic and resistance training was

more effective than resistance training alone to improve functional performance. It used a

randomized controlled trial in a Brazilian university hospital that used combined

resistance and aerobic exercise training alone to improve functional performance

of hemodialysis patients.

Pakpour, Zeidi, Chatzisarantis, Molsted, Harrison and Plotnikoff (2017) assessed

physical activity using a validated International Physical Activity Questionnaire self-

report measure at 4 weeks. The results suggest the combination of high levels of coping

planning and intention is associated with increases in physical activity.

Ferreira Silva (2018) made a study to understand how the person with Chronic

Kidney Disease realizes how the disease may affect himself. It is a descriptive type of

research with a qualitative approach that used Grounded Theory as a methodological

reference. Data were collected with 14 Chronic Kidney Disease patients through semi-

structured interviews. The author concluded that the patients perceive several changes

after the disease and his treatment is positive when faced sees it as a way of maintaining

life, but they see it as undesirable when there are feelings of need

on hemodialysis machine and limitations.

20
 Baser (2019) studied the how hemodialysis patient education program can affect

fluid control and dietary compliance. According to him, some hemodialysis patients may

experience problems in completing activities of daily living and adhering to diet and fluid

restrictions due to a decrease in self‐care power and a loss of competence. This was the

result of the study using the "Education Book for Dialysis Patients- The effect of a

hemodialysis patient education program on fluid control and dietary compliance".

Soriano (2019) selected his participants using a convenience sampling and used a

descriptive cross-sectional research as the design. The researcher was able to utilized two

instrumental tools which include Kidney-Disease Quality of Life-36 SF Filipino Version

to determine the quality of life of Chronic Kidney Disease patients and Beck's Depression

Inventory-Filipino Version to determine the level of depression among these patients.

The study concluded that younger patients with CKD have a higher level of physical

functioning as compared to older patients. He concluded that CKD patients with a higher

quality of life have a lower level of depression.

The study will be conducted in a tertiary government hospital in Bulacan which

has a 40 machine capacity in its Hemodialysis Unit. It operates from Monday to Saturday

with three shifts- 8 am, 1 pm, and 5 pm. It currently has 163 maintenance hemodialysis

patients ranging from 15-80 years old.

21
 This study aims to identify factors associated with ADL difficulty in ambulatory

HD patients in in a tertiary government hospital in Bulacan. Since there are a few studies

made that are conducted in the Philippines about hemodialysis patients, this study aims to

further discuss common problems that they experience, and in this case, the factors that

contribute to their performance in activities of daily living.

Significance of the Study

The findings may provide information beneficial to the following individuals:

Nursing Service. The Hemodialysis Unit in which the study was conducted caters

mostly indigent patients with financial limitations. The patients are supported under the

project of the Local Government Unit. The results of the study may be able to help the

nursing service department to produce more assistance projects and review policies that

will support those undergoing hemodialysis unit to cope up with their daily life in spite of

difficulties in performing activities of daily living.

Nursing Education. This study will be able to teach nursing students, nursing

practitioners, up to nursing that are taking up graduate studies to further care for and

understand hemodialysis patients. This will make the nurses understand the factors that

affect the patient's activity of daily living so that it will help them in their nursing care

22
plan, scheduling patient's treatment properly, counsel properly and aid them in

conducting their activities of daily living,

Nursing Research. This research may be able to guide future researchers to

explore other studies related to the results of this study. This will further enhance and

explore scientific data in the future related to the care of hemodialysis patients since there

are few studies related to this study conducted in the Philippines.

Hemodialysis Patients. The results of this study will also be most favorable to

the patients on hemodialysis so that further studies and methodologies may be conducted

to help them cope thru the activities of daily living whilst on hemodialysis. More holistic

care will be provided for them by fully understanding not only their clinical but also their

daily living needs.

Theoretical/Conceptual Framework

In 2017, the Department of Health, thru the Philippine Renal Registry reported

that 21, 535 Filipino CKD patients are under dialysis treatment.

A theory of nursing about activities of daily living of patients called Roper-

Logan-Tierney's Model is studied to assess and help patients with deteriorating sickness

throughout their care (Williams, 2015). It has been used as a guide in the United

Kingdom to assess and check how the life of patients has been changed due to illness,

injury, or admission to an institutionalized care rather than as a way of planning for

increasing independence and quality of life.

23
 According to Williams (2015), the Roper-Logan-Tierney theory serves as a guide

to fulfill holistic care as a basis to do nursing plan. This includes planning for patient care

and assistance that will help patients in their functional deficits. It aims to individualize

nursing care to plan care for patients who needs assistance in their activities of daily

living.

Lifespan Individuality in Living

12 Activities of Living (ALs)
Maintaining a safe
environment
Communicating
Breathing
Biological Eating food and drinking
fluids
Eliminating body wastes
Psychological Personal Cleaning and
dressing
Maintaining body
Sociocultural temperature
Mobilizing
Working and Playing
Expressing sexuality
Environmental Sleeping
Dying

Politico- Economic

24
 Figure 1. Diagram of the Roper-Logan Theory-Tierney Model of Nursing

Based on Activities of Living (Fawcett, 2020)

Figure 2 presents the conceptual model of the study that was utilized in evaluating

the effects of socio-demographic and clinical factors of hemodialysis patients at Bulacan

Medical Center on their activities of daily living

Socio-demographic factors of hemodialysis patients of this tertiary government

hospital in Bulacan refer to the patients' age, sex, years of dialysis treatment, marital

status, occupation, and number of companions. Meanwhile, clinical factors of

hemodialysis patients of this tertiary government hospital in Bulacan refer to the primary

disease related to Chronic Kidney Disease, general condition of patient, access used

during dialysis, complications during dialysis, symptoms associated with CKD V, and

laboratory results

The activities of daily living of Hemodialysis Patients refers to the patients' basic

activities of daily living and instrumental activities of daily living.

Finally, the nursing management implications includes nursing care plans,

procedures, policies that will be further derived from this study.

Demographic
Characteristics:
 Age
 Sex
 Years of Dialysis
 Marital Status
Activities of Daily
 Occupation
Living
 Number of
 Basic Nursing
Companions
Activities of Management
Daily Living Implications
 Instrumental
Clinical Characteristics
Activities of
 Primary Disease
25 Daily Living
related to Chronic
Kidney Disease
 General Condition
of the patient
 Figure 2. Conceptual Model of the Study

Using the Roper-Logan Theory-Tierney theory, this conceptual model was

formulated so that the study may assess the general ability of the patient to assess their

ability to perform activities of daily living that will further contribute to their quality of

life and sense of well-being. With the assessment that will be derived from this study,

nursing interventions will be planned to aid patients in their performance of activities of

daily living.

Statement of the Problem

The major concern of the study is to assess the demographic profile and clinical

characteristics affecting the activities of daily living of hemodialysis patients at a tertiary

government hospital in Bulacan. Specifically, this study seeks to answer the following

questions:

1. What is the demographic profile of hemodialysis patients in terms of:

1.1 Age

1.2 Sex

26
 1.3 Years of Dialysis

1.4 Marital Status

1.5 Occupation

1.6 Number of Companions?

2. What are the clinical characteristics of hemodialysis patients in terms of:

2.1 Primary Disease related to Chronic Kidney Disease

2.2 General Condition of Patient

2.3 Access used during dialysis (Fistula/Catheters)

2.4 Symptoms associated with CKD V

2.5 Complications during dialysis

2.6 Laboratory Results (CBC, Creatinine)?

3. What is the level of Activities of daily living of hemodialysis patients in terms of:

3.1 Basic Activities of Daily Living

3.2 Instrumental Activities of Daily Living?

4. Is there a significant correlation between the socio-demographic profiles and

activities of daily living hemodialysis patients in a tertiary government hospital in

Bulacan?

5. Is there a significant correlation between the clinical characteristics and activities

of daily living hemodialysis patients in a tertiary government hospital in Bulacan?

6. What nursing management implications may be drawn from the findings of the

study?

Hypotheses of the Study

27
 "There is no significant relationship between the socio-demographic profile and

the activities of daily living of hemodialysis patients in a tertiary government hospital in

Bulacan"

"There is no significant relationship between the clinical characteristics and the

activities of daily living of hemodialysis patients in a tertiary government hospital in

Bulacan"

Definition of Terms

The following terms were defined for common understanding:

1. Activities of daily living (ADLs)

Conceptual Definition - Activities of daily living (ADLs) according to Kindly

Care, n.d. are basic tasks that must be accomplished every day for any person to

survive.

Operational Definition -In this study, Activities of Daily Living refers to

people's daily self-care activities of hemodialysis patients and was categorized to

basic activities of daily living and instrumental activities of daily living.

