Effect of baby oil on pruritus, sleep quality, and quality of life in hemodialysis patients: Pretest post-test model with control groups

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1 bs_bs_banner Japan Journal of Nursing Science (2014) 11, doi: /jjns ORIGINAL ARTICLE Effect of baby oil on pruritus, sleep quality, and quality of life in hemodialysis patients: Pretest post-test model with control groups Ezgi KARADAG, 1 Serap Parlar KILIC, 2 Gülnaz KARATAY 1 and Ozgur METIN 3 1 Health High School, Tunceli University, Tunceli, 2 Department of Internal Medicine Nursing, Faculty of Health Sciences, Gaziantep University, Gaziantep and 3 Turgut Özal Tıp Merkezi, İnönü Üniversitesi, Malatya, Turkey Abstract Aim: To assess the effect of baby oil on pruritus, sleep quality, and quality of life in hemodialysis (HD) patients. Methods: This pretest post-test model with control groups study was conducted in HD units in two different provinces in eastern Turkey. The study group consisted of a total of 70 patients receiving HD treatment who met the inclusion criteria, 35 being in the intervention group and 35 in the control group. After the patients in both groups were informed about the study, they were administered a questionnaire, the Severity Scale, Visual Analog Scale, the Pittsburgh Sleep Quality Index, and the SF-36 Quality of Life Scale. Following the administration of baby oil to the patients in the intervention group three times a week for a period of 1 month, the same scales were repeated to explore their pruritic status, sleep quality, and quality of life. The same scales were repeated also for the patients in the control group 1 month later but without administering any baby oil. Results: When the Itch Severity Scale, Visual Analog Scale, Pittsburgh Sleep Quality Index, and SF-36 Quality of Life Physical and Mental Component scores of the patients in the control and intervention groups before and after the intervention were compared, the differences in the change were found to be statistically significant in favor of the intervention group (P < 0.05). Conclusion: It was found in this study that administration of baby oil had positive effects on itching, quality of life, and sleep quality in HD patients who had itching complaints. Key words: baby oil, hemodialysis, nursing, patients, pruritus. INTRODUCTION End-stage renal disease (ESRD) is a chronic and growing health problem in the world. According to the global data, ESRD prevalence increased approximately 7% and was calculated as 342 per each million (Fresenius Medical Care, 2012). The most commonly used treatment method of ESRD is dialysis (Serdengeçti, Süleymanlar, & Altıparmak, 2011; Tsay & Healstead, Correspondence: Serap Parlar Kilic, Üniversite (University) Bulvarı, Gaziantep University Faculty of Health Sciences, Department of Internal Medicine Nursing, Sehitkamil, Gaziantep 27310, Turkey. serap.parlar@gantep.edu.tr Received 7 January 2013; accepted 24 March ). There are 1 million and patients that undergo hemodialysis (HD) treatment worldwide (Fresenius Medical Care, 2012). As for Turkey, the number of subjects who were administrated HD treatment was according to the data for 2010 (Serdengeçti et al., 2011). Uremic pruritus is one of the most frequently seen problems in HD patients (Pisoni et al., 2006). Recent studies show that individuals undergoing HD experience itching problems at a rate ranging 20 90% (Hsu, Chen, Hwu, Chanc, & Liu, 2009; Kuypers, 2009; Narita, Iguchi, Omori, & Gejyo, 2008). In a study by Falodun, Ogunbiyi, Salako, and George (2011) with 107 HD patients, it was reported that 26.7% experienced itching

2 Japan Journal of Nursing Science (2014) 11, Effect of baby oil in pruritic HD patients problems. Welter, Hubner, Maldotti, Losekann, and Weber (2011) found in their study that 19.6% of the HD patients had mild, 60.9% moderate, and 19.6% serious itching problems. In Turkey, Önelmiş, Sener, Sasmaz, and Ozer (2012) reported in their study that 51% of the patients undergoing HD experienced itching problems. The mean score of pruritus was found to be as high as 7.6 of 10 points in HD patients in the study of Tol et al. (2010). Pruritus in HD patients may lead to physiological problems, such as lesions on the skin, bleeding, chronic fatigue, and sleep disorders, and psychological problems, such as anger, anxiety depression, and social isolation. These problems reduce patients quality of life and self-care ability and make compliance with the disease (Kılıç Akça & Tasci, 2011; Lin et al., 2011; Shahgholian, Dehghan, Mortazavi, Farzaneh, & Valiani, 2010). It is reported in studies carried out with HD patients that patients have low quality of life, and sleep problems is one of the factors reducing quality of life (Tol et al., 2010; Tsay & Healstead, 