The adaptation problems of patients undergoing hemodialysis: socio-economic and clinical aspects1

OBJECTIVES: to identify adaptation problems under Roy's Model in patients undergoing hemodialysis and to correlate them with the socioeconomic and clinical aspects. METHOD: a transversal study, undertaken using a questionnaire. The sample was made up of 178 individuals. The Chi-squared and Mann-Whitney U tests were undertaken. RESULTS: the adaptation problems and the socioeconomic and clinical aspects which presented statistical associations were: Hyperkalemia and age; Edema and income; Impairment of a primary sense: touch and income; Role failure and age; Sexual dysfunction and marital status and sex; Impairment of a primary sense: vision and years of education; Intolerance to activity and years of education; Chronic pain and sex and years of education; Impaired skin integrity and age: Hypocalcemia and access; Potential for injury and age and years of education; Nutrition below the organism's requirements and age; Impairment of a primary sense: hearing and sex and kinetic evaluation of urea; Mobility in gait and/or coordination restricted, and months of hemodialysis; and, Loss of ability for self-care, and months of hemodialysis and months of illness. CONCLUSION: adaptation problems in the clientele undergoing hemodialysis can be influenced by socioeconomic/clinical data. These findings contribute to the development of the profession, fostering the nurse's reflection regarding the care.


Introduction
As Nursing has advanced as a profession, the need has arisen for a conceptual landmark upon which the work's organization can be based, with the objective of understanding issues related to the client, the environment, the goal, and to qualified care (1) .
In the ambit of the profession's conceptual landmark, there is the adaptation model proposed by Callista Roy. In this model, the nurse undertakes the role of mediator for the promotion of the client's positive adaptation, developing the nursing process in six phases, namely: assessment of the behavior, assessment of stimuli, nursing diagnosis, and establishment of goals, intervention and assessment (2) . This process contributes to nursing care which is systematized and geared towards the patient's adaptation to the limitations imposed by the clinical situation.
Among the varying clinical situations, emphasis is placed on chronic kidney disease (CKD), as patients with this condition are exposed to varying adaptation problems resulting from alterations in their routine.
The main alterations are: restrictions on water and food ingestion, a continuous program of medication and dependence on the hemodialysis machine for maintenance of life (3)(4)(5) . Corroborating this statement, one study with this clientele confirmed that there is a relationship between the development of chronic kidney disease and social and environmental alterations (6) .
In this context, the nurse, through Roy's nursing process, contributes to the promotion of the client's positive adaptation. Thus, emphasis is placed on the importance of using this model in clinical practice, principally in the area of nephrology, bearing in mind the alterations in the physiological, psychological, spiritual and social contexts, caused by the CKD and its treatment.
In this perspective, discovering ways of caring for these people, guided by Roy's theoretical model, will help nurses in the identification of the most frequent adaptation problems in this clientele. Furthermore, to understand them in conjunction with the socioeconomic and clinical situation in which they are inserted entails a greater role for the nurse, who, based on this analysis, can take the social reality of the subject into account in the planning of the care, for the transformation of the problems into positive responses. Therefore, perceiving the consideration of the being who receives the nursing care as a person in constant interaction with their environment as an advantage in the adaptation model, focusing on the need for adjustment to these changes, and recognizing the importance of the nursing process, the question is raised: What are the adaptation problems of the type addressed by Roy present in chronic kidney patients receiving hemodialysis? Are these problems correlated with the socioeconomic and clinical aspects? Thus, this study's object is to identify the adaptation problems of the type addressed by Roy in patients receiving hemodialysis, and to correlate them with the socioeconomic and clinical aspects.

