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INTRODUCTION
Objectives
Operational definitions
Assumptions
Hypotheses
Conceptual/theoretical framework
CHAPTER I
INTRODUCTION
It is health that real wealth and not pieces of gold and silver.1
Health is a state of perfect harmony between all the organs and systems of the body.
Good health is more than being free from disease, good hygiene and the access to
medical and social care also important. According to world Health Organization
(WHO) health is a state of complete physical, mental and social well being not merely
social and personal resources as well as physical capabilities. Perception about health
impairment of the normal state of the living animal or plant body or one of its parts
that interrupts or modifies the performance of the vital functions.3The kidneys are the
most important excretory organs within the human body. The word excretion means
the removal of metabolic waste substances from the body. This "metabolic waste" is
the large number of chemical reactions that occur in the cells, tissues and organs. Of
these substances, some of the by-products and end-products of metabolism are toxic
and have to be removed from the body, before they will poison the body tissues.
Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) is the
Chronic kidney disease is the condition causes reduced kidney function over a period
of time. Chronic kidney disease is present when glomerular filtration rate remains
2
below 60 ml per minute for more than 3 months or when urine albumin-creatinine
End Stage Renal Disease is a chronic illness which inevitably reduces the
Hemodialysis (HD) and Renal Transplantation treatment modalities are not curative,
instead they offer symptom relief, extend life expectancy and are intended to improve
waste products in case of kidney failure and it attempts in replacing kidney function.
accompany this treatment, which have a detrimental impact on the quality of patients
life and affects individuals physical and psychological wellbeing. Much evidence
exists to suggest that stress is a significant factor in haemodialysis, since the latter
reduce stress through impact on mental and physical conditions. Among relaxation
methods Bensons relaxation method (1970) is one of the easiest to learn and
administer. The relaxation response is a physical state of deep rest that changes in the
physical and emotional response to stress and opposite of response may help people to
counteract the toxic effects of chronic stress by slowing breathing rate, relaxing
3
version of Transcendental Meditation .This will reduce the stress and reversal of some
physiologic changes associated with chronic stress.8 The majority of people report
feelings of relaxation and freedom from stress during the elicitation of the relaxation
response and during the rest of the day as well. Through this study hemodialysis
patients get a relief from stress and help to improve their quality of life.
Background of study
kidney is essential to maintenance of healthy body. The kidneys are highly vascular
organ and receive 20% to 25% of the resting cardiac output. The patients with renal
failure face a lot of challenges especially from the aspect of health status, life style as
well as their roles in life. End stage renal disease occurs when the kidneys are no
longer able to clean and filter waste and fluids from the blood circulation as they
normally do. When this occurs, it would endanger the patients life. According the
Global Burden of Disease Study, chronic kidney disease was ranked 18th in the list of
Chronic kidney disease (CKD) is a worldwide public health problem, both for
the number of patients and cost of treatment involved. Globally, CKD is the 12th
cause of death and the 17th cause of disability respectively. The prevalence of ESRD
and patients on RRT has increased over last two decades.10According to National
Kidney Foundation ESRD is defined as the point where kidney function is at 10% of
normal.11
Every year one lakhs new cases of ESRD have been detected and the demand
for dialysis is around 9 lakhs per year.12The prevalence of chronic kidney disease in
4
The world wide incidence of renal failure is about 140 per million population
and more than one million people are on dialysis. Health statistics shown that
incidence of ESRD has increased for almost 80% per year for the past 5 years, with
more than 300,000 patients being treated in the United States. The valid treatment
option for renal failure patients are hemodialysis, peritoneal dialysis and renal
transplantation.13
graft. During hemodilysis procedure patients may suffer lots of pressure and
tension.The dialysis depends onmachine for survival conflicts with the independence
Stress is one of the biggest health issues in the hemodialysis patients.Chronic renal
Haemodialysis patients use various strategies to cope up with the stressors related to
their disease and the procedures used in its treatment.15In recent days the use of
settings. Fear of medications side effects and desire for symptom relief are possible
community based study conducted in New Delhi in the year 2005, regarding
prevalence of chronic renal failure among adults, shows that prevalence of CRF in
5
A descriptive cross sectional study was conducted at Mumbai (2014) to
assess the level of stress and coping among 30hemodialysis patients were selected
conveniently by using Stress and Adaptation Questionnaire revealed that about 97%
Anxiety Stress Scale indicated that there were significant difference between stress
and anxiety after intervention and instructing Bensons relaxation technique is helped
and his/ her ability to cope with that demands.19 It is one of the biggest health issues
in the society today. Over a half of the million people will have their physical or
Chronic kidney disease can occur at any age but becomes more common with
increasing age and is more common in women. Currently 35000 people are treated
with dialysis with stress it is estimated that this number will increase > 50000 by the
year 2020, in Europe the number of dialysis patient with stress is also increasing
annually. The mortality rate in dialysis patient is very high with a mean death rate of
22% per year due to stress. This rate mainly influenced by age, with a yearly mortality
of 4% in patients younger than 20years rising to 35% in patient older than 65 years.20
the overall quality of life among 97 hemodialysis patients were selected purposively
6
by using Health survey questionnaire revealed that dialysis patients had severe stress
have found them to be both physiological and psychological stressors. The most
common physiological stressors for these clients are limitation of fluid, limitation of
food, fatigue, and sleep disturbance. The most common psychological stressors have
been reported to include role disturbance, employment status, social support, stress,
diagnosis and treatment of this condition is certainly important. Among the various
measures Bensons relaxation technique has been gaining popularity as a simple and
easy administrative mode of alternative therapy not only for stress but also anxiety,
especially with high stress. Hence the researcher got interested in assessing stress
1. To assess the pretest and post test level of stress among hemodialysis patients.
hemodialysis patients.
7
3. To find out the association with pretest level of stress and selected
sociodemographic variables.
Operational definitions
Hemodialysis patients have achieved a significant reduction in the post test level of
stress after practicing Bensons relaxation technique for 10 minutes once daily for a
Bensons relaxation technique: In this study, Bensons relaxation technique refers to a type of
breathing exercise performed in sitting position with closed eyes and relaxing the
body from toes to top and then taking a deep breath through nose and exhale from
mouth by saying one word or number for 10 minutes once daily for three days in a
week under the supervision of the researcher and all other days by themselves for a
period of 24 days.
Stress: In this study, stress refers to a mental distress associated with physical,
failure patients having stress score 14 and above undergoing hemodialysis regularly
Alappuzha district.
Assumptions
8
Bensons relaxation technique may be effective in reducing stress among
Hemodialysis patient.
Hypothesis
H01 There will be no significant difference in pretest and post test level of stress
H1There will be a significant difference in pre test and post test level of stress
H02There will be no significant association with pre test level of stress and
H2There will be a significant association with pre test level of stress and selected
sociodemographic variable.
oftheory which guides the development of the study and enables the researcher to link
the findings to nursing body of knowledge. The study framework is called the
frame work of the present study is based on Imogene King Goal Attainment theory.
The theory is based on assumption that humans are open system who
system reflects King's belief that the practice of nursing is differentiated for in that of
other health profession by what nurses do with and for individual. The major elements
9
of the theory of Goal Attainment are seen "in the interpersonal systems in which two
people, who are usually strangers, come together in a health care organization to help
The theory concepts focus on the methods to help nurses in the nurse-patient
developed a general systems framework and a theory of goal attainment where the
interpersonal, and society or social, while the theory of goal attainment pertains to the
growth and development, time, and personal space. King emphasizes that both the
nurse and the client bring important knowledge and information to the relationship
The concepts of the theory are perception, judgment, action, interaction and
transaction. These concepts are interrelated to in every nursing situation. These terms
Perception
Judgement
Individuals come together for a purpose and perceive each other. Each makes
a judgement and takes mental action to decide and act.24 In this study, judgement of
10
researcher is that Bensons relaxation technique will be effective for reducing stress
Action
Refers to the activity to achieve the goal what the individual perceives.24 In
this study it is mutual goal setting to reduce the stress among hemodialysis patients by
stress scale to analyze the stress and patients are motivated to answer the questions in
the scale.
