The hemodyalisis client's perception about having an arteriovenous fistula

Abstracts

OBJETIVO: Identificar as percepções sensoriais dos clientes frente à fistula artério-venosa (FAV) e descrevê-las a partir dos sentidos sócio comunicantes do corpo. MÉTODOS: Aplicação de técnicas criativas durante sessão de hemodiálise com cinco pacientes. Foi pedido que desenhassem algo que representasse a presença da fístula artério-venosa e em seguida foram expostas seis gravuras, cada uma com um sentido corporal, sendo argüidos sobre sentimentos provocados pela fístula artério-venosa diante de cada sentido. Os depoimentos foram gravados em fita magnética. RESULTADOS: Com a aplicação das técnicas criativas foram apontados sentimentos como tristeza, amargura e dependência, advindos da presença da fístula artério-venosa e das abordagens no convívio social. CONCLUSÃO: Ao valorizar os sentidos do paciente no convívio com a FAV, o enfermeiro redimensiona o cuidado a ele prestado.

Diálise renal; Unidades hospitalares de hemodiálise; Percepção; Fístula arteriovenosa

WCN 2007/NURSING MEETING

The hemodyalisis client's perception about having an arteriovenous fistula^*

La percepición del cliente en hemodiálisis delante a la fístula arterío venosa en su cuerpo

Giselle Barcellos Oliveira Koepe^I; Sílvia Teresa Carvalho de Araújo^II

^IGraduate Student in Escola de Enfermagem Anna Nery da Universidade Federal do Rio de Janeiro – UFRJ – Rio de Janeiro (RJ), Brazil

^IIPhD, Professor in the Escola de Enfermagem Anna Nery da Universidade Federal do Rio de Janeiro – UFRJ – Rio de Janeiro (RJ), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: To identify the sensorial perceptions of the patients towards the arteriovenous fistula and describe them from their social-communicating senses.

METHODS: Creative techniques were performed during hemodialysis session with five patients. Participants were asked to draw something that represented having an arteriovenous fistula. After drawing, six pictures were displayed, each with a body sense, and patients were questioned about the feelings toward arteriovenous fistula for each of the senses. Their statements were recorded on magnetic tape.

RESULTS: The creative techniques allowed for identifying feelings like sadness, bitterness, and dependence, caused by having an arteriovenous fistula and the approaches in social life.

CONCLUSION: When valuing the patient's senses whilst living with an arteriovenous fistula, the nurse re-estimates the care that is delivered.

Keywords: Renal dialysis; Hemodialysis units, hospital; Perception; Arteriovenous fistula/nursing

RESUMEN

OBJETIVO: Identificar las percepciones sensoriales de los clientes frente a la fístula arteriovenosa (FAV) y describirlas a partir de los sentidos sóciocomunicantes del cuerpo.

MÉTODOS: Aplicación de técnicas creativas durante la sesión de hemodiálisis con cinco pacientes. Fue pedido que dibujen algo que represente la presencia de la fístula arteriovenosa y a seguir que expusieran seis grabaciones, cada una con un sentido corporal, siendo examinados sobre los sentimientos provocados por la fístula arteriovenosa frente a cada sentido. Las declaraciones fueron grabadas en cinta magnética.

RESULTADOS: Con la aplicación de las técnicas creativas se apuntaron sentimientos como tristeza, amargura y dependencia, generados por la presencia de la fístula arteriovenosa y de los abordajes en la convivencia social.

CONCLUSIÓN: Al valorizar los sentidos del paciente en la convivencia con la FAV, el enfermero redimensiona el cuidado que presta.

Descriptores: Diálisis renal; Unidades hospitalarias de hemodiálisis; Percepción; Fístula arteriovenosa /enfermería

INTRODUCTION

This study addresses the sensorial perception that patients with chronic renal insufficiency, subject to hemodialysis treatment, have of their body considering the arteriovenous fistula (AVF). The interest toward this research arouse from an experience of working with this clientele for four years.

Hemodialysis is a treatment that removes toxic substances and excessive liquids that accumulate in the body due to kidney failure. In Hemodialysis, the blood, filled with toxins and nitrogen-containing residue, is removed from the patient into a machine. This machine, the dialyzer, cleans the blood and then returns it to the patient⁽¹⁾.

In order to remove the blood, to then clean it and send it back into the patient's body, there must be an access to the patient's blood flow. The AVF is a permanent, surgically created, access joining an artery to a vein. The needles are inserted in the vessel to obtain the necessary blood flow to pass through the dialyzer.