2. Basic ADL

28
 Conceptual Definition -- Generally are categorized into the following: bathing,

dressing, toileting, transferring, continence, and feeding.

Operational Definition - the respondents’ daily self-care activities and is

measured using Katz scale of activities of daily living,

3. Hemodialysis

Conceptual Definition - refers to the treatment received by the respondents to

filter wastes and water from your blood, as your kidneys did when they were

healthy. Hemodialysis helps control blood pressure and balance important

minerals, such as potassium, sodium, and calcium, in your blood.

Operational Definition - the treatment received by the respondents two to three

times a week for their Chronic Kidney Disease which may affect their activities of

daily living.

4. Instrumental Activities of Daily living (IADLs)

Conceptual Definition - are other task other than the ADLs that is also needed to

fulfill daily activities. IADLs include securing assistance for: companionship and

mental support, transportation and shopping, preparing meals, managing a person's

household, managing medications, communicating with others, and managing

finances.

29
 Operational Definition - are the activities done by hemodialysis patients not

necessary for fundamental functioning, but they let an individual live independently

in a community and was measured by Lawton- Brody Activities of Daily Living

Scale.

Scope and Delimitation of the Study

This study focused on the assessment of the socio-demographic profile and

clinical factors affecting the activities of daily living of hemodialysis patients in a tertiary

government hospital in Bulacan. Socio-demographic factors of hemodialysis patients

refer to the patients' age, sex, years of dialysis, marital status, occupation and number of

companions.

Meanwhile, clinical factors of hemodialysis patients refer to primary disease

related to Chronic Kidney Disease, general condition of patient, access used during

dialysis (Fistula/Catheters), symptoms associated with CKD V, complications during

dialysis, and laboratory results (CBC, Creatinine, etc.).

The activities of daily living of hemodialysis patients in a tertiary government

hospital in Bulacan refers to Basic Activities of Daily Living and Instrumental Activities

of Daily Living

The respondents of the study consisted of one hundred maintenance hemodialysis

patients.

30
Inclusion criteria: Regular Out Patient Hemodialysis Patients from 2012 to present based

on their dialysis treatment records. Included are all patients that are receiving regular

sessions regardless if two or three times a week. The researcher sought permission from

the Chief Nurse to access the records of hemodialysis clients. List of names of clients

were created by the researcher.

Exclusion criteria: Those who are admitted in the institution and not yet on regular

schedule in the hemodialysis unit. Other out patient who are not receiving hemodialysis

treatment will also be excluded from the study.

The gathering of data observed the Republic Act No. 10178 or the Data Privacy

Act of 2012, that allows the researcher to process any data from the respondents, while

observing proper gathering and processing of data with consent and agreement between

two entities.

31
 Chapter 2

Methodology of the Study

This chapter presents the method and techniques, respondents of the study,

instrument of the study, and the data processing and statistical treatment that will be

applied.

Method and Techniques Used

The descriptive-correlational method of research was utilized in the study to

determine the relationship between socio-demographic and clinical factors on the

activities of daily living of hemodialysis patients in a tertiary government hospital in

Bulacan. A correlational research systematically investigates the relationship among

variables as well as in determining the cause and effect relationship. The study used

32
quantitative research approach in analyzing and understanding the satisfaction and

achievement variables.

Standardized questionnaire on socio-demographic and clinical factors as well as

the activities of daily living of hemodialysis patients in a tertiary government hospital in

Bulacan was utilized as primary data gathering tool.

Respondents of the Study

Age Group Population

Ages 18- below 10

19- 25 years old 10
26-35 years old 20
36-60 years old 30
61 years old above 30
Total 100

Table 1. Respondents of the Study

The respondents of the study were 100 out-patient hemodialysis patients in a

tertiary government hospital in Bulacan that receives the treatment from 2012 to January

2021. The researcher sought permission to the chief nurse to access records of the

hemodialysis clients. Upon securing the permission, the researcher created a list of

hemodialysis patients. The researcher does not find it difficult to identify the client since

33
the researcher is one of the nurses attending to hemodialysis patients. The total number of

dialysis patient that undergo dialysis treatment in a particular tertiary government in

Bulacan were the respondents of this study. Upon subjecting the population to sample

size computation with confidence level of 95%, margin of error of 5% and with a

population size of 100, the result of computation for sample size is 80. but the researcher

decided to include all the 100 dialysis patient so as to gather data from all the dialysis

patients.

The research utilized purposive sampling in choosing the respondents. According

to Almeda (2016), purposive sampling is a method where the researcher chooses a

sample that agrees with his/her subjective characteristics of a representative sample. It

does not, however, aim to purposely come up with the desired or biased result but to meet

certain criteria or characteristics of the samples that fit the study.

Since the respondents has pre-existing medical condition and are susceptible in

acquiring dreaded disease such as COVID-19 and other infection, the hospital ensures

that all hemodialysis nurses had undergone swab test and that all health protocol are

being followed.

Instruments of the Study

This study used Katz Index of Independence in Activities of Daily Living

(Cronbach's alpha of 0.838) and Lawton- Brody Instrumental Activities of Daily Living

Scale (Cronbach's alpha of 0.80.) Those instruments were also used by Turgay, G. et al,

(2017) in their study entitled "Evaluation of Hemodialysis Patients in Terms of Activities

34
of Daily Living, Disability, Depression and Comorbidity" and by Mollaoğlu, M. (2011)

in the study called "Disability, Activities of Daily Living and Self-Efficacy in Dialysis

Patients."

According to McCabe (2019), Katz Index of Independence in Activities of Daily

Living is a reliable instrument to assess functional status as a measurement of the

patient's ability to perform activities of daily living independently. The Indictor orders

adequacy of performance in the six tasks of bathing, dressing, toileting, transferring,

continence, and feeding. This will be the instrument of for this study's assessment of the

Chronic Kidney Disease patients' Basic Activities of Daily Living.

According to Coyne (2019), the Lawton Instrumental Activities of Daily Living is

an applicable instrument to assess independent living skills. These skills are considered

more complex than the basic activities of daily living as measured by the Katz Index of

ADLs. The questionnaire is most reliable for studying how a person is functioning at the

present time and for identifying improvement or deterioration over time. There are 8

factors measured with the Lawton IADL scale. This will be the instrument of for this

study's assessment of the Chronic Kidney Disease patients' Instrumental Activities of

Daily Living.

The socio-demographic and clinical information of subjects were collected during

the interview. Other information were obtained using the patient's chart at the

hemodialysis unit that uses the format that is answerable to the National Registry of

Hemodialysis Patients at the National Kidney and Transplant Institute.

35
Ethical considerations.

Participants who were informed in the participation in this study were purely

voluntary and could cancel at any time. Informed Consent was asked to be signed prior to

the conduction of the survey. There is no serious risk involved in participating in the

study. The patients were explained about the purpose of this study and how this study

may be able to help them according to the objectives. This study will only utilize survey

questionnaires which will be administered prior to dialysis session. All information

gathered in this study will be treated as confidential with compliance to the RA 10173,

or the Data Privacy Act of 2012. The researcher could only access all information about

participants, will be deleted after the completion of this study. It will only take 10

minutes to answer the questions. Persons who are unable to understand the questionnaire

may be guided by their relative to provide more accurate answers.

The Graduate Studies Department of La Consolacion University Philippines (LCUP)

through the Office of Research Ethics Committee ensures that ethical requirements are

complied with to safeguard research participants' interests in thesis or dissertation

writing. Hence, the researcher secured institutional clearances and permission from both

LCUP's Graduate Studies Department, Office of the Research Ethics Committee and

Primary Hospitals in Bulacan. The following ethical considerations were put into place

for this research undertaking:

36
 1. A letter of invitation to participate in the study was forwarded via email to the

Chief Nurse.

2. There were no risks in participating in this study. No incentives will be given

to respondents who will participate in the study.

3. It was emphasized to the respondents that participation in this study is

voluntary and they may withdraw anytime.

4. All information pertaining to the respondents will remain confidential an

anonymous.

5. There will be no conflict of interest in this study.

Data Gathering Procedure

The mode of data gathering was questionnaire method. Each of the respondents

were given a structured set of questions. In gathering the data, the researcher carried out

the following procedure:

1. A letter was sent to the Medical Director of the Bulacan Medical Center to

ask permission in the conduct of proposed study.

2. With the approval, the researcher distributed the questionnaire to the

respondents personally upon completion of informed consent and assent.

Informed consent and assent was signed by the patient or with the guardian

depending on the capacity and age of the patient (those who are 18 years of

age and below).

37
 3. The researcher collected the questionnaires from the respondents and checked

whether all the questions are answered.

