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

Summary

Meticulous nursing is expected to reduce anxiety levels and enhance treatment effectiveness. This study aims to investigate the impact of meticulous nursing on elderly patients undergoing maintenance hemodialysis, thereby providing evidence for the formulation of future nursing policies for this population.

Abstract

This study investigated the impact of meticulous nursing on dialysis adequacy in 69 elderly patients undergoing maintenance hemodialysis at a single center between September 2022 and February 2023. Patients were randomized to a study group (meticulous nursing, n = 35) or a control group (conventional nursing, n = 34). Post-nursing comfort scores improved in both groups; however, the study group exhibited higher scores (90.87 ± 10.26 vs. 84.54 ± 5.84, p = 0.012). Both groups showed increased albumin and hemoglobin levels post-nursing (p < 0.05), with the study group additionally demonstrating greater reductions in blood potassium, blood sodium, and blood urea nitrogen than the control group (p < 0.05). Analysis of dialysis adequacy using Kt/V values revealed significant treatment effects (F_treatment = 178.587, p < 0.001); although the study group's Kt/V increase from September to October was non-significant (t = 1.164, p = 0.249), significant gains occurred from November to December (Δ = 0.18, t = 3.854, p < 0.001) and January to February (Δ = 0.28, t = 4.811, p < 0.001). No differences were observed in nursing satisfaction (χ² = 0.111, p = 0.740) or complication rates (χ² = 1.176, p = 0.278) between groups. These findings indicate that meticulous nursing enhances patient comfort, improves biochemical markers, boosts treatment compliance and duration, and ultimately increases dialysis adequacy.

Introduction

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.

Protocol

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.

Results

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 (F_treatment = 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 ...

Discussion

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 ef...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
EpiData	EpiData Association?Denmark	Version 3.1	For simple or programmatic data entry
SPSS	IBM?USA	Version 26.0	Statistical Software