Does the intravascular volume status in haemodialysis patients measured by inferior vena cava ultrasound correlate with bioimpedance spectroscopy?

AIMS AND OBJECTIVES: To evaluate the accuracy of traditional clinical predialytic fluid assessment by renal nurses and the efficacy of 2 additional fluid assessment methods focussing on the potential preventative effect for intradialytic hypotension (IDH). BACKGROUND: Predialytic fluid assessment remains a daily challenge for renal nurses, when aiming for adverse event free haemodialysis treatments. Adding further objective parameters obtained through noninvasive methods into pre- and intradialytic fluid assessment could potentially improve health outcomes for haemodialysis patients. DESIGN: Comparative, observational study of three fluid assessment methods on their reliability on volume status and correlation to clinical outcomes. METHODS: Clinical predialytic nursing fluid assessments in 30 haemodialysis patients were compared with additional initial bioimpedance spectroscopy (BIS) measurements, and 3 serial intradialytic ultrasound scans of the inferior vena cava (IVC-US) performed by a second renal nurse concurrently during the same session. A retrospective data analysis compared all measurements in each individual for the predictive value for IDH. A STROBE checklist for observational cohort studies was used for the reporting of results. RESULTS: Seven subjects experienced episodes of symptomatic intradialytic hypotension (S-IDH), which would have been anticipated by IVC-US or by BIS in 5 patients (71%). Using an algorithm to predict IDH would have provided a sensitivity of 100% and specificity of 95%. CONCLUSION: Both additional fluid assessment methods would have provided critical information before and during each haemodialysis session. Therefore, we consider them as being potentially effective for the prevention of intradialytic hypotension, with IVC-US being similar to BIS. RELEVANCE TO CLINICAL PRACTICE: Traditional clinical nursing fluid assessment methods in haemodialysis patients do not provide sufficient information to prevent episodes of IDH. Additional objective fluid assessment methods are useful and likely to lead to improved health outcomes in HD patients when applied by renal nurses. A combination of IVC-US, MAP and BIS has potential to reduce the risk of IDH events in HD patients significantly.

[Augmentation cystoplasty: Perioperative management for urologic nurses]. / L'entérocystoplastie d'agrandissement : indications et principes de prise en charge pour l'IDE en urologie.

INTRODUCTION: Augmentation cystoplasty (AC) is a surgical option to restore a good capacity bladder reservoir able to fill at low pressure. METHODS: The authors present the main principles for perioperative management for urologic nurses. RESULTS: AC is usually made with a piece of ileum patched to the bladder. Patient education programs are very important and are usually managed by urologic nurses. It begins in preoperative phase with the self-catheterization learning and continue in the postoperative phase with advises and prevention of the urinary mucus. CONCLUSION: AC are tricky surgeries but management and education of patients by urological nurses are key points to avoid chronic infection, stones or AC perforation.

The effects of a nurse-supervised home exercise programme on improving patients' perceptions of the benefits and barriers to exercise: A randomised controlled trial.

AIMS AND OBJECTIVES: To explore the effects of a home exercise programme on patients' perceptions of the barriers and benefits to exercise and adherence to the programme. BACKGROUND: Great efforts have been made to encourage dialysis patients to participate in rehabilitation regimens. The promotion of exercise in this population is still limited. DESIGN: This was a post hoc analysis of a randomised, two-group parallel study. METHODS: A total of 113 adult patients recruited from the haemodialysis units were randomised into two groups on a 1:1 ratio. Both groups received in-centre group exercise training weekly for 6 weeks. The intervention group patients were provided with an additional individualised nurse-led home exercise prescription and behavioural support for 12 weeks. The patients' perceptions of the barriers and benefits to exercise, adherence to the home exercise prescription and their exercise level at weeks 6 and 12 were evaluated. RESULTS: There was a significant between-group difference in the score on patient perceptions of the barriers and benefits to exercise, with the intervention group reporting a greater reduction in perceived barriers to exercise. Significant group differences were noted in exercise level upon the completion of the programme, with the intervention group reporting higher such levels. The average adherence rate to the negotiated exercise plans was 78.9%. The intervention group of patients did better at meeting or exceeding the minimum exercise goal than did the control group. CONCLUSION: Home exercise prescriptions and behavioural support provided by trained nurses are effective at helping patients to remove barriers to engaging in exercise training. RELEVANCE TO CLINICAL PRACTICE: Physical exercise in a clinical arena should not be considered the exclusive domain of physical therapists; the team could collaborate with nurses to play a core role in making physical exercise for patients an essential practice of care in a multidisciplinary team.