2002; Walters, Hays, Spitzer, Fridman, & Carter, 2002). It is reported in some studies that the prevalence of sleep disorders is over 65% in HD patients (Çölbay et al., 2007; Yong et al., 2009). Sleep disturbances are described as difficulty in falling asleep, nocturnal awakenings, remaining awake at night, daytime sleepiness, and chronic fatigue (Çölbay et al., 2007). The relationship between itching, quality of life, and sleep problems indicates that it is important to evaluate these problems as a whole (Tol et al., 2010). It is important to eliminate itching to improve quality of life and to reduce sleep problems in HD patients. It is mentioned in the published work that baby oil, which is cheap, effective, non-invasive, free of side-effects, and easily usable at home and hospital, proved to decrease the symptoms of desquamation and xerosis (Chiu & Hsieh, 2005; Kennet, Hardaker, Hobbs, & Selfe, 2007). The published work also mentions that baby oil, which contains moisturizing raw coconut oil and oil with minerals, reduces itching through its effects such as stopping the transmission of C nerve fibers and decreasing chemical stimulus and inflammation (Kennet et al., 2007; Schmelz, 2002; Wang, Tang, Chu, Chao, & Wang, 2006). Nursing services are important in improving quality of life in HD patients. Nurses can reduce patient complaints through effective symptom control. For this purpose, nurses can use some complementary/ supporting treatments. Baby oil is a non-invasive, sideeffect free, and cheap method that can be easily administrated by nurses also to relieve the itching of patients (Lin et al., 2011). It is important that nurses, who spend the longest time with patients among the healthcare staff, are aware of patients problems and produce evidence-based solutions to these problems. However, because nursing services are not sufficiently developed, especially in peripheral areas in Turkey, HD patients cannot receive nursing services sufficiently. For this reason, with this study that has been carried out in a peripheral area, the attempt has been to produce evidence-based data for nursing services regarding the problem of itching, which has not been dealt with adequately previously, although it is an important symptom in HD patients. The fact that no other study was encountered in Turkey investigating the effect of baby oil on itching in HD patients makes it important in terms of revealing the need for this kind of a study. With this study, the authors intended to assess the effect of baby oil on itching, sleep quality, and quality of life in HD patients in order to provide an example for nurses regarding symptom management. METHODS Study design This study was designed as a pretest post-test model with control groups. Setting The study was conducted in a province in eastern Turkey where health services are relatively less developed as compared to the other regions. The intervention group of the study consisted of those patients who were receiving treatment due to chronic renal failure in the HD unit of the state hospital located in Tunceli, a small province in the east of Turkey. In order to prevent any interaction between patients, the control group was selected from the patients who were receiving treatment in a HD unit in Malatya province. Sampling When the intervention group was being selected, there were 39 registered patients being treated in the HD unit of Tunceli State Hospital. Because all of these patients were included in the intervention group, the size of the sample was not calculated. However, three patients were excluded for not meeting the inclusion criteria of the study and one patient for having died after the onset of intervention, and the intervention group completed the study with 35 patients. When the control group was 181

3 E. Karadag et al. Japan Journal of Nursing Science (2014) 11, Table 1 Baseline characteristics at pretest between intervention and control groups Total sample (n = 70), n (%) Groups Intervention group (n = 35), n (%) Control group (n = 35), n (%) Significance, P-value Sex Male 43 (61.4) 23 (65.7) 20 (57.1) Female 27 (38.6) 12 (34.3) 15 (42.9) Age (mean SD) Educational level literate 17 (24.3) 9 (25.7) 8 (22.9) Primary education (age 7 11 years) 32 (45.7) 13 (37.1) 19 (54.3) Secondary education (age years) 6 (8.6) 3 (8.6) 3 (8.6) High school (age years) 12 (17.1) 8 (22.9) 4 (11.4) University 3 (4.3) 2 (5.7) 1 (2.9) Total duration of hemodialysis (months) (mean SD) Frequency of hemodialysis (weekly) Two times 3 (4.3) 2 (5.7) 1 (2.9) Three times 67 (95.7) 33 (94.3) 34 (97.1) Chi-square analyse; independent t-test; Fisher s exact test. SD, standard deviation. being selected, there were 80 registered patients being treated in the HD unit of Malatya Turgut Özal Medical Center. As 20 patients did not meet the inclusion