الفهرس 
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Abstract
Chronic renal failure is one of the most common chronic diseases which its incidence and prevalence are on the rise. The increased incidence of ESRD, longer life expectancy of dialysis patients and inability to meet the need for kidney transplantation, most of the dialysis patients experience serious symptoms. These symptoms interfere with their ability to function according to their normal capacity and hampering the quality of life.
Fatigue is one of the most frequent complaints of hemodialysis patients. It is a missed and unrecognized problem for majority of nurses working in hemodialysis unit. So the nurse should have a pivotal role and be responsible for evaluating fatigue and applying measures that directly decrease its impact which enhance patients’ activities of daily living. Among the non pharmacological interventions of fatigue are intradialytic exercises. Therefore this study was carried to determine the effect of intradialytic exercises on fatigue and activities of daily living among patients undergoing hemodialysis.
Materials
This study was carried out at the hemodialysis unit of the National Medical Institute in Damanhour El-behieria governorate. The subjects comprised eighty patients on maintenance hemodialysis three sessions per week. Those subjects were assigned into two groups study and control 40 patients in each. The study group was managed by intradialytic exercises and control group was managed by routine care in the hemodialysis unit.
Two tools were used for data collections.
Tool I: Bio-socio-demographic data and Multidimensional Assessment of Fatigue (MAF) Scale.
This scale was developed by Neuberger (2003). It was used to assess patient’s fatigue level. The MAF is a self administered questionnaire to measure 4 dimensions of self reported fatigue: degree and severity, amount of distress it causes, the degree to which fatigue interferes with activities of daily living and its timing (how often it occurs). The MAF consist of 16 items only 15 items are used to calculate the Global Fatigue Index.
Tool II: Lawton and Brody Instrumental Activities of Daily Living Scale.
This scale was developed by Lawton and Brody (1969) revised (2007). It was used to assess the level of patients’ independent living skills. The scale comprises eight items shopping, ability to use telephone, mode of transportation, responsibility for own medication, food preparation, housekeeping, laundry and ability to handle finances. Females were scored on all eight areas of function but for males the areas of food preparation, housekeeping and laundering were excluded.
Method of data collection
Tool one was translated into Arabic language by the researcher and was revised by 5 experts in the field of the study for content validity and the necessary modifications were done. Then the tool was tested for its reliability on a sample of 8 subjects using Cronbach’s alpha statistical test for internal consistency of tool items. The data was analyzed the correlation coefficient was (α= 0.89).
Tool two was translated into Arabic language and validated on Egyptian population by Shehatta 1997 and tested for reliability in a study carried out at Alexandria by Elsayed 2007 reliability was 0.83.
Each patient in the control and the study group was interviewed individually to collect Bio- socio-demographic data at the beginning of hemodialysis session.
The study subjects were assessed for their fatigue level using tool I and were assessed for their level of independent living skills using tool II.
The control group was left for routine care while the study group was practicing intradialytic exercises. The researcher provided information for each patient individually regarding these exercises in the first session.
In the second session the researcher demonstrated part one of these exercises (range of motion exercises) in the second hour of hemodialysis session three times per week. In the next hemodialysis session part two (muscle stretching exercise) was done and after that third part (muscle strengthing exercises) was done.
Pulse, respiration and blood pressure was measured by the researcher before and after these exercises.
The arm with arteriovenous fistula was relaxed and lying down and not activated during these exercises.
The data collection period for both groups was three weeks (9 sessions) starting with control group then study group to avoid contamination of data.
At the fourth week reassessment of fatigue level and level of patients’ independent living skills was done using the pervious mentioned tools.
The main findings of this study showed that:
More than two fifth of the studied patients were in the age group 35 to less than 45 years. More than half of the studied patients were married.
Thirty percent of patients in the control group and 20.0% of patients in the study group were illiterate. More than one third of the studied patients were house wife and unemployed.
More than half of the studied patients were living in rural areas.
Kidney stones, hypertension and glomerulonephritis were representing the most common causes of renal failure among the studied patients.
The majority of the studied patients weren’t performing exercises at home. Most of the studied patients were having hemoglobin level less than 12g/dl.
No statistical significant difference was found between both groups regarding fatigue dimensions pre exercises (p=0.368) while a highly statistical significant difference was found between both groups post exercises (p=0.000)*.
A highly statistical significant difference was found in relation to global fatigue index between the control and study groups after nine sessions of intradialytic exercises (p=0.000)*. Whereas, sixty seven point five percent of patients in the study group were having severe fatigue pre exercises while post exercises the percent was 12.5%.
A highly statistical significant differences were found regarding activities of daily living among studied male patients post exercises in the areas of shopping and mode of transportation P<0.05.
Statistical significant differences were found regarding activities of daily living among studied female patients post exercises in the areas of mode of transportation, food preparation and laundry at level p<0.05.
The percent of independency level increased after performing intradialytic exercises
and the percent was 92.5%
There was no statistical significant relation between pre and post global fatigue index of the studied groups and their level of activities of daily living.
from the findings of the present study it can be concluded that:
Intradialytic exercises have a beneficial effect on reducing fatigue level in hemodialysis patients, increasing potential for performance their activities of daily living and enhancing their level of independent living activities.
Based on the findings of the present study, the researcher suggested these recommendations.
A-Recommendations for the patients:
Development and application of educational sessions for hemodialysis patients to improve their understanding about fatigue and intradialytic exercises. They should be aware about the importance of these exercises that influence fatigue level, its timing, types and how to demonstrate it.
B-Recommendations for dialysis staff:
All dialysis nephrologists and nurses should be regularly encouraging hemodialysis patients to increase their level of physical activity.
Individualize exercise programs for patients with co-morbid conditions need to be developed.
C-Recommendations for administrators:
Intradialytic exercise programs should be incorporated into routine clinical practice.
A simple manual of guidelines of intradialytic exercises should be available for all nurses working at hemodialysis unit and for hemodialysis patients especially newly admitted.
Suggestion for further researches:
Replication of the study could be done with a larger homogenous sample and increasing the duration of intervention for generalization of results.
A comparative study can be conducted to find the effectiveness of intradialytic exercises versus home exercises on fatigue and activities of daily living among hemodialysis patients.