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Use of an Educational Intervention to Improve Fluid Restriction Adherence in Patients on Hemodialysis.

Patients with end stage renal disease (ESRD) who have chosen hemodialysis as their renal replacement therapy face changes in economic status, social roles, activity levels, and normal routines. They must learn to cope with a variety of different adversities, including the physical symptoms related to the treatment process, such as nausea, tiredness, and weakness (Figueiredo et al., 2012). ESRD and hemodialysis treatment dictate adjustments to lifestyle changes, while their control over treatment must be shared with an interprofessional healthcare team. Patients who must receive dialysis treatment to survive are often prone to emotions, such as feelings of helplessness, depression, and fear (Ma et al., 2013). These changes may lead to patients reconsidering their personal and professional goals within the context of living with a chronic illness (Theofilon, 2011).

Patients on hemodialysis are required to follow strict dietary and fluid restrictions. Patients learn to live with limitations of certain foods, including potassium-rich foods, such as potatoes, bananas, and oranges. In addition, patients on hemodialysis have fluid restrictions, which includes not only fluids, but also foods high in fluid content, such as ice cream and soup. To successfully manage these fluid restrictions, patients must know how to appropriately measure their prescribed fluid intake. Cristovao (2015) concluded that nursing educational support is required to help patients manage adherence to prescribed fluid restrictions. The purpose of this project was to evaluate the improvement of prescribed fluid restriction in patients with ESRD who are receiving chronic hemodialysis.


Research Design

A pre-intervention/post-intervention design was used to examine the effectiveness of an educational intervention on improving patients' knowledge regarding basic hemodialysis and prescribed fluid restriction. This approach was utilized to gauge the patient's baseline knowledge of hemodialysis and his or her prescribed fluid restriction, and changes after providing the educational intervention. The project was approved by the dialysis treatment center and Troy University Institutional Review Board.

Participants and Setting

The study took place in a hemodialysis center in the Southwestern United States. The center has 20 dialysis stations and one isolation room. Patients currently receiving their hemodialysis treatment at the center were given information regarding risk and benefits of their participation in the study and provided an opportunity to ask questions. While 20 patients agreed to participate and signed consents, 17 patients completed the study. These patients represented both adherent and non-adherent patients with a prescribed fluid restriction. Patients with an interdialytic weight gain (IDWG) greater than 2 kg were consistently considered non-adherent to their prescribed fluid restriction. All participants met the inclusion criteria of 18 years of age or older and receiving hemodialysis at least three times a week for greater than six months.

Educational Intervention

The educational intervention included classes provided by the primary investigator using educational material retrieved from the Texas ESRD Network website (ESRD Network of Texas, 2018). This educational material included information related to fluid restriction options to maintain fluid adherence, foods low in potassium, and making healthy food selections while preparing their meals, as well as basis hemodialysis knowledge relevant to maintaining adherence to a prescribed renal regimen. The educational intervention for this project was implemented on patients' regularly scheduled hemodialysis days, post-hemodialysis treatment for approximately one hour each session. Sessions consisted of a total of four sessions for the Monday/Wednesday/ Friday patients and the Tuesday/ Thursday/Saturday patients. The first educational class was conducted Mondays for the Monday/Wednesday/Friday patients. The second group was given the same opportunity to participate in the educational intervention on Tuesdays for the Tuesday/ Thursday/Saturday patients. Before the start of the educational intervention and after completing the intervention, all participants were asked to complete questions from the Chronic Hemodialysis Knowledge Survey (CHeKs).

Data Collection and Tool

The CHeKs tool was developed to evaluate patient knowledge of chronic hemodialysis care (e.g., dialysis adequacy, nutrition, anemia, access care, medications, safety) (Cavanaugh, Wingard, Hakim, Elasy, & Ikizler, 2009). The survey consists of 23 multiple-choice items (which only have one correct choice each) and has a readability grade level of 5.8. Cavanaugh and colleagues (2009) performed a factor analysis to determine if there were underlying subscales within the developed survey. Then the Kuder-Richardson-20 coefficient (KR20) was used to determine internal consistency, a measure of internal reliability for surveys with dichotomous responses. The 23-question knowledge survey had good reliability (KR20 coefficient = 0.72), and mean knowledge score was 66% [+ or -] 15% (SD). Bivariate analysis showed that scores were associated with age ([beta] = 0.01/10 years; 95% CI, -0.02 to -0.005; p=0.003), formal education ([beta] = 0.09; 95% CI, 0.03 to 0.15; p=0.004), health literacy ([beta]=0.06; 95% CI, 0.03 to 0.10; p=0.001), kidney education class participation ([beta]=0.05; 95% CI, 0.01 to 0.09; p=0.009), knowing someone else with chronic kidney disease (CKD) ([beta] = 0.05; 95% CI, 0.02 to 0.08; p=0.001), and awareness of one's own CKD diagnosis ([beta] = 0.07; 95% CI, 0.04 to 0.10; p<0.001) (Cavanaugh et al., 2009).

