Professional Documents
Culture Documents
End-stage renal disease (ESRD) is the final common established in Queen Elizabeth Hospital in July 1996.
pathway for a variety of renal and urological diseases. The program was run by a multi-disciplinary team
Renal replacement therapy (RRT) is employed to sustain comprised of renal physicians, renal nurses, clinical
life when renal function reaches end-stage. i.e. 5% psychologists, medical social workers and community
normal. Renal transplantation is regarded as the best social workers from Patient Resources Centre,
RRT in terms of restoration of renal function, survival pharmacists, renal dietitians, occupational therapists,
rate, rehabilitation and quality of life. However physiotherapists and the patient support group. The aim
transplantation is limited by the scarce supply of organs. is to achieve full physical and psychosocial rehabilitation
This results in an increasing size of dialysis population with good quality dialysis life. Apart from the day to day
worldwide. Both peritoneal dialysis (PD) and service, the program stresses on two major areas: pre-
haemodialysis (HD) are effective modes of dialysis dialysis education and comprehensive care during the
therapy. Since the invention of PD in 1976, there has CAPD preparatory and training period.
been a rapid growth in the utilization of PD. By the end
of 1997 the chronic PD population worldwide was an Pre-dialysis Education
estimated 115,000, representing 14% global dialysis Success of a comprehensive renal replacement program
patients. In Hong Kong, 80% of our prevalent ESRD depends heavily on patients' acceptance of their disease,
patients on dialysis are put on PD. This utilization rate their positive motivation and active participation in the
ranks second in the world, just next to Mexico. Majority treatment. This is related to patients' feeling of control
of patients on PD are on continuous ambulatory or lack thereof. Enhancement of patient's knowledge
peritoneal dialysis (CAPD). The patients have to perform about their illness and treatment plan can improve their
3 to 4 bag exchanges at home every day. For patients sense of control, stress adaptation and psychological
on haemodialysis, the usual regime is 2 to 3 sessions adjustment and in turn their compliance to RRT.
per week, 4 to 6 hours for each session, either in the
hospital or satellite dialysis centre. Early or timely referral of pre-dialysis ESRD patients to
nephrologists allows early patient's education and
Though dialysis maintains life, patients face life-long preparation as well as better pre-dialysis renal care. On
physical, psychological and social problems related to the other hands, studies have confirmed that late referral
their illness and treatment. Dialysis can only replace part, is associated with increase need for emergent dialysis
but not all, of the renal functions. It cannot correct the and temporary central venous catheterization and higher
co-morbid diseases and it itself incurs its own incidence of uremia-related complications, such as
complications. Anxiety, depression, fear, emotional severe hypertension or fluid overload. This is associated
fluctuation and various psychological stresses are with prolonged hospitalization at the start of dialysis and
common amongst ESRD patients especially at the early has detrimental consequence on initial morbidity and
phase of treatment. Dialysis treatment also causes a mortality. Economic evaluations of Canadian and U.S.
significant change in daily living, disruption in work data also suggested that early referral would result in
schedule and shift in social role which in turn imposes cost saving.
financial, housing, marital and employment problems.
Psychological adaptation and social adjustment are In Queen Elizabeth Hospital, pre-dialysis education
important challenges to renal patients on dialysis classes (PEC) are organized to provide patient education
therapy. and psychological guidance. The aim of PEC is to
provide basic knowledge to renal patients early in their
In order to provide comprehensive and holistic care to courses of diseases before RRT is anticipated. This
the ESRD patients, a renal rehabilitation program was allows patients to make an informed choice of their
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MEDICAL SECTION April 2003
preferred treatment modality. This also permits early The break-in period is defined as the time between
creation of a permanent peripheral vascular access for catheter insertion and routine catheter use. The
hemodialysis or insertion of Tenckhoff catheter for PD treatment strategy used during the break-in period
in a timely fashion to ensure a smooth transition to RRT. actually depends primarily on whether dialysis is needed
Patients with a creatinine of around 500 µmol/L are for the treatment and support of the patients at the time
recruited into the class. Two integrated talks on of catheter insertion. If the patient is asymptomatic with
2 consecutive Saturday afternoons are arranged. These acceptable blood chemistry, patient is instructed to come
classes are held regularly every 4 months. During the back to our dialysis unit weekly for flushing of the newly
classes, the renal physicians and renal nurses discuss inserted Tenckhoff catheter and blood testing for renal
on natural history and clinical features of ESRD, chemistry. This minimizes the manipulation of the
treatment plan and principles and options of dialysis. catheter and allows better wound healing as well as
Staff from other paramedical departments emphasizes reduces the risk of future leakage. The indications to
on the importance of exercise, diet and drug compliance. start dialysis in this phase include fluid overload,
Medical and community social workers introduce the electrolytes imbalance and severe acid-base
available community resources to kidney disease decompensations. Patients were either maintained on
patients. ESRD patients on dialysis or renal intermittent HD by temporary dual-lumen catheter or low
transplantation are invited to share their experiences and volume intermittent PD using the cycler machine. Hence
give their psychological support. the number of intermittent HD and PD sessions reflects
the need for emergent dialysis. Hospitalization rate in
CAPD Preparatory and Training Period the break-in period for the two groups was compared.