Data Processing and Statistical Treatment

Socio-demographic profile of the respondents in terms of age, sex, years of

dialysis, marital status, occupation, and number of companions, frequency and percentage

distribution will be utilized. To determine the primary disease related to CKD, general

condition of the patient, access used during dialysis, symptoms associated with CKD,

complications during dialysis and laboratory result, frequency and percentage distribution

will also be used. To determine the level of basic of activities of daily living, scores will

be added, a score 0 to 1 the patient is very dependent, 2-3 the patient is moderately

dependent, 4-5 the patient is moderately independent and a score of 6 the patient is very

independent. To determine the instrumental activities of daily living, scores will be

added. A summary score ranges from 0 (low function, dependent) to 8 (high function,

independent). To establish relationship between socio-demographic profile and activities

of daily living and socio-demographic profile and clinical factor, Spearman’s Rho

Correlations Analysis was used.

This research opted to determine the 95% validity of the study with a 5% degree

of error and set at P-values of <0.05 was assumed to be statistically significant.

38
 Chapter 3

Presentation, Analysis, and Interpretation of Data

This chapter presents analyses and interprets the data collected in the study. For

clarity of presentation and consistency in the discussion, the data are presented following

the order and sequence of the questions raised in Chapter 1, to wit: (1) socio-

demographic factors of hemodialysis patients in a tertiary government hospital in

Bulacan, (2) clinical factors of hemodialysis patients in a tertiary government hospital in

Bulacan, (3) activities of daily living of hemodialysis patients in a tertiary government

hospital in Bulacan, (4) effects of socio-demographic and clinical factors on the activities

of daily living of hemodialysis patients in a tertiary government hospital in Bulacan, and

(5) nursing implications drawn from the findings of the study.

39
Socio-demographic Factors of Hemodialysis patients

The socio-demographic factors of people living with hemodialysis patients in a

tertiary government hospital in Bulacan were evaluated in terms of the respondents' age,

civil status, sex, years of hemodialysis treatment, occupation, and number of companions

aged 18 above. These data is presented in Tables 2-6.

Age Frequency Percentage

61 and above 30 30
36 – 60 30 30
26 – 35 20 20
19 – 25 10 10
18 below 10 10
Total 100 100.0

Table 2. Socio-demographic Profile in terms of Age

The data shows that thirty (30) or thirty percent (30%) of the respondents’ age

ranges from 61 years old and above while thirty (30) or thirty percent of the respondents’

age is from 36 to 60 years old, twenty (20) or twenty percent (20%) of the respondents’

age ranges from 26 to 35 years old, ten (10) or ten percent (10%) of the respondents’ age

is from 19 to 25 years old.

The data suggests that most of the respondents are comprised of adults and the

elderly. Most disease that occur during adulthood are diabetes – the leading cause of

CKD according to the Clinical Journal of the American Society of Nephrology in 2017

and high blood pressure. These two diseases often complicates to Chronic Kidney

Disease if not diagnosed early and if not controlled with medications, lifestyle, and diet.

40
Since CKD is a slow progressing disease, this occurs overtime and may often show

symptoms and diagnosed late as the disease progress.

This is in agreement with the study by Torino (2018) that physical function can

decrease in older dialysis patients and with the study by Hall and McAdams-De Marco

(2018) that the number of symptoms and sickness are mostly experienced by the elderly

hemodialysis patients.

In a study by Yen-Lin (2017), the prevalence of CKD was four times higher in

elderly patients than in nonelderly participants. This was also due to factors like the

presence of hypertension, diabetes, mellitus, cardiovascular problems, and other

metabolic abnormalities. With also the occurrence of use of herbal therapy in the elderly,

CKD progressed more on these age group.

Civil Status Frequency Percentage

Single 40 40
Married 50 50
Separated 7 7
Widow/Widower 3 3
Total 100 100.0
Table 3. Socio-demographic Profile in terms of Civil Status

Regarding the respondents’ civil status, Figure 3 shows that 50 or 50 percent

(50%) of the respondents are married, 40 or forty percent (40%) of the respondents are

single, seven, or seven percent (7%) of them are separated and three patients or three

percent (3%) of them are widowed. Most of the patients under this study are married.

Most of the patients’ spouses are their companions during their hemodialysis treatment

41
and their support during their activities of daily living. Their spouses are also their

companions during hospitalization and clinical sessions.

Though the relationship of marital status and CKD is rarely studied, there have

been various research regarding the depression and mortality of patients with CKD in

relation with the patients’ marital status.

According to Thong (2017) hemodialysis patients who are married or those who

have partners living together with the patients, have been experiencing better emotional

and physical support than those who are single and separated from their spouses. Another

study by Wang (2018) revealed that unmarried CKD patients have shown signs of

depression than married ones which in turn may influence their quality of life and

activities of daily living.

Years of Hemodialysis Frequency Percentage

Treatment
7 and above 5 5
4–6 24 24
1–3 56 56
0 – 11 months 15 15
Total 100 100.0
Table 4. Socio-demographic Profile in terms of Years of Hemodialysis Treatment

Table 4 shows that fifty-six or fifty-six percent (56%) of these respondents have

1-3 years of Hemodialysis treatment. Whereas twenty-four, or twenty-four percent (24%)

of the respondents have been treated for 4-6 years. Fifteen or fifteen percent (15%) of

42
them have 0-11 months of Hemodialysis treatment, and five of five percent (5%) of the

respondents have years of dialysis treatment of 7 years and above.

Most patients have hemodialysis treatment for 1-3 years during the study. Most

patients in the said dialysis unit rarely miss treatment sessions and can continue treatment

compliance because the unit is offering free dialysis sessions since it a government

subsidized treatment center. Medications and materials used in dialysis and maintenance

are also subsidized by the local government unit. Most of these patients, also, have been

continuing dialysis treatment for years because kidney transplant is not yet possible for

them. While waiting for the possibility of transplant, hemodialysis is their only option

aside from peritoneal dialysis, thus prolonging their hemodialysis treatment years.

According to Lopes (2017), depression often occurs in those who have longer

treatment years in dialysis , thus, leading to poor physical activity and leading most

frequently to mortality if unidentified soon. Another study by Barbosa (2017) revealed

that the presence of comorbidities and duration of hemodialysis treatment were found the

possible factors of the quality of life of these patients.

Number of Household Frequency Percentage

Companions Aged 18 and
above
4 and above 25 25
2–3 45 45
1 21 21
0 9 9
Total 100 100.0
Table 5. Socio-demographic Profile in terms of Number of Household Companions
Aged 18 and above

43
 Table 5 shows that forty-five or forty-five percent (45%) of the hemodialysis

patients 2-3 have household companions aged 18 and above. Twenty-five or twenty-five

(25%) of these patients have 4 and more and twenty-one or twenty-one percent (21%)

have 1 adult household companion. Nine patients or nine percent (9%) said that they have

no household companions who are aged 18 and above.

The data shows that most of the respondents have 2-3 household companions

aged 18 and above that assist them in their physical activities. Though not all respondents

are married, most of them have adult companions capable of assisting them during their

basic and instrumental activities of daily living. Since also most of the respondents are

the elderly, most of them require capable companions to prevent harm and accidents

during their ADLs. They were also, oftentimes, who approves or refuses treatment care

plans suggested by the health care team.

According to Tong (2019), patients experiencing CKD have to adjust to the

disruptive implications of the disease thus requiring family impact and support system

that can co-manage and monitor the health of the patient.

This is in line with the study of Kutner (2017) that physical functioning of

hemodialysis patients are often dependent on the assistance of family members available

to them. They aid in activities of daily living that is sometimes limited to these

deteriorating patients.

Occupation Frequency Percentage

None 61 61
With Own Business 15 15
Employed 24 24
Total 100 100.0

44
 Table 6. Socio-demographic Profile in terms of Occupation

Table 6 shows that sixty-one or sixty-one percent (61%) of the respondents have

no occupation, twenty-four or twenty-four percent (24%) of them are employed, and

fifteen or fifteen percent (15%) have their own business. Most of these patients are not

able to go to work like they use to before they were diagnosed with CKD. Some of them

cannot function in their occupation due to their symptoms.

The data shows that most of these dialysis patients are unable to go to work or to

produce their own income. Most signs and symptoms experienced by these patients are

affecting their ability to return to their occupation while ongoing hemodialysis treatment

two to three times a week especially if their job description requires physical strength.

Some of them have conflicting schedules with their jobs and with their treatment

sessions, clinical check-ups, laboratory workups, and other activities related to health

management. Their financial needs are often provided by their relatives or subsidized by

the government and other organizations.

This is in agreement with the study of Suet (2018) that these patients are

experiencing multiple economic, physical, and social changes and must be supported

financially and in their physical activities in spite of their occupational status.

