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Capstone Project
Firstname, middle initial(s). Lastname
Institute name
Instructor Name
May 29, 2020
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Abstract
The nursing evidence-based practice project pertains to the PICOT question which is stated as
ESRD patients receiving hemodialysis in an out-patient setting, does fluid management
education vs. not receiving fluid management education decrease intradialytic fluid gains from
recent literature in the last 3 years. The evidence was obtained by critically appraising the
evidence available from the current literature using six peer-reviewed journal articles. The
evidence is proposed to be implemented as a practice change by the use of the Johns Hopkins
evidence-based practice (EBP) model.
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Capstone Project
The paper pertains to evidence-based project (EBP) synthesis paper and describes an
introduction of a nursing practice issue, identification of an evidence-based practice (EBP)
model used for the literature review by providing a comprehensive integrative review, describing
the implications for future research, implications for clinical practice, EBP implementation
model application, and summarizing and concluding the paper.
Introduction
Interdialytic weigh gains, abbreviated as IDWG are consequent upon the intake of salt as
well as water between the two sessions of hemodialysis. This gain in weight is an index of water
intake after accounting for the loss of fluid from the urine daily.
The proposed PICOT question is stated as follows:
“In ESRD patients receiving hemodialysis in an out-patient setting, does fluid
management education vs. not receiving fluid management education decrease interdialytic
weight gains from recent literature in the last 3 years”
Population: P: End-stage renal disease (ESRD), age 45-65, no gender-specific, no
ethnicity-specific, out-patient dialysis clinic setting receiving hemodialysis.
Intervention: I: Education regarding fluid management in the out-patient dialysis clinic
setting.
Comparison: C: No education regarding fluid management in the out-patient dialysis
clinic setting.
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Outcome: O: Outcome would show proper education and understanding of monitoring
fluid intake amongst ESRD patients would decrease intradialytic fluid gains.
Critical Appraisal of Evidence
Critical appraisal of 6 journal articles was done, published within 3 years, to furnish the
evidence for answering the proposed PICOT question. To answer the clinical PICOT question
and to undertake the evidence-based practice (EBP) project, various frameworks and models
have been developed for facilitating the understanding of sophisticated processes of introduction
of such practice changes which are based on evidence.
The evidence-based practice (EBP) model used was the IOWA model, which helps the
nurses for using the evidence in improving the outcomes for their patients. Although the model
was devised initially for utilizing research, it was modified later on for the incorporation of the
various aspects of evidence-based practice (Winkelman et al., 2013).
Various features of the Iowa model include triggers leading to the clinical question,
assessing if the question holds priority for a healthcare setting, being focused on the formation of
teams for developing the evidence-based practice initiatives and generally overviewing the
decisions regarding implementation of new practices and adoption of changes in current practice
(Winkelman et al., 2013).
The critical appraisal of the 6 journal articles is presented as clear, concise, and
comprehensive integrative review, as a discussion organized around validity, reliability, and
applicability of the researches while reviewing the similarities/differences and
strengths/limitations across studies.
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There were many differences in the level of evidence, validity, reliability, and
applicability amongst the six research studies examined as a part of the literature critical
appraisal of evidence.
Wahyuni (2019) conducted a study to describe the factors which affect interdialytic
weight gain in the patients undergoing hemodialysis by the use of the precede-proceed theory
approach. The study had a cross-sectional design with a sampling technique and a questionnaire.
The study population comprised of adults aged 46-59 with a sample of 79 out of 100 patients in a
single outpatient clinic. One trial was undertaken whereas 21 were illuminated as not meeting
criteria for the study. Crown et al. (2017) conducted a pilot study regarding enhancement of self-
care management of interdialytic fluid weight gain in subjects undergoing hemodialysis using
motivational interviewing to evaluate the impact of motivational interviewing on the interdialytic
fluid weight gain. In contrast with the study by Wahyuni (2019), the research by Crown et al.
(2017) has a prospective quasi-experimental design, having a population of adults aged 37 t 0 60
years. The sample size was 20, from amongst the total 36 patients, with one patient being
removed from the study due to hospitalization. The researchers completed one trial in three
phases.
Interdialytic weight gain, trends, predictors, and associated outcomes in the international
dialysis outcomes and practice patterns study was conducted by Wong et al. (2017), which had
the purpose of investigating IDWG and its association with adverse clinical outcomes. The study
had a sequential cross-sectional design like the study by Crown et al. (2017), to identify facility
and patient-level predictors of IDW and their temporal trends. The study population was adults
aged 39 to 70 years on hemodialysis for a minimum of one year, and the sample size was large,
being 21919 subjects. A single trial was undertaken in five phases.