Reaction
out the pre test score of stress and deciding to practice Bensons relaxation technique
Interaction
hemodialysis patients who have stress assessed by Cohen Perceived Stress Scale..
Transaction
environment to achieve goals that are valued and directs human behaviour.24In this
study, transaction is the assessment of post test score among hemodialysis patients in
Positive outcome
Stress Scale.
11
Negative outcome
12
ACTION INTERACTION TRANSACTION
REACTION
PERCEPTION
Investigator assumes that Pretest assessment Researcher assess
Find out the effect
Conducting
R Bensons relaxation technique of stress of the stress among of stress after
E may effective in reducing practice session of
S stress of hemodialysis patients hemodialysis hemodialysis practicing
Bensons relaxation
E
patients using patientsand decided Bensons
A technique to make
R Cohen Perceived to teach and relaxation
changes on stress
C JUDGEMENT demonstrate
Stress Scale. technique among
H Bensons relaxation among
E technique will be effective Bensons relaxation hemodialysis
hemodialysis
R for reducing stress among technique to the
patients.
Hemodialysis patients. patients.
group .
ACTION
Feed back*
Figure 1: Conceptual framework of the study based on Imogene .M.Kings Goal Attainment theory.*not included in the study
13
CHAPTER 2
REVIEW OF LITERATURE
Summary
14
CHAPTER 2
REVIEW OF LITERATURE
Review of literature is a body of text that aims to review the critical points
ofresearch interest, which contain information, ideas data and evidence written from a
particular stand point to fulfil certain aims or express certain views on the nature
The researcher has organized the related literature under the following
headings after reviewing various research studies and non research literature.
selected by simple random method using Jelowice Coping Scale and Customorized
Stress Questionnaire showed that hemodialysis patients used coping methods more
frequently than peritoneal dialysis patients and majority of patient used emotion
the level of stress and coping among 30hemodialysis patients were selected
conveniently by using Stress and Adaptation Questionnaire revealed that about 97%
15
A cross-sectional survey was conducted at Scotland (2014) to
sampling method using General Well-being Questionnaire for Stress showed that the
A cross sectional study was conducted at Chennai (2013) to assess the stress
and coping among 50 hemodialysis and peritoneal dialysis patients were selected
and Stress Scale indicated that overall mean stress score in chronic hemodialysis
patients was higher (78.3%) than in peritoneal dialysis patients (43.3%) p<0.01.28
factors, coping mechanism and quality of life among 113 hemodialysis patients were
selected by census method using Hemodialysis Stressor Scale and Jelowice Coping
(2013) to assess the quality of life among 161 dialysis patients and 350 participants
from community were selected conveniently by using Quality of life Index Dialysis
Version Tool and SF-36 questionnaire indicated that the overall quality of life for
dialysis patients was rated lower with the community sample (58.92 vs 75.02,
p<0.0001).30
hemodialysis patients were selected by using Medical outcome study 36 item short
form health survey questionnaire indicated that there is a close relationship between
16
A descriptive study was conducted at Hong Kong (2011) to determine the
stressors and coping methods among 50 hemodialysis patients were selected using
Baldree Haemodialysis Stressor Scale (HSS) and Jalowiec Coping Scale (JCS)
revealed that limitation of fluid was the most frequently identified stressor and most
A cross sectional study was conducted at Northern Iran (2011) to evaluate the
selected by survey method using demographic information record sheet and Baldree
physical and psychosocial problems and stress level was high in women who were
hemodialysis patients use emotion focused coping style. The study suggested that
decreases the pressure of diseases and promote mental health, quality of life and
efficiency.34
relationship between quality of life and stress among 100 hemodialysis patients were
selected conveniently by using SF-36 and Depression Anxiety Stress Scale showed
that increased depression, anxiety, and stress could reduce the quality of life of
hemodialysis patients.35
17
using Short Form Health survey questionnaire revealed that End stage renal disease
treatment related stressors and coping strategies among 224 chronic hemodialysis
Stressor Scale and Carver Coping Scale indicated that most frequently frequent
stressors reported were limitation of vacation (80.4%), followed by fatigue (79.9%) .37
stressors and coping among 60 hemodialysis patients were selected using Baldree
Hemodialysis Stressor Scale and Jalowiec Coping Scale indicated that length of time
of hemodialysis may be affects the participants appraisal of stressors and few coping
Hemodialysis Stressor Scale and Jalowiec Coping Scale indicated that hemodialysis
A descriptive study was conducted at Chennai (2003) to assess the stress and
and Coping Questionnaire showed that 65% had mild stress, 20% had moderate stress
and 63.3 % never had any coping where as 36.7 % had some coping. The study
concluded that there was a negative correlation between level of stress and coping
18
selected at two points in time, three months apart by using the Haemodialysis Stressor
Scale revealed that greatest stressors were fluid limitations and patients new to
associated with treatment related stressors among 75 haemodialysis patients aged 18-
65 years were selected at two points in time, three months apart by using the
Haemodialysis Stressor Scale revealed that hemodialysis patients had high level of
significant stressors and coping methods which are related to quality of life among 64
dialysis patients were selected by survey method by using Stress and Coping
Questionnaire revealed that limitation of physical activity was the most troublesome
stressor and length of time on the dialysis programme was not significantly related to
coping behavior.43
international data base showed that stressors had particular importance among
hemodialysis patients and these affect their physiologic as well as psychological well-
being.44
A study was conducted at Japan (1993) to assess stress and coping patterns
Stressor Scale revealed that psychosocial stressors have an impact equal to that of
physiological stressors and fluid restriction was ranked as the highest psychosocial
stressor and the top physiological stressors were muscle cramps and fatigue.45
19
An exploratory study was conducted at Columbus (1988) to assess the stress
and use of coping methods among 68 chronic hemodialysis patients were selected by
non probability sampling method using Hemodialysis Stressor Scale and Jalowiec
Coping Scale indicated that physiological stressors were more troublesome than
coping scores.46
anxiety in experimental and control groups in all intervals after intervention and no
significant difference between mean score of depression. The study concluded that
utilizing Bensons relaxation technique helped to reduce stress and anxiety among
dialysis patients.47
mean scores of general and total quality of life were significantly higher than the
corresponding pre test readings and Bensons relaxation technique had a positive
20
that there were significant differences between stress and anxiety levels in case group
before and after intervention (P <0.001)The study concluded that instructing Bensons
patients.49
A randomized control trial was conducted at India (2013) to explore the efficacy
Anxiety Stress Scale indicated that there were significant difference between stress
and anxiety level in case group before and after intervention and instructing Bensons
hemodialysis patients.18
that Bensons relaxation technique help to relieve the intensity of pain and improve the
of Bensons relaxation technique to reduce stress and improve the responses among 40
Scale revealed that 85% of the selected samples response of relaxation technique is
21
Scale and Quality Life Scales showed that Bensons relaxation technique significantly
decreases the state of stress and improved generic quality of life in the experimental
group (p<0 and improved the psychological health and quality of life.52
the ages of 44 and 50 years were selected purposively by using Perceived Stress Scale
showed that daily practice of the Benson relaxation technique lead to a significant
Summary
pre work, fact and finding of the chosen problem. This chapter described a brief
account of various studies conducted by different investigators and few citations from
the books and journals which are found to be relevant to the study.
