Self-care of patients in conservative treatment of chronic renal insufficiency

Abstracts

Trata-se de uma pesquisa qualitativa, desenvolvida no ambulatório de uremia de um hospital público do sul do Brasil. Objetivou-se descrever como pessoas com insuficiência renal crônica, em tratamento conservador, cuidam de si. Participaram 15 pessoas com insuficiência renal crônica em tratamento conservador. Na coleta dos dados, utilizou-se a entrevista narrativa de vivências. Foram identificados os temas: estilo de vida, continuidade, mudanças e adaptações; o uso das medicações no cuidado de si; o acompanhamento ambulatorial no tratamento conservador; e a atividade física e o lazer no cuidado de si. Conclui-se que o cuidado de si dessas pessoas em tratamento conservador é expresso por atitudes que vão da renúncia à aceitação da situação de cronicidade. Compreende-se que é preciso pensar no sentido mais amplo da promoção da saúde, buscando a qualidade de vida das pessoas em tratamento conservador da insuficiência renal crônica para o cuidado de si.

Insuficiência renal crônica; Enfermagem; Atividades cotidianas; Doença crônica; Acontecimentos que mudam a vida

ORIGINAL ARTICLE

Self-care of patients in conservative treatment of chronic renal insufficiency¹

El cuidado de sí de personas con tratamiento conservador de insuficiencia renal crónica

Camila Castro Roso^I; Margrid Beuter^II; Maria Henriqueta Luce Kruse^III; Nara Marilene Oliveira Girardon-Perlini^IV; Caren da Silva Jacobi^V; Franciele Roberta Cordeiro^VI

^IDoctoral student of the Nursing Graduate Program, Federal University, Rio Grande do Sul (UFRGS). CAPES scholarship. Porto Alegre, Rio Grande do Sul, Brazil. Email: [e-mail]

^IIPh.D. in Nursing. Adjunct Professor, Department of Nursing and Nursing Graduate Program, UFSM. Santa Maria, Rio Grande do Sul, Brazil. E-mail: [e-mail]

^IIIPh.D. in Education. Adjunct Professor, Department of Nursing and Nursing Graduate Program, UFRGS. Porto Alegre, Rio Grande do Sul, Brazil. E-mail: [e-mail]

^IVPh.D. in Nursing. Adjunct Professor, Department of Nursing and Nursing Graduate Program, UFSM. Santa Maria, Rio Grande do Sul, Brazil. E-mail: [e-mail]

^VMaster's student of the Nursing Graduate Program, UFSM. Santa Maria, Rio Grande do Sul, Brazil. E-mail: [e-mail]

^VIMaster's student of the Nursing Graduate Program, UFRGS. Porto Alegre, Rio Grande do Sul, Brazil. E-mail: [e-mail]

Correspondence

ABSTRACT

This qualitative research was developed in the renal outpatient clinic of a public hospital in the south of Brazil. The objective of the study was to describe how patients in conservative treatment of chronic renal insufficiency care for themselves. Fifteen patients in conservative treatment of chronic renal insufficiency participated in the research. A narrative interview was used for the collection of data. The following themes were identified: lifestyle, continuity, changes and adaptations; the use of drugs in self-care; outpatient monitoring in conservative treatment; and physical activity and leisure in self-care. It was concluded that the self-care of patients in conservative treatment is expressed through attitudes that range from denial to acceptance of the chronic condition. It is necessary to think about health promotion more amply, seeking quality of life for patients in conservative treatment of chronic renal insufficiency for self-care.

Descriptors: Chronic renal insufficiency. Nursing. Activities of daily living. Chronic disease. Life change events.