The Hemodialysis sector is very enriching in terms of the nurse-patient interaction. In this care specialty, the client attends the sector three times a week, and stays there for a daily four-hour period. This results in a comprehensive interaction, and this close relationship often means acquiring a broad knowledge about the person, his or her family context, and the process of the disease. During this interaction, I was able to observe frequent behavioral characteristics in these people, which were often repeated as forms of defense mechanisms that they expressed mostly in a non-verbal way.

This study focused on the perception regarding the AVF, because the scars and the aneurisms they often cause compromise the clients' self-image. This can cause sufferings that they usually do not verbalize. However, I limited to studying patients with recently established AVF, as I believed that the approach to these patients would be more enriching since they are in the adaptation stage.

Nursing care in Hemodialysis is rather technicist due to all the mechanization it implies. Nevertheless, I consider important that nurses working in this specialty learn to direct their attention to all the communicating senses of their patients. They should be aware to communication beyond what is visible and verbalized.

The fact that clients affirm they are well and feel comfortable in the treatment environment might keep them from showing their emotions, feelings, and thoughts. This happens because they believe that nothing can change their condition or that the team has no interest in them⁽²⁾.

When the nurse is able to understand what their client is hiding, the care delivered becomes more satisfactory, as it allows for looking after the patient's visible needs as well as those that are masked. The patients' perceptions, emotions, feelings, and imagination must be recognized because they contribute with the understanding the behaviors and reactions they have during treatment. Furthermore, this allows for the client, through social poetics and aware of his or her condition and feelings, to express him/herself more easily⁽²⁾.

The guiding questions in this study were:

- How does the client perceive him/herself regarding living with an AVF implanted in his/her body?

- How do the patient's body senses express their living with the AVF?

The study object was: the client's sensorial perception regarding the recently established arteriovenous fistula.

The objectives of the present study were:

- To identify the client's sensorial perception regarding the AVF;

- Describe how the experience of the body's socio-communicating senses reveals the client's sensorial perception regarding the AVF.

It is important that the client's perceptions, emotions, and feelings be recognized because this knowledge contributes with understanding the behaviors and reactions they have during treatment⁽²⁾.

METHODS

This is a qualitative study, of which representativeness is not based on numerical criterion.

"The qualitative approach is based on the assumption that there is a dynamic relationship between the real world and the subject, an interdependence lived between the subject and the object, an indissoluble bonding between the objective world and the subject's subjectivity. Knowledge is not reduced to isolated data, connected by an explanatory theory"⁽³⁾.

In this study, I worked with the socio-communicating body senses used by Araújo⁽⁴⁾, because I believe that the body speaks and reacts to anything that harms any of its parts. Each body is a life form that knows a lot, since it has a history and ancestral roots that are current, alive, and irradiant⁽⁵⁾.

The research was carried out from February to December 2005. The study setting was the Hemodialysis Sector in the Nephrology Unit of a University Hospital in the city of Rio de Janeiro. The five studied subjects were patients, men and women of different ages, submitted to Hemodialysis with AVF established from two to seven moths before the study.

The study was authorized by the Head of the Nephrology service, as well as by the Head of Nursing and the subjects by signing the consent form, as established by resolution n.º 196/96 concerning research with human beings. Two creative techniques were used to produce the data.

In the first technique, patients received pencil and paper and were asked to draw a picture and write a word that represented the meaning that the AVF had for them. Later, they were asked to explain each drawing and word.

The second technique involved showing the patients six drawings, each representing one of the senses (sight, sent, taste, touch, hearing, and the heart). The kynesis of the heart is confirmed by the harmony established with the other senses, which moves it from a mere symbol to the condition of a new body sense⁽⁴⁾.

For each exposed sense, a question was made about the feelings that the AVF brought about for that sense. These questions were based on the guiding questions used by Saes⁽²⁾ in the data collection stage of one of the dynamics used. They were:

- For sight: How do your eyes perceive the AVF? What emotions and feeling do your eyes cause?

- For hearing: What do you notice that people say about the AVF? What feelings and emotions do those statements cause on you?

- For the hands: How do you notice the sensations of touch on the AVF? What emotions and feeling does that touch cause on you?

- For the mouth: Do you notice any tastes in you mouth that can be associated to the AVF? What emotions and feelings do they cause?

