Effect of Meticulous Nursing on Dialysis Adequacy in Elderly Patients Undergoing Maintenance Hemodialysis

Chronic kidney disease (CKD) is defined as progressive and irreversible renal damage resulting in abnormal renal function lasting more than 3 months¹. It is classified according to the glomerular filtration rate (GFR)²level, with Stage 1 characterized by mild renal damage without directly affecting the GFR. Statistics show that there are 697.5 million patients with CKD worldwide, including 132.3 million in China, making it the country with the highest number of patients with CKD³. As one of the representative ageing-associated diseases, the prevalence of CKD increases with age^4,5. In China, the reported prevalence of CKD is 19.25% in people over 60 years, 32%-37% in those over 65 years, and more than 59% in those over 80 years while hospitalised^6,7,8, compared with 10.8% in younger populations³. Elderly patients undergoing maintenance hemodialysis (MHD) face numerous difficulties. They often experience multiple underlying diseases and complications, have long treatment cycles, and show poor compliance. This undoubtedly poses greater challenges to their treatment. In addition, these patients have a relatively high incidence of complications, experience considerable psychological pressure during treatment, and have complex nursing needs after dialysis^9,10. Notably, this population usually lacks a correct understanding of hemodialysis and disease-related knowledge, which directly reduces cooperation during treatment. Reduced cooperation and compliance, in turn, negatively affect dialysis outcomes, not only compromising physical health but also leading to a decline in quality of life¹¹. Of particular concern are patients with end-stage renal disease (ESRD), who must rely on long-term treatments such as hemodialysis, peritoneal dialysis, or kidney transplantation to maintain basic life functions, resulting in a substantial physical and mental burden¹².

For elderly patients undergoing MHD, conventional dialysis treatment strategies often struggle to meet their specific physiological and psychological needs. Because of their age, concomitant diseases, and the complexity of their physical and mental conditions, they are more prone to complications, poor dialysis outcomes, and high levels of psychological stress¹³. Particularly during long-term dialysis treatment, their quality of life and prognosis are further compromised by a lack of family support, decreased treatment compliance, and recurrent complications. Therefore, a more individualized and comprehensive set of nursing intervention strategies is urgently needed for elderly patients undergoing MHD¹⁴.

As both a concept and a culture, meticulous management is a fundamental requirement in modern management for improving the social division of labor and enhancing service quality. The concept of meticulous management was first proposed by Taylor in the early 1900s to improve work efficiency, reduce enterprise costs, and maximize outcomes¹⁵. Developed from this theory and evolving out of high-quality and holistic nursing, meticulous nursing seeks to care for patients in a more precise and delicate manner, making it a novel nursing approach widely applied in clinical practice today¹⁶. Specifically, it is a nursing service concept that consistently adheres to the principle of patient-centered care that fully embodies humanity, aiming to enhance patient comfort, accelerate physical rehabilitation, and shorten hospital stays. Meticulous nursing has been widely implemented across various clinical departments, achieving satisfactory clinical outcomes¹⁷. Meticulous nursing care is generally best conducted in the dialysis centers of secondary and higher-level hospitals. It requires professional equipment (including hemodialysis machines) and sufficient professional physicians and nursing staff. Moreover, it demands greater investment in care, such as one-to-one companionship. Notably, the 2020 kidney disease: Improving Global Outcomes clinical practice guidelines¹⁸ for hemodialysis adequacy explicitly advocate for individualized dialysis prescriptions based on elderly patients' comorbidities and physiological status, a requirement that conventional nursing rarely meets. Alternative models, such as patient navigation, focus on care coordination but lack real-time dialysis-specific interventions, whereas interprofessional team-based care¹⁹ relies on multi-disciplinary collaboration yet often overlooks immediate psychological or physical discomfort during sessions. This underscores meticulous nursing's uniqueness: it aligns with international guidelines and fills gaps in existing models by integrating tailored, real-time care.

Currently, clinical routine nursing for elderly patients undergoing MHD mainly involves standardized basic measures, such as simple health education on admission and monitoring of vital signs only before and after dialysis. A major issue is the lack of personalized management. Although some clinical departments have begun to adopt meticulous nursing²⁰, systematic research on its application in elderly patients undergoing MHD remains limited. Meticulous nursing differs from routine nursing in that it includes personalized dialysis plans, hourly monitoring during dialysis, and continuous arteriovenous fistula examinations. However, there is still a research gap in comparing the effects of the two approaches on the dialysis adequacy of elderly patients undergoing MHD. In this context, applying the concept of meticulous management to the nursing of this patient group is expected to reduce their anxiety, enhance treatment compliance, and thereby strengthen treatment outcomes. Therefore, this study focuses on elderly patients undergoing MHD, aiming to explore the effects of meticulous nursing and provide an evidence-based foundation for developing future nursing strategies for this population.