Four weeks after insertion of Tenckhoff Catheter, the After the commencement of PD, rate of peritonitis and
patient will have the comprehensive CAPD training exit site infection is measured to evaluate the effect of
program by a designated renal nurse. Home blood PEC on morbidity of ESRD patients at 3 and 6 months.
pressure monitoring are taught. Exercise program is Since patients are encouraged to contact their
arranged by the physiotherapists. Device modification, designated train-nurse or dialysis center in their early
home environment modification and enhancement of days on PD, the number of non-scheduled follow-up
activity of daily living are provided by the occupational (NSFU) can also reflect their morbidity.
therapists. For patients with employment problem,
vocational counseling, job skills training and job Results
matching services are provided in the integrated Group A comprised 107 patients (44M and 63F) while
vocational rehabilitation program. Dietitian and group B included 285 patients (147M and 138F). The
pharmacist will counsel patients according to their mean age of group A and group B are 57.5±15.3 and
individual needs. Medical social worker will attend to 59.6±14.8 years old respectively.
issues related to financial assistance, community care
services and illness adjustment. There are small peer Questionnaires were used to assess the knowledge of
group meeting with volunteers from patient support patients before and after PEC. Twelve true/false
group to provide in-depth experience sharing and questions on the concepts of renal health were asked
psychological support to patients and care-givers. before and after PEC. The two scores were compared
Difficult cases are referred to the clinical psychologist and the difference was statistically significant. This
for further counseling. suggested that PEC indeed improves the knowledge of
renal patients.
Study on Pre-dialysis Classes (PEC)
Since the organization of PEC, we have two groups of The hospitalization rate and the number of intermittent
patients, who did (Group A) and did not (Group B) attend HD and PD sessions required in the break-in period
the PEC respectively. It would be interesting to note the among both groups of patients are shown in Table 1.
impact of PEC on the clinical outcome of the two groups,
in terms of initial morbidity and mortality after
commencement of RRT.
Table 1. Morbidity during the break-in period
Group A Group B P
A total of 12 pre-dialysis education classes (PEC) were
organized in Queen Elizabeth Hospital from November Hospitalization days 12.2±13.68 20.5±16.1 <0.01*
1996 to October 2000. One hundred and ninety-four HD session 4.6±6.6 6.7±8.2 0.02*
patients and their families have attended these PD session 3.5±2.8 3.2±3.0 0.48
classes. *statistically significant
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Vol. 8 No. 2 MEDICAL SECTION
The requirement of intermittent HD was statistically patients possess a more positive attitude towards chronic
significantly higher in group B patients although the illness. They are more readily to accept the fact of ESRD
number of PD session was similar. Patients from group and prepare early for the life on dialysis. Alternatively,
B also had a significantly higher hospitalization rate this can be explained by the fact that female patients
(8 days more) in the break-in period (p<0.001). may be easier to attain family support than the male
counterparts when facing chronic illness. Further studies
The hospitalization days, peritonitis and exit site infection directing towards the psychological and social aspects
rate, scheduled follow-up (SFU) and non-scheduled of female renal patients may be warranted to clarify the
follow-up (NSFU) of group A and B patients at 3 and 6 issue.