RESUMEN

Se trata de una investigación cualitativa, desarrollada en una clínica de uremia de un hospital público del sur de Brasil. Se objetivó describir como personas con insuficiencia renal crónica en tratamiento conservador se cuidan. Participaron quince personas en esa situación. La recolección de datos utilizó entrevista narrativa de vivencias. Se identificaron los temas: estilo de vida, continuidad, cambios y adaptaciones; uso de medicamentos en el cuidado de sí; acompañamiento ambulatorio en el tratamiento conservador; y actividad física y ocio en el cuidado de sí. Se concluye que el cuidado de sí de las personas con insuficiencia renal crónica en tratamiento conservador es expresado por actitudes que van desde la renuncia a la aceptación de la situación de cronicidad. Se comprende que es necesario pensar en el sentido más amplio de la promoción de salud, buscar la calidad de vida de las personas para el cuidado de sí.

Descriptores: Insuficiencia renal crónica. Enfermería. Actividades cotidianas. Enfermedad crónica. Acontecimientos que cambian la vida.

INTRODUCTION

Chronic Renal Disease (CRD) is a silent illness that does not show significant warning signs and symptoms, which manifest and are perceived once the pathology is already established in the organism. The symptoms appears unexpectedly, in more advanced phases of the disease, subjecting the person to treatments that require lifestyle changes.¹

CRD is defined by the reduction of renal function in a progressive and irreversible manner, being classified according to the glomerular filtration rate.² There are six stages of renal function reduction, which vary according to the glomerular filtration rate, and indicate the loss of renal function.³

Chronic Renal Insufficiency (CRI) is characterized by a glomerular filtration rate less than 90 ml/min/1.73 m² during a period of three months or longer, and the incapacity of the kidneys to maintain metabolic and water-electrolyte balance, resulting in uremia. Treatment of CRI depends on the evolution of the disease, which may be conservative with the use of drugs, diets and water restriction, or with renal replacement therapies, hemodialysis, peritoneal dialysis and kidney transplant.³

Conservative treatment has the objectives to help reduce the rate of progression of renal disease, maintain kidney function and improve the clinical, psychological and social conditions of the individual. The treatment also entails control of blood sugar and blood pressure; correction of anemia; encouragement to stop smoking in order to delay progression of the CRD, and adjustment of doses of drugs excreted by the kidneys.⁴

Living with a chronic illness drives individuals and their families to center their activities on the pathology and treatment.⁵ Self-care of individuals with CRI is generally centered on adherence to diet, drugs and treatment. Thus, decisions influence the way in which each individual experiences and understands the demands and restrictions of the disease.

Self-care is the way in which each patient personally cares for him/herself. Self-care does not exclude care for others, but is an intrinsic relationship of one's care for oneself, as the subject that can establish oneself even while suffering certain hardships, taking care of oneself to attain a certain level of happiness, assigning existence to the relationship with oneself.⁶

The act of planning self-care, through actions that promote the well-being and health of the person, cannot depend solely on medical prescriptions. It is necessary that health professionals, principally nurses, seek to know and understand the life context of each person, for the practice of subjectivity of self-care in the search for health promotion.⁷

When taking care of patients with CRI, nurses should be attentive to complications from the illness, and to the stresses and anxieties that involve this condition. Promotion and encouragement of self-care through health education is one step of care in the perspective of improving self-esteem by guiding and pointing out paths to cope with the disease, and to adapt to a new lifestyle.⁴

In this context, considering the above, the study had a guiding question: how do patients in conservative treatment of chronic renal insufficiency care for themselves? To answer this question, the following objective was developed: to describe how patients in conservative treatment of CRI care for themselves.

METHODOLOGY

This is a descriptive, exploratory field study with a qualitative approach. It was developed with patients in conservative treatment of CRI in the renal outpatient clinic of a teaching hospital in the south of Brazil. Participants in the study met the following inclusion criteria: to be adult or elderly; to be diagnosed with CRI; to be following treatment in the renal outpatient clinic; to have a Glomerular Filtration Rate (GFR) of < 60 ml/min, which means to be in stage 3, 4 or 5 of CRD; to exhibit capacity for comprehension and verbal communication; and to know his/her diagnosis of CRI. The criteria of the GFR of <60 ml/min was chosen because at this rate the patient is diagnosed with moderate renal failure, shows laboratory changes, and needs greater health care and restrictions.