criteria, they were not taken into the study as well as three patients who left the town (Fig. 1). Of the remaining 57 patients, 35 were included in the control group through a simple random number table. The intervention and control groups were matched in terms of age, sex, education status, and duration and frequency of having dialysis (Table 1). The criteria for inclusion in the trial were determined as: (i) volunteering to take part in the study; (ii) having three episodes of itching (each episode 5 min or longer) within the last 2 weeks and having intermittent itching complaints during the last 6 months; (iii) not having any sign of edema during the trial; (iv) not having any open wound, cellulites, infection, deep venous thrombosis, epilepsy, hemorrhage, paraplegia, or pacemaker; (v) not having any history of allergic reaction; (vi) the number of thrombocytes being and over, not having used any drugs for itching (e.g. oral and injected antihistaminic drugs); and (vii) not having any hearing or speaking problems. Power was calculated to be 98% in the assessment made after completion of the study. For power analysis, alpha was taken as 0.05, confidence interval as 95%, and effect size as Intervention and intervention protocol The proposed temperature of the oily solution is normally 15 C (Chen, Chiu, & Wu, 2006; Chiu & Hsieh, 2005). It is recommended in the published work to A Hemodialysis Unit (N=39) Ineligibility (n=3) Allocated to Interven on (n=36) Pre Test (PSQI, VAS, SF-36 QoL, ISS) Interven on Missing (excitus n=1) Post Test (n=35) (PSQI, VAS, SF-36 QoL, ISS) Mathcing Another a Hemodialysis Unit (N=80) Ineligibility (n=20) Moving (n=3) Allocated to Control (n=35) Pre Test (PSQI, VAS, SF-36 QoL, ISS) Follow Up Post Test (n=35) (PSQI, VAS, SF-36 QoL, ISS) Figure 1 Flow chart. ISS, Itching Severity Scale; PSQI, Pittsburgh Sleep Quality Index; SF-36 QoL, SF-36 Quality of Life Scale; VAS, Visual Analog Scale. apply cool baby oil repeatedly on the affected area for a period of min (should be <30 min) (Chen et al., 2006; Chiu & Hsieh, 2005; Kennet et al., 2007). In this study, baby oil (10 15 C) was applied to the patients, 182

4 Japan Journal of Nursing Science (2014) 11, Effect of baby oil in pruritic HD patients who were included in the study and had HD 3 days a week, during these 3 days once a day prior to the HD. The patients who underwent HD twice a week (2 days) were invited again for an extra day so that an equal number of baby oil administrations (three times a week) were applied. The intervention group were applied baby oil for 30 days in total. The intervention protocol is as follows: 1 Preparatory stage and readying patients. Hands are washed thoroughly, the patient is made to wear an appropriate hospital outfit, his/her privacy is secured and a blanket is provided if necessary, the itching areas are identified, care is taken not to apply the oil on areas with edema or with impaired tissue integrity, a thermometer is used to measure the temperature of the baby oil, and the temperature of the baby oil is kept between 10 C and 15 C. 2 Applying the baby oil. The cooled baby oil is applied on the itching area, rubbed in by hand before starting the HD treatment, and the practice is continued for 15 min. 3 Interventions to be performed after applying baby oil. Patients are dried and soothed after applying the cooled baby oil, if any change is observed on the body or skin, it is recorded, the patient is maintained in a comfortable position, and the cooled baby oil is stored in a fridge after the fridge s temperature is checked. 4 Emergency interventions in cooled baby oil administration: The practice is stopped immediately if the patient feels cold or pain, or quivers, it is made certain that the vital signs of the patient are stable and the patient is kept warm, and the doctor is contacted if the patient complains about discomfort. Instruments for evaluation Questionnaire for sociodemographic and disease characteristics This form was prepared by the investigators in line with the information in the published work. The sociodemographic data were collected through six questions about age, sex, marital status, educational status, occupation, and social security status; the data on the disease and itching were collected through 14 questions about the duration of chronic renal failure (CRF), reason for having CRF, duration of HD, frequency of having dialysis, phase of the disease, presence of any other chronic diseases besides CRF, rate at which itching is experienced, duration of itching, region of itching, frequency of itching, use of any drugs for itching, use of any non-drug methods for itching, presence of dry skin problems, and experiencing sleep problems associated with itching. Itching Severity Scale (ISS) There are four items in the