International Journal of Research in Medical Sciences

Nurjannah I et al. Int J Res Med Sci. 2016 Oct;4(10):4453-4457

www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20163310
Research Article

The most frequent diagnosis on patients undergoing hemodialysis

Intansari Nurjannah1*, Fitri Mailani2
1
Department of Basic and Emergency Nursing, Faculty of Medicine, Universitas Gadjah Mada, Indonesia
2
School of Nursing, Amanah Padang, Indonesia

Received: 16 August 2016

Revised: 17 August 2016
Accepted: 10 September 2016

*Correspondence:
Dr. Intansari Nurjannah,
E-mail: intansarin@ugm.ac.id

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Hemodialysis is a routine medical intervention for patient with chronic renal failure. Patients may
responds differently when they undergoing this procedure. Investigating nursing diagnosis and collaborative
diagnoses during hemodialysis procedure need to be explored. The objective of this research is to determine the
sequence of nursing diagnosis and the collaborative diagnosis identified among kidney disease patients who are
undergoing hemodialysis.
Methods: This case study research involving 62 respondents. Research was conducted between June and July 2015.
The respondents’ cases were studied to determine what nursing diagnoses and collaborative diagnoses, using a six-
step diagnostic reasoning method.
Results: Result of this study showed 27 nursing diagnoses and 7 collaborative diagnoses experienced by the patients.
The six most commonly experienced nursing diagnoses were: activity intolerance (100%), nausea (96.8%), risk for
impaired skin integrity (91.9%), impaired urinary elimination (82.3%), insomnia (77.4%), and sexual dysfunction
(58.1%).
Conclusions: There were 27 nursing diagnoses and 7 collaborative diagnoses that were experienced by patients who
were undergoing hemodialysis.

Keywords: Diagnosis, Hemodialysis

INTRODUCTION 2011 there were reported 23,361 cases, and in 2013, there
were 24,141 patients reported.2
The rise in the number of patients with chronic kidney
failure will result in a rise in the number of patients The data from Basic Health Research (RISKESDAS) in
undergoing hemodialysis. In 2009, in the United States of 2013 indicated that the prevalence of chronic kidney
America, 570,000 people underwent dialysis treatment or disease in West Sumatra was 0.2 and it was estimated
kidney transplants, while in Great Britain it is estimated that the number of cases would rise every year.3
that there were approximately 50,000 patients with
kidney diseases.1 Based on data of the development and service of the
hemodialysis unit at RSUP Dr. M. Djamil General
As seen in data from the National Insurance Program Hospital in Padang, in 2011, there were 112 patients,
(ASKES), Indonesia is one of the countries that has a while in 2012 there was an increase to 126 patients, and
relatively high rate of patients suffering from chronic in 2013 there were 133 patients undergoing routine
kidney disease. In 2010, there were 17,507 patients; in hemodialysis.

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The rising number of hemodialysis patients calls for hemodialysis process and teach the patients about correct
attention, especially for this particular population. diet and limitations of liquids, and provide support for
Attention can be shown in the increase in nurses and self-care, while overseeing the entire process.8
nursing services for this population. Nurses play a major Comprehensive nursing care is expected to reduce and
role in the nursing care. The quality of nursing care prevent complications experienced by the patient during
indicates whether the nurse understands the problems the process of the therapy to improve the quality of life of
experienced by every patient undergoing hemodialysis. the hemodialysis patient.
Every patient is unique and responds differently to the
hemodialysis treatment. Individual patient responses The nursing profession uses the nursing process as the
present situations where the nurse must make conclusions conceptual and practical framework in caring for patients.
regarding the nursing or collaborative diagnoses The nursing process consists of assessment, diagnosis,
experienced by the patient. planning outcomes, planning intervention, implement-
tation, and evaluation.9
At the present time, the most commonly encountered
problem of this population has not yet been identified. Experience indicates that nurses often have difficulties
The identification of this problem is a diagnostic process diagnosing patients. This may be caused by an
that involves several stages. These stages are part of the improperly structure of nursing assessment. The
diagnostic reasoning process. There are various methods researcher’s experience indicates that assessments
of diagnosis, however basically an accurate diagnosis conducted by nurses are not always sequential or related
must lead to appropriate nursing intervention that to nursing diagnoses. Often nurses have specific data, but
addresses the patients’ problems. do not know how that data supports a nursing diagnosis
or the nurse may suspect a diagnosis, but does not know
Hemodialysis is a therapeutic process that replaces poor what data is needed to support that diagnosis.10
functioning of the kidneys with the use of a
semipermeable membrane that functions as a nephron to METHODS
remove metabolism waste products and correct
imbalances of liquids and electrolytes in patients who Research place and sample
suffer from kidney failure.4 The hemodialysis process can
be conducted two or three times every week and requires This research project is descriptive and quantitative with
three to five hours for each session. The results of the a cross-sectional approach. It was conducted at Dr. M.
Dialysis Consensus state that adequate hemodialysis can Djamil General Hospital in Padang from June through
be achieved with a total of 10-12 hours per week.6. July 2015. A convenience sampling technique was used
for chronic kidney failure patients who were undergoing
For patients with chronic kidney disease, hemodialysis hemodialysis at Dr. M. Djamil Hospital in Padang and
will not change the course of the kidney disease and who were willing to participate in the research project.
reinstate kidney function. Patients will continue to
experience a number of problems and complications.5 The inclusive criteria for participants were that the
Hemodialysis patients can be categorized as patients with chronic kidney failure patient was undergoing
unique conditions because they must spend a hemodialysis and was in a stable condition. The exclusive
considerable amount of time in the hospital, that is, two criteria were that the chronic kidney failure patient who
to three sessions each week to wash their blood, where was undergoing hemodialysis at the time of the data
each session requires four to five hours. This routine must collection was experiencing a decline in consciousness.
be continued for the remainder of their lives and requires
considerable time and expense. Recruitment of respondents