Between September 2022 and February 2023, 69 elderly patients undergoing MHD in our centre were enrolled as study participants. The study was approved by the ethics committee of the hospital (ethical approval no. 202208010), and patients signed informed consent forms.

1. Inclusion criteria

1. Patients who met the diagnostic criteria for ESRD proposed by the National Kidney Foundation's clinical practice guidelines for CKD and dialysis²¹.
2. Patients with a dialysis duration of more than 3 months, with two or more regular hemodialysis sessions per week.
3. Patients with no difficulty in communicating, who understand the purpose and importance of the study, and who voluntarily participated.
4. Patients aged ≥60 years.

2. Exclusion criteria

1. Patients who received hemodialysis treatment as transitional therapy or as supportive treatment for conditions such as acute renal failure or drug poisoning.
2. Patients with severe malignant tumors, severe infection, heart failure, or dysfunction of other vital organs, such as cardiac function ≥NYHA Class 4, liver function at Child-Pugh C, pulmonary function with FEV₁ < 30% of the predicted value, or severe renal insufficiency other than ESRD
3. Patients with a history of mental illness.

3. Patient grouping

1. To calculate the sample size, use the two independent sample mean comparison formula: n₁ = n₂ = 2(zα/₂ + zβ)²σ²/δ². Here, α = 0.05 (two-tailed, zα/₂ = 1.96), power (1 − β) = 0.80 (zβ = 0.84), σ = 3.1 mmol/L (serum creatinine standard deviation from the literature), and δ = 1.4 mmol/L (clinically meaningful difference). The minimum sample size per group was estimated to be 30; with a 10% dropout rate, 34-35 cases per group were included.
2. Divide patients into a control group (n = 34) and a study group (n = 35) using a random number table (see Figure 1). The random sequence for grouping was generated by computer using SPSS 26.0 software, and sealed opaque envelopes were used for allocation concealment. Due to the obvious differences in nursing measures, blinding of patients and nurses was not possible. The data were statistically analyzed by independent researchers to minimize bias.

4. Conventional nursing in the control group

1. Upon admission, train the nursing staff to inquire about the patients' medical history, record their chief complaints and clinical symptoms, and communicate with them to document their basic data.
2. Assist patients and their families in understanding the hospital environment through clearly marked hospital floor guide brochures, hospital navigation mini-programs, or the hospital's medical guide. Provide health education to patients using relevant health brochures with pictures, animated short films, or human body model demonstrations, and explain relevant disease and treatment knowledge.
3. Assess the patients' psychological state, with one-on-one psychological counselling provided for those experiencing negative emotions.
4. During blood dialysis, monitor patients' vital signs, such as blood pressure, pulse, and respiration, with prompt responses to any emergencies.
5. Maintain the indoor environment in a well-ventilated and clean state, providing patients with a comfortable, quiet, and tidy hospital setting.
6. Give health manuals to patients, guiding them on medication compliance and healthy dietary habits.

