Effectiveness of Skill Building Education on Arteriovenous Fistula Self-Care Behaviors and Quality of Life of Patients on Hemodialysis
Phase: NA
Conditions: Chronic Kidney Disease, Hemodialysis, Hemodialysis Access Failure
Sponsor: Shifa Tameer-e-Millat University

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Effectiveness of Skill Building Education on Arteriovenous Fistula Self-Care Behaviors and 
Quality of Life of Patients on Hemodialysis:  
Randomized Controlled Trial 
 
NCT number: not assign yet 
 
Date: April 20, 2025 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Introduction 
This chapter provides a succinct overview of the international and national prevalence of 
chronic kidney disease (CKD) and its associated treatments, especially hemodialysis. It will 
primarily focus on vascular access (VA) considerations for hemodialysis patients, specifically 
arteriovenous fistulas (AVF). It will compare AVF with the central venous catheter (CVC) and 
arteriovenous graft (AVG). Furthermore, it explores the relationships between hemodialysis, 
AVF, self-care behaviors, and quality of life. The chapter also highlights gaps in the existing 
literature regarding patient teaching and skill-based education, and addresses contextual issues 
that form the foundation of the study. Additionally, it outlines the problem statement, 
significance of the research, and purpose of the study, as well as presents the research question 
and hypothesis.  
Chronic Kidney Disease and Hemodialysis 
Chronic kidney disease (CKD) poses a significant global health challenge, leading to 
high mortality and healthcare expenses (Carney, 2020; Jager & Fraser, 2017; Neuen et al., 2017). 
CKD has emerged as the third fastest growing cause of death worldwide and the fifth most 
common cause of year of life lost by 2024 (Bikbov et al., 2020). Notably, a literature review of 
the epidemiology and prevalence of CKD indicated that the overall prevalence of CKD in 
Pakistan is substantial, reaching 21.2% (Imtiaz & Alam, 2023).  
CKD exhibits a gradual progression, evolving from its early stages to eventual renal 
failure. According to Jager and Fraser (2017), 3.9 million individuals living with CKD 
worldwide were treated with renal replacement therapy. Hemodialysis is the most prevalent form 
of renal replacement therapy. Specifically, 89% of cases worldwide are attributed to 
hemodialysis while 11% to peritoneal dialysis (Bello et al., 2017, 2019; Pecoits-Filho et al., 
2020). In Pakistan, the approach to hemodialysis becomes more difficult owing to its high cost 
(Shafi et al., 2018). However, hemodialysis is less costly than renal transplantation. Furthermore, 
it is the most easily available treatment in Pakistan (Imtiaz & Alam, 2021).  
Hemodialysis is the preferred method to remove accumulated toxins and waste products 
from the body with the help of a machine (hemodialyzer) through diffusion and ultrafiltration 
(Lee, 2017). It is noteworthy that hemodialysis demands a VA in which the blood can quickly 
move between the patient’s body and hemodialyzer. However, VA provides adequate blood 
flow, is easily accessible, cost-effective, has excellent long-term patency, and has a lower 

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complication rate (Santoro et al., 2014). Hemodialysis patients develop a range of complications 
related to vascular access. The complications arising in the VA lead to the critical role of patients 
in managing their VA. Patients should be educated and trained to maintain, monitor, and manage 
changes in their VA (Sousa et al., 2014, 2020). Patient care for VA significantly enhances the 
functionality and longevity of VA, as well as the quality of life, lowering the complication rates 
to ensure more efficient dialysis treatment (Lok et al., 2020).    
Vascular Access for Hemodialysis Patients 
Successful hemodialysis therapy necessitates patients to possess a VA. Effective dialysis 
depends on easy and repetitive cannulation, rapid blood flow, and excellent patency of the VA 
(Abo El-Fadl, 2020). Epidemiological data show that there is considerable variation in the 
establishment, use of VA, and patient preference in selection for VA among different countries 
worldwide (Asano et al., 2013; Balamuthusamy et al., 2020; Field et al., 2019; Pisoni et al., 
2018). Additionally, it is essential to consider the functionality and impact of VA on a patient’s 
overall health and quality of life (Gomes et al., 2013). Several VA options are available, 
including CVC, AVG, and AVF (Schmidli et al., 2018). The appropriate VA is selected based on 
various factors such as the patient’s age, vascular anatomy, comorbidities, and personal 
preferences (Asano et al., 2013). An AVF is an anastomosis between an artery and a vein, 
allowing arterial blood to flow through a large-bore vein. The engorgement of the artery and 
enlargement of the vein facilitates swift arterial blood flow, which is required for hemodialysis 
treatment. Different types of AVF anastomosis are created, such as side-to end of the vein to the 
artery, lateri-lateral, and terminalized side-to-side of the artery vein (Santoro et al., 2014). AVFs 
are named according to their placement in specific body parts. Upper extremities AVFs, such as 
radio cephalic, forearm basilic, and brachial cephalic AVFs, are more common than the lower 
extremities femoral and transpose femoral AVFs.  
The AVG is similar to the AVF, connecting the artery and vein; however, it employs a 
plastic tube. However, CVC is a catheter inserted into the subclavian, jugular, or femoral veins. 
Hemodialysis starts soon after the insertion of the CVC and from two to four weeks after the 
creation of the AVG (Lin et al., 2021). However, AVF require more time for maturation; 
therefore, hemodialysis starts six weeks after AVF creation (Sabiu & Gallieni, 2023). The 
preferred site for AVF in Pakistan is the forearm, which matures within 42 days, and 
hemodialysis is initiated after AVF maturation.  