The hemodialysis nursing practice is an advanced nursing Recruitment of prospective respondents was conducted
practice that is conducted by dialysis nurses, including by (third party) nurses who were responsible for treating
practicing nurses and specialist clinical nurses who have the patients. Prospective respondents were given
certification in dialysis training.7 information pamphlets and explanations about this
research project. The responsible nurses informed the
Hemodialysis nurses have an important role as providers researchers which prospective respondents were willing
of nursing care, health advocates, consultants, and to participate in the research project. The researchers then
educators who assist patients to achieve a better quality met with the patients and prepared the informed consent
of life and to prevent the occurrence of complications that statements for signature.
may affect the improvement of the quality of life of
hemodialysis patients.7 Data collection

Hemodialysis nurses must have the professional Data was collected after the patients signed the informed
capabilities to prepare the patient prior to hemodialysis, consent statements by a member of the research team
monitor the condition of the patient throughout through an assessment process that consisted of a

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physical examination, observation and interview. The Table 1: Frequency distribution of demographic
researchers used a six-step diagnostic reasoning method characteristics.
and recorded the collected data on data collection sheets
as material that supported a nursing diagnosis. Characteristics of respondents f %
Age (years)
Assessment was made in accordance with the patient’s <25 - -
condition, for example, if the required data had already 26-35 10 16.1
been recorded, then the patient was not reassessed, unless 36-45 8 12.9
clarification was needed. 46-55 16 25.8
56-65 20 32.3
The 6 steps method of diagnostic reasoning consists of 11: >65 8 12.9
Gender
1. Classify data and use the Intan’s Screening Male 30 48.4
Diagnoses Assessment (ISDA) or the book The fast Female 32 51.6
Method of Formulating Nursing Diagnoses for Marital Status
Diagnostic reasoning in Nursing if necessary to Married 56 90.3
find the possible nursing diagnoses and Widowed/divorced 4 6.5
collaborative problems Single 2 3.2
2. Activate possible nursing diagnoses and Education
collaborative problems Elementary School 13 20.9
3. Read or learn from appropriate references about Junior High School 17 27.4
those possible nursing diagnoses and collaborative Senior High School 28 45.2
problems and determine: University 4 6.5
Employment
a) If the diagnoses are confirmed Employed 33 53.2
b) If the diagnose are ruled out Unemployed 29 46.8
c) If more assessment is needed related to those nursing Length of time HD (year)
diagnoses and/or collaborative problems <1 22 35.5
1– 3 21 33.9
4. Using the Poster “The Map of Nursing Diagnoses ‘ >3 19 30.6
for nursing diagnoses which have an ‘A’ category
5. Continue focus assessment if necessary (for nursing Nursing diagnoses and collaborative diagnoses that
diagnoses and collaborative problems of category A arise for patients undergoing hemodialysis
and C)
6. Label the diagnoses. Nursing diagnoses and collaborative diagnoses that arose
amongst the research study of 62 chronic kidney failure
Data analysis patients who were undergoing hemodialysis can be seen
in Table 2.
Results of the data assessment were then analysed in the
order of the diagnosis that was most frequently In the Table 2 it can be seen that the six diagnoses that
experienced by patients to the least frequently are most frequently experienced by chronic kidney failure
experienced diagnosis. patients undergoing hemodialysis are Activity Intolerance
(100%), Nausea (96.8%), Risk for Impaired Skin
Ethical consideration Integrity (91.9%), Impaired Urinary Elimination
(82.3%), Insomnia (77.4%), and Sexual Dysfunction
Ethic approval sought through Ethic committee in (58.1%). The collaborative diagnosis that is most often
Faculty of Medicine Gadjah Mada University, Indonesia. identified is PC: Hypernatremia (54.8%).

