ميحرلا نمحرلا ﷲ مسب AN-Najah National University Faculty ... · 2009).Several...

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بسم هللا الرحمن الرحيم

AN-Najah National University

Faculty of Nursing

in Quality of life for patient undergoing hemodialysisNorth of West Bank

Prepared by :

Ata Al-Shareef Ayman Qaisiya Sameh yahya

Supervised by:

Miss Fatimah Hersalah (RN. MSN. CNS.)

2011-First semester 2010

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Table of Contents:

No. Content Page

I. Acknowledgement 4

II. List of Abbreviations 5

III. List of Tables 6

IX. Study Abstract 7

Chapter one

1. Introduction 8

1.1 Study background 11

1.2 Significance of study 12

1.3 Aims of Study 12

1.5 Demography 12

Chapter two

2 Literature Review 13

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Chapter Three

3 Methodology 15

3.2 Study population 15

3.3 Study design 15

3.4 Sampling 16

3.5 Instrument of the study 16

3.6 setting of the study 17

3.7 Inclusion criteria and exclusive criteria 17

3.8 Data collection 18

3.9 Ethical consideration: 18

3.10 Statistical analysis 18

Chapter Four

5 Study Results 19

Chapter Five

6 Discussion 26

7 Conclusion 30

8 Study limitations 30

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9 Recommendations 31

10 References 31

Acknowledgement

To our fathers and mothers who were the kind embrace for their

sons, who supported their sons financially and emotionally to the last day

of their study. To the University to which we belong “AN-NAJAH

NATIONAL UNIVERSITY” represented by Dr.RAMI HEMDALLAH

who always support us and our faculty. To the dean of our faculty which

we appreciate her support Dr Aidah Alqaissi the person who was

the kindhearted there for all of her students , the person who taught us

the principles of research , the person who taught us this material from

Whose experience we were benefited, and for Miss Fatima Hersalah who

supervised our work and was the best supervisor, who supported us by

her experience to finish this work perfectly. To the ministry of health

which accepted us in its hospitals as guests. To all of our colleagues from

whom we were benefited in our working the project, the students who were friends

and brothers. To all of these people we present this work.

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List of Abbreviations

QOL : Quality of life

HD : hemodialysis

ESRD :End Stage Renal Disease

Pt : patient

SPSS : Statistical Package for Social Science.

No. : Number.

WB : West Bank

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List of Tables:

Table Content

Table (1) The distribution of the study sample on the question number 1

Table (2 ) The distribution of the study sample on the question number 2

Table ( 3 ) The distribution of the study sample on the question number 11

Table (4 ) The distribution of the study sample on the question number 9






Table 10) The distribution of the study sample on the question number 6


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Abstract:

Background: Quality of life (QOL) in end-stage renal disease patients

has become an important focus of attention in evaluating hemodialysis. Patients’ adaptation to a chronic disease is determined by their beliefs about ESRD and HD.

Aim: of this study is to evaluate the quality of life in hemodialysis patents and to

research the influence of various factors related to HD and ESRD .

Method: Cross-sectional design of 100 hemodialysis patients, was recruited from

four governmental hospitals from four cities distributed in north of the west bank .participant age range from (20-65 year), chosen by convenience sample. They completed the Short-Form Health Survey (SF-36).

Result: in our study we found that in general health for (HD) pts was good, also

(60% -70%) of them have disturbances in their social function and activity

daily living related to their physical and psychological limitation .

Conclusion: as conclusion hemodialysis patients have low quality of life as

consequence of (ESRD) and (HD). There is disturbance in their function and well being status.

Key words: Quality of life (QOL), Hemodailysis (HD), End Sage Renal Disease

(ESRD).

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Chapter One

1. Introduction:

1. A Normal kidneys and their function:

The kidneys are a pair of bean-shaped organs that lie on either side of spine in the lower middle of back. Each kidney weighs about ¼ pound and contains approximately one million filtering units called nephron. Each nephron is made of a glomerulus and a tubule. The kidneys are connected to the urinary bladder, it receive urine from kidneys . Urine is stored in the urinary bladder until empted by the bladder. The bladder connected to the outside through urethra.