Fifteen patients were interviewed, with the criteria of data saturation taken into consideration for determination of the number of participants.⁸ Of these, ten were men and five were women, with ages ranging from 19 to 85, with seven adults and eight elderly. In regard to level of education, one participant was illiterate, twelve had not completed primary education, one had completed primary education, and the other had not completed secondary education. Ten participants were married, two were single, two were widowed and one was divorced.

The data was collected from March to May of 2011, and a narrative interview was used for data collection. The narrative interview is a way of obtaining access to the feelings and experiences of the individuals and to their interpretative means, referring to their life situation, with a focus on human illness.⁹ For the narrative interview, three guiding lines were established to help conduct the conversation: care with CRI, routines of CRI and physical well-being.

The interviews were audio recorded with prior consent from the participants. The interviews were then transcribed and submitted to thematic analysis, which is a specific mode of content analysis.¹⁰ Thematic analysis consists of discovering core meanings that compose a communication, where presence or frequency signify something for the analytical object studied. Thus, thematic analysis unfolds in three phases: pre-analysis, exploration of the material, and treatment and interpretation of the results obtained.¹⁰

In the pre-analysis phase the documents for analysis were chosen, the initial results of the research were retrieved, and the indicators that guided the final interpretation of the results were developed, with in-depth reading of the interviews. In the examination phase of the material, the raw data was transformed to attain the core understanding of the text. An exhaustive reading of the interviews was performed, highlighting the themes that emerged with coding. These themes were later highlighted in the phase of treatment and interpretation of the results obtained. Afterwards, rereading of the classified material and critical reflection of the results was carried out.

The research participants were identified with codes, with the letter P (for participant), followed by the number of the interview performed (P1, P2, P3, etc.). The study was approved by the Research Ethics Committee of the institution on January 11, 2011, under protocol 0366.0.243.000-10. All of the phases of the research met the requirements of Resolution 196/96,¹¹ relative to ethics for research with human beings, guaranteeing the confidentiality of the data obtained and respect for the participants. The Free and Informed Consent Form was signed by the participants after they were informed about the study.

RESULTS AND DISCUSSION

The patients in conservative treatment of CRI reported self-care by considering their everyday experience, expressed by autonomy, independence and interpersonal relationships. Thus, the data was organized into four themes, which discussed lifestyle, continuity, changes and adaptations; the use of drugs in self-care; outpatient monitoring of conservative treatment; and physical activity and leisure in self-care.

Lifestyle, continuity, changes and adaptations

The interviews pointed to lifestyle changes necessary for the self-care of patients in conservative treatment of CRI. Changes related to tobacco use and consumption of alcoholic beverages were reported by the study participants: [...] so I always take care of myself, and every three months I am here at the hospital. They cut food, alcohol, I don't eat a lot of salt, fat and sweets, and I never drink alcohol of any kind. [...] I quit everything, cigarettes and alcohol kill (P1).

I had already stopped smoking, and it has been awhile since I stopped drinking yerba mate! I also liked to drink cachaça, but I stopped that too. [...] Oh, they took out a lot of foods! There are so many types of foods with pork fat, even fatty foods, that I cannot eat! I can't eat fatty meat, for example, beef or pork rinds; only nonfat milk, food without salt, so [...] it is a ton of things! Coffee, they took out everything (P2).

Self-care is expressed through attitudes that range from renouncing food and drinks that are habitually consumed and ingested as a way of life, to stopping habits such as tobacco smoking and alcohol consumption, which may be related to pleasure. The statements reinforced the need to abandon some habits that may bring personal satisfaction. Therefore, it is understood that the decision to take care of oneself demands from the patient a commitment to his or her health situation, seeking new possibilities for personal satisfaction.

Interventions in dietary habits and in the use of alcohol and tobacco are beneficial to the success of conservative treatment, by reducing the risk of cardiovascular diseases and diabetes mellitus, and controlling blood pressure.^3,12 Understanding the risks of the disease and benefits of treatment can contribute to adherence to the proposed changes.