Method
This is a transversal study, undertaken in a clinic which is a center of excellence in dialysis, in a city in the Northeast of Brazil. The population was made up of 330 patients who are registered and receiving hemodialysis in the above-mentioned clinic. For the sample, the formula for finite populations was applied, taking into account the study's level of confidence of 95% (Zα =1.96), sample error of 5%, population size of 330 persons and the prevalence of nursing diagnoses with a conservative value corresponding to 50%. Based on the application of the formula, a sample size of 178 individuals was found.
Patient selection was through a consecutive convenience sample. The following inclusion criteria were adopted: to have a medical diagnosis of chronic kidney disease; to be registered and receiving hemodialysis in the above-mentioned clinic; to be aged between 20 and 65 years old; and to have been advised and have conditions to participate. The exclusion criteria were: chronic kidney patients with other diseases unrelated to the renal situation which could alter the profile of the adaptation problems, such as: cancer, neurological disease, advanced heart disease, advanced lung disease, progressive liver disease, cerebrovascular disease, coronary disease and extensive peripheral disease. This last criteria was adopted, as behaviors, stimuli and adaptation problems are influenced by the physiopathology of each disease (2) . Thus, it is believed that the patient with chronic kidney disease alone has adaptation problems which are specific to this condition. In organizing the data, an individual process of clinical judgment of the adaptation problems evidenced by the patients was undertaken, in two phases: the analysis, which involved the categorization of the data and the identification of gaps; and the summary, formed by the grouping, comparison, identification and relating of the etiological factors (9) . It is emphasized that, where gaps were present in the first phase, the patient was approached a second time. After this stage, the results obtained underwent a peer review process among the authors, so as to ensure a consensus judgment, the aim being, in this way, to obtain greater accuracy in the inference of the adaptation problems. Thus, for the statistical significance of the tests specified, a level of 5% (p< 0.05) was adopted.