Figure 1.1 Anatomy of the kidney

There are many function for kidneys the major one removing waste products that result from metabolism ,tissue damage and other substance and remove excess water from blood.

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Kidney also plays a major role in regulating levels of various minerals such as calcium, sodium, and potassium in the blood. Kidneys also produce certain hormones that have important functions in the body ,such as Active form of vitamin D ,Erythropoietin and Renin (Smeltezer C. et al . 2007) .

1. B Kidney failure and kidney disease: Kidney failure occurs when the kidneys partly or completely lose their

ability do normal functions. Total loss of kidney function known as End Stage

Renal Disease, ESRD is one type of kidney disease is chronic disease. (Smeltzer C et

al .2007).

1. C Causes of ESRD: Although ESRD caused by a multitude of kidney diseases, the majority of ESRD populations were either diabetic or suffering from hypertension disease. (Smeltezer C. et al . 2007). Reports from Western European and Asian Pacific region, including Australia and New Zealand showed that diabetic nephropathy as the main cause of ESRD. Data showed an increase in both incidence and prevalence of diabetic nephropathy between 1998 and 2000 (Lee, 2003). Studies from the USA showed that hypertension was the second major causative of ESRD. Glomerulonephritis considered as a third major cause of ESRD (Anderson, Brenner, 1988).

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1. D ESRD Treatment: There are two treatment choices for (ESRD): The first one is dialysis, The second one is Kidney transplantation for survival. Hemodialysis: Hemodailysis is one of the treatment options in renal replacement therapy (

Ko.B, Et al ,2007) . Hemodialysis removes waste and excess fluid from the blood

when the kidneys can't do so sufficiently. The blood drawn intravenously, sent to a

dialyzer, and returned to the body through a blood vessel. During that blood is exposed to extracorporeal semi permeable membrane and on the other side of which a dialysate solution is flowing (Tong M, et al .2001). Two major mechanisms govern the movement of molecules (diffusion and ultra filtration). Diffusion refers to the movement of a solute across a semi permeable membrane from a region of higher concentration to a region of lower concentration this transport is dependent on the physical size of the molecule relative to the size of the pores in the membrane. Ultrafiltration refers to plasma water removal by applying a negative transmembrane pressure across the dialysis membrane. This hydrostatic pressure forces plasma water from the patient out into a dialysate (Tong M, et al .2001) . The blood circulated and diffused numerous times during a dialysis session; each circulation through the machine removes more waste and excess fluid (Smeltezer C. et al . 2007).

The aim of hemodialysis treatment is to save patient life and prevent complication

that occur as a result of ESRD (Stojanovic.M. , et al ,2007) . Hemodialysis usually

performed three or more times a week for 4 hours or more. There are two major goals

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for HD the first one is to increase patient survival on other hand to prompt QOL for

them (Moreno,F,1996).

1. E Quality of life QOL and HD:

Quality of life (QOL), an individual's perception of his or her life and sense of

well-being in relation to his or her goals, expectations, standards, and concerns,

(Sloan JA .2002) . As defined by the World Health Organization, "QOL is an

individual’s perception of their position in life in the context of the culture and value

systems in which they live with the patient survival and concerns" (WHO.1993).

QOL may be profoundly altered by chronic disease. A recent prospective

evaluation of health-related QOL in a cohort of patients with chronic kidney disease

showed decreasing scores with advancing chronic kidney disease ( Mujais SK,

2009).Several studies of dialysis patients have shown that measures of QOL and

depression are correlated with mortality and hospitalization.( Kalantar-Zadeh K ,

2001).For many dialysis patients, the quality of their lives is more important than

hospitalization or mortality rates. Quality of life continues to be a significant problem

for patients receiving hemodialysis (HD) as a result of treatment HD complication and

ESRD consequences.( Kathy P 2003 ).A host of physical and psychological

symptoms occur in patients on chronic hemodialysis. (Steven D. et al . 1998).

