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The Problem and Significance
Chronic kidney failure is a disease characterized by severe limitations in the working capabilities of a patients kidneys. This disease frequently occurs among elderly patients between ages 65 and 74, due to the natural aging of organs, and factors that contribute to damaging and interrupting the organs work, such as trauma or diabetes (Jha et al., 2014). Mortality rates for patients with kidney failure are 20-25% after one year of treatment. Less than 35% of patients survive for 5 years or more (Jha et al., 2014). The primary method of treating chronic kidney failure is through dialysis procedures. This involves the use of a machine or a catheter that replaces some or all of kidney functions, removing minerals and toxins from the bloodstream and enabling survival.
Hemodialysis is one of the two primary methods of treating kidney failure. As the name suggests, it involves filtering blood through a machine that acts as an artificial kidney. It is an intrusive procedure, as to be effective, the procedure requires vascular access. Using already existent blood vessels for this procedure is recommended, as repetitive penetrations and high pressures will make the vessel collapse.
Two practices ensure secure vascular access. One of them is the creation of an arteriovenous fistula (AVF) through surgical means a specialized blood vessel that is used solely for hemodialysis. The other method is called the AV graft it works on similar principles to AVF, only in this case the organic fistula is replaced with a nonorganic plastic tube. In both cases, the determining factor is the maturation rate of the new vessel if it does not mature, then it requires replacement, often with severe complications to a patients health (Jha et al., 2014).
As it stands, US hospitals have adopted the AVF First policy. It prioritizes the use of arteriovenous fistulas over AV grafts, with the letter used only if the AVF failed to mature. As it stands, the rate of successful AVF operations, where the vessel managed to become fully mature, is over 65% (Ravani et al., 2015). The purpose of this paper is to propose a nursing intervention that will increase the likelihood of AVF maturation, and it increases the proportion of adult hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access.
Target Population and Setting
Since the primary demographic for chronic kidney disease and kidney failure are patients aged between 65 and 74 years of age, they will be the target population of this research. Statistics show that females are more prone to CKD than males due to the prevalence of diabetes in female patients. Diabetes damages kidneys, thus contributing to the development of kidney disease and failure (Jha et al., 2014).
The setting for this research will be Mayo Clinic. It is regarded as one of the best clinics that specialize in treating kidney diseases. Using this institution as a set will allow the researchers to compare the results of their intervention to the highest-quality standard procedures, to accurately determine the interventions efficacy (Ravani et al., 2015).
Application to Role of Advanced Practice Nursing
Advanced practice nursing is very important in all medical care, especially so in situations when handling elderly patients, whose bodies and minds are more vulnerable due to old age and various health problems following them. Considering the subject of this research, the nurses would be expected to know how to expertly handle hemodialysis apparatuses, know how to instruct the patients and their families on handling them should they be able to purchase and install one at home, assess and perform cannulation procedures, and monitor progress (Sabet et al., 2015). This research proposes an intervention that involves accurate assessment of AVF maturation rates by the nurses, with an Advanced Practice Nursing degree being a requirement for the interventions success.
Theoretical Framework
For this research, Jean Watsons nursing theoretical framework is deemed optimal, as it offers a clear and concise structure to the research and underlines the four major concepts of nursing that are going to be applied. Jean Watson is considered one of the major theorists in nursing, and her framework is concise and succinct at the same time. This research will follow the structure suggested in this framework, which involves assessment, planning, intervention, and evaluation (Alligood, 2014). The prelude of this research applies to all four pillars of nursing, with the focus on Health and Nursing. This research promotes health as it is aimed to reduce the number of rejected arteriovenous fistulas in elderly patients, and at the same time, it focuses on the role of nursing in achieving that goal. At the same time, successful hemodialysis procedures would allow the patient an increased degree of personal autonomy and safety, thus contributing to Human Being and Society/Environment concepts mentioned in Watsons framework (Alligood, 2014). While the success of the operation is largely related to the skill of the surgeon and other factors, such as the patients physical characteristics, there are ways for nurses to significantly improve the chances of AVF maturation. To summarize, this theoretical framework was chosen since it provides a blueprint on which it is possible to construct the research, as well as the necessary theoretical concepts that can be used to explain and justify said intervention.
Systematic Review of Literature
Chronic Kidney Disease: Global Dimensions and Perspectives
This literature source was published in The Lancet medical journal in July 2014. It is a peer-reviewed and recent source that can be used in this research. It provides information on Chronic Kidney Disease rates and perspectives for the future. This information is important as a premise to the research as it gives relevance and justification to increase the proportion of adult hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access by improving successful AVF maturation rates (Jha et al., 2014).