5. Meticulous nursing in the study group

1. Pre-dialysis nursing
   1. For the admission assessment, evaluate vital signs (temperature, blood pressure, heart rate, weight), patient cooperation, access status, and blood glucose levels (if necessary).
   2. Develop a personalized dialysis plan based on the assessment results, considering the following guidelines.
      1. Maintain the dehydration volume at ≤5% of dry body weight.
      2. Ensure dialysis time meets standard operating procedure requirements (>10 h/week).
      3. Ensure slow blood flow (140-240 mL/min, subject to tolerance), with adjustments made for sodium dialysis and dialysis fluid temperature.
   3. Environmental care
      1. Implement strict disinfection and sterilization control before starting dialysis to ensure the dialysis room is clean, comfortable, well-lit, and well-ventilated.
      2. Change the bed linen regularly, clean patient rooms and open windows for ventilation, providing patients with a quiet and comfortable hospital setting.
      3. Perform timely checks and evaluations to ensure the proper functioning of the hemodialysis equipment, with any issues reported and resolved promptly.
   4. Psychological care
      1. Train the nursing staff to communicate with the patients actively and enthusiastically, understand their current recovery status, psychological state, and needs, and encourage them to maintain a positive attitude.
      2. Use techniques such as empathy and appropriate emotional expression to help shift the patients' focus, with targeted psychological interventions provided, including sharing success stories of recovery to convey positive energy while encouraging patients to face their illness bravely and cooperate with treatment to boost their confidence.
      3. Communicate with family members to alleviate negative emotions and encourage them to care for and understand the patients, thus helping the patients establish a positive mindset.
   5. Health education based on the patients' actual situation
      1. Provide knowledge about disease, dialysis, and nursing precautions, and answer any patient questions, including explanations of the benefits of active treatment cooperation to enhance understanding and compliance.
      2. Encourage patients to engage in appropriate physical activities to enhance physical health, such as a slow walk for 30 min after a meal (each session lasting 20-30 min, with a pace of approximately 60-70 steps/min) or practice of a simplified version of Tai Chi indoors (each session lasting 15-20 min). It was recommended that patients perform the activities five times a week, including 2 rest days.
2. Nursing during dialysis
   1. Place the patient in a comfortable recumbent position when connected to the dialysis machine, with restraints applied if necessary.
   2. Set the dialysis machine at a speed of 80 mL/min, and once blood reaches the venous reservoir, gradually increase the blood flow rate (50 mL/min) to the prescribed rate, ensuring no alarms are emitted by the machine.
   3. Monitoring during dialysis
      1. Monitor blood pressure hourly after the patient is connected to the machine. If the mean arterial pressure is greater than 15 mmHg compared with pre-connection levels, the doctor is notified for symptomatic treatment.
      2. Monitor patients for signs of hypoglycemia, such as sweating and hunger. For agitated elderly patients, apply appropriate restraints if necessary.
      3. Provide psychological care to patients who insist on disconnecting from the machine to divert their attention.
      4. Arrange one-on-one companionship if necessary, and perform disconnection in accordance with medical directions, aiming to maintain the prescribed treatment duration.
      5. Assign a designated person to continuously check the patients' arteriovenous fistula for any signs of obstruction and observe changes in the bruit.
      6. Maintain low-flow oxygen inhalation at 2 L/min using a nasal cannula (primary equipment) for patients who might lose a considerable quantity of vitamins and amino acids during dialysis. Maintain continuous inhalation throughout the dialysis session, with a 5 min wait after dialysis completion before disconnecting.
      7. Before dialysis, prepare patients in the following manner to prevent protein consumption, avoid increases in the urea peak value, strictly control dialysis risk and maintain the energy balance: heat approximately 400 g of pure milk (containing 3.3 g of protein per 100 g) to 37 °C-40 °C in a water bath; steam 80 g of egg white (containing 15.2 g of protein per 100 g, egg whites of approximately two eggs) or boil with 5 mL of warm water until solidified, without adding extra salt or fat; at 2 h before dialysis, give the egg white to the patient to be eaten within 10-15 min; and 1.5 h before dialysis, give 200 g of milk to the patient, providing the remaining 200 g of milk 1 h before dialysis. Adjust intake according to tolerance to ensure a total protein intake of approximately 20 g and an energy intake of approximately 210 kcal.
      8. Assist patients in turning over every 1-2 h, with back patting and massage of compression sites as appropriate.
   4. Blood reinfusion after disconnection
      1. Reinfuse blood once the prescribed treatment time is reached. Set the blood flow rate at 80 mL/min, and maintain the volume of reinfused blood at <200 mL (calculated based on the clock's second hand making two and a half rotations).
3. Post-dialysis nursing
   1. Pre-discharge home care guidance and communication notification
      1. Clearly explain the home care guidance. Use both a written manual (with picture and text examples) and oral explanation to outline the key points of home care to the patient (such as dietary restrictions, medication timing, rest requirements, and self-monitoring indicators).
      2. Confirm the communication channel and feedback method. Inform patients of the emergency contact channels (work number, 24 h nursing hotline), and emphasize that in cases of discomfort, such as dizziness, fatigue, or wound bleeding, contact the nursing staff within 1 h.
      3. Confirm patient understanding, using questions such as Can you repeat the two key indicators to be monitored at home? to verify that the patients had understood the guidance; give the manual to the patient for reference at any time.
   2. Nursing care for the puncture site of the arteriovenous fistula
      1. Compression at the puncture point: After dialysis, press two sterile cotton swabs (dipped in normal saline) vertically against the puncture point. Adjust the pressure so that the tremor in the internal fistula could be felt, and there was no obvious bleeding. Continue compression for 15-20 min.
      2. Monitoring of puncture point status: During the compression period, observe the puncture site every 5 min to check for bleeding, exudation, or subcutaneous hematoma. If an increase in exudation was detected, adjust the compression position slightly towards the inner side of the puncture site, and maintain pressure.
      3. Post-treatment after compression: Once compression was completed, cover the puncture site with sterile gauze and advise the patient to keep the puncture site dry for 24 h and to avoid squeezing or friction.
   3. Safety care
      1. Identify previous adverse events and summarize to facilitate discussion and learning, leading to the development of preventive measures. Develop risk warning signs, such as notices for fall prevention, bed safety, and special dialysis fluids, and post these at the bedside. Affix written instructions to the dialysis machine to briefly explain its usage.
      2. Maintain a detailed nursing handover sheet, documenting the general data, treatment regimen, pre-dialysis adverse conditions, volumes of dialysis and replacement fluids used, venous pressure, status of the arteriovenous fistula, and any patient complications, to ensure continuity of nursing.
4. Modifications and troubleshooting
   1. Inconsistent implementation of meticulous nursing protocols: owing to the complexity of the meticulous nursing protocol, which includes individualized dialysis planning, real-time adjustments to blood flow, sodium, and dialysate temperature, as well as continuous psychological support, differences in implementation among nursing staff may occur during actual operations, resulting in inadequate execution of intervention measures. To prevent such issues from affecting the effectiveness of the meticulous nursing plan, follow the guidelines below.
      1. Conduct standardized training sessions for all nursing personnel involved in the study, with emphasis placed on key steps such as the pre-dialysis assessment criteria, dehydration volume limits, machine parameter adjustments, and psychological communication techniques.
      2. Develop a detailed nursing operation manual with step-by-step guidelines and checklists for each phase of dialysis (pre-, during and post-) to ensure uniformity.
      3. Assign a dedicated nursing supervisor to monitor protocol compliance during shifts, with regular audits of nursing records, including dialysis plans, vital sign monitoring logs, and patient feedback, conducted to identify and address deviations.
   2. Psychological support challenges for highly anxious patients: Some elderly patients may exhibit severe anxiety or depression that is not fully alleviated by routine psychological interventions, such as empathy or success story sharing, which potentially impacts their comfort and treatment cooperation. To address this, follow the steps below.
      1. Screen patients for severe psychological distress at baseline using the Hospital Anxiety and Depression Scale and refer high-risk cases to on-site psychologists or psychiatrists for specialized intervention.
      2. Incorporate additional calming measures, including soft background music, aromatherapy, and guided relaxation exercises, into dialysis sessions to create a more soothing environment.