months after commencement of PD were shown in Table
2. The hospitalization, peritonitis and exit site infections For those patients who have attended the PEC (group
rate were not different significantly between the 2 groups. A), the hospitalization days are significantly lower during
The NSFU episodes showed a trend of decrease both the break-in period. They received less intermittent HD
in 3 and 6 months in group A patients after sessions while the requirement of intermittent PD is
commencement of PD, although it did not reach the similar to those without the prior history of PEC (group
statistically significant level. B). This suggests that they are referred early to renal
specialists. Peritoneal access is available when
Discussion peritoneal dialysis therapy is indicated in this group of
Early or timely referral and commencement of RRT patients. Nevertheless, it will be even better if these
improves the morbidity and decreases mortality for patients can be seen by nephrologists at an even earlier
patients suffered from ESRD unequivocally. stage in the courses of their illness so that they can have
Nevertheless, it is very difficult to persuade our renal an expectant management during the break-in period.
patients to have early dialysis as long as they remain This can improve the catheter wound healing and reduce
asymptomatic. The stress associated with the the risk of future leakage of Tenckhoff catheter. Obviating
uncertainty about change in lifestyle after dialysis is the need of intermittent PD also save the productive
another major obstacle. To improve compliance and power of the patient and health care resources.
confidence on nephrologists, patient education certainly
is one of the important measures. We believe that After the commencement of PD, the effect of PEC seems
improvement in the knowledge of illness and treatment diminished. The hospitalization, peritonitis, and exit site
modalities can alleviate stress associated with infections rate all showed no statistically significant
uncertainty. The delivery of this knowledge should be difference. This is expected because both groups of
early in the course of the kidney disease because of its patients underwent the same comprehensive PD training
chronic and relentless nature of the illness. From the programme 4 to 6 weeks after the break-in period.
current study, we demonstrate that pre-dialysis education Training is still a crucial component in the process of
class (PEC) can improve the knowledge of patients self-care dialysis. It is interesting to see that the number
suffering from ESRD. The effect of PEC persists as long of NSFU episodes was slightly less in group A patients
as 6 months after commencement of PD. although the difference did not reach statistically
significant level. This may imply that group A patients
Female ESRD patients are more willing to attend the are better equipped and more ready to master the PD
PEC. One of the plausible explanations is that female exchange technique.
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MEDICAL SECTION April 2003
Although 75.4% of the group B patients also had their status of ESRD patients of the working age (age 21-55)
follow-up in the Specialist Outpatient Clinic, they are on peritoneal dialysis, haemodialysis and renal
not referred to the PEC. Majority of them are followed transplantation (TX) cared by Queen Elizabeth Hospital
up by non-nephrology specialists. This reflects that and its satellite centre, Yaumatei Renal Dialysis Centre,
late nephrology referral is indeed a common health are shown in Figure 1 and Figure 2. The transplanted
problem. patients have the best employment status and social
rehabilitation. Unemployment is a problem for all types
The Overall Rehabilitation Status of ESRD of patients. Amongst all, HD patients are having the
Patients highest unemployment rate. This may reflect the
The employment status and recovery of social life are advantage of the more flexible CAPD treatment enabling
good indexes of rehabilitation status for patients of them to better secure the job and attain normal social
chronic illness. The employment status and the social activities.
Figure 1. Employment status of patients on renal replacement therapies (working age group: age 21-55).
Figure2. Social status of patients on renal replacement therapies (working age group: 21-55).