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AVF is considered the most effective and preferred vascular access method. National and 
international guidelines advocate the use of AVF for hemodialysis therapy in patients with CKD 
(Napalkov et al., 2013) for several reasons such as lower incidence of infection (9.5%) (Demiral, 
2017) and increased patency rates (60-71%) compared to other VA (Al-Jaishi et al., 2017). In the 
case of AVF, unlike other VA, the vascular endothelium is maintained, reducing the risk of 
infection and hospitalization (Farrington et al., 2020). According to He and Liu (2023), CVC 
have more readmissions due to complications. Moreover, CVC is strongly associated with 
elevated mortality rates (35.6%) (Campos et al., 2024); hence, AVF is a better choice. 
Additionally, functional AVFs in hemodialysis patients minimize the risk of complications and 
improve well-being (Gomes et al., 2013). The preventable complications associated with AVFs, 
ranging from aneurysms to stenosis and infections, underscore the critical need to teach patients 
self-care (Sousa et al., 2014).  
Patients Role in AVF Self-Care  
The intricate nature of caring for AVF in hemodialysis patients highlights the role of 
patients’ self-care behaviors. Hemodialysis patients who practice self-care for their AVFs 
experience notable benefits such as increased satisfaction, maintained fistula functionality, 
prevention of AVF complications, low hospitalization rate, and enhanced quality of life (Avanji 
et al., 2021; Pessoa & Linhares, 2015; Riegel et al., 2021). Self-care includes a range of 
activities, skills, and self-awareness intended to improve health and well-being (Johnsson et al., 
2023; Marzband & Zakavi, 2015; Matarese et al., 2018). Self-care is a comprehensive concept 
encompassing a variety of behaviors such as self-care maintenance, self-care monitoring, and 
self-care management (Jaarsma et al., 2020). Self-care maintenance involves the activities 
required to maintain physical and mental health and prevent illness, such as exercising, taking 
prescribed medication, diet modification, and treatment adherence (Riegel et al., 2021). Self-care 
monitoring refers to the ongoing process of observing and noticing any changes in health status. 
Self-care management also includes the actions that individuals take to control and cope with 
changes in their health status.  
The self-care maintenance of AVF involves actions to maintain functionality (Pessoa & 
Linhares, 2015). It includes preventive measures such as avoiding venous puncture for blood 
samples, medicine infusion, and measuring blood pressure on the AVF arm. Additionally, 
patients are suggested to refrain from wearing tight clothing, jewelry, and lying down or putting 