22
CHAPTER 3
METHODOLOGY
Research approach
Research design
Variables
Population
Inclusion criteria
Exclusion criteria
Tool/Instruments
Content validity
Translation of tool
Pilot study
23
CHAPTER 3
METHODOLOGY
field of study.23 Research methodology is the way in which research problems are
scientifically.54
This chapter deals with methodology adopted for the study. It includes
setting of the study, population, sample and sampling technique, sampling criteria,
development and selection of the tool, description of the tool, content validity, and
reliability of the tool, pilot study, data collection process and plan for data analysis.
Research approach
Research approaches are plans and the procedures for research. It involves
Research design
Research design basically provides an outline of how the research will be carried out
and the methods that will be used.54 It is a systematic plan of what is to be done, how
The research design adopted for the study was pre experimental one group
24
Table 1: Schematic representation of research design
Experimental group O1 X O2
Key: -
O1: Pretest for assessing the level of stress among hemodialysis patients.
Variables
orsituation that can change or vary. Variables are concepts at different level
Sociodemographic variables
First section was demographic variables which includes age, gender, religion,
income, percentage of income spent for treatment, money expended so far for
25
chronic kidney disease, duration of dialysis treatment, total number of dialysis done,
average loss of working days per week, performance of daily activity, level of
physical activity, most commonly faced problem before dialysis, most commonly
faced problem during dialysis, most commonly faced problem after dialysis. Second
section was clinical variables which include post dialysis weight, temperature, pulse,
respiration, systolic blood pressure, diastolic blood pressure, blood urea nitrogen,
Dependent variable
intervention. The dependent variable is the outcome or response due to the effect of
Independent variable
by the researcher to create the effect on the independent variable.22 It is the treatment
performed in sitting position with closed eyes and relaxing the body from toes to top
and then taking a deep breath through nose and exhale from mouth by saying one
word or number for 10 minutes once daily for three days in a week under the
supervision of the researcher and all other days by themselves for a period of 24 days.
26
Purpose Setting
Study design Population
To assess the Hemodialysis unit of
Pre-experimental 35 hemodialysis
effectiveness of a selected hospital
one group pretest- patients
Bensons relaxation
posttest design
technique on stress
among hemodialysis
patients
Pretest
Assess the pre Tools and technique Sampling technique
test stress score Non probability purposive
1. Socio demographic proforma
Demonstrating sampling
2. Cohen Perceived Stress Scale
Bensons
relaxation Sample size: 35
technique hemodialysis patients
Intervention with stress score 14 and
above
Administering Bensons
relaxation technique 10
minutes daily for a Posttest
period of 24 days Statistical analysis
Assessing post test
level of stress by Descriptive: Frequency, percentage,
using Cohen mean and standard deviation
Presentation and
Perceived Stress Inferential: Pairedt test and chi-square
Scale communication of
test
research
27
Setting of the study
Settings are the most specific places where data collection occurs. It could be
hemodialysis unit. Six beds are available in the dialysis unit. Average number of
Population
age group of 20 to 80 years with stress score 14 and above which is measured by
study.22
both the inclusion and exclusion criteria were selected from Century Hospital at
Alappuzha district.
In order to select the sample from the population, investigator adopted non-
technique the researcher believes that some subjects are fit for research compared to
other individuals.
28
The researcher purposefully selected the hemodialysis patients from Century
Inclusion criteria
The criteria that specify the characteristics of the subjects in the population are
male or female.
Exclusion criteria
The criteria that specify the characteristics that a study population does not
technique.
Tool / Instruments
researcher.
Data collection tools are the procedures or instruments used by the researcher
hemodialysis patients and Cohen Perceived Stress Scale. An intense search of related
literature and extensive consultation with the experts was done for selection of the
The following methods were used for the selection of the tool
The following steps were carried out in the selecting the tool
1. Preparation of content
5. Ensuring reliability
age, gender, religion, education, type of family, marital status, occupation, place of
residence, family income, percentage of income spent for treatment, money expended
dialysis done, average loss of working days per week, performance of daily activity,
level of physical activity, most commonly faced problem before dialysis, most
commonly faced problem during dialysis, most commonly faced problem after
dialysis
respiration, systolic blood pressure, diastolic blood pressure, blood urea nitrogen,
demographic proforma and to find the association with the variables. The technique
31
Tool 2: Cohen Perceived Stress Scale
Cohen Perceived Stress Scale is a standardized 5 point rating scale which was
originally developed by Cohen. The stress scale comprises of 10 items. Each item had
five alternatives varying from the response No Stress to Severe Stress. Each
1 0 No stress
Content validity
In order to assess the content validity of the tools, the prepared tool along with
scale and research methodology are submitted to 10 experts. The experts were from
Theexperts were requested to judge the items for accuracy, relevance and
32
Translation of the tool
The language experts translated the tool in to Malayalam. The tool was given
to the English expert, to translate back to English to establish the language validity of
the tool. There was 100% agreement with the translation of sociodemographic
speciality hospital for establishing the reliability of the instrument. The reliability of
modified tool was calculated and the value was found to be 0.72 by Cronbachs alpha
Pilot study
Pilot study is defined as a smaller version or trial run done in preparation for a
major study.22
district in order to check the feasibility and practicability of the tool. The investigator
obtained written permission from the concerned authorities prior to the study. The
period of study was one week from 25-10-2016 to 31-10-2016. The samples were 10
Informed consent was taken from the study subjects and purpose of the study was
explained and confidentiality was assured. Each sample took 10 minutes to answer the
samples per day 10 minutes daily from 12 pm to 12.10 pm for 7 days. Next day
33
posttest was conducted using Cohen perceived stress scale. Data were analyzed using
After conducting the pilot study, it was found that the study was feasible, the
subjects were cooperative and the data collection instruments were relevant. So the
investigator planned to carry out the data collection for the main study on the same
problem.54
Step 1
For conducting main study, prior permission was obtained from the Medical
subjects and explained the purpose of the study to them and confidentiality was
assured to all subjects. An informed consent was taken from the study subjects. Thirty
five subjects were purposively selected from the population as per the inclusion
criteria.
Step 2
minute daily and alternative days under supervision by the researcher for a period of
24 days.
Step 3
Post test was conducted after 24 days of intervention. The tool was collected
34
Plan for data analysis
Analysis is the systematic organization and synthesis of research data and the
After the data collection, data were organized, tabulated, summarized and
objectives and hypothesis of the study. Master data sheet was prepared by the
Descriptive statistics
demographic variables.
2. Mean, percentage and standard deviation were used to analyze the pretest and
Inferential statistics
1. Pairedttest was used to compare the pretest and posttest level of stress scores.
2. Chi-square test was used to find out the association between the selected
Summary
This chapter dealt with the research approach, research design, variables,
the tool, content validity and reliability of the tool, pilot study, data collection process
The next chapter deals with the analysis and interpretation of the study.
35
CHAPTER 4
variables.
Alappuzha district.
Section V : Association between the pre test level of stress and selected
36
CHAPTER 4
translate the information collected during the course of research project into an
This chapter deals with analysis and interpretation of data obtained from 35
approach was used in the present study. The data were processed and analyzed on the
basis of the objectives and hypotheses formulated for the present study.
1. To assess the pretest and post test level of stress among hemodialysis patients.
hemodialysis patients.
3. To find out the association with pretest level of stress and selected socio-
demographic variables.
variables.
37
SectionIII: Assessment of posttest level of stress among hemodialysis
Alappuzha district.