6. Data collection

1. Collect data from both groups of patients after 6 months of nursing, including the following: general patient data, their pre- and post-study scores from the General Comfort Questionnaire (GCQ), biochemical indicators, Newcastle Satisfaction with Nursing Scale (NSNS) scores, pre-study scores from the Dyadic Coping Inventory (DCI), data on dialysis adequacy (Kt/V values) between September 2022 and February 2023 and complications during nursing.
2. Quality control measures: First, guide scale completion on-site by researchers who received unified training, with clarification of the completion requirements provided, and check the scales immediately to ensure that no omissions or errors were present. Second, confirm reliability verification, as the GCQ, NSNS, and DCI had all undergone pre-tests, all with Cronbach's α coefficients >0.89, meeting the reliability standards. Third, conduct index detection by qualified testing personnel, with biochemical indicators and Kt/V values measured according to the laboratory's standard procedures. Finally, perform data management using software for double entry, with two people conducting cross-checks. If discrepancies are found, trace the source and correct immediately.
3. General data: Collect patient information, including gender, age, education level, marital status, duration of disease, weekly dialysis frequency, and primary disease.
4. General comfort questionnaire
   1. The GCQ covers four dimensions: physiological, psychological, mental, and socio-cultural/environmental comfort. It consists of 28 questions with 4 possible responses for each: strongly disagree = 1, disagree = 2, agree = 3, and strongly agree = 4. Ask the patients to complete the questionnaire according to their subjective feelings, with higher scores indicating greater comfort²². The Cronbach's α coefficient of the GCQ was 0.93.
5. Dyadic coping inventory
   1. The DCI includes 37 items, reflecting stressful communication, supportive coping, delegated coping, collaborative coping, negative coping, and coping quality evaluation, covering six dimensions, with eight items for stressful communication. Perform scoring using a 5-point Likert scale (1 = very rarely to 5 = very frequently), with reverse scoring applied to negative coping items. The Cronbach's α coefficient of the DCI was 0.89.
      NOTE: Two items related to coping quality evaluation were not included in the total score²³. These items were removed because they were designed to assess the perceived effectiveness of responses rather than the frequency of response behaviors, and their inclusion theoretically did not align with the purpose of the total score in measuring the frequency of behaviors. The specific items excluded were: My partner has done a great job in helping me cope with stress, and we have cooperated well in dealing with stress together.
   2. The total score ranged from 35 to 175 points, with higher scores indicating more supportive coping behaviors and better dyadic coping conditions among couples.
   3. Measure biochemical indicators, including blood potassium (K⁺) levels, blood sodium (Na⁺) levels, blood phosphorus (P³⁺) levels, blood urea nitrogen (BUN), hemoglobin (Hb), albumin (ALB), and blood calcium (Ca²⁺).
6. Newcastle satisfaction with nursing scale
   1. Use the NSNS to assess patient satisfaction with nursing, covering 19 items, including nurse competency, communication, attitude, psychological support, nursing assistance, and safety management. Score each item from 1 to 5, with a total score of 19-95 points. Scores ≥77 indicated being very satisfied, 58-76 satisfied, 39-57 generally satisfied, and ≤38 dissatisfied²⁴.
   2. Calculate the satisfaction rate as follows: (the number of patients who were very satisfied + satisfied + generally satisfied) ÷ the total number of patients. The Cronbach's α coefficient of the NSNS was 0.91.
7. The Kt/V value refers to the ratio of urea clearance by the dialyzer to the volume of distribution over a specified duration of dialysis, where K, t, and V represent the BUN clearance rate of the dialyzer, the duration of dialysis treatment, and the volume of distribution of urea, respectively. Monitor the Kt/V values, as they reflect dialysis adequacy and are generally >1.222²⁵.