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pressure on the AVF arm (Adib-Hajbagheri et al., 2014; Ozen et al., 2017; Pessoa & Linhares, 
2015; Roso et al., 2015).  According to Kim and Cho (2021), patients quickly exhibit self-care 
maintenance behaviors regarding medication and fistula care. Moreover, a few experimental 
studies have revealed that patients adopt self-care maintenance behaviors related to AVF after 
educational interventions (Alsaqri et al., 2019; Sousa et al., 2021). Consistent self-care 
maintenance makes patients more attuned to their body and daily activities. Moreover, self-care 
maintenance helps patients to establish a standard baseline health indicator.  
Understanding of the baseline is crucial for recognizing the changes in the body. In 
addition, it leads to monitoring of changes closely (Riegel et al., 2012). Self-care monitoring 
behaviors regarding AVF care include looking, listening, and feeling. This involves:  
 The observation of the AVF in terms of its appearance 
 Palpating over the AVF and feeling the thrill  
 Listening to the bruits sound over the AVF.  
These behaviors assist hemodialysis patients in maintaining the functionality of their 
fistulas and preventing complications (Pessoa & Linhares, 2015). However, the literature shows 
that 98% of hemodialysis patients lack knowledge of fistula care (Pessoa & Linhares, 2015). 
Furthermore, some studies have shown that patients cannot identify signs and symptoms of 
complications (Ozen et al., 2017; Pessoa & Linhares, 2015; Sousa et al., 2021). Monitoring AVF 
in hemodialysis patients enables the detection of potential changes. Since the fistula is visible on 
the patient’s body, it can be visually inspected and cared for daily. This proactive approach 
facilitated timely intervention and management.  
Self-care management involves the implementation and evaluation of treatments and 
interventions (Riegel et al., 2019). This ultimately improves the longevity and functionality of 
arteriovenous fistulas. According to Corbin and Strauss, patient education on self-care should 
address the adoption of meaningful behavioral changes and monitoring (Corbin& Strauss, 1988). 
When patients detect the signs and symptoms of their condition, they often seek to adopt a 
variety of interventions to address or manage changes. Self-care management of AVF depends on 
the symptoms that occur. For instance, cold or hot fomentation and elevation of the AVF arm can 
be applied in cases of swelling. Similarly, pressure should be applied directly to the bleeding site 
if bleeding occurs. Furthermore, the absence of thrill or bruit sounds indicates the need for 

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medical investigation and intervention. Notably, monitoring an AVF in response to any change is 
a crucial step in its management.  
Proficiency and mastery in self-care behaviors related to AVF can result in effective 
monitoring and facilitation of better self-management (Martínez et al., 2021; Riegel et al., 2012). 
It requires intentional efforts from patients to assume responsibility for their health and 
effectively manage their condition (Blok, 2017; Ince et al., 2017; Jeffs et al., 2015; Kong et al., 
2021). Developing self-care behavior in all components of maintenance, monitoring, and 
management enables patients to care for AVF effectively. By maintaining the AVF site, 
monitoring for potential complications, and managing it effectively, patients can ensure the 
functionality of AVF. This comprehensive approach not only preserves the AVF but also 
improves the clinical outcomes and quality of life of hemodialysis patients.  
Arteriovenous Fistula and Quality of Life 
Quality of life is an indicator of the effectiveness of the medical care provided to patients 
undergoing dialysis. Evidence suggests that all key domains (physical, social, role functioning, 
emotional, mental/psychological, general health, vitality, and spiritual) of quality of life are 
closely associated with patient survival (Peipert et al., 2019). Physical health is essential for 
overall well-being, reflecting normal functioning of the body in the absence of disease and 
illness. The factors associated with this domain include pain, discomfort, rest, sleep, and energy 
levels. Moreover, it is the ability to work and the extent to which a person can perform their roles 
in daily life activities to maintain their health status (Verberne et al., 2019). Social health 
encompasses personal relationships and interactions with others and impacts the quality of life. It 
is also considered a clinical outcome(Urquhart-Secord et al., 2016). With regard to  emotional 
health, the key indicators of emotional health are emotional functioning, the experience of 
emotional pain, emotional distress, and any issue that interferes with daily life activities (Peipert 
et al., 2019). Likewise, the psychological aspect refers to the body image, self-esteem, memory, 
recognition, and concentration. Furthermore, the spiritual domain includes values, beliefs, and 
relationships with oneself and with superpowers. These factors influence the overall quality of 
life (Yang et al., 2015).  
  Reflecting the complexity of the disease itself, VA is viewed as affecting health-related 
quality of life and symptoms, both directly and indirectly (Robert & Petersen, 2013). Health-
related quality of life (HRQOL) is significantly different among patients undergoing dialysis via 