scale: (i) distribution of itching; (ii) frequency of itching; (iii) severity of itching; and (iv) sleep disturbance caused by itching. The scale was later modified by Mettang et al. (1990) and Pauli-Magnus et al. (2000). The scale was reduced to three items by deleting frequency of itching from the itching scoring used in various studies abroad and the scoring was modified (Mettang et al., 1990; Pauli-Magnus et al., 2000). As for Turkey, after language adaptation, the ISS has been applied in a research (Kılıç Akça, Karataş, & Tasci, 2011). Scores range Increasing scores indicate increasing severity and intensity of itching. The latest modified version of the scale was used by the investigator in this study. Visual Analog Scale (VAS) Developed by Price, McGrath, Rafii, and Buckingham (1983), the VAS is an easy, readily applicable measurement tool that has been administered on at least 50 responders in every culture. The VAS scale has already been used for assessing itching intensity in clinical trials worldwide and in Turkey (Chiu et al., 2008; Narita et al., 2008; Tol et al., 2010). Today, the VAS is also used for measuring various other components besides pain (Uçan, Ovayolu, & Savaş, 2007). The VAS is used to quantify some values that cannot be measured numerically at present. In this study, a form containing a 10 cm line where no itching is written at one end and very severe itching at the other end was used to determine the severity of itching and the patients were asked to mark their status on this line. The itching severity of a patient is found by measuring the distance from the point of no itching to the point marked by the patient using a standard ruler as follows: 0 2 cm, no itching; 3 4 cm, mild itching; 5 6 cm, moderate itching; 7 8 cm, severe itching; and 9 10 cm, unbearable itching (Wewers & Lowe, 1990). The Pittsburgh Sleep Quality Index (PSQI) Developed by Buysse, Reynolds, Monk, Berman, and Kupfer (1989), the PSQI is a scale providing information on sleep quality, and the type and severity of sleep disorder of an individual within the last month. The scale consists of 24 questions in total, 19 of which are answered by the individual and five by his/her spouse or roommate. With the 19 questions answered by the indi- 183

5 E. Karadag et al. Japan Journal of Nursing Science (2014) 11, vidual, seven sub-dimensions are assessed, which are: (i) sleep quality; (ii) sleep latency; (iii) sleep duration; (iv) habitual sleep efficiency; (v) sleep disturbances; (vi) use of sleeping medications; and (vii) daytime dysfunction. Each item in the scale assumes a value between 0 (no disturbance) and 3 (serious disturbance), and the score of each sub-dimension ranges 0 3. The sum of these seven sub-dimension scores gives the overall PSQI score. The overall PSQI score varies between 0 and 21. Those having an overall score of 5 or less are considered to have a good sleep quality (Buysse et al., 1989). The validity and reliability of the scale in Turkish was tested by Ağargün, Kara, and Anlar (1996) and the internal consistency coefficient was reported to be SF-36 Quality of Life Scale (SF-36 QoL) The SF-36 QoL scale was developed by Ware and Sherbourne (1992); its validity and reliability in Turkey was tested by Pinar (1995), and it was reported to be usable in chronic diseases. The SF-36 QoL consists of 36 questions and eight subdomains. While each of the eight subdomains can be assessed separately with the scale, quality of life can also be assessed in two main components: (i) physical component summary (PCS); and (ii) mental component summary (MCS). The PCS includes the areas of physical functioning, role limitation physical, bodily pain, general health perception, and energy/vitality, whereas the MCS relates to social functioning, role limitation emotional, mental health, general health perception, and energy/vitality. The PCS and MCS are standardized to a mean standard deviation (SD) of 50. The questions are of Likert type and cover the last 4 weeks. The scores of each health area range and increasing scores indicate improving quality of life. While 0 points show a poor health condition, 100 points indicate a good health condition (Acaray & Pınar, 2004; Tel, 2009). Data collection Before applying baby oil, pretest data of the intervention group were collected with a questionnaire on sociodemographic and disease characteristics, the ISS, VAS, PSQI, and SF-36 QoL. In order to assess itching accurately, the pruritic score was evaluated using both the VAS and ISS in this study. At the end of the intervention (day 30), the ISS, VAS, PSQI, and SF-36 QoL scales were completed for all the patients again. The patients in the control group were administered only the questionnaire for sociodemographic and disease characteristics, and the ISS, VAS, PSQI, and