RESULTS DISCUSSION

Demographic Characteristics Research results indicate that the chronic kidney failure
patient respondents undergoing hemodialysis experience
The results of the research regarding the respondents’ more nursing diagnoses (27 kinds) in comparison to
characteristics showed that the majority of the collaborative diagnoses (7 kinds).
respondents were between 56-65 years of age (32.3%),
female (51.6%), had achieved high school education One nursing diagnosis that was experienced by all
(45.2%), married (90.3%), employed (53.2%), and had respondents was Activity Intolerance. All of the
undergone hemodialysis for <1 year (35.5%). The respondents complained that they were limited in
frequency distribution of the respondents’ characteristics conducting activities because of physical problems
can be seen in Table 1. related to their disease. This limitation restricted their

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ability to engage in their daily activities. These findings complications.19 According to Carpenito, one of the signs
were concurrent with research conducted by Pakpour in of hypernatremia is the rise of blood pressure. 19 As
evaluating the quality of life of chronic kidney failure almost all of the respondents had higher than normal
patients who are undergoing hemodialysis.12 Pakpour blood pressure, it is understandable that PC:
found that the limitation of physical activity had the Hypernatremia was the collaborative diagnosis that was
worst score of amongst all of the domains because it most frequently identified by the researchers.
shortened the patients’ working and activity time and
limited the range and difficulty of physical activity that Table 2: List of nursing diagnoses and collaborative
was possible.12 diagnoses of chronic kidney failure patients
undergoing hemodialysis.
Activity Intolerance amongst kidney failure patients who
are undergoing hemodialysis is caused by the reduction Nursing diagnosis Frequency Percentage
of iron (Hb) levels in the blood as a result of a decrease in Activity Intolerance (D4 C4) 62 100
erythropoietin (EPO) production by the kidneys because Nausea (D12 C1) 60 96.8
the body is unable to absorb iron and there is a loss of Risk for Impaired Skin Integrity 57 91.9
blood because of other reasons. Anemia can become (D11 C2)
worse in hemodialysis patients because it is virtually Impaired Urinary Elimination 51 82.3
impossible that all of the patient’s blood can be returned (D3 C1)
to the body after hemodialysis. Some of the patient's red Insomnia (D4 C1) 48 77.4
blood cells are left behind in the dialyser or bloodline; Sexual Dysfunction (D8 C2) 36 58.1
however the amount of this loss is insignificant.13 PC: Hypernatremia 34 54.8
Acute Pain (D12 C1) 31 50
Research by Yong et al and Santos et al found that the Imbalanced Nutrition: Less Than 29 46.8
symptoms of physical disorders that chronic kidney Body Requirements (D2 C1)
disease patients who underwent hemodialysis often PC: Hypokalemia 23 37.1
complained about were sleep disorders, fatigue, pruritus, PC: Hypoxemia 20 32.3
weakness in the lower extremities that eventually Chronic Pain (D12 C1) 16 25.8
disrupted the patient’s ability to conduct daily Risk for Falls(D11 C2) 15 24.2
activities.14,15 Research by Stefanovic showed that from a Risk for Acute Confusion (D5 13 20.9
total of 58 female patients undergoing hemodialysis, 46 C4)
(79.3%) of them experienced sexual dysfunction. The Impaired Swallowing(D2 C1) 12 19.4
prevalence of sexual dysfunction amongst female patients Noncompliance (D10 C3) 11 17.7
undergoing hemodialysis is very high, reaching almost Hyperthermia (D11 C6) 10 16.1
80%. Not only female patients, but also male patients PC: Acidosis Metabolic 10 16.1
experienced sexual or erectile dysfunction.16 Ineffective Role Performance (D7 7 11.3
C3)
Almost all respondents (82.3%) experienced the nursing Risk for Spiritual Distress (D10 7 11.3
diagnosis Impaired Urinary Elimination. This result is in C3)
concurrence with research conducted by Veerappan et al, Impaired Comfort (D12 C1,2,3) 6 9.7
which found that urine elimination disorder was common Constipation (D3 K2) 6 9.7
in chronic kidney failure patients who experienced Risk for Impaired Religiosity 5 8.1
interdialytic weight gain (IDWG) and whose urine output (D10 C3)
influenced their quality of life.17 Patients who had less Risk of Vascular Trauma (D11 5 8.1
interdialytic weight gain had a higher quality of life, as C2)
did patients who had a higher volume of urine. PC: Decreased Cardiac Output 5 8.1
PC: Acidosis Respiratory 4 6.5
The increase of body weight that exceeded the Fatigue (D4 C3) 3 4.8
recommended limit of 1.5 kg had an effect on
Impaired physical mobility (D4 2 3.2
cardiovascular function and the respiratory system.18 K2)
Nausea and vomiting were also frequent problems Impaired skin integrity (D11K2) 2 3.2
experienced by patients undergoing hemodialysis. There
Risk for Infection (D11K1) 2 3.2
are several factors that cause patients to become nauseous
PC: Dysrhythmia 2 3.2
and lethargic after hemodialysis, such as hypotension, an
Risk for shock (D4K4) 1 1.6
excess of liquid intake between two sessions of
Deficient fluid volume (D2 C5) 1 1.6
hemodialysis, a problem related to dry weight,
hypertension medication, anemia, and the use of acetates Decreased cardiac output 1 1.6
(D4 C4)
in hemodialysis. The collaborative diagnosis that was
Explanation: D = Domain; C = Class.
most often experienced was PC: Hypernatremia. A
collaborative diagnosis is a diagnosis where the nurse
identifies the presence of a risk of physiological

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