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I currently work in an outpatient dialysis unit and admit newly diagnosed patients with End Stage Renal Disease (ESRD). This population is very vulnerable and some of the elder patients are economically disadvantaged. Upon initiation of dialysis several lifestyle changes occur in adapting to treatments and management of kidney failure. Diet, exercise and stress are all challenges that are incorporated with the new diagnosis and treatment of dialysis.

The goals of nutrition related to dialysis patients are focused on developing ways to keep patients healthier and avoid hospitalizations (Lutz-Mizar, Gale, & Rydzon, 2015). The renal diet is high protein and low sodium diet. If that patient is diabetic, two diets are used in conjunction. An abundance of education is provided to the patient and verification of understanding is very important to promote health and positive outcomes.

When the kidneys are not working we teach patients to avoid high phosphorus foods and to take phosphorus binders with each meal to excrete phosphorus through the bowel. By reviewing exactly what the medications are for and how they work to improve the health status of the patient are important to achieve and reach the patients' health goals. I simply explain the risks associated with eating foods that aren't recommended and in a way the patient can under why providing the "why"; I also make sure they can verbalize back to me so I know we have a shared mental model of the information being discussed.

The dialysis unit also has informative handouts provided by The Heartland Kidney Network from "My Kidney Kit" and a Renal Dietician who does one on one consults with patients and family as needed and or monthly. Diabetics may attend classes at the hospital related to nutrition by the diabetes educator also.

There is several health benefits related to exercise. Whether it be for managing diabetes or improving cardiac output and venous return, the benefits are good. Most dialysis patients live sedentary lifestyles and evidence shows sedentary dialysis patients are at higher risk of death compared to non-sedentary ones (Cupisti, D'Alessandro, Bottai, Fumagalli, and Capitanini, 2013). An assessment is done to decide together what the patient can and can't physically do.

Yoga or Tai Chi may be suggested for all ages as well as stretching or walking. Any physical activity is better than no activity at all. During dialysis, we offer the use of a pedal bike to encourage exercise and improve venous return in the lower extremities and it also provides other benefits related to stress or anxiety.

Stress related to illness is common among hospitalized patients or for anyone diagnosed with an illness or disease. Stress can increase when the outcome or prognosis is not clear. It may be beneficial to provide as much knowledge and education related to the patients situation. This may help to alleviate some of the stress.

There are also several types of stress to include physical and emotional. In the dialysis unit we also have a social worker to assist with this social work needs. She provides assessments and depression screenings along with assisting patients with financial challenges.

She visits with each patient a least monthly and listens to the needs and desires of each of them. Problem-focused engagement coping strategies are associated with longer survival and also with improvement in physical functioning and mental health (Niihata, Fukuma, & Akizawa, 2017).

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