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CVC and AVF (Maguire et al., 2022). In addition, the degree of access drastically affects 
patients’ quality of life (Nordyke et al., 2020). A study on different hemodialysis access types 
revealed that patients with AVF were more satisfied with their vascular access than those with 
CVC. This satisfaction improves patients’ overall QoL (Maguire et al., 2022; Robert & Petersen, 
2013). Moreover, a study examined HRQOL among various AV access types, and the findings 
revealed that the AVF group’s mean scores were higher in the physical composite summary, 
social functioning, mental composite summary, physical functioning, role functioning, role 
emotional, and general health domains of HRQOL than CVC after three months. Similarly, the 
average score in all HRQOL domains increased after one year compared with AVG and CVC. 
Moreover, patients with AVF were more satisfied with their lives (Kim, 2020). In contrast, 
patients showed higher dissatisfaction with CVC care (Browne et al., 2022). CVC interferes with 
normal routine activities, such as bathing, and is challenging to care for compared to AVF. In 
contrast, the current management practice for the access type is to keep the access area dry and 
clean. However, pain is less likely to be associated with CVC (Maguire et al., 2022). In contrast, 
patients with AVF are more concerned about bleeding, bruises, pain, edema, and swelling, which 
adversely affect the physical domain of QOL (Maguire et al., 2022). Hence, AVF care is more 
bothersome than catheter access, and AVF requires more significant consideration than the 
symptoms attributed to the physical domain. 
Skill Building Educational Interventions for Self-Care Behaviors  
Patients can significantly enhance the functionality of AVF by adopting self-care 
behaviors. AVF self-care behaviors can easily be incorporated into daily routines, allowing 
patients to perform consistently (Sousa et al., 2017).  Effective AVF self-care behaviors can be 
achieved through educational sessions and training. Moreover, education enhances health 
literacy, helps patients maintain their AVF in good condition, preserves patency, prevents 
complications, makes informed decisions, and actively engages in health care (Kukita et al., 
2015). However, it is essential to consider how educational sessions are delivered to the patients. 
Learning strategies must be tailored to the patient’s level of understanding and involvement.  
Teach-back is a highly effective teaching-learning strategy to improve self-care 
behaviors. The effectiveness of the teach-back mechanism is evaluated in different 
circumstances, such as in enhancing knowledge and skills while utilizing self-care skills training 
skills in adult patients. It encourages patient engagement and involvement, ensuring they 

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comprehend information, identifies mistakes and misunderstandings, and corrects them as 
needed (Pessoa & Linhares, 2015; Şahan et al., 2023). Moreover, the teach-back method was 
found to be effective in providing discharge teaching and satisfaction in emergency patients, 
improving hemodialysis patients’ self-care, reducing anxiety in C-section patients, and 
improving self-care status in post-menopausal women. Furthermore, it improves patients’ quality 
of life (Abbasi Abianeh et al., 2020; Bahri et al., 2018; Ghiasvand et al., 2017; Griffey et al., 
2015; Katrachanca & Koleske, 2017; Shen et al., 2023).  
To develop self-care behaviors for AVFs, patients require skills-building education to 
manage themselves at home. Skill-building education emphasizes the practical abilities and 
competencies of patients in managing themselves at home. This skills intervention starts by 
assessing current knowledge and recognizing it as a foundation. Then, individuals need tactical 
skills, such as “how to,” as well as situational skills, such as “what to do and when” (Dicksonet 
al., 2014; Dicksonet al., 2014 ). Skill-building education has been effective in focusing skills 
deficits and improving heart failure patients’ self-care and quality of life (Dickson et al., 2014). 
Hemodialysis patients require skills to learn self-care maintenance, monitoring, and management 
of AVF. Health education, along with skill building, works as a comprehensive approach to 
improving patients’ overall well-being. With skills-building education through the utilization of 
the teach-back strategy, hemodialysis patients address their self-care maintenance, monitoring, 
and management of their AVF, improving their overall self-care management and abilities.  
Current Practices related to AVF Care in Pakistan 
In Pakistan, in current practice, patients need to receive education regarding self-care for 
AVF. They have limited information, such as avoiding blood pressure measurement on the 
affected arm and avoiding heavy lifting and shifting with the AVF arm, as well as sleep over the 
AVF arm. In addition, they did not avoid tight jewelry and clothing on the AVF arms (Iqbal et 
al., 2018; Rashid et al., 2018). Moreover, when the patients were asked about the assessment of 
their fistula, the majority responded that they knew that there was increased pulsation over the 
fistula, but they did not assess their fistula daily (Sultan et al.,2023; Rashid et al., 2018). In 
addition, only some self-care actions were performed by the patients, despite knowing about it. 
For instance, the majority of patients responded that they had knowledge about thrill palpation, 
disinfection of AVF, and washing of AVF before dialysis, but only a few patients performed 
these actions. However, only some aspects of self-care for AVF were performed by the patients, 

