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7/29/2019 Self Management Strategies of Patients on Long Term Dialysis
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SELF MANAGEMENT
STRATEGIES OF PATIENTS ON
CHRONIC DIALYSIS
Ma. Nisan T. Manauis, RN, MAN CRNC
Board Member, RENAP
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What does the FUTURE hold?
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Patient Adaptation to Disease
Seek medicalhelp
Follow courseof treatment
Do best torecover
ESRD
Patient
Alerted tomany
complications
Managefluid
restrictions
Managedietary
regulation
Managemedication
regimen
Acute Diseases Chronic Diseases
Burks, 1999; Feste & Anderson, 1995; Holman & Lorig, 2000; Singleton, 2000
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Self Management / Self Care
Individual's efforts to
advance optimal health
prevent illness
recognize symptoms as early as possible cope with or manage chronic conditions
Can include:
self-monitoring and assessment
symptom perceptions and labeling
evaluation of severity
evaluation and selection of treatment alternative
Easton, 1993; Woods, 1989
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Benefit of Self Management
Patients who engage in
self-management of
their disease and/or its
treatment are more likelyto enjoy improved
health-related quality of
life
QUALITY
OF LIFE
SOCIAL
& ROLE
PHYSICAL
& MENTAL
BIOLOGIC
HEALTH RELATED QOL
(Horsburgh, 1999; Meers et al., 1996)
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Challenge to Self Management
One reason for the difficulty may be
connected with Parsons' (1951;
1975) conceptualization of the "sick
role. Patients are to be relieved of their usual
role responsibilities so that they can turn
their energies to recuperation
Patients are expected to seekappropriate health care and to follow the
recommendations of their health
providers to "get well" as quickly as
possible.
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Challenge to Self Management
Manner in which dialysis treatment is
usually administered
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HEALTH CARE MANAGEMENT
STRATEGIES OF LONG-TERM DIALYSIS
SURVIVORS
Curtin, Roberta Braun; Mapes, Donna L; Thomas-Hawkins,
Charlotte; August 2001
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Purpose
Explore the process by which long-term
survivors of dialysis manage their illness,
its symptoms, and its treatment
Identify common characteristics, attitudes,
beliefs, and behaviors among long-term
survivors that may be related to their long-
term survival
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Study Method
Sample
Selected based on the unique knowledge,
perceptions, and perspectives that they are presumed
to possess ESRD patients who had been treated with any
dialysis modality for a cumulative total of 15 or more
years
Recruited via a modified "snowball" technique: a fewmembers of the phenomenal group were first
identified and these members, in turn, identified
others who could also be expected to be "information-
rich"
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Study Method
Sample
18 patients currently maintained on
hemodialysis
8 patients reported having received peritonealdialysis, and 3 reported having received home
hemodialysis in the past
12 patients reported receiving kidney transplants;
several receiving more than one
DM not the primary renal disease
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Demographics
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Demographics
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Study Method
Interviews
Topical, semi-structured interviews with key
informants
2 to 6.5 hours
Broad question that introduced the general
topic
Probes and open-ended follow-up questionswere used to gently direct the discussion
Audiotaped and fully transcribed
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Findings
6 Self Management Strategies
Impression Management
Selective symptom report and management
Vigilant oversight of care
Proposal of treatment by patient
Confrontation of system--active self-advocacy
Independent adoption of treatment/use of
alternative therapies
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Impression Management
Monitoring, manipulation, and deliberate management ofself-presentation
Orchestrating interactions with health care providers in an
attempt to improve chances of receiving optimal care
Actively projecting characteristics they thought were most
valued or appreciated by providers
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Impression Management
I am treated in a way that I would not put up
with if I was in a different context. But because
my life depends on them, I am quiet
You've got this problem where you will die if you
don't have dialysis--you have got to go to this
facility and depend on these people. Then you
have to get along with them day in and day out,
no matter what kind of people they are or what
their competency is.
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Selective Symptom Report
and Management
Closely attuned to physical selves -
alert to the warnings of their bodies
and subtle signals that something is
wrong
Employing a kind of triage of their
symptoms before deciding whether toreport them to a health care
professional or manage the situation
on their own right
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Selective Symptom Report
and Management ... they know if I ever have a problem, I call `em. I mean,
I don't sit around and wait for the month--the end of the
month to tell them. I call them. I put them on the spot
right away. So they pretty much always know where I am
at.
I say ... you are my doctor. You are in charge because
you are my doctor. But when I talk to you, I want you to
listen to me and give me the time, because I have beenso many years in this business that I am very much in
tune with my body.
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Vigilant Oversight of Care
Attentiveness to the care that was
provided to them by all levels of providers
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Vigilant Oversight of Care
I think because of my high control needs, I've never been
able to sleep on dialysis.... I think what it is, I'm afraid
that I will die if I go to sleep. You know, I'm out of control
and I am not watching what is going on and I just can't
do it.