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Vol. 8 No. 2 MEDICAL SECTION
End-stage renal disease (ESRD) is the end road for many Group 2. Post renal transplant patients (n=29)
renal diseases. It, in turn, is associated with various Age of patients <30 <40 <50 <60
medical complications in other organs requiring multiple
Percentage of patients 17.2% 55.2% 86.2% 96.6%
drug therapy. Medication is an essential part of treatment
both before and after long term renal replacement
therapy. Poly-pharmacy is a common phenomenon No. of drugs ≥5 ≥6 ≥7 ≥8 ≥9 ≥10
because of the co-existing morbidities. ESRD patients, prescribed
especially those elderly, have difficulty in identifying the
Percentage 96.6% 93.1% 86.2% 69.0% 48.3% 31.0%
drugs and understanding the function of individual
of patients
medications. As part of the renal rehabilitation program
in Queen Elizabeth Hospital, the pharmacist attended
most of the new patients who were prepared for
continuous ambulatory peritoneal dialysis, Discussion
haemodialysis and after renal transplantation individually For patients on haemodialysis or continuous ambulatory
for education and counseling. peritoneal dialysis (Group 1), 70% were aged ≥60 and
31.9% were aged ≥70. Most elderly patients had poor
Result of the Drug Education Program memory and did not know much about their drug
From January 1997 to June 2002, 189 patients were treatment. Careful counseling and repeated explanation
counselled (160 patients on haemodialysis or continuous were required. Most of the patients (82.5%) had ≥5 drugs
ambulatory peritoneal dialysis and 29 patients after renal and over one third of patients (36.9%) were given ≥8
transplantation). All patients were interviewed drugs. Poly-pharmacy was common which may affect
individually with or without their helper. They were the patient compliance. Anti-hypertensive agents was
educated about the indications, administration method the most difficult class of drug to educate, this may be
and side effects of their current medications. due to the ease in blood pressure monitoring at home,
and patients tended to manipulate their own treatment
Group 1. Dialysis patients (n=160)
by altering the drug dosage, frequency or even totally
omitting the treatment.
Age of patients ≥40 ≥50 ≥60 ≥70 ≥80
Percentage of 95.0% 83.8% 70.0% 31.9% 1.9% For patients having renal transplantation (Group 2), they
patients were younger (96.6% were <60). Poly-pharmacy was
still very common with 96.6% and 69.0% of patients given
≥5 and ≥8 drugs respectively. Post renal transplant
No. of drugs ≥5 ≥6 ≥7 ≥8 ≥9 ≥10
patients were more eager to know their own drug
prescribed#
treatment than dialysis patients, probably due to the
Percentage 82.5% 67.5% 51.3% 36.9% 24.4% 15.0% younger age and their attitude towards the disease state.
of patients
#
excluding CAPD fluid In conclusion, individual counseling is time consuming
but useful. 'Hidden messages' can be revealed from
patients. To secure the continuous correct usage of
drugs, follow-up assessment by pharmacist is desirable.
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MEDICAL SECTION April 2003
Dietitian plays an important role in medical nutrition visits are highly recommended in order to improve health
therapy of renal patients throughout the disease status, control of condition and quality of life through
process from pre-dialysis stage, dialysis stage with close monitoring of clinical and nutritional status.
either haemodialysis or continuous ambulatory
peritoneal dialysis and the post renal transplantation Dietetic counseling has been the integrated part of
period. Dietary intervention aims to minimize the the renal rehabilitation program in Queen Elizabeth
consequences of declining renal function, thereby Hospital (QEH) since 1997. In the pre-dialysis classes,
maintaining the patient's well being. Goals of dietary initial dietetic advice was given to the renal patients
management include maintaining good nutritional preparing for dialysis. When reaching end-stage renal
status, preventing or minimizing uremic toxicity and failure, all new dialysis and renal transplant patients
the metabolic derangements of renal failure, and in QEH and 88% of the new dialysis patients in
retarding the rate of progression of renal failure. Yaumatei Renal Dialysis Centre (YMTRDC) attended
the dietitian individually either during the training
Medical nutrition therapy includes assessment and period of continuous ambulatory peritoneal dialysis
intervention. At the initial assessment, dietitian obtains or shortly after starting haemodialysis or after renal
a diet history with special focus on nutrients that affect transplantation. Follow up sessions were arranged
the condition and evaluate nutritional status by when necessary depending on the progress of the
anthropometry and biochemical measurements. biochemistry. For old cases, dietetic counseling
Treatment goals will be set and a nutrition prescription session was arranged during the medical clinic follow
will be given to patient. At each subsequent visit, the up sessions. Improvement in nutritional status and
dietitian will monitor the dietary intake and biochemistry, blood biochemistry was observed in 70% of the
discuss the result with the patient and modify dietary patients after dietetic counseling.
plan as needed. To ensure successful dietary
compliance, patient must undergo extensive training in At the end of 2002, a patient satisfaction survey on
principles of nutritional therapy and the design and the dietetic service was performed. Results indicated
preparation of diets and receive continuous that 96% of the patients found that the dietetic advice
encouragement. To achieve optimal result, patient's was useful and 85% followed the advice given. In this
spouse or family members should work closely with the survey, 86% of patients revealed that they had
patient to provide moral support and assist with improvement in the nutritional status and blood
acquisition and preparation of food. Regular follow up biochemistry after the dietetic counseling.