One study done on the significance of diet and lifestyle changes by patients with metabolic diseases cites that the meaning of healthy behavior is determined by interpersonal interactions, as well as interactions with the environment, in socially and culturally-distinct contexts.¹³ Health education activities are crucial alternatives for lifestyle changes of patients, seeking prevention and/or control of risk factors of chronic illnesses, through the adoption of healthy habits and attitudes.¹⁴

In the following statements, the participants signal concern with the food restrictions: [...] they took out all the salt, but now they told me to put just a little, but I don't put any, and I also can't eat chocolate and I like it, but I can't [...] I miss eating things, eating hot dogs, salty snacks, which I never ate again (P14).

[...] I have to avoid a lot of foods, such as fatty meat, I can't eat it at all [...] they cut a lot of stuff out! And I liked salt (P15).

The reports make clear the need to adopt new dietary habits as a requirement to maintain conservative treatment. In this way, lifestyle changes can be encouraged, empowered and reinforced during outpatient treatment, considering the uniqueness of each patient, through work by the nurse to perform the educational work and the care process.

However, it is important to consider that the need for privation of some foods is a limiting factor to the quality of life and social coexistence of the person with CRI, and is felt by the entire family, which needs to incorporate some aspects of the diet into its everyday life.¹⁵

The participants revealed changes in the adherence to the diet in their statements: [...] we follow most of it, we don't use fatty meat, and control salt as much as possible [...] She requires us to boil two times, I boil once, she tells me to take the broth out of the beans, but I leave the sauce, I rinse well, place them on the stove to cook, and the broth gets slightly brown, and it's done (P1).

At home I have a piece of paper from the time that the [outpatient] nurse gave this to me, all of the care that must be taken [...]. That is why I tell you [...] the directions are really good, but sometimes we end up not doing it all, in terms of our well-being, and end up not doing a lot, but the directions are really good (P7).

The statements demonstrate that each person adapts the directions to their way of life, selecting what they will and will not follow in treatment. The autonomy to choose from and adapt to the recommendations, considering what is best for oneself, is evidence of care in the maintenance of conservative treatment of CRI.

The use of medications in self-care

For effective treatment, it is necessary that patients recognize the use of drugs as a therapy measure that is important to be followed, and that they understand why they are recommended. [...] medication I use Captopril [...] but it is easy, easy since it is a pill. I take it in the morning, at midday and at night (P1).

[...] I only take two drugs [showed medicines]. Just these two up to now. And I am well; I am doing well (P10).

The statements point to limited knowledge in the use of drugs, which the patients consider to be little, in the form of pills and easy administration. One study³ of patients in conservative treatment of chronic renal disease showed that they had little knowledge in regard to the disease, the treatment and modalities of treatment. The results of that study are corroborated by the data found in the current study: [...] I never took drugs for my kidneys, but I never swelled up, thank God, until now [...]. My medicines are only for high blood pressure [...]. I take all three in the morning [...]. I never take more or less. I take them every day, and I can't ever forget to, or else my pressure will begin to rise and the problem will come back (P4).

[...] I don't take medicine for my kidneys; there is no medicine for kidneys, only for high blood pressure. There is one for the heart, which is Metoprolol, and there are two for high blood pressure, which are Losartan and Amlodipine. I only take these three medicines. And at night I take Sinvastatin, but only sometimes; I don't take it often, because I do the diet and so I sleep well (P11).

A lack of knowledge of the action of the drug can be perceived in the participants' statements. In spite of identifying the drug and being concerned with following correct times and doses, they are not clear about its use. Thus, in regard to adherence to drug therapy, limitations of knowledge in regard to indications and actions of the pharmaceuticals being used appear to be an element that may influence adoption of the correct therapy, and have repercussions for self-care of patients in conservative treatment of CRI.

Patients' knowledge about the drug therapy appears to be a factor associated to their adherence or not to the proposed therapies.¹⁶ Adhesion to drug therapies is essential for the success of treatment of patients with CRI. Nurses perform an important role in conservative treatment of CRI by clarifying and directing patients' about the effects and actions of the drugs on the system. The nursing consultation is a strategy to afford greater adhesion to the use of drugs, thereby encouraging self-care and a healthy lifestyle, and avoiding possible complications.