- For the nose: How do you perceive the smells in the region of you AVF? What emotions and feelings do they cause?

- For the heart: How do you perceive your emotions and feeling toward the AVF? What reactions do these perceptions cause?

The meeting with the group took place in October 2005. The creative techniques were recorded and transcribed for posterior analysis. During the activities, the clients were not limited to what was asked or instructed. Rather, they exposed several issues they had kept inside and that caused apprehension. This lead to the valuable understanding of how the client perceives him/herself regarding the AVF implanted in their body. The subjects were identified using codenames as a way to preserve their anonymity.]

RESULTS

Of all words written on paper, one of the most common was necessity, followed by the words love and life. The pictures that appeared were drawings of the sun, the rain, hearts, and one client drew his children.

In relation to the clients' presentation of the drawings, each with one body sense, the results are described below.

Regarding sight, subjects, in general, said they felt sad every time they look at the AVF. For some, the sadness they felt was due to the embarrassment caused by other people's glance.

"People are curious, they look, and some people ask `what is that'? Whenever I go out to the supermarket, people ask me `what is that'? The dressings on my arm, the bumps, so they ask". (Classic).

About hearing, most clients felt uncomfortable when they heard people talking about their AVF. They felt troubled, because they noticed the people were somewhat shocked.

"A lot of people feel shocked, others feel sorry, - `oh my, what is that horrible thing" (Divine)

"I went to a girl's house and she touched it and said: what is this thing shaking? You're like a robot!" (Classic)

Regarding touch, none of the clients reported feeling uncomfortable with people touching the AVF, some actually like that sort of approach.

As to the mouth, most patients associated the AVF with a taste of bitterness. One client assigned the AVF to sweet and bitter tastes; bitter due to the discomfort cause by the treatment, and sweet because it is the reason of his survival.

The clients found it difficult to express their feelings though sent. Therefore, none of them assigned any sent to the AVF region. Only one client said it smelled like life.

Some cried when speaking about the heart and showed their fragility and the anguish caused by the AVF and the hemodialysis treatment as a whole.

" I feel sorry for myself " (Divine).

" I wish it were a fast treatment; that it didn't have to be on my arm". (Clara)

" it makes me sad, you feel sad because I think that my arm isn't normal, there's something in it, it makes me sad. You can't feel happy when there's something inside your arm, it makes you sad. I wish I didn't have to keep this in my arm". (Classic)

"If I had a choice, I wouldn't be here. But since I have to go through this . . ." (Beauty)

DISCUSSION

The word necessity might be associated with the importance that the AVF has for the treatment. The drawing of sun and rain represent that the AVF was established just as important as these elements to the patients' lives. The word love along with the drawing of a heart represented that their love for the AVF is associated with their love for life.

Some clients see the AVF as something that brings hope. This was concluded with the drawing of one patient's children. In this case, the patient stated that the AVF lengthens his life and gives him the opportunity to stay a little longer close to his family.

Love, hope, and the extreme need that clients associated with the AVF occur due to the awareness that they have that the AVF is the means for their treatment, which is so important to extend their lives.

The client undergoing dialysis treatment struggles with a daily conflict between love and hate toward the machine and the treatment. They are aware they would not survive without treatment, but, on the other hand, it makes them constantly remember that their life is hanging by a thread⁽²⁾.

The picture presentations to the clients, each with a body sense, developed an array of feelings, which they often had not verbalized until that moment. I believe that this resulted from the freedom given to clients to verbally express everything that bothered them, not restricting them to what was exposed through the pictures.

In view of the statements regarding sight, which caused sadness and embarrassment because of other people's glances at them, I believe that what people think about you, or about something about you, affects the way you act and feel. We think through others, while others think through us⁽⁴⁾.

Regarding hearing, during the statements, I realized that the shocked and curious voices, which often showed some repulsiveness, hurt some clients. However, they evaluate that expressing this feeling is useless, since they have to live with the AVF constantly, which is something that will always be strange and will always cause some sort of reaction on others. Therefore, they prefer to learn how do accept the fact and get used to it, thus repressing their feelings.

We hold many feelings, because we are not used to exposing the most sincere part of our inner-self. The problem with knowing how far we can go allows us to think about limits and expressing our feelings⁽⁴⁾.

Regarding the touch, I believe that the clients do not mind people touching the AVF, and some even appreciate it in some occasions, because, unconsciously, touch brings them safety, which gives them comfort and well-being. The touch from others, or shaking hands, relieves us from tensions⁽⁴⁾.