SF-36 QoL scales without administering any baby oil. The same scales were repeated for each patient after 30 days. Data analysis The data were evaluated with the SPSS software (SPSS, Chicago, IL, USA) using numbers or percentages. The c 2 -test and independent Student s t-test were used when comparing whether there was any difference between the intervention and control groups in terms of basic characteristics. The differences between the scores of the ISS, VAS, PSQI, and SF-36 QoL obtained from the intervention and control groups were analyzed by using the independent Student s t-test. To assess the before and after differences within the same group, the paired sample Student s t-test was used. Ethical consideration Written permissions were obtained for this study from the ethics committee (no. 295) of Gaziantep University, Faculty of Medicine, the hospital managements of the provinces where the study was conducted, and the Provincial Health Directorate. Additionally, informed consents were obtained from all patients in line with the Declaration of Helsinki. RESULTS Sample characteristics A total of 70 patients receiving HD treatment were included in this study, 35 in the intervention group and 35 in the control group. Approximately 61.4% of the patients who took part in the study were male and 38.6% were female, mean age was years, 45.7% of them were graduates of primary school, their mean duration of HD was months, and the majority of the patients (95.7%) were receiving HD treatment three times a week. The intervention and control groups used in the research had similar features, such as sex, age, education level, total duration of HD, and frequency of HD (Table 1). These findings gave homogeneity to the groups. Though it is not given in the table, 41.4% of the patients were retired, 68.6% of them were married, and 94.3% of them had social security. The mean duration of CRF was months in patients. It was found that all the patients included in the study had itching complaints as required by the sampling criteria and 31.4% of them had experienced itching problems for a period longer than 1 year. 184

6 Japan Journal of Nursing Science (2014) 11, Effect of baby oil in pruritic HD patients Table 2 Disease-related characteristics of the intervention and control groups Total sample (n = 70), n (%) Groups Intervention group (n = 35), n (%) Control group (n = 35), n (%) Duration of CRF (months) (mean SD) Duration of pruritus 0 1 months 9 (12.9) 5 (14.3) 4 (11.4) 2 6 months 19 (27.1) 12 (34.3) 7 (20.0) 7 12 months 20 (28.6) 11 (31.4) 9 (25.7) 13 months 22 (31.4) 7 (20.0) 15 (42.9) Dry skin Yes 53 (75.7) 23 (65.7) 30 (85.7) No 17 (24.3) 12 (34.3) 5 (14.3) Effect on sleep of itching Yes 63 (90.0) 32 (91.4) 31 (88.5) No 7 (10.0) 3 (8.6) 4 (11.4) Presence of other chronic disease Yes 43 (61.4) 16 (45.7) 27 (77.1) No 27 (38.6) 19 (54.3) 8 (22.9) CRF, chronic renal failure; SD, standard deviation. The majority of the patients (75.7%) had dry skin problems and 90.0% had sleep problems associated with itching. Approximately 61.4% of the patients had other chronic diseases accompanying CRF (Table 2). The patients concomitant chronic diseases included hypertension (40.0%), diabetes mellitus (15.7%), hepatitis (5.7%), and hyperthyroidism (1.4%). Although hepatitis is a disease that affects itching, it was not a factor that affected the results, because the number of patients with hepatitis was the same in both groups. It was found that 41.4% of the patients had itching complaints at least twice a week on average. The body areas that itched most were the arms legs (38.6%), back (25.7%), whole body (24.3%), abdomen (10.0%), and head neck (1.4%). When the pre-intervention severity of itching in all the patients was examined as per the VAS, it was seen that 32.9% of them experienced mild itching, 32.9% moderate, 22.9% intense, and 11.4% unbearable. Difference of the VAS, ISS, PSQI, and SF-36 QoL Physical and Mental Component scores between intervention and control group When the VAS, ISS, PSQI, and SF-36 QoL Physical and Mental Component scores of the patients in the control and intervention groups before and after the intervention were compared, the differences in the change were found to be statistically significant in favor of the intervention group (P < 0.05; Table 3). When compared to the pretest and control group, there was a significant decrease to the advantage of the intervention group in VAS (t = , P = 0.001) and ISS (t = 4.735, P = 0.001) scores. When compared to the pretest and control group, there was a significant decrease to the advantage of the intervention group in PSQI (t = 5.727, P = 0.001) scores (Table 3). When compared to the pretest and control group, there was a significant increase to the advantage of the intervention group in SF-36 QoL