Outpatient monitoring in conservative treatment

The statements express the need for control of chronic illnesses through consultations and laboratory exams. The participants demonstrate knowledge of risks of complications through directions received and clarification of their health condition. [...] it is to take care of blood pressure and cholesterol, and to avoid having a stroke, a bunch of things. The person who treats me is the doctor [from the outpatient clinic], but in the beginning there were young doctors [students], and then it was the doctor himself. (P2).

I only have one functioning kidney, so I do treatment in this outpatient clinic. I have to do a heart exam, come to take blood, and schedule consultations as well. They always tell me that I have to take better care of myself, of my health, my blood pressure, and eat less salt in my diet, which sometimes I am able to control, but sometimes I can't (P15).

Conservative treatment in renal outpatient clinics is based on drug prescriptions, dietary guidance, laboratory monitoring, psychological support and preparation for renal replacement therapies (RRT). Thus, it aims for the control of established chronic diseases and correction of the patient's metabolic and renal disorders.³

In one study about the perceptions and knowledge of patients in conservative treatment of CRD, patients cited that treatment was done through diet, physical exercise, the use of drugs and other aspects related to preparation for RRT.³ Outpatient monitoring helps patients in conservative treatment to stay informed, as shown in the following statement: [...] oh, I take a lot of medicines, and never forget. I also always do all of the exams! And there is this business with the kidney, which depends on the consultation, they say that it is the same or it didn't get better. And lately it is even going down [patient's TFG], you know? It was going down a lot and he [the physician] even asked to do this fistula (P3).

This statement shows commitment to the requirements for maintenance of conservative treatment. Patients in advanced stages of CRI (stage 4 or 5) should be prepared to initiate RRT, avoiding urgent procedures such as construction of an arteriovenous fistula. Preparations include measures to be taken prior to RRT treatment, such as: vaccination against hepatitis B, psychological support for the patient and his/her family, social support and opportunity to discuss RRT modalities, with the purpose of being able to have a choice of treatment.¹⁷

Progression of the rhythm of CRI can be rapid or slow, varying according to each patient and the underlying pathologies. Thus, work by the nurse to provide orientations about the disease and its progression is important, as this facilitates self-care in that the patients are able to identify their own needs, and choose what is best for him/her.

The study participants expressed that their commitment to conservative treatment when followed by the multiprofessional team in the renal outpatient clinic: [...] when I went to the nutritionist, she told me what to do, and we do it, to improve something, right, always like that. I have seen the nurses various times, and they always orient me about food [...], because I was always like that. If the doctor asks, I do it! I have always taken my medicines as directed, I take care of myself and I know that the disease is dangerous. The more I take care of myself the better for me. I do everything they tell me to (P9).

[...] I control everything, the day I have to come here, collect blood, I control everything. I have kept all of my records since my first blood test (P11).

Involvement with conservative treatment of CRI is perceived in the statements. Both demonstrate following the healthcare team's directions in the effort for self-care. Commitment and responsibility to conservative treatment can be attained with measures that go beyond education, through the accumulation of information and lifestyle changes. Being conscious of the severity of their health situation is essential for these patients, as this encourages the prevention of future complications and motivates lifestyle changes.¹⁴

Physical activity and leisure for self-care

The practice of physical activities provides benefits to the quality of life of people of diverse age groups. These activities can benefit the body by improving blood pressure, blood sugar levels, cholesterol and body weight, and reducing morbidity and mortality from heart diseases. [...] I exercise very little [...] I don't like to walk, you know? I am always moving, but I don't do long walks [...] I like fishing a lot, and people who fish have to walk (P1).

They told me to walk at our house in the country, but I can't! [...] Before I walked, hoed, everything, but now I can't. I also have a lot of pain in my knee (P3).