Clinical Characteristics of Hemodialysis patients

The clinical characteristics of people living with hemodialysis patients in a

tertiary government hospital in Bulacan were evaluated in terms of the respondents'

primary disease related to CKD, access used during Hemodialysis, current physical state,

45
symptoms experienced before dialysis, symptoms experienced during and after dialysis,

and laboratory results which includes hemoglobin, creatinine, and potassium levels.

These data is presented in Tables 7-14.

Primary Disease Related to Frequency Percentage

Chronic Kidney Disease
Chronic Glomerulonephritis 40 40
Diabetic Nephropathy 30 30
Obstructive Uropathy 1 1
Hypertensive Nephrosclerosis 25 25
Gouty Nephropathy 2 2
Polycystic Kidney Disease 2 2
Total 100 100.0
Table 7. Clinical Profile in terms of Primary Disease Related to Chronic Kidney
Disease
Table 7 describes the primary disease that contributed to the Chronic Kidney

Disease of the respondents. Forty or forty percent (40%) of them have Chronic

Glomerulonephritis, Thirty or thirty percent (30%) have Diabetic Nephropathy, twenty-

five or twenty-five percent (25%) have Hypertensive Nephrosclerosis, two patients or

two percent (2%) have Gouty Nephropathy, two patients or two percent (2%) have

Polycystic Kidney Disease, and the remaining one patient or one percent (1%) of the

respondents have Obstructive Uropathy.

Chronic Glomerulonephritis, Hypertensive Nephrosclerosis, and Diabetic

Nephropathy are the most common etiological factors among these patients because

when they are left untreated and diagnosed progresses to Chronic Kidney Disease, thus

requiring dialysis treatment in the later stage. Due to financial restrictions, most of the

patients have no regular physical and laboratory examinations, or ignoring early signs

and symptoms of CKD. Chornic Kidney Disease prevention focuses on the slowing on

46
the progress of the etiological factors discussed. Therefore, most of these patients were

diagnosed at a later stage when the disease has already progressed requiring abrupt and

long term hemodialysis treatment and kidney transplant.

Though Chronic Glomerulonephritis is the most occurring primary disease

causing Chronic Kidney Disease in the respondents, according to Dong-Chan (2016),

Diabetic Nephropathy has the most number of complications that will be experienced

soon by these patients and that will require most attention and treatment. There are 108

million cases of Diabetes according to World Health Organization (2021) thus increasing

the chance for the increase rate in the number of Chronic Kidney Disease patients.

In Table 8, the data shows the respondents’ vascular access that is used for

hemodialysis. Seventy-six patients or seventy- percent (76%) of them uses Arteriovenous

Fistula, ten or ten percent (10%) of them are on Permanent Catheter, and 11 patients or

11 percent (11 %) of them are on Jugular or Subclavian Temporary Dual Lumen

Catheter. Two or two percent (2%) and one or one percent (1%) of them are on Femoral

Temporary Dual Lumen Catheter and Arteriovenous graft respectively.

AVF is mostly concurrent among the respondent since there are less

complications using the said access. Patients are also more comfortable when they have

arteriovenous fistula which than an obvious and protruding permanent or temporary

catheter that also causes more complications. They can also adhere to the need of early

AV fistula implantation because financially, the operational cost of the procedure can be

subsidized by the government upon request of the patients.

47
 AVF also allows these patients to perform ADLs more efficiently and

comfortably than with them having a dual lumen catheter that can be hazardous during

their activities specifically with taking a bath, eating, toileting, dressing, and walking.

However, activities oftentimes are also restricted with limited arm movement and certain

restrictions to prevent harm to the fistula site.

This is in agreement with the study by Robbins (2018), which describes most

patients uses AVF mostly on their hemodialysis but are experiencing difficulty in

activities due to limited movements and function of the arm with the fistula. Patients are

being extra careful during activities requiring physical exertion with their affected arm to

prevent fistula complications.

Access used during Hemodialysis Frequency Percentage

AV Fistula 76 76
AV Graft 1 1
Jugular/Subclavian Dual Lumen Catheter 11 11
Femoral Dual Lumen Catheter 2 2
Permanent Catheter 10 10
Total 100 100.0

Table 8. Clinical Profile in terms of Access used during Hemodialysis

Table 9 shows the current physical state of the respondents. 35 respondents are

pale, 24 of the respondents have edema, and 18 of them have distended abdomen. 15 of

48
these respondents needed wheelchair to move. 12 of the respondents are overly thin and

8 of them have missing or amputated arms or legs.

The data shows that the respondents mostly have pallor, abdominal distention,

and edema. Pallor is most common in hemodialysis patients because CKD affects the

production of hemoglobin in the kidneys that they rarely achieve the normal hemoglobin

levels in comparison with healthy living individuals. Abdominal distention and edema are

common in this patients due to poor compliance with their daily fluid intake. Most of

them drink beyond the allowable fluid intake according to their dry weight.

These was also described in the study by Horigan (2013), which describes these

signs to be associated with decreased survival, physical activity, and quality of life.

Presence if this signs, if not treated properly may decrease the quality of life and lessen

the ability of these patients to perform ADLs, according to this study.

Current Physical State Frequency

Pale 35
With Distended Abdomen 18
With Edema 24
Overly Thin 12
With Amputated Limbs (arms or legs) 8
Needs Wheelchair 15

Table 9. Clinical Profile in terms of symptoms associated with Chronic Kidney

Disease- Current Physical Sta

Symptoms associated with Chronic Frequency

Kidney Disease- BEFORE hemodialysis
Headache 18
Shortness of Breath 33

49
 Chills 14
Dizziness 11
Stomach Pain 17
Vomiting 20
Lack of Sleep 41
Fatigue 31
Abdominal Fullness 23
Thirst 22
Loss of Appetite 1

Table 10. Clinical Profile in terms of symptoms associated with Chronic Kidney
Disease- BEFORE hemodialysis

The clinical characteristics of hemodialysis patients were also evaluated by their

symptoms experienced before their treatment. 41 of the respondents experiences lack of

sleep, 33 of them have shortness of breath 31 experiences fatigue, 23 have abdominal

fullness and 22 have thirst prior to their treatment. 20 of the respondents experiences

vomiting, 18 of them complains of headache, 17 have stomach pain, 14 of them have

chills, 11 experiences dizziness and 1 respondent have loss of appetite before

Hemodialysis treatment. Data shows lack of sleep, shortness of breath, and fatigue as the

most common symptoms before hemodialysis.

The symptoms experienced by the respondents during and after Hemodialysis

Treatment were also evaluated as described in Table 11. 30 of them have chills, 29 have

body pains and experiences thirst, 25 complains of headache, 23 of them have fatigue,

and 21 has lack of sleep during and after hemodialysis. 12 of these respondents have

cramps, 10 have dizziness and stomach pain, 7 have abdominal fullness and shortness of

breath and 6 experiences vomiting during and after Hemodialysis. The data shows chills,

body pains, and thirst as the most common symptoms during and after dialysis.

50
 Lack of sleep in Chronic Kidney Patients are experienced by the respondents due

to their high creatinine levels prior to hemodialysis treatment as well as dizziness and

headache. Shortness of breath mostly occurs with the respondents who have excessive

fluid intake prior to hemodialysis session along with abdominal distention and edema.

Chills mostly occur among these respondents during hemodialysis due to the

presence of infection from patients still using dual lumen catheters for a longer time.

Body chills have been reported by the respondents after experiencing chills during their

treatment.

The above data of symptoms before, during, and after dialysis, along with restless

leg syndrome and pruritus is in agreement with the study of Scherer (2017) that describes

these symptoms as a physical and emotional burden for these long term patients

undergoing the same treatment frequently. The study recommends and reviews

management of these symptoms for the improvement of the patients.

In another study by Cabrera (2017), patients with CKD experiencing symptoms

not addressed during hemodialysis have generally shown lower scores on the indicators

of quality of life. These scores decline progressively if not addressed immediately with

decreasing renal function.

Symptoms associated with Chronic Frequency

Kidney Disease- DURING AND AFTER
hemodialysis
Headache 25
Shortness of Breath 7
Chills 30
Dizziness 10

51
 Stomach Pain 10
Vomiting 6
Body Pains 29
Lack of Sleep 21
Fatigue 23
Abdominal Fullness 7
Thirst 29
Cramps 12

Table 11. Clinical Profile in terms of symptoms associated with Chronic Kidney
Disease- DURING AND AFTER hemodialysis

Table 12 to 14 describes the current laboratory results of the respondents that

relates to their clinical characteristics needed for this study. Figure 12 shows that forty-

six or forty-six percent (46%) of the patients have hemoglobin levels of 100g/dl above,

thirty-five or thirty-five percent (35%) of them have results of 81-99 g/dl, fifteen or

fifteen (15%) of them have levels of 61-80 g/dl, and the remaining four patients or four

percent (4%) have lower hemoglobin levels of 60g/dl and below.