1.2 Study background:

The quality of life (QOL) is an important predictor of outcome in end-stage renal

disease (ESRD) patients. Therefore, (QOL) in (ESRD) patients have become an

important focus of attention in evaluating hemodialysis. Patients adaptation to a

chronic disease is determined by their beliefs about (ESRD) and( HD) (Wasserfallen

J .2004) .many studies take risk factors for poor QOL for hemodialysis patient

(Seica1 A.2009) .

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1.3 Significance of study:

According to our past experience from training in many hospitals,

we noticed that there were many complaints from Pts about their disease

(ESRD) and treatment (HD). Otherwise, we noticed that some patients refused

to regimen their necessary treatment and they refused cooperation with

health instructions that prescribed from health team.

So, we selected our topic to study it, and measure the (QOL) for (HD) Pts and to identify the effects of (ESRD) and (HD). As well as, we hope to give some

recommendations according to study result .

1.4 Aims of Study:

The aim of this study is to assess the quality of life for hemodialysis patient, by

using SF-36 instrument.

1.5 Hypothesis:

1- Quality of life (QOL) for patient undergoing hemodialysis (HD) is low.

1.6 Demography:

Our study conducted in north of the West bank of Palestine including the towns of: Nabulus, Tulkarem, Salfeet, Jenin. with population 320, 160, 65,220.

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Chapter Two

Literature Review:

Quality of life affected by several factor, disease and treatment is some of

factor that also affect the quality of life. Pts with (ESRD) and who treated by

(HD) negatively affect quality of life. (Cleary.J, Drennan.J 2004). So that Social

support associated with improved physical health and the religious may serve as

coping mechanism for dealing with kidney disease (Rambod.M, Rafii.F, 2007)

.Another study conclude Self-care self-efficacy have great impact on outcomes of

QOL (Tsay.H, et al, 2001)

Anxiety and depression are considered as frequent disorders in end-stage renal disease patients (Untas A.2009) .Major depression is highly prevalent in the general population and is associated with grave consequences in terms of excessive mortality, disability, and secondary morbidity. Indeed, depression seems to affect people more frequently during their more productive years, tending to recur without appropriate recognition and management (Sartorius N, 2001). but when we compare the

subjective (QOL) of patients with major depression and subjects undergoing

hemodialysis, the pts with major depression significantly have lower (QOL) (Marcelo

T., et al, 2006). Patient on (HD) who understands their chronic disease they are able

to control their illness and have low emotional response (Covic.A, et al, 2004).

A Canadian study of 99 dialysis patients suggested that depression or anxiety associated with hemodialysis Pts (Graven JL .1987). Study that take a large proportion of 160 hemodialysis patients experience depressive mood (TsayS.2001). Another study concluded that Depression is associated with decreased health-related quality of life

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and increased mortality in hemodialysis patients (Rebecca A. et al, 2006) .so that Caregiver were not always aware of this inducing a sense of emotional distance and a sense vulnerability in the patient (Hargen.B , 2004). There is many coping

mechanism that use to reduce of the affect of depression on (QOL). Hemodialysis

patients with strong spiritual beliefs had higher social function this will prevent

depression and improve quality of life than those with weak spiritual beliefs ( Kao.T

,2007)

However how pt receive his treatment it also effect (QOL) such higher dose

hemodialysis (3 times every week ) was associated with better physical health and

less bodily pain than who receive 2 time weekly (Hnruh.M , et al ,2003) . on other

hand, There was a tenancy for those who dialyzed at home to score higher on quality

of life self care ability and sense of coherence than those who dialyzed themselves in

Center ( Agoborg .M , 2005). The preparedness and training for patient to undergo

(HD) for long term reverse the poor clinical outcome by improving the nutritional

status and (QOL) in (HD) patients. (Furuta A, et al, 2007).

Finally (ESRD) Pts have many hormonal disturbances and higher disturbances

in (QOL) than the normal population ( SYang.H ,etal 2008) . so that (QOL) for

patients on (HD) is markedly impaired. Co morbid conditions and older age and poor

income substantially reduce (QOL) in (HD) patients (Stojanovi M, et al, 2007) .