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In addition to the retrospective and cross-sectional studies described above, a prospective
cohort study was undertaken by Hecking et al. (2018), to determine if greater fluid overload and
lower interdialytic weight gain are independently associated with mortality in a large
international hemodialysis population. The purpose of the study was to explore the excess IDWG
amongst those having cardiovascular disease, higher systolic blood pressure (SBP), and adverse
outcomes. The research had a prospective cohort design and was observational. The study
population comprised adults having a mean age of sixty-one years from an outpatient dialysis
center with cardiovascular diseases. The sample size was large as the study by Wong et al.
(2017), is 38614. The study was conducted as one trial in four groups each over one month.
A study was undertaken by Ahmed, Abdalla, Satti, Qazi & Lappin (2018) determine if
the duration of treatment, ultrafiltration rate, IDWG, and albumin level had an impact on
mortality. The study had a cross-sectional design like the one by Wahyuni (2019), and comprised
a study population of adults greater than eighteen years of age and having a mean age of fifty
years. The sample size comprised 59 dialysis subjects who were undergoing dialysis at least
three times a week. One trial was undertaken by the researchers.
Siciliano (2017) conducted a study for the identification of reasons for the lack of
compliance with fluid and sodium restriction, in addition to, or other than the lack of knowledge
on the topic. The researcher made an identification of a variety of interventions that improved
adherence as well as related outcomes. The study had an observational design and used a study
population of adult patients aged eighteen years or more who were undergoing hemodialysis
with a mean of more than 3 percent IDGW. The sample size comprised one outpatient dialysis
clinic of sixty patients.
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There were many differences in the level of evidence, validity, reliability, and
applicability amongst the six research studies examined as a part of the literature critical
appraisal of evidence. Wahyuni (2019) undertook to study the effects of giving the patients with
> 2% IDWG education on how to manage fluid intake between treatments, compared to those
who were not given such education on fluid intake, thirst, or self-efficacy. The researcher found
no significant changes in IDWG when it came to education and thirst between treatments,
whereas the fluid intake and self -efficacy demonstrated a significant change when subjects
received educated regarding IDWG and fluid management.
Wayhuni (2019) concluded that educational interventions in the case of IDWG could be
effective in managing patients to reduce mortality. In place of an educational intervention as
undertaken by Wahyuni (2019), Crown et al. (2017) investigated the role of motivational
interviewing (MI). Since, it was an experimental (quasi-experimental) study unlike the studies by
Wayhuni (2019), Wong et al. (2019), Hecking et al. (2018), Ahmed et al. (2018), and Siciliano
(2017), the authors undertook an intervention, which comprised monitoring and documentation
of IDWG for four weeks before MI. Later on, MI was provided to each individual in a 30-minute
personal session. During the 30 minute weekly MI over 4 weeks, IDWG was monitored and
documented. IDWG after the 4 weeks MI was monitored & documented.
The study undertaken by Wahyuni (2019) furnished level 2 evidence. However, there are
concerns regarding the validity of the research as the sample size was quite small, and further
research is required to validate the findings of the research. The same is true for reliability, and
more reliable needs further testing with a larger sample size. As for the particular setting, it
would be reliable for that particular setting and changes for that particular setting. The study has
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high applicability to the proposed PICOT question as it discusses certain aspects of education
versus non-educated patients and IDWG.
The results of the study by Crown et al. (2017) demonstrated no statistically significant
improvement of IDWG during the period of the intervention, probably because of the study bein
short and small. However, a potential reduction in median IDWG was observed in the study. The
results of the study by Wong et al. (2017) were in contrast with those by Crown et al. (2017), as
the former found a significant decrease in IDWG in the US and Europe whereas a modest
decrease in IDWG in Japan, Australia, and New Zealand following a Volume First initiative. The
study found a reduction in mortality due to a decrease in IDWG and other complications from
Fluid overload. The differences in results and findings of two pieces of research can be attributed
to their different designs. In comparison to the study by Wahyuni (2019), the study by Crown et
al. (2017) had a higher validity, although it provided only level 1 evidence.
There was a positive response amongst the participants and that the MI coaching did
encourage and assist with understanding IDWG. Even with the small study, it has fair validity as
far as patient understanding and motivation to maintain and control IDWG is concerned.
