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27 Journal of Research Development in Nursing & Midwifer Original Article
2017/Vol 14 / No 2
Impact of Jacobson Relaxation on Dialysis Adequacy in ElderlyHemodialysis
Patients
Background: Dialysis adequacy is one of the determining factors
Shirin Madadkar Dehkordi for survival in elderly patients. Improving the dialysis adequacy
Department of Critical Care highly affects the remission and prognosis of old dialysis patients.
Nursing, Faculty Member, School of Current study was conducted to evaluate the effects of Jacobson
Nursing and Midwifery, Shahr- relaxation technique on dialysis adequacy in elderly people, who are
EKord University of Medical, under dialysis treatment.
Shahrkord, Iran Methods: ods: This is a clinical trial performed on 80 hemodialysis
Mehdi Basiri Moghadam (MSc) patients in two hemodialysis centers of Gonabad and Yazd, Iran, in
MSc. Dept. of Pediatrics Nursing, 2013. The patients were selected through purposive sampling method,
Social Development & Health and randomly assigned into the two groups of control (n=40) and
Promotion Research Center, intervention (n=40). The participants in intervention group were
Gonabad University of Medical
Sciences, Gonabad, Iran provided by three sessions of relaxation training, and were asked to
Corresponding Author: perform the relaxation daily for six weeks, while the control group
Shirin Madadkar Dehkordi just received the routine cares. Afterwards, the adequacy of dialysis
was compared between the two groups. The data was collected using
E.mail: the demographic information, and the dialysis adequacy was
shirinmadadkar@gmail.com calculated by KT/V equation.
Tell: 09139775406 Results: A significant statistical difference was found between
groups regarding the mean difference of dialysis adequacy in pre- and
Address: Shahrkord, University of post-intervention (P<0.001).Besides, dialysis adequacy increased
Medical Shahrkord post-intervention in the case group and decreased slightly in the
Received: 23 Aug 2016 control group compared to pre-intervention.
Revised: 9 Sep 2016 Conclusion: Training and performing the relaxation method lead to
Accepted: 19 Jan 2017 an improved dialysis adequacy in elderly patients under
hemodialysis.
Keywords: Dialysis adequacy, Hemodialysis, Jacobson relaxation,
Old patients
This paper should be cited as Madadkar Dehkordi SH, Basiri Moghadam M. Impact of Jacobson Relaxation on Dialysis Adequacy in
ElderlyHemodialysis Patients. J Res Dev Nurs Midwifery. 2017;14(2):27-33.
Impact of Jacobson Relaxation on Dialysis …/28
Introduction Nurses are excellent in applying the
Aging is a natural process, during which behavioral techniques such as progressive
physiological and psychological changes muscular relaxation because they have the
occur in the body. Therefore, most of the most contact with the patients. Progressive
senile people require special health care due muscular relaxation is non-invasive and is
to chronic diseases (1). Chronic kidney well-trained by the nurses. Besides, the caring
disease is among the main problems in this roles of the nurse are highlighted by training
age, and various body systems get affected by this technique (10). Consequently, using this
the uremia resulting from this disease (2). technique as one of the branches of
The prevalence of chronic renal failure supplementary non-pharmacologic medicine
(CRF) has been 240 cases per million is developing among the nursery protocols.
throughout the world, and about 8% is added This relaxation technique is so easy to learn
yearly to this rate (3). Chronic kidney and perform, and brings no further expense
diseases are considered as the eighth mortality for the patients. The nature of this technique
reason in the USA (4). According to the makes it more acceptable for the patients and
statistics reported by the Iranian ministry of they are encouraged to apply it. Relaxation is
health in 2014, prevalence of these diseases is regarded as a coping technique, and it has the
680 cases per million in Iran, and it has the potency to improve the person’s ability for
yearly incidence of 1200-1600 people (3). facing the disease consequences or treatment
The patients with end stage kidney disease sequels. The progressive muscular relaxation
need alternative treatments to survive; originates from the theory that a
hemodialysis is the most common therapeutic psychological condition known as increased
method in these patients (5, 6). Dialysis muscular and nervous tension is the base for
adequacy is among the important factors anxiety conditions and psychosomatic
affecting survival rate and life-expectancy in disorders. Jacobson has stated that muscular
elderly CRF patients. Inefficient dialysis relaxation results in mental relaxation as well
adequacy results in increased hemodialysis (12).