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Chapter three

Methodology:

3-1 Study population:

The population of the study is (HD) patients. It accounts 100 patients 25

from Tulkarem , 38 from Nablus , 25 from Jenin and 12 from Salfeet.

Patients are 60 male and 40 female, there ages range between (20-65) years.

3-2 Study Design:

This study was designed as descriptive, non experimental, cross sectional

health status survey of Quality of life for patient undergoing hemodialysis treatment

was carried out.

Cross-sectional designs involve the collection of data at one point in time ,the phenomena under study are captured during one period of data collection. Cross-sectional studies are appropriate for describing the

status of phenomena or for describing relationships among phenomena at

a fixed point in time.

Advantages of cross-sectional studies:

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1-Relatively inexpensive and takes up little time to conduct;

2-Can estimate prevalence of outcome of interest because sample is

usually taken from the whole population;

3-Many outcomes and risk factors can be assessed;

4-Useful for public health planning, understanding disease etiology and

for the generation of hypotheses;

5-There is no loss to follow-up.

Disadvantages of cross-sectional studies:

1-Difficult to make causal inference;

2-Prevalence-incidence bias (also called Neyman bias). Especially in

the case of longer-lasting diseases, any risk factor that results in death

will be under-represented among those with the disease.

3-3 Sampling:

Convenience sample is a subset of individual chosen from a the

mentioned hospitals. We visited each center for two days and took all

patients who met inclusion criteria.

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3-4 Instrument of the study:

Short form health questionnaire (SF-36) was used to measure Quality of life. The

questionnaire contained 36 questions covering eight scales divided into two

Physical function, edit containwhich Functional Scaleswas he first one groups: T

Role Function Physical causes, Role Function-Emotional factors, Social function and

Pain. The second one was Well-being Scales which in contained Psychological well-

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being, Vitality and General Health. This form measured the individual's (QOL) in

general over the last four weeks. It took 5-10 minutes to complete ( Mingardi G et al

.1998).

Validity

SF-36 is international tool to test quality of life , we was take two form of SF-36

from the SF-36 free website (www.sf-36.com) one of them in English and the other in

Arabic language . Study tool was subjected for the test by experts who recommended

for its validity for the achieving of the study purposes.

Reliability:

Instrument was tested by pilot test. We was give 7(HD) Pts from AlWatanee

hospital SF-35 instrument and ask them to fill it, after 10 days we ask them to fill

other one after that we administer it to SPSS .Khronapach Alpha which was (0.87)

this result acceptable for the study purposes.

3-6 Setting of the study :

Our study conducted in Palestine Country especially in the north of WB

four governmental hospitals included ,This study was made in kidney department in

the mentioned hospitals.

Inclusion criteria and exclusive criteria: 3-7

Inclusion Criteria:

1- Hemodialysis patient in the mentioned center who receive (HD) for two times or

more weekly.

2- Patient who receive hemodialysis for period more than one year.

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3- Who use Arteriovenous fistula for (HD).

4- Patient age range from 20-65 year.

Exclusion Criteria:

1- Patient who has hepatitis B and C.

2- Patient with amputations and congenital deformity.

3-8 Data collection:

We used the face to face method to collect the data. Pts were receive consent form that contain brief information about study. Pt was signature it if he

accepted to participate in study, pt was fill questionnaire alone if he need an

explanation ,ask us to help him .The place of the meeting was in the

Kidney department, beside the patient for period ranged from 10 to

15 minutes.

3-9 Ethical consideration:

Permission was obtained from the Palestinian ministry of health to conduct this

study and to use the facilities in the hospital. A signed consent was obtained from

each participant after discussing with each of them the purpose of the study and all

related matters to the research purpose , pts was given the right to withdrawn from

study any time without any consequences.

3-10 Statistical analysis:

We was use SPSS Statistical Package for Social Science (10 version) to analysis

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data. Arabic form of SF-36 was inserted to SPSS program to analyses 100

questionnaire.

Chapter Four

Study Results:

The ages of study participants ranges and distributed according to this scale:

20‐30 year (n=20; 20%), 3‐‐50 year (n=52; 52%), 50‐65 year (n=28; 28%).