Results
Among the patients interviewed, 52.2% were male, 62.9% had a partner, and the mean age was 46.6 years old (±12.3). Regarding family income, 92.1% received one minimum salary, with variation from one to 30 salaries (the value of R$622.00 was considered as the minimum Brazilian salary at the time of the study). In relation to education, the mean was 8.5 years of study (±4.8).
The results regarding the analysis of association between the clinical aspects and the adaptation problems addressed by Roy are presented in Table 1. Hyperkalemia is characterized by a rise in the serum concentration of potassium. However, differing from the findings of this research, one study undertaken with chronic kidney patients showed a relationship of hyperkalemia with the decline of the renal function present in the condition, rather than with the advance of age (10) .
The adaptation problem of edema had statistical association with the variable of income. Edema and weight gain in a short period are considered to be signs commonly identified in the population with kidney disease, as they are a consequence of the inefficient maintenance of the sodium balance by the organism (11) .
It stands out, furthermore, that the association of the edema with cardiovascular risk factors is an important predictor for mortality in these patients, it being relevant to observe this sign (12) .
Income was also associated with the impairment of a primary sense: touch. Alterations in the basal and intermediary layers of the epidermis, in chronic renal patients undergoing long-term dialysis treatment, are common and affect the nerve endings, provoking a reduction in the functional capacity, being characterized as a polyneuropathy (13) .
In the light of the above, the relationship between income and the above-mentioned adaptation problems is explained, as the low income can be reflected in difficulty in accessing the service, inadequate nutrition, and difficulty in undertaking pharmacological and dialysis treatment (3) , which contributes significantly to the inefficacy of the treatment, and consequently   (4) . It is known that people at more advanced stages of CKD present the above-mentioned physical and emotional alterations, which trigger sexual dysfunction (5) .
The association between marital status and the problem of sexual dysfunction may be related to the fact that, as the majority of the patients are in affective relationships, they are probably sexually active; as a result, they have a higher probability of presenting dysfunction in this area. Furthermore, kidney disease, per se, causes reduced libido, which is one of the factors related to this dysfunction (14) . In the light of this, social support and counseling regarding the issue are indicated for this clientele, seeking strategies to minimize the problem.
The impairment of a primary sense: sight was statistically associated with the variable of years of study.
One study indicates the association between retinopathy and chronic kidney disease, regardless of the presence of diabetes mellitus, evidencing the link between the microcirculation of the retina and renal compromise (11) .
As a result, loss of vision in renal patients may be present due to alterations in the ocular microcirculation.
However, in relation to years of education, there are no studies indicating a relationship between the impairment of this sense and a low educational level.
Intolerance to activity also presents a statistical association with the variable of years of education. This adaptation problem, one of the main symptoms of CKD, is evidenced by fatigue and a difficulty in undertaking activities of daily living, and may be related to reduction of red blood cells. Anemia is one of the complications presented by such patients, and is caused by shortage of iron and the relative deficiency of erythropoietin (15) .
The relationship between intolerance for activity and years of education may be explained by the fact that a low educational level is related to nonadherence to therapy, as the patient does not understand his illness and the importance of the treatment. This fact results in worsening of the complications of CKD, such as anemia, caused by the nonuse of the erythropoietin (3) .
Another adaptive problem associated with the variable of years of education was chronic pain, which was also associated with sex. One study which addressed pain in patients with chronic kidney disease indicated that there was no association of the presence of the pain with sex (16) . Chronic pain can be related to renal osteodystrophy, one of the complications resulting from renal compromise, manifested by lack of control of the increase of phosphate which provokes bone mineralization. It is a painful condition, and is associated with an increased risk of fracture, with difficulty for selfcare, as well as increasing mortality in patients receiving dialysis (17) .
A low educational level, a striking characteristic among those investigated in this study, may have repercussions in nonadherence to drug treatment and diet, which can trigger complications in CKD, such as osteodystrophy, a disease which affects the bones and causes intense pains (14) . Thus, in the light of the need for appropriate compliance with medications and diet for controlling problems secondary to CKD, such as anemia and renal osteodystrophy, it is fundamental for the multi-professional team to make use of teaching strategies which are reflected in the assimilation of the information received for the control of this clientele's therapeutic regimen.
The problem of impaired skin integrity was associated with age. The problem of potential for injury was associated with the variables of age and years of education. In consonance with the association mentioned above, one study reveals that the alterations in the skin are related to age progression, as the individual suffers numerous degenerative changes in this organ with advancing age (18) . Therefore, it is important for patients and health professionals to have knowledge regarding possible skin alterations in the population with kidney disease, such that these may be recognized at an early stage and treated appropriately.
Nutrition less than the organism's requirements was associated statistically with age. This problem may be related to the changes in nutritional metabolism, a frequent problem in patients receiving HD (12) .  (14) .
In the light of this fact, the measuring of the calcium must be routine in patients undergoing hemodialysis with any type of vascular access, so as to avoid complications which could even be fatal.
The impairment in the primary sense: hearing was associated with sex and with the evaluation of urea kinetics. However, a study aiming to characterize the audiological findings in patients with chronic kidney disease did not find significant difference for hearing problems in relation to sex in this clientele (20) .
In relation to the kinetic evaluation of the urea adequate the dialytic process is, so as to prevent or delay possible complications (14) . to the extent that they impede or hinder the patient's mobility and his ability to undertake self-care (14) . As a result, the rapid action of the nurse in this important problem must be focused upon the prevention and/or minimization of the harm.

Conclusion
Based on the statistical associations identified in the variables of the present study, it is concluded that the adaptive problems of the clientele receiving hemodialysis may be influenced by socioeconomic and clinical variables. The variables with the highest rate of association were: Impairment of a primary sense: vision, and years of study; Loss of ability for self-care, and months of hemodialysis; Sexual dysfunction and marital status and sex; Potential for injury, and age; Impairment of a primary sense: touch, and income; Chronic pain and sex; Mobility -gait and/or coordination restricted, and months of hemodialysis.
There was an association, mainly, in the items of educational level, income, age and sex presented by the clientele. Therefore, one can state that these variables may directly influence the adaptation problems suffered by this population, and that these, as they cannot be changed by nursing, must be discussed and reflected upon with other professionals, with a view to directing the care in accordance with the social context in which the patient is inserted.
The identification of these associations stands out as a contribution of the study, as the nurse working in nephrology can reflect regarding her care, which is directed to the adaptation problems, as well as towards the socioeconomic and clinical issues, such as to allow the obtaining of positive adaptation in this clientele.
As a difficulty, this study indicates the shortage of research reporting on the issue studied here, so as to discuss the data for comparison. As a limitation, emphasis is placed on the fact that this study was undertaken only with chronic kidney patients receiving hemodialysis treatment.