frequency and duration, and imposes Findings of the study performed by Hou et
additional therapeutic expenses on health al. (2011) indicated the favorable impact of
systems (7). Based on the literature, progressive muscular relaxation on quality of
inadequacy of dialysis is one of the main life (QoL) in hemodialysis patients (13).
mortality reasons in CRF patients. Another research in 2006 demonstrated that
In order to provide high quality care, nurses the relaxation technique might reduce the
of special departments should consider the patients’ anxiety and enhance their QoL (14).
emotional and moral issues of the patients as Additionally, this technique could control and
well as the physical aspect. These aspects eliminate the unfavorable physiological
affect each other and mightimprove overall effects induced by psychological tension and
health (8).Subsequently, using supplementary stress; these positive impacts are made
and non-pharmacological treatments is highly through psychoendocrine system and
insisted in health systems (9). Supplementary activation of the sympathetic and
medicine mostly has little side effects and parasympathetic systems.
risks, and could be applied with or without Dialysis as a solution for CRF
other methods resulting in positive influence managementis a tense process, and the stress
on physical and psychological disorders (10). of this methodcould lead in reduced adequacy
Progressive muscular relaxation technique of dialysis. Therefore, regarding the dialysis-
is one of the non-pharmacologic approaches, induced psychological tensions and the raise
which was introduced by Edmond Jacobson in senile population, the current study was
in 1983. This technique requires the patient’s performed to assess the impact of Jacobson
active involvement in care and treatment relaxation on dialysis adequacy in elderly
program, and this is considered as a fixed rule people under treatment by hemodialysis.
in holistic nursing (11).
Journal of Research Development in Nursing & Midwifery. 2017. Vol 14: No 2
29/ Madadkar Dehkordi and Basiri Moghadam
Methods sessions. The patients were asked to close
The study population of this clinical trial their eyes, relax, and focus on their
consisted of all the patients under respiration. Afterwards, they had five deep
hemodialysis in two hemodialysis centers of breaths, during which the lungs were
22-Bahman, Gonabad, Iran and Shahid completely filled with air followed by a slow
Rahnemoon, Yazd, Iran in 2013. Due to expiration. Meanwhile, they were requested
insufficient samples in Gonabad and to think of calm, freedom and laxation. In the
unavailability of other cities of Khorasan next step, muscular contraction and relaxation
Razavi province for the researcher, eighteen were performed for fourteen muscle groups
people were selected from Gonabad and 62 including facial muscles (frontal, levator
from Yazd. palpebrae superioris, mandibular, and
The inclusion criteria: 1) age of over 60, 2) orbicularis oris), neck, fingers, palms,
2-3 dialysis per week, 3) passing of at least 6 forearms, arms, shoulders, back, chest,
months from the first dialysis, and 4) absence abdomen, gluteals, thighs, shanks, and plantar
of any psychological disorders such as muscles. Contraction and relaxation of each
depression diagnosed by a doctor. The muscle lasted five and tenseconds,
exclusion criteria: 1) finding out exchange of respectively. During the whole process, it was
the trained information between the two necessary for the patients to be concentrated
groups, 2) absenteeism 3) hospitalization due on the contracting and relaxing muscle.
to any reason during the study, and 4) Finally, the patients were requested to relax
psychological crisis induced during the study. their whole body, have five deep breathes,
The sample size was calculated as 80 open their eyes slowly, and return to normal
according to the formula for comparison of condition (11).
the means. Data collection tool was a Relaxation technique was performed
questionnaire consisting of two parts of the several times under the supervision of the
demographics and the information regarding researcher in these three sessions. After the
the disease, dialysis adequacy, and the training, the patients were asked to complete
intervention. KT/V calculation software was the 10-15 min relaxations before sleeping for
utilized for assessing the dialysis adequacy, six weeks at home.The intervention was not
and KT/V of ≥ 1.2 was considered as dialysis implemented during the dialysis due to the
adequacy cut-off point. noise and routine cares performed in the
The samples were selected from the centers department.
based on the inclusion and exclusion criteria. The participants were provided with a
Afterwards, the participants were randomly checklist for recording the date, time, and
assigned into the two groups of intervention duration of the technique, and also the reason
(n=40) and control (n=40). Nine patients from if not performing. This relaxation checklist
Gonabad and 31 from Yazd were included in was collected from the patients by the
control group. researcher weekly. In addition, a compact
In order to control those variables that disk about relaxation training was given to the
affect the dialysis adequacy, similar patients; and the researcher made phone calls
conditions including three dialysis sessions with the participants once every other day to
per week, four-hour dialysis sessions, dialysis manage any possible problem regarding the
solution flow of 500 mL/min, and blood flow technique and also to control whether or not
of 300 mL/min were set for all the study they completed theform.