Physical Component (t = 4.600, P = 0.001) and Mental Component (t = 3.486, P = 0.001) scores (Table 3). While there was no significant difference between the pretest post-test scores of the control group in VAS (t = 0.627, P = 0.535), and SF-36 QoL Physical Component (t =-0.629, P = 0.534) and Mental Component (t =-1.308, P = 0.200) scales; an increase was seen to the disadvantage of the control group in ISS (t =-2.917, P = 0.006) and PSQI (t =-2.513, P = 0.017) scores. DISCUSSION It was found in this study conducted with HD patients who had itching that nearly half of the patients had itching problems for more than 1 year. Itching is the most commonly seen problem in HD patients and it can be irritating (Che-yi, Wen, Min-Tsung, & Chiu-Ching, 2005; Lin et al., 2011). Itching develops at any stage in the course of the prognosis of the disease in 185

7 E. Karadag et al. Japan Journal of Nursing Science (2014) 11, Table 3 Difference of VAS, ISS, PSQI, and SF-36 QoL physical and mental component scores between intervention and control groups at pretest and post-test Scores Intervention group, mean (SD) Control group, mean (SD) Significance, P-value VAS Pretest 5.68 (1.82) 5.77 (2.36) t = (0.866) Post-test 3.17 (1.67) 5.71 (2.24) t = (0.001) Difference 2.51 (1.46) 0.05 (0.53) t = , P = t = 0.627, P = t = , P = ISS Pretest (8.95) (7.34) t = (0.384) Post-test 8.85 (6.97) (7.22) t = (0.001) Difference 3.34 (5.17) (2.66) t = 3.823, P = t =-2.917, P = t = 4.735, P = PSQI Pretest 9.42 (4.66) (4.60) t = (0.489) Post-test 7.05 (3.41) (4.04) t = (0.001) Difference 2.37 (2.69) (1.81) t = 5.214, P = t =-2.513, P = t = 5.727, P = SF-36 QoL Physical component Pretest (14.84) (10.59) t = (0.001) Post-test (16.41) 27.51(10.36) t = (0.001) Difference (12.03) (2.68) t =-4.854, P = t =-0.629, P = t = 4.600, P = Mental component Pretest (12.39) (9.23) t = (0.057) Post-test (15.75) (9.42) t = (0.001) Difference (12.38) (3.73) t =-4.036, P = t =-1.308, P = t = 3.486, P = The score difference between intervention and control groups was evaluated with the independent Student s t-test. The score difference between the pre- and post-tests of the same group was evaluated with the paired sample Student s t-test. ISS, Itching Severity Scale; PSQI, Pittsburgh Sleep Quality Index; SD, standard deviation; SF-36 QoL, SF-36 Quality of Life Scale; VAS, Visual Analog Scale. the majority of the patients receiving HD treatment (Narita et al., 2008). When the studies assessing itching in HD patients were reviewed, Stahle-Bachdahl (1992) found that 66.6% of HD patients had itching problems, Balevi and Uysal (2000) 80%, Balaskas, Bamihas, Karamouzis, Voyiatzis, and Tourkantonis (1998) 53.7%, Pauli-Magnus et al. (2000) 22%, and Zucker, Yosipovitch, David, Gafter, and Boner (2003) 48%. It was found in this study that the body areas of patients that were itching the most were arms legs, back, whole body, abdomen, and head neck. Similarly, Lin et al. (2011) found that 74% the backs of their patients itched the most, 73% their lower extremities, 65.5% their upper extremities, 48% their trunks, and 27.9% their heads. It is stated in the published work that itching was observed mostly in the backs, arms, chests, and heads of HD patients (Patel, Freedman, & Yosipovitch, 2007; Pisoni et al., 2006). It was observed in this study that 32.9% of the patients experienced mild itching, 32.9% moderate, 22.9% intense, and 11.4% unbearable. The intensity and severity of itching in HD patients varies from patient to patient. While some patients have diffuse itching that is very difficult to endure and resistant to treatment, some others have short-lasting, localized, and temporary itching (Kılıç Akça & Tasci, 2011; Pisoni et al., 2006). Studies carried out on a different population report that 30 40% of dialysis patients have mild skin problems, 35 50% moderate, and 15 30% severe (Balaskas, Chu, Uldall, Gupta, & Oreopoulos, 1992; Szepietowski et al., 2002). Chiu et al. (2008) stated in their study that 37.4% of HD patients never experienced itching, 43.9% of them had moderate itching, and 18.7% very severe itching. Balaskas et al. (1998) found in their study that 48.3% of HD patients had mild itching, 41.1% of them moderate, and 10.3% severe. 186