7. Statistical analysis

1. For statistical analysis, use SPSS 26.0 statistical software.
2. Use the Kolmogorov-Smirnov method to test normality. Express measurement data in line with normality as mean ± standard deviation. Compare inter-group matched-pair means using the paired t-test and use independent samples t-tests for group comparisons.
3. Analyze repeated measurement data using repeated measures analysis of variance (ANOVA).
4. Express count data as frequency (n) or percentage (%). Use the chi-squared (χ²) test for data that met the test conditions and Fisher's exact test for data that did not. A bilateral p-value of <0.05 was considered statistically significant.

The results of this study demonstrate the efficacy of meticulous nursing in enhancing dialysis adequacy and overall patient outcomes among elderly patients undergoing MHD. Specifically, the repeated measures ANOVA revealed a significant treatment effect on Kt/V values (Ftreatment = 178.587, p < 0.001), with the study group exhibiting progressive improvements over time (e.g. Δ = 0.18 in November-December and Δ = 0.28 in January-February, both p < 0.001). These findings underscore the role of personalized dialysis plans, real-time monitoring, and psychological support in optimizing dialysis efficiency. Additionally, the study group showed favorable changes in biochemical markers, including reduced blood K⁺, Na⁺, and BUN levels, alongside increased Hb and ALB (all p < 0.05), which can be attributed to structured nutritional interventions and tailored health education. The significant improvement in GCQ scores (90.87 ± 10.26 vs 84.54 ± 5.84, p = 0.012) further highlights the impact of meticulous nursing on patient comfort and compliance.

General data

There were 22 men and 12 women in the control group, with a mean age of 63.43 ± 3.28 years and a mean disease duration of 24.47 ± 8.47 months. The study group included 19 men and 16 women, with a mean age of 63.18 ± 3.16 years and a mean disease duration of 24.32 ± 8.15 months. There were no significant differences in gender, age, education level, or marital status between the two groups (p > 0.05). No significant difference in DCI scores was observed between the study and control groups (see Table 1).

Comparison of general comfort questionnaire scores

There were no significant differences in pre-nursing GCQ scores between the two groups (p > 0.05). The GCQ scores increased in both groups compared with pre-nursing scores, with post-nursing GCQ scores in the control group lower than those in the study group (84.54 ± 5.84 vs 90.87 ± 10.26, t = 2.613, p = 0.012; see Table 2).

Comparison of biochemical indicators

No significant differences were observed in blood K+, blood Na+, blood P3+, BUN, Hb, ALB, or blood Ca2+ levels between the two groups pre-nursing (p > 0.05). Post-nursing, blood K+, blood Na+, and BUN levels decreased in the study group compared with pre-nursing values, whereas ALB levels increased in the study group, and Hb levels increased in both the study and control groups (p < 0.05). Compared with the control group, the study group exhibited lower blood K+, blood Na+, and BUN levels and higher Hb and ALB levels (p < 0.05; see Table 3).

Comparison of dialysis adequacy

The effect of different nursing approaches on Kt/V values over 6 months was explored using one-way repeated measures ANOVA. The Shapiro-Wilk test indicated that the data in each group were approximately normally distributed (p > 0.05). Mauchly's test of sphericity confirmed equal variance-covariance matrices between the groups (p > 0.05). Data were expressed as mean ± standard deviation (see Table 4). The results are summarized as follows.