Most of the patients under study have and acceptable level of hemoglobin because

some of their medications that corrects anemia like erythropoietin, ferrous sulfate, and

iron sucrose are financially subsidized together with their hemodialysis treatment, thus,

they seldom miss their dose. They also have free laboratory checkups which allows them

and the physician to monitor their hemoglobin levels.

Though most of the patients in the study have hemoglobin levels of 100g/dl and

above, according to the study of Collins (2012), if patients are unable to maintain

acceptable hemoglobin levels and failure to correct anemia, this will further increased the

52
risk of morbidity and mortality on CKD patients. Anemia in CKD is prevented by

maintenance medications of erythropoietin and iron treatment.

Laboratory Result- Hemoglobin Frequency Percentage

100g/dl above 46 46
81-99 g/dl 35 35
61-80 g/dl 15 15
60g/dl and below 4 4
Total 100 100.0
Table 12. Clinical Profile in terms of Laboratory Result- Hemoglobin

Laboratory Result- Creatinine Frequency Percentage

1501 µmol/L and above 5 5
901- 1500 µmol/L 45 45
601-900 µmol/L 37 37
600 µmol/L and below 13 13
Total 100 100.0
Table 13. Clinical Profile in terms of Laboratory Result- Creatinine

Table 13 shows the Creatinine results of the respondents showed that forty-five

or forty-five percent (45%) of the them have a creatinine level that ranges from 901-

1500 µmol/L, thirty-seven or thirty-seven percent (37%) have a creatinine level of 601-

900 µmol/L, thirteen or thirteen percent (13%) of them has 600 µmol/L and below

creatinine levels, and the remaining five or five percent (5%) of the respondents have a

creatinine level of 1501 µmol/L and above.

Creatinine of these patients are corrected only during hemodialysis treatment

which they have 2 or 3 times a week depending on the doctor’s order. As discussed, they

seldom miss their hemodialysis treatment because their treatment is subsidized by the

government. They are also being monitored regularly since their laboratory check-ups are

also free. Increase creatinine of these respondents are often associated with poor diet that

53
affects their protein levels, and poor vascular access which affects the blood circulation

during dialysis treatment.

Above data shows that respondents show that most of them have creatinine

levels of 901- 1500 µmol/L. According to Mahmood (2014), the progress of Chronic

Kidney Disease may lead to dangerous creatinine levels which may affect their physical

activity, thus affecting their quality of life and increasing the risk of morbidity and

mortality.

The potassium level of the 100 respondents is shown on Table 14. Eighty-two

patients or eighty-two percent (82%) of the respondents have a normal potassium level in

their latest laboratory results (3.5-5.5 meqs). Thirteen or thirteen percent (13%) of the

respondents have a below normal potassium levels that is 3.49 meqs and below and five

or five percent (5%) of them have a potassium level of 5.6 meqs and above.

Almost all of the respondents show normal potassium results. Laboratory

examinations are free in the said unit, thus patients and their doctors are able to monitor

their serum potassium levels. Hyperkalemia associated with Chornic Kidney Disease is

also corrected during their regular hemodialysis treatment.

Musso (2014) states that high potassium levels associated in CKD is corrected

by diffusion during hemodialysis treatment. Potassium levels when increased and

decreased affects the neural and muscular function activity of patients which can affect

their activities. Potassium also affects cardiac activity which can produce symptoms that

can be associated with increased or decreased physical activities.

54
 Laboratory Result- Potassium Frequency Percentage
5.6 meqs and above 5 5
3.5 – 5.5 meqs 82 82
3.49 meqs and below 13 13
Total 100 100.0
Figure 14. Clinical Profile in terms of Laboratory Result- Potassium

Activities of Daily Living of Hemodialysis patients

The activities of daily living of hemodialysis patients in a tertiary government

hospital in Bulacan were evaluated using the Katz Index of Independence in Activities of

Daily Living and Lawton- Brody Instrumental Activities of Daily Living. The data is

shown on Tables 15 and 16.

Basic Activities of Daily Living Frequency Percentage

6 – Full Function 38 38
5 – Full Function 15 15
4 – Moderate Impairment 16 16
3 - Moderate Impairment 8 8
2 – Severe Functional Impairment 6 6
1 - Severe Functional Impairment 17 17
0 - Severe Functional Impairment 0 0
Total 100 100.0
Table 15. Basic Activities of Daily Living

Using the Katz Index of Independence in Activities of daily living, 38 of the

respondents have a score of 6 and 15 respondents got a score of 5 which indicates full

function. 16 respondents scored 4 and 8 respondents got a score of 3 which both indicate

moderate impairment. However, 6 respondents got a score of 2 and 17 of them got a

score of 1 which indicates severe functional impairment. This is shown on Table15.

Full function in basic activities of daily living is mostly shown by the

respondents in the study. Most of them have no or little difficulties performing bathing,

55
dressing, toileting, transferring, continence, and feeding. Most of the time, these patients,

requires little assistance by their relatives or guardians but can still perform these

functions.

Mollaoglu (2011) also assessed the patients’ disability and activities of daily

living using Katz Index of Independence and describes the relationship between their

physical function and demographic factors and clinical symptoms to determine self-

efficacy.

Instrumental Activities of Daily Living Frequency Percentage

8 – High Function 26 26
7 – High Function 3 3
6 – High Function 16 16
5 – Moderate Impairment 18 18
4 – Moderate Impairment 8 8
3 – Moderate Impairment 10 10
2 – Low Function, Dependent 1 1
1 – Low Function, Dependent 12 12
0 – Low Function, Dependent 6 6
Total 100 100.0
Table 16. Instrumental Activities of Daily Living

Table 16 shows the results of the respondents’ score in the Lawton-Brody

Instrumental Activities of Daily Living Scale. The data shows that 26 respondents got a

score of 8, 3 of them got a score of 7, and 16 got a score of 6 which indicates that 44

respondents have high function in terms of instrumental activities of daily living. 18

respondents scored 5, 8 of them scored 4, and 10 scored 3, which means that 36 patients

have moderate impairment. 1 respondent scored 2, 12 of them scored 1, and 6 of the

respondents scored 0, which means 19 of them has low function in terms of instrumental

activities of daily living.

56
 The data shows that most of the respondents have high function in terms of

instrumental activities of daily living. They describe themselves having to function in

terms of ability to use the telephone, shopping, food preparation, housekeeping, laundry,

mode of transportation, responsibility for own medications, and ability to handle

finances. Most of the time, these patients, requires little assistance by their relatives or

guardians but can still perform these functions.

Turgay (2017) also used Lawton-Brody Instrumental Activities of Daily Living

Scale and concluded that walking, speed, and age are associated with activities of daily

living. In his study, it was concluded that hemodialysis and age progression can affect

patients at varying levels in their instrumental activities of daily living.

Effects of Socio-demographic Factors to activities of daily living and Instrumental

activities to daily living in Hemodialysis Patients

In conducting the study, it was hypothesized that There is no significant

relationship between the socio-demographic profile and the activities of daily living of

hemodialysis patients in a tertiary government hospital in Bulacan. To determine the

extent of relationship of the factors above on the respondents' quality of life, the data

were subjected to Spearman’s Rho Correlation Analysis.

Results of the Speaman’s rho correlation analysis in Table 17 revealed the

relationship between the demographic profile and activities of daily living. However,

57
only occupation has a low relationship to activities of daily living. Four of these

demographic factors, namely civil status, age, years of hemodialysis treatment, and

number of household companions have a relationship with activities of daily living but to

a very low correlation.

Results also revealed that all of the demographic profile studied has a

relationship with instrumental activities of daily living but with very low correlation.

However, in the study of Ulutas and Farragher (2016), disability in the

performance of activities of daily living are affected by the demographics of these

patients due to increasing age, years of treatment, and financial and physical support and

thus the need for further assistance to function.