However, there are issues in the reliability of the study and further research needs to be
performed to allow the study to have greater reliability with larger sample sizes as well as
additional tools to assist with MI to elicit a positive response on IDWG. The applicability of the
study by Crown et al. (2017) to the PICOT question lies in its relevance to patient education and
the effects of IDWG.
The sample size and statistical evidence of the study by Wong et al. (2017) show a high
validity of Volume First initiative and an improved IDWG and mortality. It was a large study,
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and international participants were used for comparison. There were a lot of sources used and
being a level 2 of evidence, the study had high reliability. The study directly applies to the
PICOT question by being on an educational program for Dialysis patients on IDWG and
mortality related to excessive IDWG.
Hecking et al. (2018) investigated monthly primary individual goals including those for
caregivers being set for IDWG including fluid intake, dietary intake, and medication
management to increase compliance and decrease IDWG. The researchers compared IDWG
before goal-setting and the enhancement of complications from IDWG as well as systolic blood
pressure (SBP) & cardiovascular events. The authors found that when the monthly individual
goals were in place, there was a reduction in IDWG and a more stable cardiovascular system as
well as a reduction in SBP.
Although the study by Hecking et al. (2018) furnishes the highest level of evidence (level
3) amongst all the studies appraised, the validity, as well as reliability of the study, are limited
due to multiple limitations of the study. These include, but are not limited to improper weighing
before and after treatment, the study being observational, and listing only specific clinics. The
study used education such as “nephrocare to set personal monthly goals on IDWG with patients,
which applies to the PICOT question.
Unlike the study by Crown et al. (2017), which was non-conclusive about the effects of
an intervention on reducing IDWG, the study by Ahmed et al. (2018) was found significant
evidence concerning the effects of dietary education regarding albumin levels and education on
treatment duration in improving the albumin levels and reducing mortality. The researchers
found no correlation between the ultrafiltration rate and albumin levels. However, the
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researchers found improved Albumin levels when patients were educated on treatment duration,
IDWG, and dietary needs at home. The researchers found that more than 4 dl of Albumin
correlates with an increase in mortality and an increase in IDWG. Ahmed et al. (2018) finally
concluded that longer treatment duration correlates with improved albumin levels and IDWG
when patients were educated about dietary and treatment needs.
Like the other studies described above, having limitations to their designs, the study by
Ahmed et al. (2018) had several limitations which include the researchers not measuring what
was claimed to be measured. The sample size was small and a majority of the statistical data
was from an EMR. Further testing was needed to improve the validity of the research. The
reliability of the study was limited by the small size, limited patient data, and lack of studies on
this topic, more studies need to be performed. However, even with the reduced validity and
reliability, the study does assist with the PICOT question.
Siciliano (2017) attempted to observe the effects of education on improving compliance
to decrease the IDWG. The researchers found patient denial, resistance to change, lack of
motivation, and understanding to lead to increased IDWG and increased mortality as well as
complications. The validity of the study was limited by having an observational design, not too
reliable, and being limited to one clinic setting patients and having no other studies available at
the time to verify the validity. This study was based on personal observations and experiences,
severely limiting its reliability. Even though the interventions have shown to be effective,
different settings were need to be studied to evaluate efficacy. Although furnishing level 1
evidence only, the study applied well to the PICOT question.
Implications for Future Research
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The findings of research by Wahyuni et al. (2019) were in line with the previous
researches having similar research problems. One of the limitations which were identified in the
research was the weak relationship strength of the variables during the calculation of the
coefficient of correlation. A better design was indicated along with a better theoretical
framework and well-defined independent and dependent variables.
Similarly, the findings of research by Crown et al. (2017), especially the finding of
motivational interviewing on its own not being sufficient in alteration of intradialytic weight gain
was in line with the previous researches having similar research problems. One of the limitations
which were identified in the research was the research being a pilot study only, and the short-
time frame of the study. A bundle of interventions including motivational interviewing was
required for the study to be more representative of the research problem.
The findings of research by Wong et al. (2017) were in line with the previous researches
having similar research problems, with minor differences. The limitations which were identified
in the research were potential reasoning confounding and non-availability of dietary salt intakes.
A better design was indicated along with a better theoretical framework to address the
deficiencies in the design of the research.