The distribution of the study sample according to the Academic qualification was

Primary ( n= 26;26%), Preparatory ( n= 26;26%), Secondary ( n= 30;30%), B.A( n=

14;14%), M.A ( n= 4;4%).The results of the study questions which are most of patient

in the secondary school.

A-The result of according well being scale:

1- General health:

Question (1): In general, would you say your health is.

Table (1): The distribution of the study sample on the question number 1:

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Percentage No. In general , would you say your health is

14.0 14 Excellent

15.0 15 Very good

43.0 43 Good

14.0 14 Fair

14.0 14 Poor

100% 100 Total

It has been shown from the table (1) that (43%) of participants their general health

good status .

Question (2): Compare to one year ago, how would you rate your health in general

now?

Table (2): The distribution of the study sample on the question number 2;

Percentage No. In general , how would you rate your health

12.0 12 Much better now than a year ago

28.0 28 Somewhat better now than a year ago

36.0 36 About the same as one year ago

14.0 14 Somewhat worse now than a year ago

10.0 10 Much worse now than a year ago

100% 100 Total

It has been shown from the table (2) That the rate (36%) participants their general

health is the same as one year ago.

Question 11:

: The distribution of the study sample on the question number 11: Table (3)

Definitely false

Mostly false

Don't know

Mostly true

Definitely true

11. How TRUE or FALSE is each of the following statements for you?

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4.016.030.026.024.0a. I seem to get sick a little easier than other people

18.020.024.028.0 10.0b. I am as healthy as anybody I know

6.018.040.016.020.0c. I expect my health to get worse 20.020.022.026.012.0d. My health is excellent

The table (3) Pts didn’t known the outcome of their disease and treatment. Such as they don’t know how they get their illness when they compare with other patients.

2- Vitality and Psychological well-being (MH)

Question (9):

The distribution of the study sample on the question number 9: : Table (4)

None of the time

A little of the time

Some of the time

A good bit of the time

Most of the time

All of the time

9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question,

10.0 12.0 22.0 24.0 16.0 16.0a. did you feel full of pep? 10.010.030.018.012.020.0b. have you been a very nervous person? 6.030.028.018.0 4.014.0c. have you felt so down in the dumps

nothing could cheer you up? 12.012.038.020.010.08.0d. have you felt calm and peaceful? 20.018.0 22.024.014.0 2.0e. did you have a lot of energy? 18.028.020.016.0 12.06.0f. have you felt downhearted and blue? 12.020.0 20.034.010.04.0g. did you feel worn out? 10.020.034.018.06.012.0h. have you been a happy person? 2.016.022.038.06.016.0i. did you feel tired?

The table (4) showed that the (HD) pts become nervously, depressed and worn out some times .on other hand they feel happy and more energy in some of times.

Functional scale : Results according B-

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1- Physical function

Question 3:

Table (5): The distribution of the study sample on the question number 3

(HD) Pts have physical limitation .as a result of it they can't do vigorous activity

.they have some of limitation to do moderate activity . they are able to do light

activity and self care.

2- Role Function-Physical (RP)

Question 4:

The distribution of the study sample on the question number 4: : Table (6)

No Yes 4. During the past 4 weeks, have you had any of the following

not limited at all

limited a little

limited a lot. .

.

3-The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

22,0 36,042,0a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.

28.0 54.0 18,0 b Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?

34.0 44.0 22,0 c. Lifting or carrying groceries. 34.0 54.0 12.0 d. Climbing several flights of stairs. 58.0 34,0 8.0 e. Climbing one flight of stairs. 44.0 40.0 16.0 f. Bending, kneeling or stooping. 26.0 32.0 42.0 g. Walking more than one mile. 40.0 46.0 14.0 h. Walking several blocks. 58.0 28.0 14.0 i. Walking one block. 66.0 18.0 16.0 j. Bathing or dressing yourself.

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problems with your work or other regular daily activities as a result of your physical health?

24.0 76.0 a. Cut down the amount of time you spent on work or other activities?