Section V : Association between the pre test level of stress and selected
The socio demographic variables of the subjects are described in terms of age,
residence, family income, percentage of income spent for treatment, money expended
done, average loss of working days per week, performance of daily activity, level of
physical activity, most commonly faced problem before dialysis, most commonly
faced problem during dialysis, most commonly faced problem after dialysis. The
technique was structured interview and data were analyzed using descriptive statistics
38
60
51.4%
50
40 34.3%
20-40
Percentage
30 40-60
60-80
20 14.3%
10
0
20-40 40-60 60-80
Figure 3 illustrates that more than half (51.4%) of the samples were in the age
group of 60-80 years, more than one third(34.3%) of the samples were in the age
group of 40-60 years and more than one tenth (14.3%) of the samples were in the age
39
68.6%
70
60
50
40 31.4%
percentage
Male
30 Female
20
10
0
Male Female
Gender
sex. (n=35)
It is evident from figure 4 that more than two third(68.6%) of the samples
were males and less than one third (31.4%) of the samples were females.
40
60 54.3%
50 45.7%
40
Percentage
Hindu
30
Christian
Muslim
20
10 0%
0
Hindu Christian Muslim
Religion
on Religion. (n=35)
Figure 5 depicts that more than half (54.3%) of the samples were Hindu and
less than half (45.7%) of the samples were Christians whereas no subjects were from
Muslim.
41
42.8%
45
40
35 28.6%
30
Percentage
25 Up to high school
17.1%
20
Higher scondary
15 8.6%
10 Diploma
2.9%
5 Graduation
0 Post greaduation and above
Education
on education. (n=35)
Figure 6 illustrates that less than half (42.8%) of the samples educated up to
high school, more than one fourth (28.6%) of the samples had higher secondary
education, less than one fifth (17.1%) of the samples had diploma education, less than
one tenth (8.6%) of the samples had graduation and remaining very few samples
42
100%
100
90
80
70
Percentage
60
50 Nuclear family
Joint famliy
40
30
20 0%
10
0
Nuclear family Joint famliy
Type of family
Data presented in figure 7 depicts that all (100%) of the samples belonged to
43
70 65.71%
60
50
Percentage
40
30 Married
20%
20 14.29% Unmarried
Divorced/separated
10 0%
Widow/Widower
0
Marital status
Figure 8 shows that less than two third(65.71%) of the samples were married,
one fifth (20%) of the samples were unmarried, less than one fifth (14.29%) of the
44
35
30 28.6%
25 22.9%
percentage
20%
20
17.1%
15
Daily wager
11.4%
Self employed
10
Unemployed
Private employed
5
Government employed
Occupation
occupation. (n=35)
Figure 9 illustrates more than one fourth (28.6%) of the samples were
government employed, less than one fourth (22.9%) of the samples were private
employed, one fifth(20%) of the samples were self employed, less than one fifth
(17.1%) of the samples were unemployed and more than one tenth(11.4%) of the
45
80 74.3%
70
60
50
Percentage
Panchayat
40
Muncipality
Corporation
30 20%
20
5.7%
10
0
Panchayat Muncipality Corporation
Place of residence
Figure 10 shows that less than three fourth (74.3%) of the samples were
residing in Panchayat, one fifth (20%) of the samples were in Corporation and few
46
60
51.4%
50
40 34.3%
30
Rs 10000
Percentage
Rs 10001-20000
20 11.5% Rs 20001-30000
Rs 30001
10
2.8%
Figure 11 illustrates that more than half (51.4%) of the samples hadmonthly
family income of Rs 10001 - 20000, more than one third (34.3%) of the samples
hadfamily income of Rs 10000 , more than one tenth (11.5%) of the samples had
monthly family income of Rs 20001 to 30000 and very few(2.8%) of the samples
47
80%
80
70
60
< 25%
50 25-50 %
50-75 %
Percentage
40 75-100%
30
20%
20
0% 0%
10
0
< 25% 25-50 % 50-75 % 75-100%
Percentage of income spent for treatment
Figure 12 illustrates that majority (80%) of the samples were spent 25-50
percentage of their family income for treatment , one fifth (20%) of the samples were
spent 50-75 percentage of their family income and none of them were spent less than
48
40 37.1%
35
30
25.7%
25 22.9%
Percentage
20
14.3% Rs 10000
15 Rs 10001-50000
Rs 50001-100000
10
Rs 100001
5
50001 to 100000 for treatment, more than one fourth(25.7%) of samples expended Rs
10001 to 50000 for treatment, less than one fourth (22.9%) of samples expended Rs
100001 for treatment and more than one tenth (14.3%) of samplesexpended Rs
49
11.4%
14.3% 31.4% Own savings
Assistance from family
Pension
Assistance from others
42.9%
Financial support
Figure 14 illustrates that less than half (42.9%)of samples were financially
supported by assistance from family, less than one third (31.4%) of the samples were
financially supported with own savings, more than one tenth (14.3%) of the samples
were financially supported by pension and less than one tenth (11.4%) of the samples
50
70
62.9%
ESI
60
Arogya insurance
50
Others
40 None
Percentage
30
20%
20 17.1%
10 0%
0
ESI Arogya Others None
insurance
Medical insurance
Findings from Figure 15 evidenced that more than half (62.9%) of the samples
had no any medical insurance, one fifth(20%) of the sampleshad Arogya insurance,
less than one fifth (17.1%) of the samples had ESI and none of them had other
medical insurance
51
50 45.7
45
40
Diabetes melitus
35
Percentage
30 22.9%
Hypertension
25 20%
20 11.4% Diabetes and hypertension
15
Diabetes and others
10 0%
0%
5
Hypertension and others
0
Hypertension, diabetes and
others
Co-morbidities
Figure 16: Bar diagram showing percentage distribution of samples based on co-
morbidities. (n=35)
Figure 16 depicts that less than half (45.7%) of samples had diabetes and
hypertension, less than one fourth (22.9%) of the samples had hypertension, diabetes
and others, one fifth (20%) of the samples had only hypertension and more than one
52
100%
100
90
80
70
percentage
60
Yes
50
No
40 Don't know
30
20
0% 0%
10
0
Yes No Don't know
Family history of chronic kidney disease
Figure 17 shows that all the samples (100%) had no family history of chronic
kidney disease.
53
8.6%
42.8%
Figure 18 illustrates less than half (42.8%) of the samples were received
dialysis treatment for 1to 3 years, more than one fourth (25.7%) of the samples were
received dialysis treatment for 3 to 5 years, less than one fourth(22.9%) of the
samples were received dialysis treatment less than 1year and less than one tenth
(8.6%) of the samples were received dialysis treatment more than or equal to 5 years.
54
45 42.9%
40
35
28.6%
30
Percentage
25 100
20% 101-200
20 201-300
15 301
8.5%
10
0
100 101-200 201-300 301
Total number of dialysis done
Figure 19 depicts that less than half(42.9%) of the samples had undergone 101
to 200 dialysis, more than one fourth (28.6%) of the samples had undergone dialysis
between 201 to 300, one fifth (20%) of the sampleshad undergone less than or equal
to100 dialysis and less than one tenth(8.5%) of the samples had undergone greater
55
8.6%
14.3%
1-2 days
3-4 days
Unable to go for work
60% 17.1% Unemployed
less than one fifth (17.1%) of the samples were unable to go for work, less than one
sixth(14.3%) of the samples were loss 3-4 working days per week and less than one
tenth (8.6%) of the samples were loss 1-2 working days per week .
56
77.1%
80
70
60
50
Percentage
40 By self
30 22.9% Assistance from family
Assistance from others
20
10 0%
0
By self Assistance Assistance
from from
family others
Figure 21 shows that more than three fourth (77.1%) of the samples were
perform their daily activity by self and less than one fourth(22.9%) of the samples
57
77.1%
80
70
60
Percentage
50
40
17.1%
30 5.8%
20 Completely dependent
10 Partially dependent
0 Completely independent
Figure 22 illustrates more than three fourth (77.1%) of the samples were
completely independent to do their physical activity, more than one sixth (17.1%) of
the samples were partially dependent and very few (5.8%) of the samplewere
58
60%
60
50
40%
40
Percentage
30
Breathing difficulty
20
0% Edema
0%
10 Anorexia
Vomiting
0
It is evident from Figure 22 that more than half (60%) of the samples were
facing breathing difficulty before dialysis, less than half (40%) of the samples were
facing edema before dialysis and none of them had anorexia and vomiting before
dialysis.