The findings of research by Hecking et al. (2018) were in line with the previous research,
with minor design differences. One of the limitations which were identified in the research was
the observational design of the study which could not establish causation. An interventional
design could have better addressed the issue of establishing causation.
The findings of research by Ahmed et al. (2018) were in line with the previous researches
having, but with larger designs. One of the limitations which were identified in the research was
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the small size of the sample. A bigger sample could have detected correlations existing in larger
cohorts. The findings of research by Siciliano (2019) were could not be compared to those of the
previous researches as the investigator did not present a discussion of the findings.
Integration of the evidence from the various sources of evidence described above clearly
demonstrates that there is sufficient evidence that in the end-stage renal disease patients
receiving hemodialysis in an out-patient setting, fluid management education decreases
interdialytic weight gains, and has a protective role in mortality.
The limitations of the current EBP review include the scarcity of literature appraised due
to various constraints and nature of the EBP project. However, the evidence obtained and
integrated is sufficient to address the PICOT question proposed.
Implications for Clinical Practice
The needed practice change in the case of ESRD patients receiving hemodialysis in an
out-patient setting is proper fluid management education to decrease the interdialytic weight
gains. However, irregular patient compliance limits the efficacy of the intervention, and the
special consideration for the practice change is regular follow up with the nephrology care
provider for the enhanced compliance of the intervention to be ensured.
EBP Implementation Model Application
The implementation plan shall be undertaken by the use of the Johns Hopkins model of
evidence-based practice. The implementation model has the following steps:
Step A: Asking the clinical practice problem which is proper fluid management
education.
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Step B: Obtaining the pertinent best current literature using scientific databases like
Cochrane and PubMed, by using keywords like fluid management, interdialytic weight gain
(IDWG), end-stage renal disease (ESRD), hemodialysis, etc.
Step C: Critical appraisal of the evidence, by determining the quality of evidence,
validity, reliability, as well as applicability to the proposed PICOT question.
Step D: Integrating the evidence into practice, by using the Johns Hopkins EBP model,
starting with an inquiry into a practice issue, proposing the practice questions, obtaining the
evidence, translating the evidence, and coming up with the best practice, which in this case is the
fluid management education in the ESRD patients receiving hemodialysis in the out-patient
settings.
Step E: The final step is evaluating the outcomes which occur as a result of integrating
the evidence into practice.
The Johns Hopkins Nursing Evidence-based Practice Model (Vera, 2020).
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Summary and Conclusions
To summarize and conclude, the practice change required for better patient outcomes is
that in the ESRD patients receiving hemodialysis in an out-patient setting, fluid management
education decreases intradialytic fluid gains, as guided by the evidence obtained from the
critically appraised current literature in the past 3 years. The practice change from not providing
fluid management education to providing fluid management education is undertaken using the
Johns Hopkins evidence-based practice (EBP) model.
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References
Ahmed A., Abdalla A., Satti M., Qazi J., Lappin D. (2018). Hemodialysis Session Duration,
Ultrafiltration Rate, Interdialytic Weight Gain and their Association with Albumin in
Patients on Intermittent Hemodialysis in a Regional Dialysis Unit: A Cross-sectional
Study. Cureus.10(12). 2-7.
Crown S., Vogel J., Hurlock-Chorostecki C. (2017). Enhancing Self -Care Management of
Interdialytic Fluid Gain in Patients on Hemodialysis: A Pilot Study using Motivational
Interviewing. Nephrology Nursing Journal. 44(1). 49-55.
Hecking M., et al. (2018). Greater fluid overload and Interdialytic weight gain are independently
associated with Mortality In a large International hemodialysis population. Nephrology
Dialysis Transplant. (33). 1832-1842.
Siciliano E. (2018). Interventions for Improving Interdialytic Weight Gains in At-Risk Patients
on Hemodialysis. Nephrology Nursing Journal. 45(1) 83-85.
Vera, D. (2020). 2017 EBP Models and Tools. Hopkinsmedicine.org. Retrieved 31 May 2020,
from https://www.hopkinsmedicine.org/evidence-based-practice/ijhn_2017_ebp.html.
Wahyuni E., Haloho F., Laili, N. (2019). Gain (IDWG) in Hemodialysis Patients with Precede-
Proceed Theory Approach. IOP Conf. Series: Earth and Environmental Science 246
(2019) 012034. DOI:10.1088/1755-1315/246/1/012034
Winkelman, C., Workman, M., & Ignatavicius, D. (2013). Medical-surgical nursing (7th ed.).