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Vol. 8 No. 2 MEDICAL SECTION
The interdisciplinary renal team of Queen Elizabeth matching community care services, finding a maid,
Hospital composes of doctors, nurses, medical social identifying relatives from China, or placing them in a
workers and staff from other supporting departments. residential home. It is important for the families to involve
The role of the medical social worker is multifaceted. patients in working out their caring arrangement so that
We assess the family's coping strategies, support they can feel a part of decision and accept readily.
network, learning styles and abilities and financial
situation. Equally important, we communicate this Patients may experience emotional stresses/problems
information to the team and identify intervention arising from alteration of social and role responsibilities,
strategies that will provide the family with comprehensive dependence/independence issue, loss of sense of
care for their medical and psychosocial need. well-being, uncertainty about future and change in
employment/income/financial security. These emotions
Our main effort is to maintain patients and their families may be triggered by lack of information, social support
with a quality life on dialysis. To that end, we provide and inability of self-care. Therefore, it is necessary to
counseling and identify community services/resources help patients foster coping skills, release stressful
to patients and families to cope with renal disease and emotions, develop healthy emotional responses (avoid
changes in family, home, workplace and community. performing a sick role) and re-establish a balance in their
That includes helping them to adapt to dialysis life. Involvement of families during the helping process
treatments, adjust emotionally to chronic renal failure, is essential. Besides, self-management and
and cope with financial and accommodation concerns. empowerment can help patients regain control over
certain aspects of their lives and health. The adjustment
We perform psychosocial assessment on patients and problem accounts for 19.2% of our service.
establish ongoing relationship by seeing them regularly
throughout the course of treatment. The patients and Throughout the process of social counseling and
their families have many concerns especially in the initial intervention, it is essential to respect the dignity of the
stage of dialysis such as financial, caring and emotional patients, and be sensitive to and respectful of their
aspects. There is no question that dialysis does carry wishes. Early education about renal disease, its
financial implication. Amongst the end-stage renal treatments and productivity can help in their overall
disease patients, 53% of all the attendance is related to adjustment on dialysis including both emotionally and
financial problems. That includes costs of medical physically. Furthermore, patients easily feel vulnerable,
treatment and monthly consumable items. For patients out of control and low self-esteem. Immediate and
having financial hardship, they can apply for Disability constant comfort and encouragement especially from
Allowance although screening and assessment will be families and professional staff can generate positive
carried out before patients are considered eligible for impact on their adjustment. These elements can
such allowance. The Comprehensive Social Security structure a supportive social environment that can
Assistance allows those without work to have a safety improve how they feel and their ability to function.
net.
In the helping process, we need to have a sense of
In addition to their financial concern, many people on reflection "If we were patients or their families, how would
dialysis, especially the aged, do face caring problem. It we react". It can let us take a more empathetic attitude
attributes to 21.8% of the service to ESRD clients. We and adopt a more flexible approach in our intervention.
try to facilitate family members to help keep the change Life after renal failure can be very challenging both
of caring system and living environment for patients to physically and psychologically. It is hoped that our effort
minimal. Some families may mobilize their members, no will facilitate patients and their families to overcome these
matter living together or living apart, to look after patients challenges with a view to achieving a fulfilling and
but some may look for external assistances such as meaningfully life.
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MEDICAL SECTION April 2003
End-stage renal disease (ESRD) is a chronic illness in in employment although many of them have regained
which functional capacities in performing self-care, working capacity of varying degree. Their main barrier is
domestic and work activities decline as the disease the need of regular dialysis for 3 to 4 times in a day. They
progress. Continuous ambulatory peritoneal dialysis will be arranged to join the Patient Retraining and Vocational
(CAPD), haemodialysis and renal transplantation are all Resettlement Service jointly organized by our occupational
effective treatments for ESRD. Renal rehabilitation for therapy department and the Employee Retraining Board.
these patients involves a multidisciplinary team in which It is an integrated program providing vocational counseling,
occupational therapist is a member. In Queen Elizabeth job skills training and job matching services.