My problem is that it is really hard for me to lose weight. Three or four years ago, I walked a lot, three times per week, and then it became harder [...] I have a lot of back pain (P7).

Walking was the physical exercise most cited by the participants. The statements express the difficulties in doing this activity, which may be related to the advance of the CRI. The appearance of low back pain, weakness, tremors, edema and cardiovascular changes are often associated with the progression of kidney disease.¹⁸

In one study of physical exercise among patients with chronic renal disease, it was proven that higher levels of physical exercise and lower levels of time spent sitting down are associated with lower prevalence of CRI.¹⁹ According to the Ministry of Health, physical exercise is recommended for the promotion of health and prevention of disease, and generates benefits when done for at least 30 minutes at moderate intensity, most days of the week.¹²

For the study participants, leisure activity is one way of maintaining an active life: [...] when I have time I do crochet. I have a lot of orders for crochet. I don't do it for money; I do it for family, friends [...] I have not travelled because of my high blood pressure, I can't travel! [...] it's been two years since I have gone away because of this problem (P4).

[...] sometimes I go out, talk with friends on the sidewalk, walk there by foot. I walk a little, but not much [...] I don't travel. I never liked to travel; only when I have to. What I really like is country work (P6).

The physical difficulties sometimes presented by people in conservative treatment of CRI sometimes influence their ability to do leisure activities. Among manual activities, crochet was highlighted by the study participants as a form of leisure and spending time. In addition to keeping busy, participants use the products of this activity as a way to establish relationships and express affectionate bonds by giving presents to family and friends on important dates. Through crochet, the study participants stay active and productive, since the process of creation of pieces and the final product provide satisfaction and happiness. By encouraging leisure activities of patients with CRI, nurses can help them to confront everyday contradictions, making possible their self-care, comfort, well-being, alleviation, happiness and peace.

CONCLUSIONS

Based on this study, it is understood that living with a chronic illness encompasses social and cultural effects, and the experiences of people. Self-care of patients in conservative treatment of CRI is expressed through attitudes that range from denial to acceptance of the chronic situation.

Self-care is expressed through changes in the everyday lives of these patients, with changes to their lifestyles. Renouncement of certain foods and drinks, and of the practice of certain habits considered pleasurable, is one form of self-care. The adoption of new dietary and lifestyle habits makes the maintenance of conservative treatment possible; however, according to the study participants, this has repercussions on quality of life.

The study showed that the patients in conservative treatment of CRI had limited knowledge of the pharmacological measures to prevent the worsening of the underlying illnesses. They did not have consistent and clear information about the drug action, leading them to flawed interpretations of the effects of these pharmaceuticals on their systems. Thus, work by the nurse for health education of these patients is important to encourage self-care and adhesion to conservative treatment.

Outpatient monitoring can contribute to self-care. It is one way to control chronic illnesses, as well as a source of support to maintain conservative treatment, and gain clarification about the progression of the chronic renal disease. By working together, the nurse and entire multiprofessional team can perform efficient health education through understanding the health situation of each person for the promotion of his/her health.

Physical activity and leisure become compromised with the evolution of physical losses from the CRD, influencing self-care of patients in conservative treatment. In light of the results of the research, it is recommended that health professionals, primarily nurses, think more amply about health promotion, seeking quality of life of patients in conservative treatment of CRI for self-care.