8 Japan Journal of Nursing Science (2014) 11, Effect of baby oil in pruritic HD patients The results on severity of itching obtained in the abovementioned studies are parallel to the results reached in this study. Dry skin is the most common dermatological problem experienced by dialysis patients and leads to fluid loss in the stratum corneum (Narita et al., 2008). Dry skin is one of the main causes of itching (Wang et al., 2006). The effect of medical treatments remains limited in eliminating uremic pruritus in HD patients (Tol et al., 2010). However, it is mentioned in the published work that topical moisturizers can be effective in treating uremic pruritus (Aşıcıoğlu, Kahveci, Koç, & Özener, 2011; Kılıç Akça & Tasci, 2011; Yalçın, 2012). Application of moisturizers produces a superficial film layer on the skin and helps protect barrier functions to some extent. An oily layer also prevents epidermal fluid loss by detaining fluid under the stratum corneum (Yalçın, 2012). Morton et al. (1996) reported in their study that simple emollient therapy was effective on dry skin and improved decreased hydration, and they demonstrated that regular use of moisturizers reduced symptoms in 43% of the patients. It is also reported that baby oil protects the integrity of skin and reduces itching (Lin et al., 2011; Wang et al., 2006). It was found in this study that there was a significant difference between the intervention and control groups with respect to their mean itching in both VAS and ISS scores after the patients had been administrated cooled baby oil. While itching intensity declined in the patients of the intervention group, itching intensity did not decrease and, in fact, it was seen to increase in the control group according to the ISS. It was also stated in the published work that cool administration relieved uremic pruritus (Patel et al., 2007; Yosipovitch et al., 2001). Lin et al. (2011) also found that the post-intervention itching intensity decreased in the patients who had been administrated both cooled and non-cooled baby oil, whereas there was no difference between the post-intervention itching intensity scores in the patients who had not been administrated baby oil. Constant daytime and night-time itching causes patients to experience chronic fatigue and sleeplessness and this worsens their quality of life (Kılıç Akça & Tasci, 2011; Najafabadi et al., 2012). It was found in this study that the patients in both groups had sleep problems. However, there was a statistically significant improvement in sleep quality in the intervention group, whereas there was a statistically significant further impairment in sleep quality in the control group. Zucker et al. (2003) found that 61% of the patients had difficulty in falling asleep due to itching and 44% of them experienced sleep interruptions. Lin et al. (2011) found in their study that 55.91% of HD patients had sleep problems due to itching, 48.39% of these patients woke up at night due to itching, and 37.63% of them required sleeping pills to overcome the sleeplessness caused by itching. Similar to the results of this study, it was found in the same study that baby oil had a positive effect on the sleep scores. Yosipovitch et al. (2001) also reported in their study that itching intensified at night, leading to sleep problems in 60% of the patients. Uremic pruritus is a symptom that negatively affects quality of life in patients with chronic kidney disease (Aşıcıoğlu et al., 2011; Marthur et al., 2010; Yosipovitch et al., 2001). Walters et al. (2002) found in their study of HD patients that quality of life of the patients was higher in the early stages of HD and it gradually declined in later periods. In the study made by Szepietowski et al. (2002) with HD patients who had itching, they found the mean score of the mental component of quality of life to be and the mean score of the physical component of quality of life to be Similarly, the mean scores of mental and physical components of quality of life of HD patients were found to be low in the study of Tsay and Healstead (2002). In this study, the patients mean scores of quality of life were found to be below 50 in both the control and the intervention group the former with higher points before the intervention. However, a statistically significant increase was found in the post-intervention physical and mental component scores of quality of life in the intervention group who had been administrated baby oil, whereas no significant change in quality of life was observed in the control group. Because the authors encountered only one study investigating the effect of baby oil on itching, the results obtained in this study were not discussed adequately. CONCLUSION It was found in this study that administration of baby oil had short-term positive effects on itching, sleep quality, and quality of life in HD patients who had itching complaints. Nurses have important responsibilities in managing uremic pruritus as they spend a longer time with patients than other caregivers. It was seen in this study that it is possible for nurses to improve patients quality of life through regular assessment of uremic pruritus and employment of effective symptomatic treatment in HD patients. Baby oil can be used safely for treating uremic pruritus because it has no negative 187