59
20%
2.9%
Muscle cramps
5.7%
Giddiness
Nausea
Head ache
71.%4
Figure 23 illustrates more than three fourth (71.4%) of the samples were
facing muscle cramps during dialysis, one fifth (20%) of the samples were facing
head ache, less than one tenth (5.7%) of the samples were facing giddiness and very
60
80%
80
70
60
Percentage
50
Fatigue
40
17.2% Itching
30 Joint stiffiness
20 2.8% Dizziness
0%
10
0
Fatigue Itching Joint Dizziness
stiffiness
Most commonly faced problem after dialysis
Figure 24 shows that majority (80%) of the samples were facing fatigue after
dialysis, less than one fifth (17.2%) of the samples were facing dizziness and very few
61
Section I (B): Distribution of clinical variables of subjects
42.8%
45
40 34.3%
35
30 22.9%
Percentage
< 50kg
25
50-60 kg
20
60-70 kg
15 70-80 kg
10
0%
5
0
< 50kg 50-60 kg 60-70 kg 70-80 kg
Post dialysis weight
Figure 25 depicts that less than half (42.8%) of the samples had post dialysis
weight between 50 to 60 kg, more than one third (34.3%) of the samples had post
dialysis weight less than 50 kg, less than one fourth (22.9%) of the samples had post
dialysis weight between 60 to 70 kg and none of the samples belonged to post dialysis
62
100%
100
90
80
70
Percentage
60
50
< 98.6 F
40 <98.6 -99F
30 99F
0% 0%
20
10
0
< 98.6 F <98.6 -99F 99F
Temperature
Figure 26 illustrates that all the samples (100%) had temperature between
98.6F to 99F.
63
80
71.4%
70
60
50
Percentage
< 50 beats/min
40 28.6%
50-70 beats/min
30 70-90 beats/min
90 beats/min
20
0% 0%
10
0
< 50 50-70 70-90 90
beats/min beats/min beats/min beats/min
Pulse
Pulse. (n=35)
Figure 27 shows that less than three fourth (71.4%) of the samples had pulse
between 70 to 90 beats/min, more than one fourth (28.6%) of the samples had pulse
between 50 to 70 beats/min and none of the samples had pulse less than 50 and
64
54.3%
60
45.7%
50
40
Percentage
30
< 20 breaths/min
20-25 breaths/min
20
25-30 breaths/min
0% 30 breaths/min
10 0%
Respiration
on respiration (n=35)
Figure 28 shows that more than half (54.3%) of the samples had respiration
between 20 to 25 beats/min, less than half (45.7%) of the samples had respiration
between 25 to 30 beats/min and none of the samples had respiration less than 20 and
65
57.1%
60
50
40
Percentage
10 0%
0
< 100 100-140 140-170 170
mmHg mmHg mmHg mmHg
Systolic blood pressure
Figure 29 illustrates that more than half (57.1%) of the samples had systolic
blood pressure between 140 to 170 mmHg, less than one fourth (22.9%) of the
samples had systolic blood pressure between 100 to140 mmHg, one fifth (20%) of the
samples had systolic blood pressure greater than or equal to 170 mm Hg and none of
the samples had systolic blood pressure less than 100 mmHg.
66
2.8%
< 90 mmHg
90-120 mmHg
120 mmHg
48.6% 48.6%
diastolic blood pressure less than 90 mmHg and 90 to120 mm of Hg and very few
(2.8%) of the samples had diastolic blood pressure greater than or equal to 120
mmHg.
67
60
51.4% 48.6%
50
40
Percentage
0
< 135 mEq/L 135-145 145 mEq/L
mEq/L
Serum sodium
Figure 31 illustrates that more than half (51.4%) of the samples had serum
sodium level less than 135 mEq/L , less than half (48.6%) of the samples had serum
sodium level between 135- 145 mEq/L and none of the samples belonged to serum
68
44.6%
45
40
31.4%
35
30
Percentage
25 18.3%
<80 mg/dl
20
80-100 mg/dl
15
100-120mg/dl
5.7%
10 120 mg/dl
5
0
Figure 32 illustrates that less than half (44.6%) of the samples had blood urea
nitrogen level between 100 to 120 mg/dl, less than one third (31.4%) of the samples
had blood urea nitrogen level between 80 to100 mg/dl, less than one fifth (18.3%) of
the samples had blood urea nitrogen level greater than or equal to 120 mg/dl and very
few(5.7%) of the samples had blood urea nitrogen level less than 80 mg/dl.
69
47.5%
50
45
40
35 30%
Percentage
30
25 < 3 mEq/L
20 15% 3-6 mEq/L
15 6-9 mEq/L
10 7.5%
9 mEq/L
5
0
<3 3-6 6-9 9
mEq/L mEq/L mEq/L mEq/L
Serum potassium
Figure 33 illustrates that less than half (47.5%) of the samples had serum
potassium level between 6 to 9 mEq/L, more than one fourth (30%) of the samples
had serum potassium level greater than or equal to mEq/L, more than one
tenth(15%)of the samples had serum potassium level 3 to 6 mEq/L and less than one
tenth (7.5%) of the samples had serum potassium level less than 3meq/L.
70
40
35.2%
35
28.6% 30.5%
30
25
Percentage
20 < 5.5mg/dl
15 5.5-7.5 mg/dl
5.7% 7.5-10.5 mg/dl
10
10.5mg/dl
5
Serum creatinine
Figure 34 illustrates that more than one third (35.2%) of the samples had
serum creatinine level 7.5to 10.5mg/dl, less than one third (30.5%) of the samples had
serum creatinine level greater than or equal to 10.5mg/dl, more than one fourth
(28.6%) of the samples had serum creatinine level between 5.5to 7.5 mg/dland very
few (5.7%) of the samples had serum creatinine level less than 5.5 mg/dl.
71
Section II: Assessment of pre test level of stress among hemodialysis patients in a
60
48.6%
51.4%
50
40
Percentage
30 No stress
Mild stress
20 Moderate stress
Severe stress
10 0%
0%
0
No stress Mild Moderate Severe
stress stress stress
Pretest level of stress
Figure 35: Bar diagram showing distribution of samples based on pre test level
of stress. (n=35)
pre test level of stress, more than half (51.4%) of the samples had moderate level of
stress, less than half (48.6 %) of the sample had severe level of stress and none of the
72
Section III: Assessment of post test level of stress among hemodialysis patients in
57.1%
60
50
40
Percentage
31.4%
30 No stress
Mild stress
20 Moderate stress
11.5%
Severe stress
10 0%
0
No stress Mild Moderate Severe
stress stress stress
Post test level of stress
Figure 36: Bar diagram showing distribution of samples based on post test level
of stress. (n=35)
Figure 36 shows that the percentage distribution of samples based on post test
level of stress, in which more than half (57.1%) of the samples had moderate stress,
less than one third(31.4%) of the samples had mild stress , more than one tenth
(11.5 %) of the samples had severe stress and none of them had no stress.