Educational strategies and challenges in peritoneal dialysis: a qualitative study of renal nurses' experiences.

AIMS AND OBJECTIVES: The aim of the study was to explore renal nurses' experiences, strategies and challenges with regard to the patient education process in peritoneal dialysis. BACKGROUND: Patient education in peritoneal dialysis is essential to developing a successful home-based peritoneal dialysis program. In this area research is scarce and there is a particular lack of focus on the perspective of the renal nurse. DESIGN: Qualitative design formed by thematic qualitative text analysis. METHODS: Five group interviews (n = 20) were used to explore the challenges peritoneal dialysis nurses face and the training strategies they use. The interviews were analyzed with thematic qualitative content analysis using deductive and inductive subcategory application. RESULTS: The findings revealed the education barriers perceived by nurses that patients may face. They also showed that using assessment tools is important in peritoneal dialysis patient education, as is developing strategies to promote patient self-management. There is a need for a deeper understanding of affective learning objectives, and existing teaching activities and materials should be revised to incorporate the patient's perspective. Patients usually begin having questions about peritoneal dialysis when they return home and are described as feeling overwhelmed. Adapting existing conditions is considered a major challenge for patients and nurses. CONCLUSIONS: The results provided useful insights into the best approaches to educating peritoneal dialysis patients and served to raise awareness of challenges experienced by renal nurses. Findings underline the need for nosogogy - an approach of teaching adults (andragogy) with a chronic disease. Flexibility and cooperation are competencies that renal nurses must possess. RELEVANCE TO CLINICAL PRACTICE: Still psychomotor skills dominate peritoneal dialysis patient training, there is a need of both a deeper understanding of affective learning objectives and the accurate use of (self-)assessment tools, particularly for health literacy.

Validation: A Family-Centered Communication Skill.

Family-centered care can seem challenging when family member behavior, choices, attitudes, or emotions are "difficult" or "challenging" to deal with. Yet nurses can develop skills to effectively interact with families in a wide variety of circumstances and then become able to practice family-centered care in any situation that might arise. One particularly useful skill is "validation," which means accepting what the family member says or does as a valid expression of thoughts and feelings in that particular circumstance at that particular time. Validation does not mean there is agreement or acceptance of unsafe behaviors, only that the nurse acknowledges that the family member's concerns and feelings are important and should be listened to and taken seriously, even in the presence of disagreement. Validation, which should be individualized, can take many forms, ranging from providing complete attention to reflection of statements, identification of possible unexpressed emotions, normalization, and finally, a full and genuine sense of connection. Understanding and practicing validation can empower nurses and family members, as well as support effectivefamily-centered communication and problem solving even in challenging circumstances.

Increasing Vaccination Rates in a Pediatric Chronic Hemodialysis Unit.

Children with chronic kidney disease (CKD) are at an increased risk for serious complications from vaccine-preventable childhood diseases. Despite this risk, vaccination rates remain low. The barriers to vaccination in the pediatric population on dialysis are multifactorial. The advanced practice registered nurse (APRN) is well poised to serve as a wellness champion for this chronic population. This article chronicles an APRN-led quality improvement project to increase vaccination rates to 100% in an outpatient pediatric population on hemodialysis. A quality improvement system was created to systematically review immunizations upon admission to the hemodialysis unit and annually thereafter. Over a two-year period, immunization rates improved significantly.

Camps and Their Benefit to Pediatric Nephrology Patients.

Children with end stage renal disease (ESRD) frequently miss great amounts of school due to hospitalizations and three-times-a week hemodialysis (if that is their modality); thus, they miss opportunities to be with their peers and learn normal social interactions with other students. Because of this lack of normal socialization, many children with ESRD are behind in development in contrast to their peers and need opportunities to enhance their growth and development. One way this can occur for children with ESRD is by providing them opportunities to attend age-appropriate and disease-appropriate camps.

Active surveillance of prostate cancer: a questionnaire survey of urologists, clinical oncologists and urology nurse specialists across three cancer networks in the United Kingdom.