The interaction of time per treatment for Kt/V values was significant between the two groups (Finteraction = 312.413, p < 0.001), indicating that the effect of different nursing approaches on Kt/V values varied across the three time points. Moreover, Kt/V values changed over time in both groups (Ftime = 124.572, p < 0.001). Different nursing approaches had varying effects on Kt/V values (Ftreatment = 178.587, p < 0.001). Further comparison of Kt/V values during the November-December and January-February periods revealed higher values in the study group than in the control group. No statistically significant differences in Kt/V values were observed between the two groups during the September-October period (p > 0.05).

Comparison of nursing satisfaction

Post-nursing satisfaction rates were 91.18% in the study group and 85.71% in the control group. A comparison between the two groups revealed no statistically significant difference (χ² = 0.111, p = 0.704; see Table 5).

Comparison of complications

In the study group, complications included infection (n = 1) and fistula occlusion (n = 1), with a complication rate of 5.88%. In the control group, complications included infection (n = 3), fistula occlusion (n = 1), and heart failure (n = 2), with a complication rate of 17.14%. Comparison of complication rates between the two groups showed no statistically significant difference (χ² = 1.176, p = 0.278).

Figure 1: Graphical abstract. Graphical summary of the research plan. The researchers divided the patients into a control group (n = 34) and a study group (n = 35) using the random number table method. The control group received conventional nursing intervention, whereas the study group received refined nursing intervention. Please click here to view a larger version of this figure.

Table 1: General data. General information about patients. There were no significant differences in gender, age, education level, or marital status between the two groups. No significant difference in Dyadic Coping Inventory scores was observed between the study and control groups. Inter-group matched-pair means were compared using the paired t-test, and independent samples t-tests were applied for group comparisons. Data are expressed as mean ± standard deviation.

Table 2: Comparison of GCQ scores. There were no significant differences in pre-nursing GCQ scores between the two groups. The GCQ scores increased in both groups compared with pre-nursing scores, with post-nursing GCQ scores in the control group lower than those in the study group. Abbreviations: GCQ = General Comfort Questionnaire; *: statistically significant compared with pre-nursing scores. Inter-group matched-pair means were compared using the paired t-test, and independent samples t-tests were applied for group comparisons. Data are expressed as mean ± standard deviation.

Table 3: Comparison of biochemical indicators. No significant differences were observed in blood K+, blood Na+, blood P3+, BUN, Hb, ALB, and blood Ca2+ levels between the two groups pre-nursing. Post-nursing, blood K+, blood Na+, and BUN levels decreased in the study group compared with pre-nursing values, whereas ALB levels increased in the study group, and Hb levels increased in both the study and control groups. Compared with the control group, the study group exhibited lower blood K+, blood Na+, and BUN levels and higher Hb and ALB levels. Abbreviations: BUN = blood urea nitrogen; Hb = hemoglobin; ALB = albumin; *: significantly different compared with pre-nursing values. The chi-squared test was used for data that met the test conditions.

Table 4: Comparison of Kt/V values over time. The interaction of time per treatment for Kt/V values was significant between the two groups, indicating that the effect of different nursing approaches on Kt/V values varied across the three time points. a: Statistically significant difference between the two groups. One-way repeated measures analysis of variance was used. Data are expressed as mean ± standard deviation.

Table 5: Comparison of nursing satisfaction. A comparison between the two groups revealed no statistically significant difference. The chi-squared test was used for data that met the test conditions. Data are expressed as mean ± standard deviation.

Maintenance hemodialysis is currently the most commonly used and effective therapy for elderly patients with ESRD²⁶. Because MHD requires persistent, lifelong treatment, the stress associated with long-term therapy imposes physiological, psychological, and economic pressures on patients, considerably affecting their treatment compliance and outcomes. The conventional nursing model tends to be fragmented, inadequately addressing patients' negative emotions and compromising the timeliness and effectiveness of nursing interventions. Therefore, the integration of meticulous nursing into the care of elderly patients undergoing MHD can improve various clinical indicators.