73
Section IV: Comparison of pre test and post test level of stress among
57.1%
60
51.4%
48.6%
50
40 31.4%
Percentage
30
Pretest
20 Posttest
11.5%
10
0% 0%
0%
0
No stress Mild stress Moderate Severe
stress stress
Comparison of pretest and posttest level of stress
Figure 37: Bar diagram showing comparison of pre test and post test level of
than half (51.4%) of the samples had moderate level of stress and less than half
(48.6 %) of the sample had severe level of stress. Whereas after practicing Bensons
relaxation technique, more than half (57.1%) of the samples had moderate stress, less
than one third (31.4%) of the samples had mild stress and less than on fourth (11.5 %)
74
Section V: Analysis of the effectiveness of Bensons relaxation technique on
This section deals with the analysis of difference between pre test and post test
level of stress and to assess the effectiveness of Bensons relaxation technique among
H01: There will be no significant difference in post test level of stress among
hemodialysis patientsafter practicing Bensons relaxation technique.
H1: There will be a significant difference in post test level of stress among
Table 3: Mean, SD, Mean difference and calculated t-value of stress among
(n=35)
Data presented in the table 3 reveals that the mean post test score 17.69 with SD
5.63 was significantly lower than the mean pre test score 24.71 with SD 5.42 with a
mean difference of 7.02. Since the calculatedt value 19.78 which was greater than
the table value (2.032) with degrees of freedom 34 at p< 0.05 level of significance.
75
Hence the null hypothesis (H0) was rejected and research hypothesis (H1) was
accepted. The study concluded that the Bensons relaxation technique is very effective
Section V: Association between the pretest level of stress and selected socio
demographic variables.
This section attempts to study the association of the pretest level of stress
among hemodialysis patients and selected socio demographic variables like age,
residence, family income, percentage of income spent for treatment, money expended
dialysis done, average loss of working days per week, performance of daily activity,
level of physical activity, most commonly faced problem before dialysis, most
commonly faced problem during dialysis, most commonly faced problem after
dialysis, post dialysis weight , temperature, pulse, respiration, systolic blood pressure,
diastolic blood pressure, serum sodium, blood urea nitrogen, serum potassium, serum
creatinine.
haemodialysis patients with selected socio demographic variables, chi-square test was
H02: There will be no significant association with pretest level of stress and
H2: There will be a significant association with pretest level of stress and selected
sociodemographic variable
76
Table 4: Association between pretest level of stress and selected socio
demographic Variables. (n=35)
Variables 2 df p value
Inference
77
Most commonly faced problem during 2.473
dialysis 5 11.07 NS
dialysis 2 5.99 NS
Clinical variables
2 5.99 NS
Data presented in the table 4 shows that Chi-square was used to determine the
variables such as age, gender, religion, education, type of family, marital status,
treatment, money expended so far for treatment, financial support, medical insurance,
most commonly faced problem during dialysis, most commonly faced problem after
dialysis, post dialysis weight , temperature, pulse, respiration, systolic blood pressure,
diastolic blood pressure, serum sodium, blood urea nitrogen, serum potassium, serum
creatinine.
The calculated Chi-square value was less than the table value at 0.05 level of
significance, hence the null hypothesis (H02) can be accepted and research hypothesis
(H2) can be rejected. So there was no significant association between pretest level of
79
CHAPTER5
RESULTS
Objectives
Hypotheses
Results
80
CHAPTER 5
RESULTS
This chapter deals with the findings of the study. The present study was
Objectives
hemodialysis patients.
3. To find out the association with pretest level of stressand selected socio-
demographic variables.
Hypotheses
H01 There will be no significant difference in pretest and post test level of stress
H1There will be a significant difference in pre test and post test level of stress
H02There will be no significant association with pre test level of stress and
81
H3There will be a significant association with pre test level of stress and selected
clinical variable.
variables.
Section IV : Comparison of pre test and post test level of stress among
district.
Alappuzha district.
Section VI : Association between the pre test level of stress and selected
Section VII : Association between the pre test level of stress and selected
clinical variables.
82
Results
variables.
More than half of the samples (51.4%) were in the age group of 60-80 years.
Less than half of the samples (42.8%) had up to high school education
More than one fourth of the samples (28.6%) were government employed.
Less than three fourth of the samples (74.3%) were place of residence in
Panchayat.
More than half of the samples (51.4%) had monthly family income between
10001 to 20000.
Majority of the samples (80%) were spent 25 to 50 percentage of their income for
treatment.
More than one third of samples (37.1%) expended Rs 50001 to 100000 for
treatment.
Less than half of the samples (42.9%) were financially supported by assistance
from family.
More than half of the samples (62.9%) had no any medical insurance.
Less than half of samples (45.7%) had both diabetes and hypertension.
All the samples (100%) had no family history of chronic kidney disease.
83
Less than half of the samples (42.8%) were received dialysis treatment for 1-3
years.
Less than half of the samples (42.9%) had undergone 101 to 200 dialysis.
More than three fourth of the samples (77.1%) were perform their daily activity by
self,
More than three fourth of the samples (77.1%) were completely independent to do
More than half of the samples (60%) were facing breathing difficulty before
dialysis.
Less than three fourth of the samples (71.4%) were facing muscle cramps during
dialysis.
Less than half of the samples (42.8%) had post dialysis weight between 50-60 kg.
Less than three fourth of the samples (71.4%) had pulse between 70 to 90
beats/min.
breaths/min.
More than half of the samples (57.1%) had systolic blood pressure between 140 to
170 mm Hg.
As an equal proportion of samples (48.6%) had diastolic blood pressure less than
More than half of the samples (51.4%) had serum sodium level less than 135
mEq/L.
84
Less than half of the samples (44.6%) had blood urea nitrogen level between 100
to 120 mg/dl.
Less than half of the samples (47.5%) had serum potassium level between 6 to 9
mEq/L.
More than one third of the samples (35.2%) had serum creatinine level 7.5 to 10.5
mg/dl.
More than half of the samples (51.4%) had moderate level of stress, less than
half of the sample (48.6 %) had severe level of stress and none of them had no stress
and mild stressbefore administering Bensons relaxation technique with mean score of
24.71.
More than half of the samples (57.1%) had moderate stress, less than one third
of the samples (31.4%) had mild stress, more than one tenth of the samples (11.5 %)
had severe stress and none of them had no stress after practicing Bensons relaxation
85
Section V: Analysis of effectiveness of Bensons relaxation technique on stress
Pairedt test was used to assess the effectiveness of Bensons relaxation technique
after administering Bensons relaxation technique. The mean post test score 17.69
with SD 5.42 was significantly lower than the mean pretest score 24.71 with SD 5.63
with a mean difference of 7.02. Since the calculated value 19.78 which was greater
than the table value (2.032) with degrees of freedom 34 at p<0.05 levelof significance.
Hence the null hypothesis (H0) was rejected and research hypothesis (H1) was
accepted. The study concluded that the Bensons relaxation technique is very much
Section VI: Association between the pre test level of stress and selected socio
demographic variables.
Chi-square was used to determine the association between the pretest level of
income, percentage of income spent for treatment, money expended so far for
kidney disease, duration of dialysis treatment, total number of dialysis done, average
loss of working days per week, performance of daily activity, most commonly faced
problem before dialysis, most commonly faced problem during dialysis and most
The calculated Chi-square value was less than the table value at p<0.05
level of significance, hence the null hypothesis (H02) can be accepted and research
86
pretest level of stress and selected socio demographic variables. It is concluded that
Section VII: Association between the pre test level of stress and selected clinical
variables.