The CHeKs tool contains four questions primarily related to diet and fluid restriction. For example, one question asks: "You are ordering food from a restaurant menu. Which item below is the best for you to avoid to control your potassium? Steamed rice, corn, baked potato, noodles."

Demographic and renal laboratory data were collected from the electronic medical record, including patient's dry weight, height, gender, age, prescribed fluid amount, length of time receiving hemodialysis, co-morbidities (hypertension, diabetes, and/or heart disease), pre- and post-dialysis weights, and pre- and post-Kt/V serum laboratory values.

Data Analysis

The IBM Statistical Package for the Social Science (SPSS) version 25 was used for all statistical analyses. Demographic and renal laboratory information and summary scores, and select items from the pre-intervention and post-intervention CHeKs questionnaires were entered into SPSS. Preliminary analysis was conducted using descriptive statistics to evaluate means and frequencies for key variables. Inferential statistics were used to compare differences in pre- and postintervention data.


Description of the Sample

The sample in the study included 10 males (58.8%) and 7 females (41.2%). The mean, standard deviation, and range for participants by age and years on hemodialysis are displayed in Table 1. The mean age of participants was 55.47 (SD=12.57), with a range of 29 to 73 years. The majority of participants (70.5%, n=12) were older than 50 years. The mean years on hemodialysis was 4.79 (SD=4.12), with a range of 0.5 to 15 years. The majority reported being on hemodialysis less than 5 years (58.82%, n=10).

Participates were asked whether they had the co-morbidities of hypertension, diabetes, and/or heart disease. Table 2 displays the frequencies of the co-morbidities. Below 30% (29.4%, n=5) of participants reported having only one of these co-morbidities, 52.9% (n=9) had two of these co-morbidities, and 17.6% reported having all three co-morbidities (17.6%, n=3) listed for this study. Twelve participants (70.6%) reported multiple co-morbidities. The single most reported co-morbidity was hypertension (94.1%, n=16).

Fluid restrictions for the participants ranged from 1,000 mL to 2,000 mL per 24 hours. Fluid restriction ranges are dependent on the patient's weight, height, urine output, and comorbidities. The majority reported being restricted to 1,000 mL (70.58%, n=12) per day.

Renal Fluid Adherence

Each patient was weighed before and after each hemodialysis treatment. Weights were obtained from the patient's electronic chart. The mean, standard deviation, and range for dry weights, pre-weights, and post-weights in kilograms are shown in Table 3. The IDWG represents the increase in weight from the end of the hemodialysis treatment to the next treatment and reflects adherence with fluid restrictions. The IDWG was computed by subtracting the pre-weight from the previous dialysis post-weight. Eight IDWGs were computed over the course of three weeks, beginning with hemodialysis treatment for Week 1, Day 2 (the treatment after the educational session). through Week 3, Day 3. The goal for fluid adherence was an IDWG of 2 Kg or less. The mean IDWG was 1.74 kg (SD=.63, n=17), with levels ranging from 0.74 to 2.88. Table 4 displays the frequency and percentages of participants meeting and not meeting fluid adherence goals.

The rate of fluid adherence represents the percentage of hemodialysis treatments in which the IDWG was 2 kg or less. The mean rate of fluid adherence based on eight hemodialysis treatments was 72.05% (SD=21.44, n=17), with a range of 37.50% to 100%. A comparison of the mean rate of fluid adherence for the first four and last four treatments revealed an improvement in mean rate from 69.12% (SD=27.28) to 75.00% (SD=23.38), respectively.

The pre- and post-educational intervention Kt/V laboratory values were collected and recorded. The Kt/V formula is used to quantify dialysis treatment adequacy. K represents dialyzer clearance of urea, t reflects dialysis time, and V is the volume of distribution of urea, approximately equal to patient's total body water. Normal Kt/V values should be less than or equal to 1.3 (National Kidney Foundation [NKF], 2015). A paired samples t test was computed for the difference in the mean baseline and post-intervention Kt/V. While the post-intervention Kt/V was decreased, both means exceeded target values. The difference in the baseline Kt/V (M=1.56, SD=0.35) and post-intervention Kt/V (M=1.54, SD=0.29) was not statistically significant (t[16]=0.482, p>0.05). These data are shown in Table 5.