Elsevier.
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Wong Y., et al. (2017). Interdialytic Weight Gain: Trends, Predictors, and Associated Outcomes
in the International Dialysis Outcomes and Practice. American Journal of Kidney
Disease. 69(3). 367-379.

Unformatted Attachment Preview

1 Capstone Project Firstname, middle initial(s). Lastname Institute name Instructor Name May 29, 2020 2 Abstract The nursing evidence-based practice project pertains to the PICOT question which is stated as ESRD patients receiving hemodialysis in an out-patient setting, does fluid management education vs. not receiving fluid management education decrease intradialytic fluid gains from recent literature in the last 3 years. The evidence was obtained by critically appraising the evidence available from the current literature using six peer-reviewed journal articles. The evidence is proposed to be implemented as a practice change by the use of the Johns Hopkins evidence-based practice (EBP) model. 3 Capstone Project The paper pertains to evidence-based project (EBP) synthesis paper and describes an introduction of a nursing practice issue, identification of an evidence-based practice (EBP) model used for the literature review by providing a comprehensive integrative review, describing the implications for future research, implications for clinical practice, EBP implementation model application, and summarizing and concluding the paper. Introduction Interdialytic weigh gains, abbreviated as IDWG are consequent upon the intake of salt as well as water between the two sessions of hemodialysis. This gain in weight is an index of water intake after accounting for the loss of fluid from the urine daily. The proposed PICOT question is stated as follows: “In ESRD patients receiving hemodialysis in an out-patient setting, does fluid management education vs. not receiving fluid management education decrease interdialytic weight gains from recent literature in the last 3 years” Population: P: End-stage renal disease (ESRD), age 45-65, no gender-specific, no ethnicity-specific, out-patient dialysis clinic setting receiving hemodialysis. Intervention: I: Education regarding fluid management in the out-patient dialysis clinic setting. Comparison: C: No education regarding fluid management in the out-patient dialysis clinic setting. 4 Outcome: O: Outcome would show proper education and understanding of monitoring fluid intake amongst ESRD patients would decrease intradialytic fluid gains. Critical Appraisal of Evidence Critical appraisal of 6 journal articles was done, published within 3 years, to furnish the evidence for answering the proposed PICOT question. To answer the clinical PICOT question and to undertake the evidence-based practice (EBP) project, various frameworks and models have been developed for facilitating the understanding of sophisticated processes of introduction of such practice changes which are based on evidence. The evidence-based practice (EBP) model used was the IOWA model, which helps the nurses for using the evidence in improving the outcomes for their patients. Although the model was devised initially for utilizing research, it was modified later on for the incorporation of the various aspects of evidence-based practice (Winkelman et al., 2013). Various features of the Iowa model include triggers leading to the clinical question, assessing if the question holds priority for a healthcare setting, being focused on the formation of teams for developing the evidence-based practice initiatives and generally overviewing the decisions regarding implementation of new practices and adoption of changes in current practice (Winkelman et al., 2013). The critical appraisal of the 6 journal articles is presented as clear, concise, and comprehensive integrative review, as a discussion organized around validity, reliability, and applicability of the researches while reviewing the similarities/differences and strengths/limitations across studies. 5 There were many differences in the level of evidence, validity, reliability, and applicability amongst the six research studies examined as a part of the literature critical appraisal of evidence. Wahyuni (2019) conducted a study to describe the factors which affect interdialytic weight gain in the patients undergoing hemodialysis by the use of the precede-proceed theory approach. The study had a cross-sectional design with a sampling technique and a questionnaire. The study population comprised of adults aged 46-59 with a sample of 79 out of 100 patients in a single outpatient clinic. One trial was undertaken whereas 21 were illuminated as not meeting criteria for the study. Crown et al. (2017) conducted a pilot study regarding enhancement of selfcare management of interdialytic fluid weight gain in subjects undergoing hemodialysis using motivational interviewing to evaluate the impact of motivational interviewing on the interdialytic fluid weight gain. In contrast with the study by Wahyuni (2019), the research by Crown et al. (2017) has a prospective quasi-experimental design, having a population of adults aged 37 t 0 60 years. The sample size was 20, from amongst the total 36 patients, with one patient being removed from the study due to hospitalization. The researchers completed one trial in three phases. Interdialytic weight gain, trends, predictors, and associated outcomes in the international dialysis outcomes and practice patterns study was conducted by Wong et al. (2017), which had the purpose of investigating IDWG and its association with adverse clinical outcomes. The study had a sequential cross-sectional design like the study by Crown et al. (2017), to identify facility and patient-level predictors of IDW and their temporal trends. The study population was adults aged 39 to 70 years on hemodialysis for a minimum of one year, and the sample size was large, being 21919 subjects. A single trial was undertaken in five phases. 