Demographic Spearman’s Activities Verbal Instrumental Verbal

Profile Rho of Interpretation Activities Interpretation
Daily of
Living Daily
Hemodialysi Living
s
Civil Status Correlation 0.177 Very Low 0.124 Very Low

58
 Coefficient Correlation Correlation
Sig (2 0.079 Not 0.219 Not
tailed) Significant Significant
Age Correlation -0.125 Very Low 0.012 Very Low
Coefficient Correlation Correlation
Sig (2 0.214 Not 0.907 Not
tailed) Significant Significant
Years of Correlation 0.021 Very Low -0.019 Very Low
Hemodialysi Coefficient Correlation Correlation
s Treatment Sig (2 0.839 Not 0.852 Not
tailed) Significant Significant
Occupation Correlation 0.360 Low 0.227 Very Low
Coefficient Correlation Correlation
Sig (2 0.000* Significant 0.023* Significant
tailed)
Number of Correlation -.066 Very Low -.046 Very Low
Household Coefficient Correlation Correlation
Companions Sig (2 0.514 Not 0.647 Not
tailed) Significant Significant

*Significant @0.05

Table 17. Composite Table of the Significant Relationship Between Socio-

Demographic Profile and Activities of Daily Living and Instrumental

Activities of daily living of hemodialysis patients using Spearman’s rho

correlation analysis

Effects of Clinical Characteristics to activities of daily living and Instrumental

activities to daily living in Hemodialysis Patients

59
 Results of the Speaman’s rho correlation analysis in Table 18 revealed that the

cause of their Chronic Kidney Disease, current vascular access, current physical state,

and the symptoms they experience before, during and after dialysis has a relationship to

activities of daily living but with a very low correlation.

Though some of the patients reported difficulties at ADLs and IADLs, results

revealed that all these factors have a relationship with Instrumental Activities of Daily

Living but with very low correlation. They affect the activities of the respondents but to

a very low level.

However, in the study of Horigan, (2013), signs and symptoms correlate with

the decreased survival, quality of life, and physical function. Also, according to Robbins

(2018), arteriovenous fistula limits the movements of the patients’ arms and shoulders

that limits mobility to do routine activities by themselves. According also to Seung

(2017), Diabetes, together with the progress of Chornic Kidney Disease, also affects the

activities of these patients due to decreasing peripheral nerve function.

Clinical Spearman’s Activities

Living Verbal Instrumental Verbal
Characteri Rho Hemodialys Interpretation Activities Interpretation
stics is of

60
 Daily
Living
Cause of Correlation -0.090 Very Low 0.052 Very Low
Chronic Coefficient Correlation Correlation
Kidney Sig (2 0.374 Not 0.611 Not
tailed) Significant Significant
Current Correlation -0.044 Very Low -0.021 Very Low
Access Coefficient Correlation Correlation
Sig (2 0.664 Not 0.837 Not
tailed) Significant Significant
Current Correlation 0.114 Very Low 0.031 Very Low
Physical Coefficient Correlation Correlation
State Sig (2 0.259 Not 0.759 Not Significant
tailed) Significant
Symptoms Correlation -0.065 Very Low -0.001 Very Low
before Coefficient Correlation Correlation
hemodialy Sig (2 0.523 Not 0.993 Not
sis tailed) Significant Significant
During Correlation 0.021 Very Low 0.029 Very Low
and After Coefficient Correlation Correlation
Hemodial Sig (2 0.835 Not 0.776 Not
ysis tailed) Significant Significant
*Significant @0.05

Table 18. Composite Table of the Significant Relationship Between Clinical

Characteristics and Activities of Daily Living and Instrumental Activities of

daily living of hemodialysis patients using Spearman’s rho correlation

analysis

Nursing Implications Drawn from the Findings of the Study

Some useful implications were drawn based on the results of the study such as:

61
 Chronic Kidney Disease affects the activities of daily living of those are in

Hemodialysis in varying extents. Nursing care plans must be implemented to

encourage patients to enhance physical activity, decrease symptoms, and prevent

further harm and risk must be implemented.

 Older CKD patients, patients who have no companions to assist them, those who

are financially incapable requires nursing care plans that is needed to further

identify risk of functional impairment, assist in the compliance to hemodialysis

treatment, and increase patients’ independence.

 The symptoms experienced before, during, and after hemodialysis, though having

very low relationship, still affects their activities of daily living. Symptoms

before, during, and after hemodialysis must be observed, assessed and addressed

immediately according to severity so as not to further cause any complications.

 Nursing care plans must be implemented to encourage patients to enhance

physical activity, decrease symptoms, and prevent further harm and risk must be

implemented.

Chapter 4

Summary, Conclusions and Recommendations

62
 This chapter presents the summary of findings, conclusions and recommendations

concerning the effects of socio-demographic and clinical factors on the activities of daily

living of hemodialysis patients in a tertiary government hospital in Bulacan.

This study made use of descriptive correlation method of research that utilized

Katz’ Index of Independence in Activities of Daily Living and Lawton- Brody

Instrumental Activities of Daily Living as primary data gathering tool. The respondents

of the study were 100 out-patient hemodialysis patients in a tertiary government hospital

in Bulacan that receives the treatment from 2012 to January 2021.

The following null hypothesis was subjected for testing at 0.05 level of

significance.

"There is no significant relationship between the socio-demographic profile and

the activities of daily living of hemodialysis patients in a tertiary government hospital in

Bulacan"

"There is no significant relationship between the clinical characteristics and the

activities of daily living of hemodialysis patients in a tertiary government hospital in

Bulacan"

The data collected were tabulated and processed using the Statistical Packages for Social

Sciences (SPSS) Version 23 and Graph Pad InStat Version 3 and the data were presented

using appropriate tables and texts. The results were analyzed and interpreted using

statistical tests such as Frequency and Percentage Distribution in the presentation of

socio-demographic factors, clinical factors, current physical state of hemodialysis patient,

63
current access, symptoms before dialysis, during and after hemodialysis, laboratory test

of patient, basic and activities instrumental of daily living of the patient and was

subjected to Spearman’s Rho Correlations Analysis This statistical tool was used to

determine the relationship between socio-demographic profile as well as clinical

characteristics with the activities of daily living hemodialysis patients.

Summary of Findings

Problem 1: Socio-demographic profile of hemodialysis patients in a tertiary

government hospital in Bulacan

Hemodialysis patients in a tertiary government hospital in Bulacan were mostly

adults, male, married, are in hemodialysis treatment for 1-3 years, and unemployed.

Problem 2: Clinical characteristics of hemodialysis patients in a tertiary

government hospital in Bulacan

Most of the respondents have Chronic Glomerulonephritis as the primary disease

related to Chronic Kidney Disease (40%). Majority of these respondents have Arterio

Venous Fistula as their vascular access used during hemodialysis (76%). Most of the

respondents describes their physical state as pale (35%), followed by edema (24%), and

distended abdomen (18%). Before hemodialysis, majority of the experiences lack of

sleep (41%), shortness of breath (33%), and fatigue (31%). During and after

hemodialysis, most of them experiences chills (30%), body pains (29%), and thirst

(29%).

64
 Most of these patients have an acceptable level of hemoglobin for Chronic

Kidney Patients which is 100g/dl and above (46%). Most of the respondents have

creatinine level of 901-1500 µmol?L (45%). 82% of the respondents have a normal

potassium level of 3.5-5.5 meq.

Problem 3: Activities of Daily Living of Hemodialysis patients

Using the Katz Index of Independence in Activities of daily living, 38 of the

respondents have a score of 6 and 15 respondents got a score of 5 which indicates full

function. Results of the respondents’ score in the Lawton-Brody Instrumental Activities

of Daily Living Scale. The data shows that 26 respondents got a score of 8, 3 of them

got a score of 7, and 16 got a score of 6 which indicates that 44 respondents have high

function in terms of instrumental activities of daily living.

Problem 4: Effects of socio-demographic and clinical characteristics on the

activities of daily living of Hemodialysis Patients

Socio-demographic Factors and Activities of Daily Living.

Results of the Speaman’s rho correlation analysis revealed the relationship

between the demographic profile and activities of daily living. However, only occupation

has a low relationship to activities of daily living. Four of these demographic factors,

namely civil status, age, years of hemodialysis treatment, and number of household

companions have a relationship with activities of daily living but to a very low

correlation.

65
 Results also revealed that all of the demographic profile studied has a

relationship with instrumental activities of daily living but with very low correlation.

Clinical Factors and Activities of Daily Living. Results of the Speaman’s rho

correlation analysis revealed that the cause of their Chronic Kidney Disease, current

vascular access, current physical state, and the symptoms they experience before, during

and after dialysis has a relationship to activities of daily living but with a very low

correlation.

Same results also revealed that all these factors have a relationship with

Instrumental Activities of Daily Living but with very low correlation.

Problem 5: Nursing Implications are drawn from the findings of the study

Some useful implications were drawn based on the results of the study such as:

 The symptoms experienced before, during, and after dialysis associated with

Chronic Kidney Disease affects the basic and instrumental daily activities of

Hemodialysis Patients. In line with this, nurses must be aware of the signs and

symptoms experienced during dialysis and must intervene to prevent further

decrease in function. This is in agreement with the study by Caltabiano and

Bonner (2010) that revealed renal nurses are ideally positioned to engage in

early identification and regular monitoring of both fatigue and activity levels in

people with chronic kidney disease.