As for the mouth, I believe that the bitter taste represents intense sadness and bitterness. One client assigned both bitter and sweet tastes to the AVF; bitter due to the discomfort caused by the treatment and sweet because it is the reason for his survival.

The AVF does not have a specific taste for the clients, since it is not a beverage or food, but each patient was capable of associating it to a specific taste. This demonstrates that the sense of taste is capable of speaking what we feel. The gustative sensitivity thinks because it thinks the taste of life itself⁽⁴⁾.

Although the sense of smell was considered as something difficult to explain, I believe that when we stop and breathe, and imagine the smell that something has, we are taken to other dimensions. For the author⁽⁴⁾, the sense of smell has sensorial memory and allows us to breathe and remember smells and perfumes of life from the contact with people and objects.

The heart represents our emotions and feelings; it is the source of all emotion⁽²⁾. I realized that while speaking about it, the clients exposed their most hidden feelings.

In this moment, it appeared to me that their emotions were set free, completely, with no barriers. The clients showed themselves in a very special way.

Their fragility is related to the fact that there is some unbalance in their lives, i.e., they do not have a `normal' life, like others, since they have to get used to something strange in their bodies (AVF), be in a hospital three times a week, and other unpleasant situations due to the treatment. Some authors affirm that the human being becomes potentially more complex and fragile in situations that cause an unbalance to their systems, threatening their well-being, their lives, future objectives, and, finally, their relationship with the world, with others, and with themselves⁽⁶⁾.

CONCLUSIONS

The dynamic activities used in the study allowed clients to verbalize the feelings they were keeping inside, usually for a long time. This happened very calmly, with no embarrassments, and very freely. This opportunity made it possible to share emotions, sorrows, sufferings, and reinforce the bonds of life and hope.

It was very fulfilling to research the thoughts of this clientele, and understand the subjective aspect of these individuals. This understanding makes us more sensitive to some reactions that our clients have during the treatment, which we often do not understand the reason. This also makes us capable to help these people to face the whole process better, thus contributing with the delivery of quality nursing care.

The sight and hearing were stated as senses that monopolize the patients' emotions, since they reaffirm their health problems through the AVF and others' comments, which cause embarrassment and sadness.

I would like to emphasize me belief that care in hemodialysis should go beyond managing all the technical aspects involved. We should pay attention the clients, per se, and not only the mechanical side involving them.

REFERENCES

• 1. Smeltzer SC, Bare BG. Brunner & Suddarth: tratado de enfermagem médico-cirúrgica. 9a ed. Rio de Janeiro: Guanabara Koogan; 2002. v.3.
• 2. Saes SC. O cuidar da enfermeira no imaginário do cliente com necessidades especiais de saúde na área renal: um desafio através dos sentidos corporais e da sociopoética [tese]. Rio de Janeiro: Escola de Enfermagem Anna Nery. Universidade Federal do Rio de Janeiro; 2003.
• 3. Chizzotti A. Pesquisa em ciências humanas e sociais. 4a ed. São Paulo: Cortez; 2000.
• 4. Araújo STC. Os sentidos corporais dos estudantes no aprendizado da comunicação não-verbal do cliente na recepção pré-operatória: uma semiologia da expressão através da sociopoética [tese]. Rio de Janeiro: Escola de Enfermagem Anna Nery. Universidade Federal do Rio de Janeiro; 2000.
• 5. Gauthier J. Sociopoética: encontro entre arte, ciência e democracia na pesquisa em ciências humanas e sociais, enfermagem e educação. Rio de Janeiro: EEAN/UFRJ; 1999.
• 6. Santos I, Gauthier J, Figueiredo NMA, Petit SH. Prática da pesquisa em Ciências Humanas e Sociais: abordagem sociopoética. Rio de Janeiro: Atheneu; 2005.

*

Estudo extraído do Trabalho de Conclusão de Curso "A percepção do cliente frente à Fístula Artério Venosa: um desafio dos sentidos corporais", premiado em 2º lugar no 14º Pesquisando em Enfermagem da Escola de Enfermagem Anna Nery da Universidade Federal do Rio de Janeiro – UFRJ – Rio de Janeiro (RJ), Brasil.

Publication Dates

• Publication in this collection
  23 June 2008
• Date of issue
  2008

History

• Accepted
  25 Aug 2007
• Received
  21 June 2007