6 In addition to the retrospective and cross-sectional studies described above, a prospective cohort study was undertaken by Hecking et al. (2018), to determine if greater fluid overload and lower interdialytic weight gain are independently associated with mortality in a large international hemodialysis population. The purpose of the study was to explore the excess IDWG amongst those having cardiovascular disease, higher systolic blood pressure (SBP), and adverse outcomes. The research had a prospective cohort design and was observational. The study population comprised adults having a mean age of sixty-one years from an outpatient dialysis center with cardiovascular diseases. The sample size was large as the study by Wong et al. (2017), is 38614. The study was conducted as one trial in four groups each over one month. A study was undertaken by Ahmed, Abdalla, Satti, Qazi & Lappin (2018) determine if the duration of treatment, ultrafiltration rate, IDWG, and albumin level had an impact on mortality. The study had a cross-sectional design like the one by Wahyuni (2019), and comprised a study population of adults greater than eighteen years of age and having a mean age of fifty years. The sample size comprised 59 dialysis subjects who were undergoing dialysis at least three times a week. One trial was undertaken by the researchers. Siciliano (2017) conducted a study for the identification of reasons for the lack of compliance with fluid and sodium restriction, in addition to, or other than the lack of knowledge on the topic. The researcher made an identification of a variety of interventions that improved adherence as well as related outcomes. The study had an observational design and used a study population of adult patients aged eighteen years or more who were undergoing hemodialysis with a mean of more than 3 percent IDGW. The sample size comprised one outpatient dialysis clinic of sixty patients. 7 There were many differences in the level of evidence, validity, reliability, and applicability amongst the six research studies examined as a part of the literature critical appraisal of evidence. Wahyuni (2019) undertook to study the effects of giving the patients with > 2% IDWG education on how to manage fluid intake between treatments, compared to those who were not given such education on fluid intake, thirst, or self-efficacy. The researcher found no significant changes in IDWG when it came to education and thirst between treatments, whereas the fluid intake and self -efficacy demonstrated a significant change when subjects received educated regarding IDWG and fluid management. Wayhuni (2019) concluded that educational interventions in the case of IDWG could be effective in managing patients to reduce mortality. In place of an educational intervention as undertaken by Wahyuni (2019), Crown et al. (2017) investigated the role of motivational interviewing (MI). Since, it was an experimental (quasi-experimental) study unlike the studies by Wayhuni (2019), Wong et al. (2019), Hecking et al. (2018), Ahmed et al. (2018), and Siciliano (2017), the authors undertook an intervention, which comprised monitoring and documentation of IDWG for four weeks before MI. Later on, MI was provided to each individual in a 30-minute personal session. During the 30 minute weekly MI over 4 weeks, IDWG was monitored and documented. IDWG after the 4 weeks MI was monitored & documented. The study undertaken by Wahyuni (2019) furnished level 2 evidence. However, there are concerns regarding the validity of the research as the sample size was quite small, and further research is required to validate the findings of the research. The same is true for reliability, and more reliable needs further testing with a larger sample size. As for the particular setting, it would be reliable for that particular setting and changes for that particular setting. The study has 8 high applicability to the proposed PICOT question as it discusses certain aspects of education versus non-educated patients and IDWG. The results of the study by Crown et al. (2017) demonstrated no statistically significant improvement of IDWG during the period of the intervention, probably because of the study bein short and small. However, a potential reduction in median IDWG was observed in the study. The results of the study by Wong et al. (2017) were in contrast with those by Crown et al. (2017), as the former found a significant decrease in IDWG in the US and Europe whereas a modest decrease in IDWG in Japan, Australia, and New Zealand following a Volume First initiative. The study found a reduction in mortality due to a decrease in IDWG and other complications from Fluid overload. The differences in results and findings of two pieces of research can be attributed to their different designs. In comparison to the study by Wahyuni (2019), the study by Crown et al. (2017) had a higher validity, although it provided only level 1 evidence. There was a positive response amongst the participants and that the MI coaching did encourage and assist with understanding IDWG. Even with the small study, it has fair validity as far as