Hospital, occupational therapists serve about 100 renal
patients each year. The service offered varies according In the period from 1995 to October 2002, 72 patients from
to the patients' needs and the stages of their illness. our renal unit were referred for Patient Retraining service.
24 of them had undergone renal transplant surgery, 45
The procedures of CAPD require fine manipulation of were on CAPD and 3 received other treatment. They were
small, sterilized parts such as caps, catheter tubes and relatively young in age, ranging from 21 to 58 with a mean
pegs of the dialysis package. These patients, especially of 39 years. 42 of them (60%) had the education level of
the elderly, suffer from generalized weakness and Form 3 or below and 23 (30%) completed secondary
reduced dexterity and finger sensation. The main concern school. About half of them had been unemployed for more
of occupational therapy is to help them to carry out the than 1 year and up to 6 years before seeing us. After
exchange procedures independently. At this stage, we attending the vocational counseling and skill training, 43
concentrate on providing necessary adaptations to the of them (about 60%), found either a part-time or a full-
handles and knots of the dialysis package. We may give time job. Those required 4 CAPD exchanges per day
suggestions in building up the handles, changing the usually worked as part-time. The categories of job
orientation of the handles and knots to meet the capacity involved were very diverse including accounting clerk,
of the patients or teaching proper body mechanics to general clerk, security guard, convenience shop assistant
facilitate stronger pinch. We will also work with the renal or courier service. Among the 20 patients who worked
nurses to propose simplified operational procedures. for full time, the average salary was HK$7,329. For the
part-time jobs, the mean salary was HK$3,344. Some
The next concern of occupational therapy is to help patients quitted the job within 3 months due to various
maintaining the activities of daily living (ADL) of the reasons. The average 3 months sustain rate was about
patients. We provide ADL training, recommend assisting 72%. Details are tabulated in Table 1. The experience of
devices for daily activities, and advise on energy these patients indicated that many ESRD patients retain
conservation techniques to maximize utilization of the varying degree of working capacity and are productive
patients' potential for independent ADL. For those who members of the society when suitable assistance is given.
are cared by the family members, we will provide advices
and training to the carers to help relieving their burden in The mission of Occupational Therapy is to help our client
performing ADL for the patient. We will also conduct brief to lead a meaningful life of their choice by maximizing
screening on home safety. Recommendation on home their residual capacity to contribute to their self-care, work
modification and/or reduction of home hazard will be and leisure. At the moment, we could only afford to provide
provided when needed. brief service on ADL and work. We wish we could extend
our services to help our clients and their carers to
The younger patients have less difficulty in handling the restructure their living so as to achieve a more meaningful
CAPD procedures and ADL. However, they face difficulty and happy life.
Table 1. Number of subjects who can find a job and the 3 months employment rate
Subjects No of subjects No. of subject employed No. of subject employed at 3 months after discharge
Renal transplant 24 19 (80%) 13 (54%)
CAPD 45 24 (53%) 18 (40%)
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Vol. 8 No. 2 MEDICAL SECTION
Contemporary medical treatment is an effective means QEH Renal Support Group is to promote the idea of
to prolong the life of end-stage renal disease (ESRD) mutual support and self-help, through which patients can
patients. The side effects of treatment, however, are share their common experience and practical tips and
known to exploit the quality of life of patients and instigate ultimately they can build up their own community social
negative influences on their other aspects. A holistic care network. The group has two volunteers stationing in both
for ESRD patients and caregivers is therefore crucial QEH Renal Dialysis Centre and Yaumatei Renal Dialysis
and necessary to fulfill their needs at different stage. In Centre during follow-up days to recruit new members
Queen Elizabeth Hospital, the Department of Medicine, and promote their services and activities. Besides, a
QEH Renal Support Group and Patient Resource Centre supporting network is established to provide individual
jointly provide different psychosocial support and care and facilitate information delivery for group
educational services to enhance patients' understanding members constantly by phone calls. Psychosocial
on their illness and treatment thus empowering them to activities are organized, such as health talks, sports
master their own life. training sessions, social gatherings and other community
activities, so as to promote a healthy life style and
During the pre-treatment phase, a two-day dialysis class enhance the quality of life of group members.