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and they demonstrated good knowledge, attitude, and practice. For instance, they knew why they 
needed AVF, felt the need to take care of their AVF, avoid cannulation on the AVF arm, and 
avoid weight lifting (Iqbal et al., 2018; Rashid et al., 2018). When they were asked about how 
often they received information on self-care of AVF from health care providers, they responded 
that the health care staff told them only about pressure application at the AVF site and the time to 
remove the dressing over the AVF after dialysis. Information related to AVF self-care should be 
included. Similarly, they must receive written information on AVF self-care (Sultan et 
al.,2023).Consistently, no significant correlation was found in knowledge regarding dialysis 
duration because of the need for more repetition of relevant information on AVF self-care by 
healthcare staff (Rashid et al., 2018).  
Gap in the Literature 
Self-care of AVF in hemodialysis patients is an important consideration. The literature 
shows that educational interventions effectively enhance AVF self-care behaviors in 
hemodialysis patients. Health care providers can design an educational program or protocols to 
develop AVF self-care behavior in hemodialysis patients (Ibeas et al., 2017; Sousa et al., 2017; 
Trask et al., 2016). Moreover, several guidelines recommend educating hemodialysis patients to 
take care of their AVF (Ibeas et al., 2017; Kukita et al., 2015; Schmidli et al., 2018). The existing 
literature indicates that numerous educational interventions have influenced treatment adherence 
among hemodialysis patients across various aspects, including medication adherence, dietary 
modification, adjustment of fluid and electrolyte balance, and management of interdialytic 
weight gain, except for AVF care (Cho & Kang, 2021; Sultan & Froelicher, 2023; Tao et al., 
2020;Yangöz et al., 2021). Moreover, limited literature is available on the self-care behavior of 
patients with AVF; few studies suggest the theoretical aspects of AVF self-care of hemodialysis 
patients that address only the self-care maintenance of AVF. Minimal information is provided on 
interventions that should be included in the educational program to empower patients for their 
fistula care (Pessoa & Linhares, 2015a; Sousa et al., 2021). Only one study highlighted self-care 
maintenance and self-care monitoring of AVF by integrating the theoretical and practical aspects 
of their educational intervention (Sousa et al., 2021). Therefore, designing more effective and 
structured interventions are required to guide and train the hemodialysis patients for adopting 
AVF self-care behaviors while considering the all the component of self-care (Self-care 

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maintenance, self-care monitoring and self-care management). Thus, this study will focus on 
adopting the self-care behavior of AVF via skills building education. 
Problem Statement  
AVF plays a crucial role in hemodialysis therapy, yet its care is often overlooked leading 
to compromised functionality (Pessoa & Linhares, 2015). A dysfunctional fistula poses 
significant health risks, contributing to higher morbidity in terms of complications such as 
infection, bleeding, stenosis, thrombosis, and aneurysm. These complications can lead to medical 
and surgical treatment and, ultimately, a higher mortality rate. Self-care of the AVFs allows the 
patient to determine whether their fistula is functioning correctly. In Pakistan, the primary 
researcher has observed that patients often only become aware of their AVF dysfunction when 
they come for a hemodialysis session. This lack of awareness is due to not knowing how to 
properly maintain, monitor, and manage their AVF at home, which prevents them from 
effectively managing it. The dysfunction of their AVF necessitates the radiological evaluation. 
Based on the radiology findings, an alternative route may be required for hemodialysis (Sultan, 
et al., 2023). This condition not only becomes painful but also places patients at risk of 
complications and inadequate dialysis. Furthermore, it leads to a financial burden due to 
additional medical intervention and unplanned treatment. Therefore, a functional AVF is a 
significant requirement for hemodialysis treatment. Effective self-care behaviors, including all 
components (maintenance, monitoring, and management) is crucial for AVF functionality. To 
mitigate the issues related to AVF and develop self-care behaviors in hemodialysis patients, 
education and training are essential. These efforts are likely to empower patients to identify 
abnormalities promptly and seek timely intervention, reduce complications, ultimately enhancing 
dialysis efficiency, and improving their overall quality of life.  
Significance of the Study 
Skill building educational intervention plays a crucial role in influencing the self-care 
behaviors of patients. Providing patient education and imparting skills on how to care for their 
AVF can foster a positive change in the health of patients. Patients are more likely to engage in 
proactive health care behavior when equipped with the knowledge and necessary skills. 
Moreover, it encourages a sense of ownership in their health care journey. Knowledge 
acquisition and behavior modification through skill building are essential for improving the 
health-related outcomes and quality of life (Liu et al., 2016). Practicing proper hygiene and self-