Chi-square was used to determine the association between the pretest level of
stress and selected clinical variables such as post dialysis weight, temperature, pulse,
respiration, systolic blood pressure, diastolic blood pressure, serum sodium, blood
The calculated Chi-square value was less than the table value at p<0.05
level of significance, hence the null hypothesis (H03) can be accepted and research
The next chapter deals with discussion, summary and conclusion of the study
87
CHAPTER 6
Discussion
Summary
Conclusion
Nursing implications
Limitations
Recommendation
88
CHAPTER 6
This chapter deals with the discussion of the findings, summary and conclusion,
nursing implications, limitations and recommendations of the study. The findings are
Discussion
District. The findings of the study were discussed with reference to the objectives and
Objective 1: To assess the pretest and post test level of stress among hemodialysis
patients
The finding of the study revealed that in pretest more than half of the samples
(51.4%) had moderate level of stress, less than half of the sample (48.6 %) had severe
level of stress and none of them had no stress and mild stressand post test level of
stress showed that more than half of the samples (57.1%) had moderate stress, less
than one third of the samples (31.4%) had mild stress, more than one tenth of the
samples (11.5 %) had severe stress and none of them had no stress.
the level of stress and coping among 30hemodialysis patients were selected
89
In the present study, pairedt test was used to compare the effectiveness of
As per the analysis by paired t test test showed that calculated t value 19.78
which was greater than the table value (2.72) with degrees of freedom 34 at 0.01 level
of significance. Hence the null hypothesis (H0) was rejected and research hypothesis
(H1) was accepted. The study concluded that the Bensons relaxation technique is very
mean scores of general and total quality of life were significantly higher than the
Objective 3: To find out the association with pre test level of stressand selected
socio-demographic variables.
The investigator used chi-square test to find out the association between pre
test level of stress and selected socio demographic variables. The study revealed that
90
Summary
district. The conceptual frame work accepted for this study was based on Roys
The research approach used for the study was quantitative research approach.
Research design adopted for the present study was one group pre test post test design.
Dependent variable was the stress among hemodialysis patients in a selected hospital
at Alappuzha district. The setting was Century Hospital, Mulakkuzha. The population
with stress score 14 and above which is measured by Cohen using Perceived Stress
Scale in Century hospital. Non probability purposive sampling method was used to
select samples.
The tools used in this study were sociodemographic Performa and Cohen
using Perceived Stress Scale. Tool validity done by the experts. The reliability of the
For conducting the study, the researcher underwent 5 days training programme
in Bensons relaxation technique, from an authorized trainer and got certificate for the
Hospital, Edappon, Pandalam. The main study was conducted in Century Hospital,
Mulakkuzha. Pre test stress score was assessed in the first week by using Cohen
Perceived Stress Scale and taught them about Bensons relaxation technique and how
to perform it. After 25 days post test was done by using the same tool.
91
tool was collected and recorded systematically. The result showed that the
mean posttest score 17.69 with SD 5.63 was significantly lower than the mean pretest
score 24.71 with SD 5.42 with a mean difference of 7.02. Hence null hypothesis was
rejected. So Bensons relaxation technique was very effective in reducing stress level
of hemodialysis patients
Data were analyzed using descriptive and inferential statistics. The results
showed that Bensons relaxation technique was effective in reducing the stress level
There was significant difference in the pre test and post test level of stress among
There was no significant association between pre test level of stress and selected
sociodemographic variables.
Conclusion
person suffers from renal failure, their kidneys are not functioning properly or no
longer work at all. Renal failure can be a progressive disease or a temporary one
depending on the cause and available treatment options. Hemodialysis is the most
frequent treatment method for End stage renal disease. However, it has been argued
that a number of restrictions and modifications accompany this treatment, which have
a detrimental impact on the quality of patients life and affects individuals physical and
the mind & brain and useful in reducing stress, to improve quality of life as well.
Nursing implications
92
The findings of the present study generate some implications to health care
nursing education and nursing research. The dissemination of the knowledge takes
place when the research findings are made use of in the following fields.
93
Nursing practice
The nurses working in the dialysis unit are in the best position to understand the
problems of patients.
The main objective should be towards reduction of stress and improving the coping
Nurses in dialysis unit should provide support, information, alternative solution and
assist the patient to utilize better problem solving methods to enhance their quality
of life.
Nurses working in the dialysis unit Bensons relaxation technique also can use for
Nursing education
Nursing graduates must be equipped to meet the challenges emerging in the health
care services with a focus to enhance the existing situations in a cost effective
The curriculum must give more importance for early detection and prevention life
Skill oriented curriculum can be prepared for nurses working in nephrology units to
94
Prepare the students to practice alternative therapies to reduce the stress of
hemodialysis patients.
education progarmmes.
Nursing administration
The nurse leaders must gain knowledge regarding Bensons relaxation technique to
dialysis.
research.
Health administrator should make education department aware about the newer
Nursing research
infancy, even though many of them are empirical and easily tested. The findings of
95
To make the nursing care evidence based nurse should be interested and motivated
Limitations
Generalization of findings was not possible because of the small sample size.
Long term effect of Bensons relaxation technique was not assessed due to limited
time.
Recommendations
This chapter is followed by references used for the study and the appendices.
96
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101
48. Ali Mahdavi, Mohammed Ali Heidari Gorji. Implementing Bensons Relaxation
50. Jorm AF, Morgan AJ and Hetrick SE, relaxation for stress, Cochrane database
51. Sanjay kumar, Suresh Chand. Prevalence of chronic renal failure in adult in Delhi,
52. Irvin JH, Domar AD, et.al, the effects of Benson relaxation on reduction of stress
53. Polit F D, Beck T C. Nursing Research, Principle and methods. 7th ed.
54. Green P E, Tull D S. Research methods and technique. 3rd ed. New Delhi: New
55. Talbott L A, Principles and practice of Nursing Research. 4th ed. Philadelphia:
Mosby Publishers;1999.
102
APPENDICES
103
APPENDIX A
104
105
APPENDIX B
STUDY
106
107
108
109
APPENDIX C
LETTER GRANTING PERMISSION TO CONDUCT MAIN STUDY
110
111
112
113
APPENDIX D
From,
Mrs.Reshma.R.S
1st year M.Sc.Nursing
Josco college of nursing
Edappon
To,
Respected madam
I Mrs .Reshma.R.S , 1st year M. Sc Nursing student belongs to Medical and Surgical
Nursing department of Josco college of Nursing, Edappon, Pandalam. As a part of partial
fulfillment of M.Sc.Nursing Programme, I would like to do a dissertation on A study to
assess the effectiveness of Bensons relaxation technique on stress among
hemodialysis patients in a selected hospital at Alappuzha district.
For which I have prepared a tool for the same.
Herewith I have enclosed,
1. Statement of problem
2. Objectives of the study
3. Hypothesis
4. Operational definition
5. Tool
6. Criteria check list
Hence I request you to kindly examine the tool item wise and give your valuable
opinion and suggestion.
Thanking you , yours sincerely
(Reshma .R.S)
Date:
Place:
114
APPENDIX E
Kindly go through the items in the content. There are three response columns
is the scale, namely strongly agree (SA), agree (A), disagree (DA).Place a tick mark
() against the specific columns. If you disagree (DA) to any one of the items, place
1 Formulation of objectives
a) Comprehensiveness
b) Realistic
c) Stated in terms of
behavioral outcomes
2 Selection of content
a) Accurate
b) Relevant
of understanding of
patient
3 Organization of content
a) Logical sequence
b) Continuity of
115
presentation
c) Integration
4 Language
Feasibility of Practicability
5 a) Acceptability to patient
b) Interesting
c) It will be of practical
informal teaching
6 Teaching Aids
a) Simple and
understandable
b) Appropriate
c) Relevant
d) Easy to follow
e) In sequence
116
Criteria for validation of research tool
Please tick the column according to your agreement. Please write the modifications
2
3
10
11
12
13
14
15
16
17
18
19
117
20
21
22
23
24
II CLINICAL 1
VARIABLES
2
3
4
5
6
7
8
9
10
III PERCEIVED 1
STRESS SCALE
2
10
I have gone through the tools and suggest the above mentioned modifications
Date: Signature and designation
Place
118
APPENDIX F
1. Sr. Sajitha
Assoc. Professor
2. Mrs.Aneesha
Assoc. Professor
3. Mrs. Seethalekhsmi
Assoc. Professor
Assoc. Professor
Consultant Nephrologist
6. Dr. Sudheer
Consultant Nephrologist
119
7. Dr. HaiHaran
Consultant Psychologist
Director
Kottarakara
Chertala
120
APPENDIX G
undersigned and she can proceed with this tool /content to conduct the research work.