REFERENCES

• 1. Thomé EGR. Homens e doença renal crônica em hemodiálise: a vida que poucos veem [tese]. Porto Alegre (RS): Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Enfermagem; 2011.
• 2. Travagim DAS, Kusumota L. Atuação do enfermeiro na prevenção e progressão da doença renal crônica. Rev Enferm UERJ. 2009 Jul-Set; 17(3):388-93.
• 3. Gricio TC, Kusumota L, Cândido ML. Percepções e conhecimentos de pacientes com doença renal crônica em tratamento conservador. Rev Eletr Enferm [online]. 2009 [acesso 2011 Set 20]; 11(4):884-93. Disponível em: http://www.fen.ufg.br/revista/v11/n4/pdf/v11n4a14.pdf
• 4. Roso CC. O cuidado de si de pessoas com insuficiência renal crônica em tratamento conservador [dissertação]. Santa Maria (RS): Universidade Federal de Santa Maria, Programa de Pós-Graduação em Enfermagem; 2012.
• 5. Ramos IC, Queiroz MVO, Jorge MSB. Cuidado em situação de doença renal crônica: representações sociais elaboradas por adolescentes. Rev Bras Enferm. 2008 Mar-Abr; 61(2):193-200.
• 6. Foucault M. História da sexualidade 3: o cuidado de si. Rio de Janeiro (RJ): Graal; 1985.
• 7. Silva SED, Padilha MI, Rodrigues ILA, Vasconcelos EV, Santos LMS, Souza RF, et al. Meu corpo dependente: representações sociais de pacientes diabéticos. Rev Bras Enferm. 2010 Mai-Jun; 63(3):404-9.
• 8. Fontanella BJB, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cad Saúde Pública. 2008 Jan; 24(1):17-27.
• 9. Lira GV, Catrib AMF, Nations MK. A narrativa na pesquisa social em saúde: perspectiva e método. Rev Bras Promoç Saúde. 2003; 16(1/2):59-66.
• 10. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12Ş ed. São Paulo (SP): Hucitec; 2010.
• ¹¹
  Ministério da Saúde (BR), Conselho Nacional de Saúde, Comissão Nacional de Ética em Pesquisa. Resolução n. 196 de 10 de outubro de 1996: diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. Brasília (DF): MS; 1996.
• 12. Ministério da Saúde (BR). Prevenção clínica de doenças cardiovasculares, cerebrovasculares e renais. Brasília (DF): Secretaria de Atenção à Saúde, Departamento de Atenção Básica; 2006.
• 13. Vieira CM, Cordeiro SN, Júnior RM, Turato ER. Significados da dieta e mudanças de hábitos para portadores de doenças metabólicas crônicas: uma revisão. Cien Saude Coletiva. 2011 [acesso 2011 Out 12]; 16(7):3161-8. Disponível em: http://www.scielosp.org/pdf/csc/v16n7/16.pdf
• 14. Santos ZMSA, Lima HP. Tecnologia educativa em saúde na prevenção da hipertensão arterial em trabalhadores: análise das mudanças no estilo de vida. Texto Contexto Enferm. 2008 Jan-Mar; 17(1):90-7.
• 15. Fraguas G, Soares SM, Silva PAB. A família no contexto do cuidado ao portador de nefropatia diabética: demandas e recursos. Esc Anna Nery. 2008 Jun; 12(2):271-7.
• 16. Moreira LB, Fernandes PFCBC, Monte FS, Galvão RIM, Martins AMC. Conhecimento sobre o tratamento farmacológico em pacientes com doença renal crônica. Rev Bras Cienc Farm 2008 Abr-Jun; 44(2):315-25.
• 17. Bastos MG, Bregman R, Kirsztajn GM. Doença renal crônica: frequente e grave, mas também prevenível e tratável. Rev Assoc Med Bras. 2010; 56(2):248-53.
• 18. Bezerra KV, Santos JLF. Daily life of patients with chronic renal failure receiving hemodialysis treatment. Rev Latino-Am Enferm. 2008 Jul-Ago; 16(4):686-91.
• 19. Bharakhada N, Yates T, Davies MJ, Wilmot EG, Edwardson C, Henson J, et al. Association of sitting time and physical activity with CKD: a cross-sectional study in family practices. Am J Kidney Dis. 2012; 60(4):583-90.

1

Artigo extraído da dissertação - O cuidado de si de pessoas com insuficiência renal crônica em tratamento conservador, apresentada ao Programa de Pós Graduação em Enfermagem (PPGENF) da Universidade Federal de Santa Maria (UFSM), 2012

Publication Dates

• Publication in this collection
  01 Oct 2013
• Date of issue
  Sept 2013

History

• Received
  26 June 2012
• Accepted
  11 Dec 2012