patient understanding and motivation to maintain and control IDWG is concerned. However, there are issues in the reliability of the study and further research needs to be performed to allow the study to have greater reliability with larger sample sizes as well as additional tools to assist with MI to elicit a positive response on IDWG. The applicability of the study by Crown et al. (2017) to the PICOT question lies in its relevance to patient education and the effects of IDWG. The sample size and statistical evidence of the study by Wong et al. (2017) show a high validity of Volume First initiative and an improved IDWG and mortality. It was a large study, 9 and international participants were used for comparison. There were a lot of sources used and being a level 2 of evidence, the study had high reliability. The study directly applies to the PICOT question by being on an educational program for Dialysis patients on IDWG and mortality related to excessive IDWG. Hecking et al. (2018) investigated monthly primary individual goals including those for caregivers being set for IDWG including fluid intake, dietary intake, and medication management to increase compliance and decrease IDWG. The researchers compared IDWG before goal-setting and the enhancement of complications from IDWG as well as systolic blood pressure (SBP) & cardiovascular events. The authors found that when the monthly individual goals were in place, there was a reduction in IDWG and a more stable cardiovascular system as well as a reduction in SBP. Although the study by Hecking et al. (2018) furnishes the highest level of evidence (level 3) amongst all the studies appraised, the validity, as well as reliability of the study, are limited due to multiple limitations of the study. These include, but are not limited to improper weighing before and after treatment, the study being observational, and listing only specific clinics. The study used education such as “nephrocare” to set personal monthly goals on IDWG with patients, which applies to the PICOT question. Unlike the study by Crown et al. (2017), which was non-conclusive about the effects of an intervention on reducing IDWG, the study by Ahmed et al. (2018) was found significant evidence concerning the effects of dietary education regarding albumin levels and education on treatment duration in improving the albumin levels and reducing mortality. The researchers found no correlation between the ultrafiltration rate and albumin levels. However, the 10 researchers found improved Albumin levels when patients were educated on treatment duration, IDWG, and dietary needs at home. The researchers found that more than 4 dl of Albumin correlates with an increase in mortality and an increase in IDWG. Ahmed et al. (2018) finally concluded that longer treatment duration correlates with improved albumin levels and IDWG when patients were educated about dietary and treatment needs. Like the other studies described above, having limitations to their designs, the study by Ahmed et al. (2018) had several limitations which include the researchers not measuring what was claimed to be measured. The sample size was small and a majority of the statistical data was from an EMR. Further testing was needed to improve the validity of the research. The reliability of the study was limited by the small size, limited patient data, and lack of studies on this topic, more studies need to be performed. However, even with the reduced validity and reliability, the study does assist with the PICOT question. Siciliano (2017) attempted to observe the effects of education on improving compliance to decrease the IDWG. The researchers found patient denial, resistance to change, lack of motivation, and understanding to lead to increased IDWG and increased mortality as well as complications. The validity of the study was limited by having an observational design, not too reliable, and being limited to one clinic setting patients and having no other studies available at the time to verify the validity. This study was based on personal observations and experiences, severely limiting its reliability. Even though the interventions have shown to be effective, different settings were need to be studied to evaluate efficacy. Although furnishing level 1 evidence only, the study applied well to the PICOT question. Implications for Future Research 11 The findings of research by Wahyuni et al. (2019) were in line with the previous researches having similar research problems. One of the limitations which were identified in the research was the weak relationship strength of the variables during the calculation of the coefficient of correlation. A better design was indicated along with a better theoretical framework and well-defined independent and dependent variables. Similarly, the findings of research by Crown et al. (2017), especially the finding of motivational interviewing on its own not being sufficient in alteration of intradialytic weight gain was in line with the previous researches having similar research problems. One of the limitations which were identified in the research was the research being a pilot study only, and the shorttime frame of the study. A bundle of interventions including motivational interviewing was required for the study to be more representative of the research problem. The findings of research by Wong et al. (2017) were in line with the previous researches having similar research problems, with minor differences. The limitations which were identified in the research