units. All the other variables influencing A consult session was also held for those
dialysis adequacy such as the machine and who accompanied the patients, and they were
filter types, dialysis medications, filter advised to monitor the relaxation exercise on
clearance coefficient, and machine the specified time. No intervention was done
temperature were matched. in the control group. Finally, the dialysis
The Jacobson relaxation technique was adequacy was repetitively measured at the
taught to the intervention participants by the determined time points, and the results were
researcher in the hospital during three private compared with the previous data.
Journal of Research Development in Nursing & Midwifery. 2017. Vol 14: No 2
Impact of Jacobson Relaxation on Dialysis …/30
The statistical analysis mean KT/V as indicator of dialysis adequacy
the data was analysed by SPSS version 14 was 1.09±0.35.
using Mann-Whitney U test to compare the Several studies have shown the inadequacy
dialysis adequacy between the two groups. In of dialysis in various centers and hospitals in
addition, the paired t-test was used for Iran. For example, Delavari et al. found the
making comparison between the changes of inadequacy of dialysis in Kordestan, Iran, and
dialysis adequacy pre- and post-intervention revealed that 78.9% of the patients had
in each group. P-value of less than 0.05 was dialysis adequacy of less than 1.2 (15).
considered as significant. The dialysis adequacy was more favorable
The ethical considerations in this study compared to similar studies,
The written approvals were taken from the which is probably due to the educational base
officials of Gonabad and Yazd Universities of of the centers. It should be considered that
Medical Sciences and the written consents conduction of the different studies in these
were taken from the patients. This trial was centers has led in appropriate training and
registered in Iranian Registry of Clinical awareness of the patients and personnel.
Trials with the code of The findings indicated that although means
IRCT2013042713132N1 following the of pre- and post-intervention adequacies were
evaluations of regional Ethics Committee and not significantly different in the groups, the
receiving the ethical code of K8/5/91/1. post-relaxation adequacy of the treatment
Results group increased in comparison with that of
The Mean age was 75.35±7.3 , mostly in control group. The KT/V enhancement from
the range of 75-80 years. Most of the 1.12 to 1.21 is clinically remarkable, since
participants were men (73%), married (59%), according to the information provided by
and had education level of under diploma USRDS (United States Renal Data System)
(93%). The two groups were not significantly seven percent reduction in the mortality risk
different (P>0.05) regarding the demographic is expected by each 0.1 increase in KT/V up
characteristics. to 1.2 (16).The rise in dialysis adequacy in
Mean of KT/V indicator of dialysis the present study might be attributed to
adequacy was 1.09±0.35. The diseases that applying the supplementary medicine in
most likely predispose the patients to CRF addition to the routine treatment for these
and hemodialysis were diabetes (40%) and patients. Furthermore, one of the long-time
systemic hypertension (53%). The results of side effects of hemodialysis and uremic
paired t-test demonstrated that the alteration syndrome is psychological tension and
between the mean difference of the dialysis anxiety that could result in decreased dialysis
adequacy pre- and post-intervention was not adequacy in these patients.
statistically significant (P=0.05).Moreover, In the current study, relaxation technique as
according to Mann-Whitney test no one of the concentration methods led in
significant difference was observed between reduction of muscular tension and
the mean of post-intervention dialysis unfavorable physiological effects induced by
adequacies of the two groups (P=0.07). stress and anxiety in hemodialysis patients.
Nonetheless, mean of the changes in dialysis The national standards, Iranian studies, and
adequacy whether before or after the guidelines of special diseases office in
intervention was significantly higher in the ministry of health of Iran have stated the level
treatment group compared to control group of 1.2 as the suitable dialysis quality
(P<0.001) (Table 1). (minimum acceptable level).Nonetheless, the
Discussion international standards being used in different
The impact of Jacobson relaxation studies are higher, such as 1.4-1.7 that has
technique on dialysis adequacy of elderly been stated by the American nephrologists
patients under treatment with hemodialysis (16). However, reaching the minimum
was assessed in the present study and the acceptable level of quality seems difficult in
Iran (17).
Journal of Research Development in Nursing & Midwifery. 2017. Vol 14: No 2
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