BACKGROUND: Active surveillance is considered a mainstream strategy in the management of patients with low-risk prostate cancer. A mission-critical step in implementing a robust active surveillance program and plan its resource and service requirements, is to gauge its current practice across the United Kingdom. Furthermore it is imperative to determine the existing practices in the context of the recommendations suggested by the recent National Institute for Health and Clinical Excellence guidance on active surveillance of prostate cancer. METHODS: An internet questionnaire was circulated to urologists, clinical oncologists and urology nurse specialists across three geographically distinct cancer networks. Twenty five questions across four domains were assessed. (i) hospital resources (staff and clinical areas) utilised for active surveillance (ii) enrolment criteria (iii) follow up (iv) criteria that trigger conversion to active treatment. RESULTS: We received 35 responses, 20 of which were from urologists. The survey data suggests that there is marked heterogeneity in enrolment criteria with patients having features of intermediate-risk prostate cancer often recruited into Active Surveillance programs. Only 60 % of our respondents use multiparametric MRI routinely to assess patient suitability for active surveillance. In addition, marked variation exists in how patients are followed up with regard to PSA testing intervals and timing of repeat biopsies. Only 40 % undertake a repeat biopsy at 12 months. Tumour upgrading on repeat biopsy, an increase in tumour volume or percentage of core biopsies involved would prompt a recommendation for treatment amongst most survey respondents. In addition allocation of resources and services for active surveillance is poor. Currently there are no dedicated active surveillance clinics, which are well-structured, -resourced and -supported for regular patient counselling and follow up. CONCLUSION: This variability in enrolment criteria and follow up is also demonstrated in international and national series of active surveillance. Resources are not currently in place across the UK to support an active surveillance program and a national discussion and debate to plan resources is much required so that it can become a mainstream therapeutic strategy.

Does Hemodialysis Dialysate Potassium Composition Matter?.

Dyskalemia is known to cause cardiac arrhythmias and cardiac arrest. In persons undergoing hemodialysis, potassium dialysate composition has been identified as a contributingfactor in addition to co-morbidities, medications, dietary potassium intake, and stage of kidney disease. Current evidence recommends a thorough evaluation of all factors affecting potassium balance, and lower potassium concentration should be used cautiously in patients who are likely to develop cardiac arrhythmias. Nephrology nurses play a key role inpatient assessment and edu- cation related to potassium balance.

Safe and effective catheterisation for patients in the community.

Approximately 450 000 people use long-term urinary catheters in the UK. Permanent catheters are used by 3% of the community population and occupy an estimated 4% of a district nurse's caseload in the UK. Catheterisation is defined as 'drainage or aspiration of the bladder or urinary reservoir' and can be intermittent or indwelling. Long-term indwelling catheterisation can be transurethral or suprapubic via the anterior abdominal wall. This article will discuss the safe and effective use of different forms of catheterisation for patients in the community setting.

IV Iron: To Give or to Hold in the Presence of Infection in Adults Undergoing Hemodialysis.

Intravenous (IV) iron is often given to treat iron deficiency anemia in adults undergoing hemodialysis. Evidence supports an association between IV iron and infection exits, which often create a clinical dilemma: whether to give or to hold in the presence of infection. This article presents the best available evidence regarding the risk of IV iron and infection along with nephrology nursing practice implications.

The Canadian Organ Replacement Register: Nursing's important contribution.

You are a charge nurse in a large hemodialysis unit in Ontario.One of the clerical staff has approached you today to assist withan update to her statistics on new and existing patients in yourunit. You are asked to clarify the cause of death for one patientand to clarify the date of transfer to the home dialysis programfor peritoneal dialysis on another patient. Finally, you are asked toremind the nurse practitioner (NP) to complete a registration formfor another patient who has just started chronic hemodialysis inyour unit. While you know the collection of data is important, thereare lots of patients to look after and you feel frustrated by havingto take time away from planning urgent hemodialysis requests--which are your priority--to source out information to complete aform. You reflect on this need for statistical data and wonder wherethe information on this form ends up and how it helps your patientswho are living with end stage kidney disease (ESKD).

A prospective clinical trial of specialist renal nursing in the primary care setting to prevent progression of chronic kidney: a quality improvement report.

BACKGROUND: Early detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at 'high risk of CKD progression', defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance. METHODS: The study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several 'intermediary' secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate. RESULTS: There was a significant improvement in ACR (average decrease of -6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains. CONCLUSIONS: The results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry number: ACTRN12613000791730.

The effect of transcutaneous electrical nerve stimulation for pain relief during extracorporeal shock-wave lithotripsy procedure.