were potential reasoning confounding and non-availability of dietary salt intakes. A better design was indicated along with a better theoretical framework to address the deficiencies in the design of the research. The findings of research by Hecking et al. (2018) were in line with the previous research, with minor design differences. One of the limitations which were identified in the research was the observational design of the study which could not establish causation. An interventional design could have better addressed the issue of establishing causation. The findings of research by Ahmed et al. (2018) were in line with the previous researches having, but with larger designs. One of the limitations which were identified in the research was 12 the small size of the sample. A bigger sample could have detected correlations existing in larger cohorts. The findings of research by Siciliano (2019) were could not be compared to those of the previous researches as the investigator did not present a discussion of the findings. Integration of the evidence from the various sources of evidence described above clearly demonstrates that there is sufficient evidence that in the end-stage renal disease patients receiving hemodialysis in an out-patient setting, fluid management education decreases interdialytic weight gains, and has a protective role in mortality. The limitations of the current EBP review include the scarcity of literature appraised due to various constraints and nature of the EBP project. However, the evidence obtained and integrated is sufficient to address the PICOT question proposed. Implications for Clinical Practice The needed practice change in the case of ESRD patients receiving hemodialysis in an out-patient setting is proper fluid management education to decrease the interdialytic weight gains. However, irregular patient compliance limits the efficacy of the intervention, and the special consideration for the practice change is regular follow up with the nephrology care provider for the enhanced compliance of the intervention to be ensured. EBP Implementation Model Application The implementation plan shall be undertaken by the use of the Johns Hopkins model of evidence-based practice. The implementation model has the following steps: Step A: Asking the clinical practice problem which is proper fluid management education. 13 Step B: Obtaining the pertinent best current literature using scientific databases like Cochrane and PubMed, by using keywords like fluid management, interdialytic weight gain (IDWG), end-stage renal disease (ESRD), hemodialysis, etc. Step C: Critical appraisal of the evidence, by determining the quality of evidence, validity, reliability, as well as applicability to the proposed PICOT question. Step D: Integrating the evidence into practice, by using the Johns Hopkins EBP model, starting with an inquiry into a practice issue, proposing the practice questions, obtaining the evidence, translating the evidence, and coming up with the best practice, which in this case is the fluid management education in the ESRD patients receiving hemodialysis in the out-patient settings. Step E: The final step is evaluating the outcomes which occur as a result of integrating the evidence into practice. The Johns Hopkins Nursing Evidence-based Practice Model (Vera, 2020). 14 Summary and Conclusions To summarize and conclude, the practice change required for better patient outcomes is that in the ESRD patients receiving hemodialysis in an out-patient setting, fluid management education decreases intradialytic fluid gains, as guided by the evidence obtained from the critically appraised current literature in the past 3 years. The practice change from not providing fluid management education to providing fluid management education is undertaken using the Johns Hopkins evidence-based practice (EBP) model. 15 References Ahmed A., Abdalla A., Satti M., Qazi J., Lappin D. (2018). Hemodialysis Session Duration, Ultrafiltration Rate, Interdialytic Weight Gain and their Association with Albumin in Patients on Intermittent Hemodialysis in a Regional Dialysis Unit: A Cross-sectional Study. Cureus.10(12). 2-7. Crown S., Vogel J., Hurlock-Chorostecki C. (2017). Enhancing Self -Care Management of Interdialytic Fluid Gain in Patients on Hemodialysis: A Pilot Study using Motivational Interviewing. Nephrology Nursing Journal. 44(1). 49-55. Hecking M., et al. (2018). Greater fluid overload and Interdialytic weight gain are independently associated with Mortality In a large International hemodialysis population. Nephrology Dialysis Transplant. (33). 1832-1842. Siciliano E. (2018). Interventions for Improving Interdialytic Weight Gains in At-Risk Patients on Hemodialysis. Nephrology Nursing Journal. 45(1) 83-85. Vera, D. (2020). 2017 EBP Models and Tools. Hopkinsmedicine.org. Retrieved 31 May 2020, from https://www.hopkinsmedicine.org/evidence-based-practice/ijhn_2017_ebp.html. Wahyuni E., Haloho F., Laili, N. (2019). Gain (IDWG) in Hemodialysis Patients with PrecedeProceed Theory Approach. IOP Conf. Series: Earth and Environmental Science 246 (2019) 012034. DOI:10.1088/1755-1315/246/1/012034 Winkelman, C., Workman, M., & Ignatavicius, D. (2013). Medical-surgical nursing (7th ed.). Elsevier. 16 Wong Y., et al. (2017). Interdialytic Weight Gain: Trends, Predictors, and Associated Outcomes in the International Dialysis Outcomes and Practice. American Journal of Kidney Disease. 69(3). 367-379. Name: Description: ...
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