Technological advancement and development in MHD have made long-term survival for these patients a reality¹⁸. Moreover, the accurate and timely assessment of dialysis adequacy, enhanced dialysis quality, and efforts to achieve adequate dialysis have had a substantial impact on improving the long-term survival rates of patients undergoing MHD²⁷. Specifically, dialysis adequacy refers to the appropriate clearance of toxins while maintaining sufficient protein intake and keeping toxin levels low during the interdialytic period. The process of ultrafiltration during dialysis safely and steadily removes retained sodium and water from the body, allowing patients to feel comfortable post-dialysis without experiencing cardiovascular incidents or imbalances in electrolytes and acid-base levels. This enables patients undergoing long-term dialysis to recover with fewer complications, a state referred to as optimal dialysis or dialysis adequacy²⁸. Clinically, several indicators are commonly used to assess dialysis adequacy in patients undergoing MHD, such as anemia, nutritional status, and electrolyte balance, which, although related to dialysis adequacy, are insufficient to measure it accurately²⁹. In the early 1980s, the National Cooperative Dialysis Study proposed the urea kinetic model, which began quantifying dialysis dose to develop treatment plans using Kt/V, which remains the most widely used indicator for evaluating dialysis adequacy today³⁰. This study shows that implementing meticulous nursing can increase the Kt/V value in elderly patients undergoing MHD, thereby improving their dialysis adequacy. This can be attributed to several factors. First, the personalized pre-dialysis plan (dehydration volume ≤5% of dry body weight and dialysis time >10 h/week) ensures sufficient contact between the dialysate and the blood, laying a foundation for effective toxin clearance. Second, during dialysis, blood pressure is monitored hourly, and psychological interventions are provided to patients who wish to end dialysis early, preventing incomplete treatment and ensuring the prescribed dialysis duration (t). Finally, continuous monitoring of the arteriovenous fistula is performed to maintain unobstructed blood flow and ensure the stability of the dialyzer urea clearance rate (K), thereby increasing the Kt/V value.

In this study, no significant differences in biochemical indicators were observed between the two groups before nursing. After 6 months, the study group showed a significant decrease in K⁺, Na^+, and BUN and a significant increase in ALB and Hb compared with the control group (p < 0.05). This improvement is closely associated with multiple detailed interventions outlined in the protocol for meticulous nursing. First, dietary and nutritional guidance: the protocol specifies that patients should consume small amounts of high-protein food (milk containing 3.3 g of protein per 100 g and egg whites containing 15.2 g of protein per 100 g) within the first 2 h of dialysis, with a target of approximately 20 g of protein and 210 kcal. This standardized nutritional support directly addresses protein loss during dialysis, contributing to increases in ALB and Hb levels¹⁵. Second, targeted health education: the protocol requires health education to be provided tailored to the patients' individual conditions, including explanations of disease knowledge, dialysis precautions, and the importance of dietary self-management (e.g., avoiding high-potassium and high-sodium foods). This enhances the patients' understanding of dietary restrictions, resulting in reduced K⁺ and Na⁺ intake and lower post-nursing blood K⁺ and Na⁺ levels. Finally, regular indicator monitoring: the protocol mandates the periodic collection and comparison of biochemical indicators as part of data collection, allowing nurses to adjust nursing plans in a timely manner (e.g., modifying dietary advice based on P³⁺ or Ca²⁺ levels). It also encourages patients to actively participate in their treatment by understanding changes in their own indicators. This two-way interaction further promotes improvements in biochemical indicators.

In addition, an examination of biochemical indicators in elderly patients undergoing MHD clearly reflects their treatment compliance, medication status, and dietary habits. Specifically, K⁺ and Na⁺ levels indicate dietary self-management and the risk of cardiovascular complications, blood P³⁺ and Ca²⁺ reflect adherence to a low-phosphorus diet and medication compliance, and BUN levels reflect protein absorption³¹. Analysis has shown that meticulous nursing helps improve patients' clinical biochemical indicators, with considerable improvements in renal function and notable increases in serum ALB levels observed among elderly patients undergoing MHD following the implementation of meticulous nursing. These patients often experience a decline in quality of life, altered lifestyle habits, and poor adherence to diet and medication after prolonged treatment, in addition to the effects of the disease itself, resulting in elevated K+, Na+, and BUN values and decreased ALB and Hb levels. The meticulous nursing approach adopted in this study included direct interventions, such as regular monitoring of relevant indicators, maintaining records, and periodic comparisons, to encourage elderly patients undergoing MHD to pay attention to their health status and actively engage in treatment. Additionally, when faced with problems, patients were encouraged to seek guidance from doctors, nurses, or community health service centers for correct treatment and care during recovery³². Regular blood tests allowed the patients to understand changes in their biochemical indicators at each stage, and active communication about specific measures to improve these indicators promoted proactive responsibility and problem-solving related to their own health and self-care. Furthermore, the application of strategies such as standardized medication, dietary care, and promotion of healthy lifestyles contributed to improving the internal environment for patients³³.