 Chronic Kidney Disease affects the activities of daily living of those are in

Hemodialysis in varying extents. Nursing care plans must be implemented to

66
 encourage patients to enhance physical activity, decrease symptoms, and prevent

further harm and risk must be implemented.

 Older hemidialysis patients, patients who have no companions to assist them,

those who are financially incapable requires more focused and efficient nursing

care plans that is needed to further identify risk of functional impairment, assist in

the compliance to hemodialysis treatment, and increase patients’ independence.

 The symptoms experienced before, during, and after hemodialysis, though having

very low relationship, still affects their activities of daily living. Symptoms

before, during, and after hemodialysis must be observed, assessed and addressed

immediately according to severity so as not to further cause any complications.

 Nursing care plans must be implemented to encourage patients to enhance

physical activity, decrease symptoms, and prevent further harm and risk must be

implemented.

Conclusions

Based on the findings of the study, the following conclusions were drawn:

1. Chronic Kidney Disease patients in Out Patient Hemodialysis Treatment are

mostly with an average of 1-3 years of treatment ,with long term vascular

access of AVF, and unemployed. They have varying signs and symptoms

experienced before, during, and after hemodialysis with acceptable results of

hemoglobin, potassium and creatinine results intended for CKD patients.

2. Though the activities of daily living of most Hemodialysis Patients was

assessed as good, with most of the respondents having full function using

67
 Katz Index of Independence of Daily Living and having full function using

the Lawton-Brody Instrumental Activities of daily living, some of the patients

are already having difficulties and are becoming dependent.

3. Socio-demographic factors do not significantly affect the activities of daily

living of Hemodialysis Patients with most factors (civil status, age, years of

hemodialysis treatment, number of household companions) showing very low

correlation using spearman’s rho correlation analysis.

4. Clinical factors significantly do not significantly affect the activities of daily

living of Hemodialysis Patients with most factors (cause of Chronic Kidney

Disease, Current access, current physical state, symptoms before

hemodialysis, and symptoms during and after dialysis) showing very low

correlation using spearman’s rho correlation analysis.

5. A number of implications may be considered by the hospital and its health

care providers to give holistic care to hemodialysis patients to aid in their

activities of daily living. Several considerations must be observed to care for

these patients such as their hemodialysis treatment schedule, health teaching,

financial and social assistance, and continuous monitoring,

Recommendations

In view of the conclusion drawn, the following recommendations are proposed.

1. For the nursing administration, existing nursing policies must be reviewed in

the hemodialysis unit if it is helpful to the patients’ ability to cope with their

activities of daily living and to the improvement of their quality of life.

68
 2. For the nursing education, nursing curriculum undergraduate and graduate

studies must include principles to care for hemodialysis patients in order to

assist clients to cope with their activities of daily living.

3. For the nursing service, nurses will enable to understand the factors that affect

the patient's activity of daily living so that it will help them in their nursing

care plan, scheduling patients’ treatment properly, counsel properly and aid

them in conducting their activities of daily living. The greater effort to

incorporate education and motivation into the routine care is warranted to

increase physical activity to levels that may result in health benefits.

4. Further research may be derived from this study to aid in the activities of daily

living of Chronic Kidney Disease Patients. Not much nursing research

regarding hemodialysis patients and treatment have been conducted in the

Philippines, the findings of the study may be a future reference to other

research.

5. That the implications drawn from the findings of the study be considered by

the management of the tertiary government hospital in study.

69
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APPENDIX A. PERMISSION LETTER

April 16, 2021

79
Dr. Hjordis Marushka B. Celis
Chief of Hospital
Bulacan Medical Center

Dear Dr. Celis:

Greetings!

The undersigned is a graduate student at the La Consolacion University Philippines who

is currently pursuing the degree Master of Art in Nursing Major in Nursing
Administration and completing the thesis/dissertation entitled, Clinical Characteristics
of Hemodialysis Patients on their Assessment of Activities of Daily Living: Basis for a
Structured Guidelines for CKD patients

In this regard, may I respectfully request your good office to, please, allow this researcher
to administer the research instruments to the One hundred (100) Out- Patient
Hemodialysis Patients in a Tertiary Government Hospital in Bulacan ___ and gather
the necessary data to complete the study. Rest assured that all the gathered
information/data will be handled with utmost care and confidentiality.

Your positive response is highly appreciated. Thank you.

Yours truly,
Alexandra C. Torres
Student

Noted by:

Mr. Carlo Vincent Jordan

Adviser

DR. ENRICO F. ROSALES

Vice President, Graduate Studies

Approved by:

Dr. Hjordis Marushka B. Celis

Chief of Hospital

APPENDIX B. LETTER TO RESPONDENTS

April 20, 2021

80
Hemodialysis Patients and Relatives
Hemodialysis Unit
Bulacan Medical Center

Good Day! I am Alexandra C. Torres, a student of Master of Arts in Nursing – Major in

Nursing Administration at La Consolacion University of the Philippines, is in need of
your help to gather the necessary and proper in formation thru this survey form. My
research is entitled "Clinical Characteristics of Hemodialysis Patients on their
Assessment of Activities of Daily Living: Basis for a Structured Guidelines for CKD
patients".

The results of this study aims to help in providing the proper and quality to Chronic
Kidney Disease Patients and to the nurses who provides care for them. You are one of the
100 respondents that belong to this study.

Please answer the form completely and honestly. If there are any clarifications, you can
ask me for explanation on the data necessary. Your answers maybe compared and
combined with your dialysis medical records for accuracy of information.

Rest assured that the information gathered on this study will be solely used for the
purposes of this study and will remain confidential. The information gathered will not be
used for other purposes other than this research.

The proposal of this research and the questionnaire you are about to answer was reviewed
by the Research Ethics Committee of La Consolacion University Graduate School prior
to the induction of this data gathering. In case of any clarification, complains, and
questions to the Research Ethics Committee, you may reach them thru their e-mail
address: lcuprec.secretariat@gmail.com.

Yours truly,

Alexandra C. Torres
Student

APPENDIX C. INFORMED CONSENT

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Project title:

Factors Associated with the Activities of Daily Living of Hemodialysis Patients at a

Tertiary Government Hospital in Bulacan: A Viewpoint to Address the Needs of

Hemodialysis Patients

Purpose and conduct of study

This study would like to determine the relationship between the socio-

demographic profile and activities of daily living.

Participant's information (nature and extent of involvement)

All information will be treated confidential. The participation in this research in

voluntary in nature.

Risk and inconveniences

There is no serious risk involved in participating in the study. This study will only

utilize survey questionnaires which will be administered prior to dialysis session. It will

only take 10 minutes to answer the questions.

Possible benefits for the participants

The research findings will have a substantial impact on hospital administrators to

produce more assistance projects that will support those undergoing hemodialysis to cope

with their daily life despite difficulties in performing activities of daily living.

Provisions for injury or related illnesses

This study will only involve a survey questionnaire; therefore the occurrence of either

injury or illness because of your participation is very unlikely.

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Voluntariness of participation

Your participation in this research study is completely voluntary. You have an

option to refuse to participate and have an opportunity to withdraw from the study

anytime without any obligations.

Confidentiality and Data Management

The researcher will make sure that your identity will remain confidential. All

other pertinent information that you have provided including answers to questions in the

survey and your medical records will be kept private and will be used solely for the

objective of the study. Actual survey forms and master list will be kept for 1 year after

the completion of the study and will be properly discarded thereafter. Partial results to the

study may be made available upon request.

CONSENT FORM

I hereby confirm with that I have read the above information and all questions that I have

raised were properly answered and addressed to my contentment. I clearly understand the

nature of the study. I understand that my involvement in this project is entirely voluntary

and that I have the freedom to decline or withdraw anytime. I therefore agree to

participate in this study.