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care monitoring and self-care maintenance can empower patients and their families to identify 
the potential issues in their AVF. Early recognition of issue in the functionality of AVF might 
allow for prompt intervention, reducing the risk of serious complications. Educating patients and 
their families about AVF care can contribute to the longevity and functionality of AVF. 
Moreover, it improves the hemodialysis treatment and positively impacts their quality of life. 
Furthermore, financial, physical, emotional, and psychological burden may be reduced. This 
educational and skills building intervention has the potential to be integrated into the protocol of 
dialysis units. Moreover, it can ensure structured training for the health care provider, fostering 
expertise in AVF care, and improving the clinical practices.  
Purpose of the Study 
This study will assess the effectiveness of skill building educational interventions in 
improving the self-care behaviors and quality of life of AVF in hemodialysis patients.   
Research Question 
What is the effect of skill building education on the self-care behaviors of AVF care in 
patients undergoing hemodialysis treatment?  
What is the effect of skill building education on the quality of life in patients with AVF 
undergoing hemodialysis treatment? 
Hypothesis 
Ho 1. Skill building education interventions will have no effect on the self- care 
behaviors of AVF in patients undergoing hemodialysis treatment.  
Ha 1. Skill building education interventions will have a significant effect on the self- care 
behaviors of arteriovenous fistula in patient undergoing hemodialysis treatment.  
Ho 2.  Skill building education interventions will have no effect on the quality of life in 
patients with arteriovenous fistula undergoing hemodialysis treatment. 
Ha 2.  Skill building education interventions will have a significant effect on the quality 
of life in patients with arteriovenous fistula undergoing hemodialysis treatment. 
Patient education is a paramount strategy, often considered as the most practical approach 
to augmenting patient knowledge and promoting self-care (Sousa et al., 2020). Moreover, 
patients should be taught to assess and monitor their AVF for signs and symptoms nonfunctional 
AVF (Alsaqri et al., 2019). The literature reports that patients’ education regarding the AVF self-
care positively affect self-care behaviors (Sousa et al., 2020). Consequently, there is pressing 

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need to implement intervention aimed at fostering self-care behaviors of hemodialysis patients 
related to AVF.  
Theoretical Framework 
Self-care embodies a proactive approach directed toward sustaining health through the 
adoption of health promoting behaviors and the management of illness. This concept transcends 
the mere treatment of illness and incorporates a broad spectrum of daily activities engaged to 
preserve their wellbeing (Riegel et al., 2012). For instance, activities such a tooth brushing, 
bathing, and food consumption exemplify the practical application of self-care. This concept has 
been elucidated by numerous theorists in their theories and models. The middle-range theory of 
self-care for chronic illness focuses on the self-care behaviors associated with the diagnosis of 
chronic illness.  Moreover, it emphasizes that the healthcare provider needs to understand where 
patients having difficulties in adopting and maintaining self-care behaviors (Riegel et al., 2012). 
Healthcare providers can play crucial role in promoting the self-care of the patients. Moreover, 
individuals prioritizing self-care predominantly emphasize self-improvement (Marzband & 
Zakavi, 2015). The middle-range theory of self-care for chronic illness guided the organization 
and conceptualization of the study variables.  The middle-range theory of self-care for chronic 
illness possesses three components: self-care maintenance, self-care monitoring and self-care 
management (Riegel et al., 2012). Initially, patients will be introduced to the basic principles of 
self-care maintenance, followed by monitoring techniques and training in management strategies. 
This hierarchical approach may facilitate systematic skills acquisition and knowledge 
advancement for ensuring patients develop a comprehensive understanding and proficiency in 
AVF self-care behaviors.  
Self-care Maintenance  
Self-care maintenance pertains to conscientious behaviors to sustain overall wellbeing, 
promote optimal health, and preserve both physical and emotional equilibrium (Riegel et al., 
2012). Hemodialysis patients are expected to actively participate in their care, including 
maintaining the health and functionality of their AVF. The most common AVF self-care 
instructions include refraining from applying pressure on the AVF, avoiding blood pressure 
monitoring and blood sampling from the AVF arm, avoiding tight clothing and jewelry on the 
AVF arm, and abstaining from exerting force or carrying heavy weights with the AVF arm 
(Pessoa & Linhares, 2015). Furthermore, Costa Pessoa et al., (2020) identified three themes for 