38.0 62.0 b. Accomplished less than you would like? 30.0 70.0 c. Were limited in the kind of work or other activities 36.0 64.0 d. Had difficulty performing the work or other activities (for

example, it took extra time)

The table (6) shown that the large distribution of pts their disease interfere with daily activity because pain and time that spent in treatment and physical limitation.

3- Role Function-Emotional factors (RE)

Question 5:

Table (7): The distribution of the study sample on the question number 5:

No Yes 5. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as result of any emotional problems (such as feeling depressed or anxious)?

22.0 78.0 a. Cut down the amount of time you spent on work or other activities?

34.0 66.0 b. Accomplished less than you would like 34.0 66.0 c. Didn't do work or other activities as carefully as usual

The large distribution of pts have limitation in time , achievement, performance , doing their works according to psychological status.

4- Bodily Pain (BP):

Question (7):

How many bodily pain have you had during the past 4 weeks ?

Table (8): The distribution of the responds of the study sample on the question

number 7:

Percentage No. How many bodily pain have you had during the past 4

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weeks ?

18.0 18 Not at all

18.0 18 Slightly too much

18.0 18 Slightly

14.0 14 Moderately

26.0 26 Quite a bit

6.0 6 Extremely

100% 100 Total

It has been shown from the table (8) that (26%) they have quite a bit of pain.

Question (8)

During the past 4 weeks, how much did pain interfere with your normal work

(including work outside the home and house work)?


number 8:

Percentage No. During the past 4 weeks , how much did pain interfere with

your normal work ( including work outside the home and

house work)

18.0 18 Not at all

28.0 28 Slightly

20.0 20 Moderately

22.0 22 Quite a bit

12.0 12 Extremely

100% 100 Total

It has been shown from the table (12) that (28%) of participant their pain slightly

interfere with normal work.

5-Social function (SF)

Question (6):

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During the past 4 weeks, to what extent has your physical health or emotional

problems interfered with your normal social activities with friends, neighbors or

groups?


number 6:

Percentage No. During the past 4 weeks, to what extent has your physical

health or emotional problems interfered with your normal

social activities with friends, neighbors or groups ?

30.0 30 Not at all

32.0 32 Slightly

20.0 20 Moderately

8.0 8 Quite a bit

10.0 10 Extremely

100% 100 Total

It has been shown from the table (10) that social relationship slightly limited.

Question (10):

During the past 4 weeks, how much of the time has your physical health or emotional

problems interfered with your social activities (like visiting friends, relatives , etc..)??


number 10:

Percentage No. During the past 4 weeks, how much of the time has your

physical health or emotional problems interfered with your

social activities ( like visiting friends, relatives , etc..)?

10.0 10 All the time

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22.0 22 Most of the time

30.0 30 Some of the time

24.0 24 A little of the time

14.0 14 None of the time

100% 100 Total

It has been shown from the table (11) that social activities are limited in some times.

Chapter five

Discussion:

The aim of our study is to to assess the quality of life (QOL) for patient

undergoing hemodialysis (HD) .

Method discussion:

The sample was chosen by convenience method controlled by inclusion and

exclusion criteria, we were face some obstacles, because there are many patients have

problems like amputation ,hepatitis which we considered as exclusion criteria ,so

that we can't take participant by simple random because it not enough to give us

large number that need to achieve aims of our study.

discussion:Results

Well-being Scales: A-

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General Health (GH): I.

That present from table (1) that (43% of total population) have good health status,

and it is the same as one year ago. because they follow up care program, regimen in

their diet and medication, continuous routine of care, and availability of treatment.

Another finding about health it is the perception of illness, (30% of total

population) don't know if they get sick a little easier than other people or not, the get

of sickness it deferent according personal believe, culture, and spiritual state . (HD)

pts they see themselves as health as anybody they know, because they are know

people with the same disease and receive same treatment ,all of them come to center

three time weakly ,receive same care . Large distribution of (HD) pts didn’t know the

consequences of their disease .(26% of total population ) answer mostly true their

health excellent because they are regimen for treatment ,they are free of complication

Pt s didn’t known the outcome of their disease and treatment .the self perception

about illness different according people cognitive

II -Vitality (VT):

The large distribution ( 24% of total population) a good bit of a time they feel full

of pep because they able to deal with their illness. (24% of total population) a good

bit of a time have energy, because there disease and treatment interfere how they will

use this energy. (34% of total population) some time feel happy, when they forget

their disease and treatment.( 38% of total population) answer a good bit of a time they

feel tired because of the effort they paid to receive treatment and the influence of

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disease.