I want to learn and I want to know. When I sit in that
chair, I'm watching. You may see me lying back, but I'm
watching, you know. I make sure there is no air comingback to the arterial line, because if they start fumbling
with the bag and air is getting introduced into the line,
you know. I'm always watching everybody.
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Proposal of Treatment by Patient
Actively suggesting treatments, interventions,
medications, or other alternative approaches to
their care was reported by 15 of the 18
respondents
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Proposal of Treatment by Patient
But I go, if I hear anything, you know--I
always go to them and talk to them. I don't
care what they say but I tell them if I heard
this new--I heard this. And you know, theylisten ... I don't know anything about the
heart, but if I hear anything that, you know,
that's new, I will ask the doctor too.
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Confrontation of System - Active
Self-Advocacy
Confronting providers either by declining a
particular activity, treatment, intervention,
or by insisting that treatments be carried
out in what they considered the "correct"manner
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Confrontation of System-Active
Self-Advocacy I watch them like a hawk. This one nurse I don't
particularly like went--I felt like she needed to
change her gloves before she came to me and
she'd emptied all the garbage cans, andgranted, all she had to do was tape me up, but I
still didn't want her around me if she'd been
emptying the garbage cans. And that takes a lot
of--"oh god, how do I say it? Do I say it? Do Isay it?" And so I say, "I don't think you should be
touching me with it."
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Independent Adoption of Treatment
/ Use of Alternative Therapies
When unable to obtain the
treatments they felt they needed
from health care providers via anyof the methods already
discussed, patients chose to be
non - compliant with prescribed
therapies or go outside of thesystem to get satisfaction
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Independent Adoption of Treatment
/ Use of Alternative Therapies
I started tapering off my blood pressure
meds myself and I would skip days so I
was taking it every other day instead of
every day. And my blood pressure stayedfine on the machine, so then I stopped
taking it completely and my blood pressure
behaved. So then I told my doctor about itinstead of telling him ahead of time
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Discussion
HealthcareSystem
Patient
Self
Mgt
Health -care
Provider
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Discussion
Nursing Tenet of
Patient Dependency
& Passivity
Strict Patient
Compliance
Clinic Atmosphere
Of Dependency
& Passivity
BARRIER
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Conclusion: Nursing Implications
SELFIMPRESSION
UNMASK
THE TRUTH
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Conclusion: Nursing Implications
SELECTIVE REPORTING
MANAGEMENTSYMPTOM TRIAGE &
BASIC SELF CARE
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Conclusion: Nursing Implications
USE OF ALTERNATIVE
THERAPIES
OPEN COMMUNCATION
TIME & INFORMATION
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SELF-MANAGEMENT KNOWLEDGE AND
FUNCTIONING AND WEIL-BEING OF
PATIENTS ON HEMODIALYSIS
Roberta Braun Curtin, Dara C. Bultman Sitter
Dorian Schatell, and Betty A, Chewning
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Goal
Describe the association between
hemodialysis patient self-management
behaviors and functioning and well-being
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Objectives
List self-management behaviors used by
patients on hemodialysis.
Compare and contrast protective/proactive
self-management strategies & cooperative
/ participatory self-management strategies.
Discuss the significance of patient
knowledge and physical and mentalfunctioning.
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Method
Sample
372 patients from 15 facilities
At least 1 year in dialysis and 18 y/o
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Self Management Strategies
Suggestion of Treatment to Provider
Adoption of Alternative Therapies to
Manage Health Issues
Selective Symptom Management
Assertive Self Advocacy
Impression Management Oversight of Care
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Other Points of Interest
Sources of Information Acquisition
Participation in Self Care Activities during
Hemodialysis
Time on Dialysis
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Results
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Results
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Results
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Results
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Results
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Results
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Results
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Results
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Results
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Results
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Results
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Discussion
The ability to measure self-
management strategies among
patients on hemodialysis is an
important first step towardassessing their involvement in
their own care and treatment.
The logical next step is to designand implement effective
interventions to improve patient
outcomes.
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Discussion
Cooperative/participatory type of self
management is both positively associated
with physical functioning and is among the
more often performed self-managementactivities.
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Discussion
An equally important finding has to do with
the protective/proactive self-management
strategies that were less utilized.
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Discussion
The five topic categories queried clearly
relevant to patients on hemodialysis.
Anemia
Diet and Medication
Kidney Function
Dialysis Treatment
Rehabilitation
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Practical Nursing Implications
Self Management Activity Survey is useful in
identifying and characterizing the kinds of
strategies chronic kidney disease (CKD) patients
are currently employing in their attempts to selfmanage their care and to interact productively
with their care providers
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Practical Nursing Implications
Educational and
counseling interventions
might be initiated to help
CKD patients improve theirapproaches to self
management and to
minimize their need forprotective/proactive
strategies
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Practical Nursing Implications
The association bet.participatory strategies for self-
management & better
functioning and those between
the more protective / proactivestrategies & poorer functioning
underscore the importance of
good communication between
patients and the health careteam on self management
behaviors, physical and mental
health functioning overall.
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--NISAN MANAUIS