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functional AVF. These themes are: self-care actions for preserving AVF, self-care actions for 
prevention and monitoring of AVF complications, and self-care action at perioperative AVF 
construction. Self-care actions aimed at AVF preservation including actions that are necessary 
for the self-care maintenance of AVF. Furthermore, these self-care maintenance actions were 
examined across eight studies (Costa Pessoa et al., 2020).  According to Riegel (2012), self- care 
behaviors build on the foundation of self-care maintenance. When patients master self-care 
maintenance, they can easily adopt self-care monitoring actions. 
Self-care Monitoring  
Self-care monitoring entails vigilant observation or attentive listening to one’s body. The 
primary objective of self-care monitoring is to differentiate the normal anatomy and physiology 
from abnormal condition or changes in the body (Riegel et al., 2012).  In chronic illness, self-
care monitoring includes measuring blood pressure, sugar level, height and weight and observing 
wound condition. Adopting self-care monitoring allows patients to notice the change in their 
physical health.  According to Costa Pessoa (2020) the second theme is prevention and 
monitoring of complications of AVF, indicates that action must be taken to identify or prevent 
the complications. Among these complications were thrombosis, bleeding, infection, hematoma, 
and steal syndrome. Therefore, the AVF limb must be examined regularly to determine its 
appearance and presence of thrill. Recognizing the physical changes initiates the decision-
making process regarding the necessary course of action. Consequently, it becomes imperative 
for individuals to be aware of their symptoms and proficient  in self-care monitoring (Riegel et 
al., 2019). Implementing self-care monitoring of AVF among hemodialysis patients is readily 
achievable. Furthermore, a systematic review and meta-analysis (Almasri et al., 2016) focusing 
on outcomes for vascular access for hemodialysis underscores the necessity for regular limb 
examination. This examination should enable patients to visually inspect, palpate, and auscultate 
their AVF.  Routine monitoring of AVF blood flow can be accomplished by palpating the AVF 
site with the palm to detect the presence of a thrill. This tactile observation enables patients to 
discern between the normal and abnormal conditions of the AVF. Additionally, the identification 
of bruit can be detected by auscultating/using a stethoscope. This auscultation is relatively 
straightforward and can be conveniently conducted at home by the patients themselves (Sousa et 
al., 2017).  

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 Self-care Management 
The monitoring of any change or identification of symptoms leads to self-care 
management. When patient monitored their symptoms, then they are prompted to take action or 
make decisions regarding their care or interventions (Riegel et al., 2012). In self-care 
management, the patients can evaluate the treatment implementation. Patients who manage their 
self-care can improve their health status, and overall well-being, and enhance their quality of life 
(Riegel et al., 2012). They can decide what further actions could be required to positively 
change/manage their health and overall wellbeing. For instance, when patients notice that 
medication for the blood pressure is not controlling the blood pressure. So, they consult with the 
physician to change the medication so that they can have better control over their blood pressure.  
Self-care management depends upon the presence of symptoms. Monitoring of the arteriovenous 
fistula in hemodialysis patients enables the detection of potential changes and facilitates timely 
intervention. For instance, patients can perform self-care management actions such as cold 
compression within 24 hours in case of a puncture to the AVF area or in the presence of any 
redness, swelling, or pain (Pessoa & Linhares, 2015). Likewise, report to the health care 
providers in case of absence of thrill or bruit sound.  Proficiency and mastery in maintaining 
health behaviors related to AVF can result in effective monitoring and management. Likewise, 
effective monitoring leads to effective management (Martínez et al., 2021; Riegel et al., 2012). 
However, different factors affect the patient’s self-care behaviors AVF. such as motivation, 
knowledge, skills, abilities to understand and implement the process, cognitive impairment, 
culture, and norms (Arnault, 2018; Cocchieri et al., 2015).  
Study Design 
The randomize control trial (RCT) parallel design with the allocation ratio 1:1 will be 
employed to assess the effectiveness of a skill-building educational intervention on the self-care 
behaviors and quality of life of AVF in hemodialysis patients. An RCT is considered the gold 
standard for evaluating the impact of an intervention on outcomes. In a parallel RCT design, one 
group receives the intervention while the other group receives routine care. In this study, one 
group will receive a skill building educational intervention focused on AVF self-care behaviors 
while the other group will receive routine care information.  