Psychological well-being (MH):

There are many disturbances in psychological state for (HD) pts. Such as, some times they become very nervous, feel so down in the dumps nothing could cheer they up , feel downhearted and blue, feel worn out , it is the same with what Untane find that anxiety and depression are considered as frequent disorders in end-stage renal disease patients( Untane et al .2009) . This emotional reaction result from many dimension. The first of all, all people hope continue high quality of life but this difficult for (HD) pts. The second one (HD) pts lose of many interests, finally as we notice that many of them think negatively about consequence of ( HD) and (ESRD). On other hand, (38 % of total population ) some of the time they feel calm and peaceful , because they understand treatment for their disease it is agree with Covic finding that (HD) pts who understand their chronic disease they are able to control their illness and have low emotional response (Covic.A, et al, 2004) B-Functional Scales:

I-Physical function (PF):

(HD) pts have limited a lot to do vigorous activity, and limited a little to do

moderate activity, but they were able to do self care like bathing and dressing without

any limitation. Fatigue, fluid and diet restriction, electrolyte imbalance, anemia, and

weakness all of this factors produce physical limitation. Luckily, physical limitation

can reduced by adherence to treatment it is the same with Mok E 2001 finding

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II-Role Function-Physical (RP):

The large distribution of (HD) pts their disease interfere with their daily activities

like limited of time ,achievement, performance ,and doing works according to their

physical health , because they feel tiered and fatigue during the work, it was agree

with Welch and his colleague 2001 large number of hemodialysis patients have high

scale of fatigue and physical limitation.

III-Bodily Pain (BP)

Pain has highly relevance to patient outcomes. (HD) pts (26% of total population) feels quite a bit of Pain it is the significant problem it is similar with Davison SN at 2003 finding. Pain result from consequence of treatment and complication of illness like metabolic acidosis, electrolyte disturbance, and bone disease. The presence of pain slightly interfere with normal work activity (including work outside the home and house work) , pts age above 20 year of age they able to tolerate pain and can live with pain .

IV-Role Function-Emotional factors (RE)

The large distribution of pt (66%- 78% of total population) have limitation in their

time, achievement, performance , doing their works according to psychological

status, because they have pain ,stress, complication of illness , and fear

from unknown outcome.

V-Social function (SF)

Physical health or emotional problems slightly limit (HD) pts social relationship

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and interfere sometimes with their social activities , but coping with illness and

treatment reduce it effect ,on other hand culture invite good relationship between

people and provide social support for them .

Finally (HD) patients have disturbance in their physical health, social function,

role function, general health, and have badly pain. So that, (QOL) negatively affected

by (ESRD) and (HD), it is the same with study that was done by Cleary.J, and his

colleague 2004. These results prove our hypothesis Quality of life (QOL) for patients

undergoing hemodialysis (HD) is low.

Conclusion:

As a conclusion, we found that participant's disease (ESRD) and treatment (HD)

has negatively affected their quality of life. Such as, they have physical limitation,

emotional problems, bodily pain, and social limitations. All of these factors interfere

with (QOL).

We notice that (HD) pts receive just medical treatment; there isn’t psychological

treatment to promote their psychological state, or specific training to decrease their

physical limitation .So that, hemodialysis (HD) patients have low quality of life.

Study limitations:

1- Their insufficient time and budget to take all centers in Palestine.

2- There is large number of patients not met criteria to enter this study.

Recommendations:

1- There is need to provide psychosocial support for patient.

2- Provide them with effective training program to reduce physical limitation.

31

3- Provide patient with effective health education about their disease and

treatment.

4- Make some of social activities in centers to increase patient social function.

5- Use of palliative therapy to reduce patient pain.

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