Knowledge of Hemodialysis and CKD

The CHeKs tool includes 23 questions that evaluate the patient's knowledge of hemodialysis and management of CKD. Summary scores for the number of correct items for the CHeKs questions were computed. The mean, standard deviation, and range of scores are shown in Table 6. A paired samples t test was conducted to examine for differences in pre- and post-intervention summary scores. The number of items answered correctly pre-intervention (M=14.71, SD=3.1) compared to post-intervention (M=17.94, SD=2.16) was statistically significant (t[16] = -8.765, p<0.001) (see Table 7).


The primary focus of this project was implementation of an educational intervention for patients with ESRD who were receiving hemodialysis as their treatment of choice. Utilizing the CHeKs tool allowed for pre- and posteducational intervention results to be compared and to identify improvements in hemodialysis and fluid restriction knowledge.

Results of the study indicated a statistical significance of increased knowledge of hemodialysis treatment. Questions on fluid or diet restrictions were used for this study. Application of the educational intervention in a chronic hemodialysis setting provides an appropriate strategy to increase patient knowledge regarding hemodialysis treatment and fluid restriction. Clinical education supports improvement in patient's self-efficacy and fluid restriction management, and reinforces lifestyle changes dictated by ESRD and hemodialysis (Cristovao, 2015). By helping patients and reinforcing continued education, patients become more conscious of the choices they make for improved adherence to their prescribed fluid restriction and hemodialysis regimen. Failure to comply with fluid restrictions places patients at risk for fluid overload, visits to the emergency room, and admission to the hospital. Educational interventions in a chronic care clinical set ting are most effective when provided before the initiation of dialysis and on a continuous schedule (Cristovao, 2015). Effective education is measurable by the goals of patient outcome and when adherence to the treatment regimen is achieved.

Although not statistically significant, improvements in fluid restriction adherence were noted. The I DWG mean of 1.74 kg was less than the target goal of 2 kg or less. In Weeks 2 and 3, 82.4% to 88.2% of participants met fluid adherence goals for the second and third days of weekly dialysis treatment. Only six (35.3%) participants met fluid adherence goals for the first day of dialysis for Weeks 2 and 3. A comparison of the rate of fluid adherence for the first and last four dialysis treatments indicated improvements in fluid adherence over the course of the project.

Nursing Practice

Education is the best tool for preparing a patient to adapt to the change of living with the need for hemodialysis three times weekly, and to hopefully live a healthier and longer life (Cristovao, 2015). Educating patients on self-care is important. It is also important to recognize that non-adherence is not necessarily irrational or misguided behavior. Non-adherence is highly influenced by patient knowledge, attitudes towards their illness, past experiences with their illness, and the treatment associated with the illness (Khalil, Darawad, Al Gamal, HamdanMansour, & Abed, 2013). Educational interventions will assist patients who are non-adherent to learn the important steps to stop the cycle of repeating behavior that is not healthy or safe. Patients must be willing and capable of participating in their care. Application of educational interventions in a chronic clinic setting can provide tools to increase adherence, longevity, and positivity in the patients (Cristovao, 2015). Numerous studies suggest that educating the patient with ESRD regarding fluid restriction adherence can have positive outcomes. The morbidity, mortality, and financial burden associated with CKD makes this diagnosis a healthcare priority. Educational intervention programs, especially when education is specific to the disease process, are imperative for better patient outcomes (Khalil et al., 2013). Identifying factors that may worsen dietary and fluid non-adherence may lead to improved therapeutic interventions within the prescribed renal regiment and patients reconsidering their personal goals within the context of living with a chronic illness (Khalil et al., 2013).

Recommendations include providing one-to-one educational interventions to patients who are identified as high risk for nonadherence to their fluid restriction prescription. One-toone sessions may need to be considered when educating higher risk patients who are not compliant with their prescribed renal treatment and helping patients develop a plan of action to improve their fluid restriction adherence. The action plan should be reviewed regularly by the healthcare team in the chronic hemodialysis center and updated as needed for a positive outcome. Implementation of updated educational interventions assures patients are receiving the latest information to help them achieve their goals and live longer, healthier lives.

Study Limitations_

Study limitations include the small sample size, duration of the study, and the limited sample. A small sample size may reduce the strength of a study and increase the margin of error, which can render the study ineffective. Another limitation of the study was the duration of the study. Increasing the duration of the study would provide a longer period for reinforcement of education and collection of outcome information. Finally, the use of one hemodialysis center was also a limitation.


ESRD presents ongoing challenges for the healthcare community worldwide. Increasing educational interventions in chronic hemodialysis centers can provide a stable foundation for patients on hemodialysis to increase adherence to their renal regimen, with a strong reference to the fluid restriction prescription. Regular implementation of educational interventions may help improve self-management skills and motivate patients to participate in their own renal treatment for optimal health and outcomes, such as prevention of emergency room visits, better utilization of medical resources, and minimizing the intrusion of the renal disease into their preferred lifestyles.