Survey of Factors that Affect the Arteriovenous Fistulas Survival in Semnan and Mahdishahr, Iran
This source covers the topic of factors that affect survival rates for patients that use arteriovenous fistulas for their hemodialysis. The work was published in 2015 in the Academic Journal of Surgery a highly-renowned and trusted source of peer-reviewed medical knowledge. Although the study was conducted in Iran, its results apply to the US standards as it was conducted in a high-level hospital setting with impressive survival rates. This source states that survival rates are largely connected to chances of successful AVF maturation and confirm that skill and experience of nurses performing cannulation procedures can affect chances of successful AVF maturation in a positive way (Sabet et al., 2015).
Fistula First Initiative: Advantages and Pitfalls
This source was published in Clinical Journal of American Society of Nephrology in 2014 and is the source that gave the idea of nursing intervention through the improvement of assessment and implementation of cannulation in AVF to increase the proportion of adult hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access. This study found that accurate assessment and proper cannulation performed by experienced nurses improve successful AVF maturation rates, which is used as a basis for this research (Charmaine, 2014).
Cannulation Technique Influences Arteriovenous Fistula and Graft Survival
This study was performed and published in 2014 by Kidney International Journal. It is a credible and reliable peer-reviewed source of information that offers more facts to support the intervention proposed in this research (Parisotto et al., 2014). The reason for finding several sources by different authors is to provide unbiased and differentiated support for the planned nursing intervention.
Associations between Hemodialysis Access Type and Clinical Outcomes: A Systematic Review
This study was published in 2015 by the Clinical Journal of American Society of Nephrology, which is a dedicated academic journal that focuses on nephrology and kidney problems. This study offers insights on the effectiveness of standard Hemodialysis procedures and clinical outcomes, which is important for this research. It provided an understanding of the techniques and medical procedures used at the moment and served as an initial framework that would be improved upon (Ravani et al., 2015).
Intervention
As it was already mentioned, one of the major ways for a nurse to positively impact the chances of the arteriovenous fistula maturation process is through high-quality cannulation procedure. Some researches have shown that in cases where the procedure was performed by experienced and highly-skilled nurses, chances of AVF maturations improved from circa 60-65% to around 80%. A 15% net increase is a serious improvement and should be invested in.
This research proposes grading the nursing personnel of Mayo clinic into 3 competence categories, based on their education, skill, and experience in cannulation assessment and procedure, with only the highly competent nurses being allowed to cannulate new AVF. Aside from that, the decision on whether or not the AVF is ready for cannulation should not be based solely on the amount of time that passed after the operation, but rather on case-by-case analysis and deliberation.
Expected Outcomes
It is expected that the intervention would be successful in improving the situation with AVF maturation rates and increase the chances of success from 65% to about 80% (Charmaine, 2014). Succeeding in this goal will lower several patients that would require an AV graft due to the fistulas failure to maturate properly, and thus increase the number of patients that use arteriovenous fistulas as the primary mode of vascular access. Since AVF is much safer and less prone to complications and contamination than the AV graft, it can be safely assumed that successful intervention will also increase survival rates and efficacy of treatment. Replacing the failed AVF with an AV graft is associated with numerous healthcare risks and additional expenses for the operation. Intervention success or failure will be measured in the percentage of successful AVF maturations per 1,000 patients requiring hemodialysis.
Evaluation Plan
To determine whether the intervention was a success or failure, a test number of patients with chronic kidney disease or kidney failure will be treated using the new nursing intervention model. The results would be compared to the control group, which would be using standard practices for AVF care used in Mayo Clinic. The statistics of AVF maturation failure would then be compared between the two groups, to determine the success or failure of the intervention. To eliminate bias and random spikes in successes or failures of the intervention based purely on the condition of a patients cardiovascular system, the intervention must be applied for a prolonged period.
References
Alligood, M.R. (2014). Nursing theorists and their work. New York, NY: Elsevier.
Charmaine, E.L. (2014). Fistula first initiative: Advantages and pitfalls. Clinical Journal of American Society of Nephrology, 2(5), 1043-1053.
Jha, V., Garcia-Garcia, G., Iseki, K., Li, Z., Naicker, S., & Yang, C.W. (2015).
Chronic kidney disease: global dimension and perspectives. The Lancet, 382(9888), 260-272.
Parisotto, M.T., Schoder, V.U., Mariunis, C., Grassmann, A.H., Scatizzi, L.P., &
Marcelli, D. (2014). Cannulation technique influences arteriovenous fistula and graft survival. Kidney International, 86(4), 790-797.
Ravani, P., Palmer, S.C.,Oliver, M.J., Quinn, R.R., MacRae, J.M., & James, T.M.
(2015). Associations between hemodialysis access type and clinical outcomes: a systematic review. Clinical Journal of American Society of Nephrology, 24(3), 465-473.
Sabet, B., Soltani, S., Mafi, A.,Yaghmaie, S., Ghorbani, R., & Keramati, A. (2015).
Survey of factors that affect the arteriovenous fistulas survival in Semnan and Mahdishahr, Iran. Academic Journal of Surgery, 2(1), 14-17.
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