is arranged to patients and their caregivers to prepare
them to receive treatment and provide an introduction Regular meetings are organized between medical
on community resources for seeking assistance. It volunteers, group committee members and the social
provides a comprehensive support to boost the workers of Patient Resource Centre (PRC) to evaluate
confidence of patients and caregivers. Peer counselor the needs of patients and the future orientation of the
serves as a model to evaluate their strength and group. PRC performs as the supporting role for the
confidence to face the future changes, clear their group, by providing volunteer training and supervision
misconceptions, comfort their frustration and provide of volunteers; and offering professional advice, financial
practical tips for them. In addition, a training class is supports, facilities and venues for patient group activities.
designed for patients and their caregivers who are going
to receive Continuous Ambulatory Peritoneal Dialysis Through the collaboration between medical volunteers,
(CAPD). It helps patients to acquire skills on the patient support group and PRC, a seamless psychosocial
procedure and self-caring techniques. service could be provided to fulfill the needs of patients
and caregivers in physiological and psychosocial
In the treatment and rehabilitation phase, individual and aspects. Furthermore, it can fully utilize the resource
social supports are important to patients. The role of through this collaboration.
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MEDICAL SECTION April 2003
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Vol. 8 No. 2 MEDICAL SECTION
Flexibility Exercise muscle testing and hand held dynamometer. Hand held
Gentle muscle stretching improves the range of motion dynamometer provides more objective outcome
of the body and major joints. Increased flexibility improves measurement.
functional performance and prevents musculo-skeletal
injury. The combination of flexibility and strengthening Cardio-pulmonary Assessment
exercises improve patients' ability to perform activities of Six minute walk test is an universal accepted field test. It
daily living, such as reaching, fending and carrying. is safe, simple and well tolerated by most patients, even
frail elderly. It was first described by McGavin and
Strengthening Exercises colleagues in 1977. Participants are instructed to 'walk
Specific muscle groups strengthening exercise increases continuously as quickly as possible' up and down one of
muscle mass and muscle strength. Muscle strength is two hallways (at least 100 feet). Pace should be adjusted
increased or maintained with two to three sessions of but running is not allowed. Perceived exertion (PE) ratio
exercise per week. Cuff weights, sandbags or elastic scale developed by Borg can be used to assess the
bands can be used to train the muscle. Exercise with low subjective effort of the patient during exercise. Six minute
resistance but high number of repetition is recommended walk test in addition to PE measurement reinforce the
but not for high resistance. Simple and easily available assessment on the effort domain. It is reliable and feasible
equipment is more appropriate for patient training. for many patient populations including the renal patients.
Criteria for terminating the test include dizziness, angina,
Cardiovascular Exercise Training fatigue, severe musculoskeletal pain as in leg
Cardiovascular activities require the movement of large claudication, signs of vascular insufficiency, progressive
muscle groups in rhythmic manner. The goal of fall in systolic blood pressure of 20 mmHg or more in the
cardiovascular exercise training is to achieve and sustain presence of increasing heart rate and workload.
an activity of increased energy requirements
(approximately 40% to 85% of peak capacity) for 3. Exercise Approach
increasing periods of time. Cardiovascular benefits can Department Based Exercise Program
also be obtained from short periods of sustained aerobic It is more flexibility in time allocation, space and equipment
activity (10 minutes) several times a day. For optimal resources utilization. The professional advice can be
cardiovascular conditioning, it is recommended to build given to all patients in the initial phase of the program by
up the sustained activity gradually with close monitoring the physiotherapists. The exercise program is conducted
by the physiotherapist. Unaccustomed exercise type and under supervision. The proper program should include
unsupervised progress may be more harmful and should the warm-up exercise, the graded strengthening, aerobic
be avoided. Careful screening and evaluation of risk exercise depending on the individual and the cooling
factors by the physician is essential prior implementation down exercise. The utilization of upper and lower limb
of any exercise program. Patients should always be ergometers can provide appropriate loading to individual
advised to start slowly and proceed gradually. patient.
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