________________________ ___________________ ________________

Name of respondent Signature of respondent Date

or Representative or Representative
if patient is under 18 years old if patient is under 18 years old
APPENDIX D. INSTRUMENT OF THE STUDY

PART 1 - Demographics:
Name: _____________________________

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Civil Status (check ✓)
▢ Single ▢ Separated
▢ Married ▢ Widow/ Widower

Age (check ✓)
▢ 18 below ▢ 36- 60 years old
▢ 19- 25 years old ▢ 61 years old and above
▢ 26- 35 years old

Years of Hemodialysis Treatment (check ✓)

▢ 0-11 months ▢ 4-6 years

▢ 1-3 years ▢ 7 years and above

Occupation (check ✓)

▢ none ▢ employed
▢ with own business ▢ others: (Please indicate)
____________

Number of household companions aged 18 above (check ✓)

▢ 0 ▢ 1

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 ▢ 2-3 ▢ 4 and above

PART 2 - Clinical Characteristics: (Place a check in the box that describes your
answer)
1. According to your doctor, what caused your Chronic Kidney Disease?
▢ Chronic Glomerulonephritis (madalas na impkesyon sa ihian)
▢ Hypertensive Nephrosclerosis (madalas na high blood)
▢ Diabetic Nephropathy (komplikasyon ng diabetis)
▢ Gouty Nephropathy (komplikasyon sa gout)
▢ Obstructive Uropathy (harang sa daanan ng ihian)
▢Other Diagnosis (Please indicate)
_________________________________
2. What is the current access you use for hemodialysis?
⃞ AV fistula ⃞ Dual Lumen Catheter
⃞ AV Graft (intrajugular/subclavian)
⃞ Dual Lumen Catheter (femoral)
⃞ Permanent Catheter
3. Check the characteristics that describe your current physical state.
⃞ pale ⃞ overly thin
⃞ with distended abdomen ⃞ with amputated limb (arms or legs)
⃞ with edema ⃞ needs wheelchair
4. Which among these symptoms are you experiencing BEFORE hemodialysis?
⃞ headache ⃞ lack of sleep
⃞ shortness of breath ⃞ fatigue
⃞ chills ⃞ abdominal fullness
⃞ dizziness ⃞ thirst
⃞ stomach pain ⃞ others (Please indicate)
⃞ vomiting ____________________

85
 5. Which among these symptoms are you experiencing DURING AND AFTER
hemodialysis?
⃞ headache ⃞ lack of sleep
⃞ shortness of breath ⃞ fatigue
⃞ chills ⃞ abdominal fullness
⃞ dizziness ⃞ thirst
⃞ stomach pain ⃞ cramps
⃞ vomiting ⃞ others (Please indicate)
⃞ body pains ___________________

6. Please check the data that describes your CURRENT laboratory results:
Hemoglobin
▢ 60 g /dL below ▢ 81- 99 g /dL
▢ 61- 80 g /dL ▢ 100 g /dL above
Creatinine
▢ 600 μmol/L below
▢ 601- 900 μmol/L
▢ 901 -1500 μmol/L
▢ 1501 μmol/L above
Potassium
▢ 3.49 meq below
▢ 3.5 meq – 5.5 meq (normal)
▢ 5.6 meq above
PART 3 – ACTIVITIES OF DAILY LIVING
(KATZ INDEX OF INDEPENDENCE IN ACTVITIES OF DAILY LIVING)

ACTIVITIES INDEPENDENCE: DEPENDENCE:

86
 (1 POINT)
POINTS (1 OR 0) NO supervision, direction or personal (0 POINTS)
assistance WITH supervision, direction,
personal assistance or total care
BATHING (1 POINT) (0 POINTS)

POINTS:___________ Bathes self completely or needs help Needs help with bathing more
in bathing only a single part of the than one part of the body, getting
body such as the back, genital area or in or out of the tub or shower.
disabled extremity. Requires total bathing.
DRESSING (1 POINT) (0 POINTS)

POINTS:___________ Gets clothes from closets and drawers Needs help with dressing self or
and puts on clothes and outer garments needs to be completely dressed.
complete with fasteners. May have
help tying shoes.
TOILETING (1 POINT) (0 POINTS)

POINTS:___________ Goes to toilet, gets on and off, Needs help transferring to the
arranges clothes, cleans genital area toilet, cleaning self or uses bedpan
without help. or commode.
TRANSFERRING (1 POINT) (0 POINTS)

POINTS:___________ Moves in and out of bed or chair Needs help in moving from bed to
unassisted. Mechanical transferring chair or requires a complete
aides are acceptable. transfer.
CONTINENCE (1 POINT) (0 POINTS)

POINTS:___________ Exercises complete self-control over Is partially or totally incontinent

urination and defecation. of bowel or bladder.
FEEDING (1 POINT) (0 POINTS)

POINTS:___________ Gets food from plate into mouth Needs partial or total help with
without help. Preparation of food may feeding or requires parenteral
be done by another person. feeding.

TOTAL POINTS = ______ 0,1,2= Low (severe functional impairment)

3,4 = Moderate (moderate functional impairment)
5,6 = High (patient with full function)

PART 4 – INSTRUMENTAL ACTIVITIES OF DAILY LIVING

(LAWTON-BRODY INSTRUMENTAL ACTIVITIES OF DAILY LIVING
SCALE)
87
 Scoring: For each category, CIRCLE the item description that most closely

resembles the client's highest functional level (either 0 or 1).

A. Ability to Use Telephone E. Laundry

1. Operates telephone on own
initiative-looks up and dials
numbers, etc.
2. Dials a few well-known numbers
3. Answers telephone but does not
dial
4. Does not use telephone at all
B. Shopping
1. Takes care of all shopping needs
independently
2. Shops independently for small
purchases
3. Needs to be accompanied on any
shopping trip
4. Completely unable to shop
1 1. Does personal laundry completely 1
2. Launders small items-rinses stockings, 1
3. All laundry must be done by others
1 0
1
0
F. Mode of Transportation
1 1. Travels independently on public 1
transportation or drives own car
0 2. Arranges own travel via taxi, but 1
does not otherwise use public
0 transportation
3. Travels on public transportation 1
0 when accompanied by another
4. Travel limited to taxi or automobile 0
with assistance of another
5. . Does not travel at all 0

PART 4 – INSTRUMENTAL ACTIVITIES OF DAILY LIVING

(LAWTON-BRODY INSTRUMENTAL ACTIVITIES OF DAILY LIVING
SCALE)

88
 C. Food Preparation
1. Plans, prepares and serves
adequate meals independently
2. Prepares adequate meals if
supplied with ingredients
3. Heats, serves and prepares
meals, or prepares meals, or
prepares meals but does not
maintain adequate diet
4. Needs to have meals prepared
and served
D. Housekeeping
1. Maintains house alone or with
occasional assistance (e.g. "heavy
work domestic help")
2. Performs light daily tasks such as
dish washing, bed making
3. Performs light daily tasks but cannot
maintain acceptable level of
cleanliness
4. Needs help with all home
maintenance tasks
5. Does not participate in any
housekeeping tasks
G. Responsibility for Own
Medications
1 1. Is responsible for taking medication 1
in correct dosages at correct time
0 2. Takes responsibility if medication is 0
prepared in advance in separate
0 dosage
3. Is not capable of dispensing own 0
medication
0
H. Ability to Handle Finances
1 1. Manages financial matters 1
independently (budgets, writes checks,
pays rent, bills, goes to bank), collects
and keeps track of income
1
2. Manages day-to-day purchases but
needs help with banking, major
1 purchases, etc. 1
3. Incapable of handling money
0
0
0

Score: ___________ Score: _________

Total Score: _______________

Reference: Results of 0-2 (low function, dependent)
Results of 3-5 (moderate impairment)
Results of 6-8 (high function, independent)

APPENDIX E. RESEARCH BUDGET PROPOSAL

89
Project title:

Clinical Characteristics of Hemodialysis Patients on their Assessment of Activities of

Daily Living: Basis for a Structured Guidelines for CKD patients

COST ESTIMATE

Item Cost Source

Bond Paper for printing 300 Personal
Ink 250 Personal

Total 550 Personal

APPENDIX F. Curriculum Vitae

ALEXANDRA CLARIDADES TORRES

90
Personal Information
Address : 168 San Marcos Calumpit Bulacan
Email Address : alexandraclaridades@gmail.com
Birth date : 24 August 1987
Mobile number : +639989941958
Age : 33

Qualifications Obtained
Inclusive Year :
Degree Earned : Master of Arts in Nursing Major in
Nursing Administration
School : La Consolacion University Philippines
Address : City of Malolos, Bulacan Philippines

Inclusive Year : 2004-2008

Degree Earned : Bachelor of Science in Nursing
School : Chinese General Hospital Colleges
Address : Blumentritt, Metro Manila, Philippines

Bridging Programs / Qualifying Examinations

Nephrology Nurse Certification Exam

Exam Provider : Renal Nurses Association of the Philippines
Date taken : January 2013
Location : Manila, Philippines
Board Rating : Passed/ Top 3

Philippine Nursing Licensure Examination

Exam Provider : Professional Regulation Commission
Date taken : June 2008
Location : Manila, Philippines
Board Rating : 85%

Work/Practice History
Position : Nurse I – Hemodialysis Unit
Name of Hospital : Bulacan Medical Center
Address : Mojon, Malolos, Bulacan, Philippines
Date started : January 16, 2012- Present

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