Cavanaugh, K.L., Wingard, R.L., Hakim, R.M., Elasy, T.A., & Ikizler, T.A. (2009). Patient dialysis knowledge is associated with permanent arteriovenous access use in chronic hemodialysis. Clinical Journal of the American Society of Nephrology, 4(5), 950-956. doi:10.2215/CJN.04580908

Cristovao, A. (2015). Fluid and dietary restriction's efficacy on chronic kidney disease patients in hemodialysis. Revista Brasileria de Enfermagem, 68(6), 1154-1162. doi: 10.1590/0034-7167.20 15680622i

End Stage Renal Disease (ESRD) Network of Texas. (2018). Patient education. Dallas, TX: Author. Retrieved from patients-families/patient-education

Figueiredo, A.E., Goodlad, C., Clemenger, M., Haddoub, S.S., McGrory, J., Pryde, K., ... Brown, E.A. (2012). Evaluation of physical symptoms in patients on peritoneal dialysis. International Journal of Nephrology, 2012, 305424. doi:10.1155/ 2012/305424

Khalil, A.A., Darawad, M., Al Gamal, E., Hamdan-Mansour, A.M., & Abed, M.A. (2013). Predictors of dietary and fluid non-adherence in Jordanian patients with end-stage renal disease receiving hemodialysis: A cross-sectional study. Journal of Clinical Nursing, 22(1-2), 127-136. doi:10.1111/j.13652702.2012.04117.x

Ma, L.C., Chang, HJ., Liu, Y.M., Hsieh, H.L., Lo, L., Lin, M.Y., & Lu, K.C. (2013). The relationship between health-promoting behaviors and resilience in patients with chronic kidney disease. Scientific World Journal, 2013, 124973. doi: 10.1155/2013/124 973

National Kidney Foundation (NKF). (2015). KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update. American Journal of Kidney Diseases, 66(5), 884-930.

Theofilon, P. (2011). Noncompliance with medical regimen in hemodialysis treatment: A case study. Case Reports in Nephrology- 2011, 145-150. doi: 10. 1155/2011/476038

Jewell Robinson Parker, DNP, FNP-BC, APRN, CNN, is a Nurse Practitioner, Emergency Department, Piedmont Hospital, Newnan, GA.

Statement of Disclosure: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation can be found on page 48.
Table 1
Mean, Standard Deviation, and Range for Demographic Variables

Variable                    M        SD       Range

Age                         55.47    12.57    29 to 73
Years on hemodialysis       4.79     4.12     0.5 to 15

Table 2 Frequencies of Co-Morbidities (N=17)

                                 n        %

Heart disease                    1        5.9

Hypertension                     4        23.5

Hypertension, hemodialysis,      3        17.6

Heart disease, hypertension      2        11.8

diabetes, hypertension           7        41.2

Table 3

Mean, Standard Deviation, and Range for Weights (N=17)

Variable                         M        SD       Range

Dry weights (Kg)                 93.12    26.50    54 to 141
Pre-dialysis weights (Kg)        95.28    26.92    56 to 145
Post-dialysis weights (Kg)       93.46    26.83    54.01 to 141.98

Table 4
Frequency and Percentages for Pre-Dialysis Fluid Compliance (N=17)

                            IDWG Goal
                            Met               Not Met
                            n        %        n         %

Dialysis Treatment

Week 1, Day 2               12       70.6     5         29.4
Week 1, Day 3               15       88.2     2         11.8
Week 2, Day 1               6        35.3     11        64.7
Week 2 Day 2                14       82.4     3         17.6
Week 2, Day 3               15       88.2     2         11.8
Week 3, Day 1               16       35.3     11        64.7
Week 3, Day 2               15       88.2     2         11.8
Week 3, Day 3               15       88.2     2         11.8

Table 5 Paired Sample t Test of Pre- and Post-Interventions Kt/V (N=17)

Variable                         M        SD

Pre-Intervention Kt/V            1.56     0.35
Post-Intervention Kt/V           1.54     0.29

Notes: [t.sub.16] = 0.482, p>0.05

Table 6
Means, Standard Deviation, and Ranges of Summary Survey Scores

Variable                  M        SD       Range

Pre-Test Scores           14.70    3.10     1 to 23
Post-Test Scores          17.94    2.16     1 to 23

Table 7
Paired Sample t Test of Pre- and Post-Interventions
Survey Scores

Variable                         M        SD

Pre-intervention scores          14.71    3.10
Post-intervention scores         17.94    2.16

Notes: [t.sub.16] = -8.765, p<0.000.
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Author:Parker, Jewell Robinson
Publication:Nephrology Nursing Journal
Article Type:Report
Date:Jan 1, 2019
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