The findings of this study indicate that meticulous nursing can substantially improve the comfort levels of elderly patients undergoing MHD, possibly due to effective nursing measures that alleviate the psychological burden of treatment, enhance patient comfort, and increase treatment compliance, thereby improving dialysis adequacy³⁴. The study group also focused on patient needs by actively assisting them to change positions hourly, providing bedside companionship for restless and anxious patients, and addressing symptoms of discomfort promptly, which effectively enhanced comfort. However, the findings revealed that meticulous nursing did not greatly improve patient satisfaction, possibly because the study prioritized ensuring treatment duration over strictly adhering to patient preferences.

The results of this study show that meticulous nursing can substantially improve dialysis adequacy, biochemical indicators, and treatment comfort in elderly patients undergoing MHD. Its effectiveness is based on the scientific implementation of a series of core nursing steps. Based on practical experience, the key factors affecting the success of the intervention include the following. First, the precise formulation of personalized dialysis plans: in the pre-dialysis stage, a comprehensive evaluation of the patients' vital signs, degree of cooperation, vascular access status and blood glucose levels is conducted, followed by the development of an individualized dialysis plan based on the assessment results (such as dehydration ≤5% of dry body weight, dialysis time ≥10 h/week and adaptive adjustment of blood flow, sodium concentration and dialysate temperature). This step forms the foundation for all subsequent nursing measures, and its precision directly determines whether the dialysis dose (Kt/V value) can reach the treatment target. The study confirmed, through one-way repeated measures ANOVA, that the Kt/V value improved significantly over time (F_treatment = 178.587, p < 0.001), with increases of 0.18 and 0.28 observed in November-December and January-February, respectively (both p < 0.001), verifying the core effect of the personalized plan on dialysis adequacy. Second, the closed-loop management of dynamic biochemical monitoring and health education: key indicators, including K⁺, Na⁺, BUN, Hb, and ALB, were regularly monitored, and targeted health education was provided based on the patient's actual condition, explaining the importance of the indicators and emphasizing dietary and medication compliance. The study showed that post-nursing levels of BUN, K⁺, and Na⁺ in the study group were significantly lower than those at pre-nursing levels (p < 0.05), whereas Hb and ALB levels significantly increased post-nursing (p < 0.05), with statistically significant differences between the two groups (both p < 0.05). The core of this closed-loop management lies in helping patients intuitively understand their own health status through data feedback, prompting them to actively adjust their behaviors (such as restricting high-potassium foods and taking medications regularly), in combination with educational guidance, thus forming a positive cycle of monitoring-feedback-improvement.

Compared with routine nursing care for elderly patients undergoing MHD, meticulous nursing offers several advantages. First, unlike the one-size-fits-all approach often adopted in routine nursing, meticulous nursing emphasizes the formulation of personalized nursing plans based on detailed pre-dialysis assessments (such as vital signs, dry body weight, and comorbidities) to accommodate the unique physiological and psychological states of each elderly patient. This contrasts with the more generalized approach of routine nursing and even the holistic nursing model, which may lack such meticulous personalization. Second, meticulous nursing incorporates targeted psychological interventions, including empathy, emotional support, and sharing of successful cases, while actively involving family members to alleviate patients' anxiety and improve treatment compliance. Although holistic nursing also addresses psychological needs, meticulous nursing implements these needs through organized, frequent, and proactive emotional interactions, which are often lacking in routine or standardized care³⁵. Finally, meticulous nursing goes beyond general health education by providing disease-specific and treatment-matched knowledge and by encouraging patients to actively participate in self-management, consistent with empowerment theory (such as the information-motivation-behavioral skills model) in chronic disease management. This level of patient participation is not typically emphasized in routine nursing³⁶.

This study has some limitations. First, all patients included in the study were from the same hospital, which limits the regional and participant scope. In addition, due to the small sample size, short study period, and narrow range of participants, a multi-center, large-sample study will be conducted next to improve generalizability. The follow-up period will be extended to 12-24 months to track long-term Kt/V values, complication rates, and mortality for more in-depth observation. Second, as implementing meticulous nursing requires the mobilization of all nurses in the hospital, measuring its effect is challenging. To further promote this program, standardized protocols should be developed and refined, and nurses should receive systematic training. By integrating family support and exploring the feasibility of telemedicine, post-dialysis care can be enhanced to improve patient compliance. Finally, this study did not use a blinded assessment of outcome indicators, which might have introduced bias due to the subjective tendencies of the assessors and affected the objectivity of the results.

In conclusion, based on the results of this study, in terms of short-term effects, the application of meticulous nursing can effectively improve the comfort of elderly patients undergoing MHD, improve biochemical indicators, enhance treatment compliance, ensure the prescribed treatment duration, and thus improve dialysis adequacy. Further evaluation is needed to determine the applicability of these findings on a larger scale.