9 E. Karadag et al. Japan Journal of Nursing Science (2014) 11, effects on body functions, is a non-invasive method, can be applied easily, and reduces healthcare costs. Therefore, the authors suggest that HD nurses should be encouraged to administrate baby oil, that patients with itching problems are advised to use it, and that experimental studies with large samples are carried out to obtain more evidence on this subject. LIMITATIONS The short-term effects of baby oil were evaluated in this study. Therefore, the results obtained in this study are only valid for the short-term effects of baby oil on itching. ACKNOWLEDGMENTS The authors wish to thank the doctors, nurses, and patients of HD units and also research assistants Sevda Arslan, Akgün Yeşiltepe and Veysel Alkın who contributed throughout the data collection process. REFERENCES Acaray, A. & Pınar, R. (2004). The evaluation of the quality of life in chronic hemodialysis patients. Cumhuriyet Üniversitesi Hemşirelik Yüksekokulu Dergisi, 8, (in Turkish). Ağargün, M. Y., Kara, H. & Anlar, Ö. (1996). Validity and reliability of Turkish version of Pittsburgh Sleep Quality Index. Türk Psikiyatri Dergisi, 7, (in Turkish). Aşıcıoğlu, E., Kahveci, A., Koç, M. & Özener, Ç. (2011). Uremik pruritis: Still itching. Turkish Nephrology, Dialysis and Transplantation Journal, 20, (in Turkish). Balaskas, E. V., Bamihas, G. I., Karamouzis, M., Voyiatzis, G. & Tourkantonis, A. (1998). Histamine and serotonin in uremic pruritis: Effect of Ondansetron in CAPD-pruric patients. Nephron, 78, Balaskas, E. V., Chu, M., Uldall, R. P., Gupta, A. & Oreopoulos, D. G. (1992). Pruritis in continuous ambulatory peritoneal dialysis and hemodialysis patients. Peritoneal Dialysis International, 13 (Suppl. 2), Balevi, S. & Uysal, H. (2000). Cutaneous alterations among patients undergoing hemodialysis. Genel Tıp Dergisi, 10, (in Turkish). Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R. & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, Chen, Y. C., Chiu, W. T. & Wu, M. S. (2006). Therapeutic effect of topical gamma-linolenic acid on refractory uremic pruritus. American Journal of Kidney Diseases, 48, Che-yi, C., Wen, C. Y., Min-Tsung, K. & Chiu-Ching, H. (2005). Acupuncture in haemodialysis patients at the Quchi (LI11) acupoint for refractory uraemic pruritus. Nephrology Dialysis, Transplantation, 20, Chiu, S. L. & Hsieh, P. L. (2005). Nursing of using cold and hot. In: L. J. Su (Ed.), Practical basic nursing (4th edn). pp. 3 54). Taipei: Wey Far Books Co. Ltd. Chiu, Y. L., Chan, H. Y., Chuang, Y. F., Hsu, S. P., Lai, C. F., Pai, M. F. et al. (2008). Association of uraemic pruritis with inflammation and hepatitis infection in haemodialysis patients. Nephrology Dialysis, Transplantation, 23, Çölbay, M., Yüksel, Ş., Fidan, F., Acartürk, G., Karaman, Ö. & Ünlü, M. (2007). Evaluation of the hemodialysis patient with Pittsburgh sleep quality index. Tüberküloz ve Toraks Dergisi, 55, (in Turkish). Falodun, O., Ogunbiyi, A., Salako, B. & George, A. K. (2011). Skin changes in patients with chronic renal failure. Saudi Journal of Kidney Diseases and Transplantation, 22, Fresenius Medical Care. (2012) Dialysis market. [Cited 20 Sep 2012.] Available from URL: com/reports/fmc/annual/2008/gb/english/401040/dialysis market.html Hsu, M. C., Chen, H. W., Hwu, Y. J., Chanc, C. M. & Liu, C. F. (2009). Effects of thermal therapy on uremic pruritus and biochemical parameters in patients having haemodialysis. Journal of Advanced Nursing, 65, Kennet, J., Hardaker, N., Hobbs, S. & Selfe, J. (2007). Cooling efficiency of 4 common cryotherapeutic agents. Journal of Athletic Training, 42, Kılıç Akça, N., Karataş, N. & Tasci, S. (2011). The effect of acupress on pruritus status of patients having hemodialysis. Erciyes University, Institute of Health Sciences Department of Nursing, Unpublished Doctoral Thesis. (in Turkish). Kılıç Akça, N. & Tasci, S. (2011). Uremic pruritis in hemodialysis patients and acupressure practice. Maltepe Üniversitesi Hemşirelik Bilim ve Sanat Dergisi, 4, (in Turkish). Kuypers, D. R. (2009). Skin problems in chronic kidney disease. Nature Clinical Practice Nephrology, 5, Lin, T. C., Lai, Y. H., Guo, S. E., Liu, C. F., Tsai, J. C., Guo, H. R. et al. (2011). Baby oil therapy for uremic pruritis in haemodialysis patients. Journal of Clinical Nursing, 21, Marthur, V. S., Lindberg, J., Germian, M., Block, G., Tumlin, J., Smith, M. et al. (2010). A longitudinal study of uremic pruritus in hemodialysis patients. Clinical Journal of The American Society of Nephrology, 5, Mettang, T., Frıtz, P., Weber, J., Machleıdt, C., Huè Bel, E. & Kuhlmann, U. (1990). Uremic pruritus in patients on hemodialysis or continuous ambulatory peritoneal dialysis (CAPD). The role of plasma histamine and skin mast cells. Clinical Nephrology, 34,

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