The purpose of this study was to investigate the effect of transcutaneous electrical nerve stimulation (TENS) for pain relief during extracorporeal shock-wave lithotripsy (ESWL) procedure. An experimental study with repeated measures design was used in this study. Fifty patients aged 20-65 years receiving ESWL treatment were used for this convenience sample. Two applications were used for each patient: one involving administration of TENS instrument for ESWL treatment and the other without TENS. For effective stimulation, 2 stimulator electrodes were placed paravertebrally at L1 and 2 near the lithotripter shock tube before ESWL. Blood pressure, heart rate, pain intensity, analgesic use, and side effects were measured every 10 minutes during the procedure and after the end of ESWL. Results showed that TENS application decreased patients' intensity of pain and amount of analgesic requests and, related to that, decreased the incidence of side effects and increased patients' satisfaction during ESWL. TENS application is recommended as a pain-relieving technique during ESWL.

Pelvic floor muscle rehabilitation using biofeedback.

Pelvic floor muscle exercises have been recommended for urinary incontinence since first described by obstetrician gynecologist Dr. Arnold Kegel more than six decades ago. These exercises are performed to strengthen pelvic floor muscles, provide urethral support to prevent urine leakage, and suppress urgency. In clinical urology practice, expert clinicians also teach patients how to relax the muscle to improve bladder emptying and relieve pelvic pain caused by muscle spasm. When treating lower urinary tract symptoms, an exercise training program combined with biofeedback therapy has been recommended as first-line treatment. This article provides clinical application of pelvic floor muscle rehabilitation using biofeedback as a technique to enhance pelvic floor muscle training.

Streamlining biofeedback for urge incontinence.

The aim of this study was to determine the important elements of biofeedback-assisted pelvic floor muscle exercises to treat urge incontinence. Urge suppression and pelvic floor muscle exercises were most beneficial. Responders can be identified early in treatment, allowing for fewer sessions.

Isothermal dialysis to control intradialytic hypotension and patient comfort: a pilot study.

Isothermal hemodialysis to improve intradialytic tolerance in hypotension-prone patients has been effective in outpatient settings. The purpose of this pilot study was to examine thermal control in an acute care setting and describe comfort issues associated with thermal control Although complaints of cold or shivering occurred more frequently with the isothermal hemodialysis group, cold discomfort was managed by nursing interventions and was not a cause of significant discomfort. No statistically significant difference was observed in blood pressure or patient's comfort level between standard and isothermal dialysis. However, isothermal hemodialysis may be an appropriate hemodialysis option for control of intradialytic hypotension in the acute care setting. Further research is recommended.

Haematuria: from identification to treatment.

Haematuria has a prevalence of 0.1% to 2.6%. Potential diagnoses may include infection, kidney stones, trauma, exercise or spurious causes, such as foods, drugs or menstruation, and a tumour. Approximately 20% of patients with haematuria have a urological tumour, with a further 20% found to have a significant underlying pathology. Haematuria is subsequently known as the 'classic presentation' of bladder cancer with 70-80% of patients experiencing painless, gross (visible) haematuria. However, in all cases of visible haematuria, a tumour should be suspected until proven otherwise. A patient with visible haematuria requires urgent, stringent investigation, warranting specialist assessment and subsequent selective referral through a series of patient-centred investigations at a haematuria clinic. One-stop clinics have been shown to improve the patient experience in early diagnosis of potentially life-threatening conditions. Yet despite morbidity and mortality from bladder cancer increasing, the haematuria service has remained largely unchanged for several decades. This paper will discuss the tests and investigations that need to be undertaken in an individual with either visible or non-visible haematuria, and outline the care that is needed to support patients through the investigation process, with special focus on bladder tumour.

Challenges for the clinical nurse specialist in uro-oncology care.

Cancer is a complex illness that over the years has provoked much fear and speculation for patients, their relatives and health professionals. Emphasis has been placed on cancer management from the point of diagnosis, as well as treatments and their associated risks. As a result of increased technology and improved treatment modalities, more people are now surviving cancer and go on to live longer and healthier lives. While such an achievement is commendable, it places a significant strain on the healthcare economy. The Cancer Reform Strategy acknowledges that the management of cancers in the UK warrants clear definitive protocols and guidelines, to ensure a strategy that is capable of achieving the desired outcomes for those individuals who are affected by the disease. Integral to this objective is the multidisciplinary team, in which the role of the cancer nurse specialist is fundamental to achieving holistic patient outcomes. However, this article addresses the challenges of a uro-oncology clinical nurse specialist from a conceptual, as well as a personal, perspective. It focuses on the role that is specific to the management of patients who are diagnosed with urological cancers.