Signature ..
Name .
Designation
Department
Place:
Date:
121
122
123
124
125
126
127
128
129
APPENDIX H
Study title:
A study to assess the effectiveness of Bensons relaxation technique on
stress among hemodialysis patients in a selected hospital at Alappuzha district.
Investigator:
Mrs. Reshma.R.S
IIndYear M.Sc Nursing student
Josco College of Nursing
Edappon, Pandalam
Dear Participant,
In signing this document, you are giving consent to the investigator
to participate in the research study of 2nd year M.Sc. Nursing course. You will be the
subject of a research study to assess the effectiveness of Bensons relaxation
technique on stress among hemodialysis patients. The study doesnt include any
foreseeable risk or harm to you.
Your participation in this study is voluntary and you are under no obligation
to participate. You have the right to withdraw at any time and your relationship with
the health care authority will not be affected.
The study data will be coded so it will not be linked to your name. Your
identity will not be revealed while the study is being conducted or when the study is
reported or published. All study data will be collected by Mrs.Reshma.R.S, and will
be stored in a secure place and not shared with any other person without your
permission.
I have explained this study to the above subject and I have sought his/her
understanding for the informed consent.
Signature of the investigator
I have been explained and made to understand the need and importance of this study
and I am voluntarily willing to participate in the study.
Signature of the subject
130
APPENDIX I
o . . .
o
,
,
..
.
.
.
.
131
APPENDIX J
ATTENDANCE CERTIFICATE
132
APPENDIX K
design.
Sample size : 35
sample
2016
31 2016
133
APPENDIX L
134
APPENDIX M
135
APPENDIX N
136
APPENDIX O
TOOL (ENGLISH)
TOOL 1
personal data. You are requested to kindly read each item and put a tick [] mark in
the box provided against the most appropriate option. The details will be kept
1. Age in years
2. Gender
2.1 Male
2.2 Female
3. Religion
3.1 Hindu
3.2 Christian
3.3 Muslim
4. Education
137
4.2 Higher secondary education
4.3 Diploma
4.4 Graduation
5. Type of family
6. Marital status
6.1 Married
6.2 Unmarried
7. Occupation
7.3 Unemployed
8. Place of residence
8.1 Panchayath
8.2 Municipality
8.3 Corporation
9.1 Rs 10000
138
9.3 Rs 20001- Rs 30000
9.4 Rs 30001
11.1 Rs 10000
11.4 Rs 100001
12.3 Pension
13.1 ESI
13.3 Others
13.4 None
14. Co-morbidities
14.2 Hypertension
139
14.3 Diabetes and hypertension
15.1 Yes
15.2 No
16.2 1- 3 year
16.4 5 year
17.1 100
17.4 301
18.1 1 2 days
18.2 3 4 days
18.4 Unemployed
19.1 By self
140
19.2 Assistance from family
21.2 Edema
21.3 Anorexia
21.4 Vomiting
22.2 Giddiness
22.3 Nausea
23.1 Fatigue
23.2 Itching
23.4 Dizziness
141
SE`CTION B: POST DIALYSIS CLINICAL VARIABLE
1.1 < 50 kg
1.2 50 60 kg
1.3 60 70 kg
1.4 70 kg
2. Temperature
2.3 99 0 F
3. Pulse
3.4 90 beats/min
4. Respiration
4.2 20 25 breaths/min
4.3 25 30 breaths/min
4.4 30 breaths/min
5.4 170 mm of hg
142
6. Diastolic pressure
6.1 < 90 mm of hg
6.2 90 - 120 mm of hg
6.3 120 mm of hg
7. Serum sodium
9. Serum potassium
9.2 3 6 meq/L
9.4 9 meq/L
143
TOOL 2
Instructions:. Kindly read each questions carefully and put a tick [] mark in the
appropriate option with blue or black ball point pen. Kindly answer all the questions.
144
with all the things that you had to
do?
7. In the last month, how often have
you been able to control irritations in
your life?
8. the last month, how often have you
felt that you were on top of things?..
9. In the last month, how often have
you been angered because of things
that were outside of your control?
10. In the last month, how often have
you felt difficulties were piling up so
high that you could not overcome
them?
0 = Never
1 = Almost Never
2 = Sometimes
3 = Fairly Often
4 = Very Often
Interpretation of tool
0 -No stress
145
APPENDIX P
TOOL (MALAYALAM)
: :
1.
1.1 20 40
1.2 40 60
1.3 60 80
2.
2.1
2.2
3.
3.1
3.2
3.3
4.
1..4
4.2
4.3
4.4
4.5
146
5.
5.1
5.2
6.
6.1
6.2
6.3
6.4 /
7.
7.1
7.2
7.3
7.4
7.5
8.
8.1
8.2
8.3
9.
9.1 10000
9.4 30001
147
10.
10.1 25
10.2 50 25
10.3 75 50
10.4 100 75
11.
11.1 10000
11.4 100001
12.
12.1
12.2
12.3
12.4
13.
13.1 . .
13.2
13.3
13.4
14.
14.1
14.2
148
14.3
14.4
14.5
14.6
15.
15.1
15.2
15.3
16.
16.1
16.2 3 1
16.3 5 3
16.4 5
17.
17.1 100
17.4 301
18.
18.1 2 1
18.2 4 3
18.3
18.4
149
19.
19.1
19.2
19.3
20.
20.1
20.2
20.3
21.
21.1
21.2
21.3
21.4
22.
22.1
22.2
22.3
22.4
23.
23.1
23.2
23.3
23.4
150
APPENDIX Q
Institute. The response is defined as your personal ability to encourage your body to
release chemicals and brainsignals that make your muscles and organs slow down and
increase blood flow to the brain. In his book The Relaxation Response, Dr.Benson
describes the scientific benefits of relaxation, explaining that regular practice of the
disorders.
3. Deeply relax all your muscles, beginning at your feet and progressing up to your
face. Keep them relaxed. [Relax your tongueand thoughts will cease.]
4. Breathe through your nose. Become aware of your breathing. As you breathe out,
say the word "one" silently to yourself. For example, breathe in, and then out, and say
5. Continue for 10 to 20 minutes and open your eyes to check the time, but do not use
an alarm. When you finish, sit quietly for several minutes, at first with your eyes
closed and later with your eyes opened. Do not stand up for a few minutes.
6. Do not worry about whether you are successful in achieving a deep level of
relaxation. Maintain a passive attitude and permit relaxation to occur at its own pace.
151
When distracting thoughts occur, try to ignore them by not dwelling upon them and
7. With practice, the response should come with little effort. Practice the technique
once or twice daily, but not within two hours after any meal, since the digestive
152
APPENDIX R
153
154
PRRETEST AND POST TEST STRESS SCORE
1 36 28
2 24 12
3 32 29
4 26 13
5 28 20
6 25 15
7 27 19
8 31 24
9 29 20
10 28 17
11 33 28
12 18 10
13 29 21
14 16 11
15 14 9
16 30 24
17 15 8
18 25 14
19 28 17
20 29 21
21 22 13
22 30 18
155
23 17 11
24 25 17
25 29 21
26 19 12
27 31 22
28 27 18
29 25 17
30 20 11
31 29 20
32 25 19
33 3 28
34 29 19
35 22 13
156
APPENDIX T
1. Reliability
2. Mean =
1
3. () = 1 ( ( ))f
()2
4.Chi-square, 2 =
157