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Participants 
This study will involve participants meeting the eligibility criteria. Specifying inclusion 
and exclusion criteria enhances the likelihood of obtaining reliable and reproducible results and 
protects valuable individuals from exploitation (Nikolopoulou, 2023). A set of defined inclusion 
and exclusion criteria has been established to ensure that participants are appropriately selected 
to address the study's objectives. 
Inclusion Criteria 
The study will include patients:  
1. 
diagnosed with end-stage renal disease on hemodialysis through an arteriovenous fistula  
2. 
aged 18 years or above. 
3. 
who can read and understand the Urdu language. 
Exclusion Criteria 
  
The study will exclude patients:  
1. having any physical or mental disabilities that can interfere with their capacity to perform 
daily life activities. 
2. with any visual and hearing impairment.  
Recruitment  
Patients will be recruited from two dialysis units. Effective recruitment and advertisements 
play a vital role in reaching and engaging potential participants. Annexure 1 includes information 
that will be shared with unit managers and staff at these two units about the study.  
Screening  
Medical Record Screening. The PI will obtain hospital approvals to review patients’ medical 
records at the two hemodialysis units. The process will include creating a detailed checklist 
based on the study inclusion and exclusion criteria to guide the review of each medical record. 
The PI will take any necessary measures to ensure that medical records are anonymized and 
patient confidentiality is protected by pseudonymization (replacing their medical record number 
or ID with the private identifier). The PI will review the medical records and document each 
potential participant’s eligibility based on the inclusion and exclusion criteria (Annexure 2). 
Contacting Eligible Participants. A data analyst will be hired who will contact and brief the 
potential patients in the dialysis units during their dialysis procedure in all shifts on daily basis 
until the sample size achieved. A brief contact with patients will include sharing the study 

16 
 
purpose, what participation would involve, and why they were selected (Annexure 3). Patients 
will be allowed time to ask questions.  If the patients express interest in participating, a meeting 
will be scheduled to go through the informed consent form in detail. Consenting will take place 
in a private room in the dialysis unit after dialysis procedure.   
Study Setting  
This proposed study will be conducted at two dialysis units within a private tertiary-level 
hospital in Islamabad, Pakistan. These units are located in different buildings of the hospital. 
Unit one is within the main premises of the hospital, whereas unit two is in a medical centre 
managed by the hospital. This medical unit is located six kilometers distance from the main 
hospital. Unit one accommodates up to 100 hemodialysis patients on a daily basis, divided across 
three shifts: morning, afternoon, and evening. Similarly, unit two, accommodates up to 70 
hemodialysis patients on a daily basis, following the same shift schedule. Each hospital units 
consists of several rooms, 4-6 beds in each room. 
The study is planned to be conducted between January-2024, to December 2026 upon the 
approval of the study from the relevant ethical review boards. 
Group Assignment 
Control Group 
The control group will receive the routine care information at the hemodialysis units. The 
health care staff provide the usual routine care to patients during their regular dialysis 
procedures. There is no predetermined schedule for the routine care at these units but it consists 
of the application of dressing on the AVF and health care staff providing the following 
information to patients verbally: 
 Refraining from pulling or pushing objects with the arm having a fistula  
 Avoid measuring B.P. on the AVF arm  
 Do not apply pressure on the fistula area 
 Do not provide a sample from the affected side 
 Wash the fistula with soap and water 
 Remove the bandage upon return home following dialysis 
All the research process in the control group will be conducted in the same manner as those in 
the intervention group, with the exception of intervention itself. 

17 
 
Intervention Group  
The intervention group will receive skill-building education as developed by Sousa 
(2021) to enhance self-care behaviors in hemodialysis patients with AVF. Sousa’s educational 
model is based on the middle-range theory of self-care for chronic illness and includes both 
didactic and practical components (Riegel et al., 2012).  The didactic part provides knowledge 
base about AVF self-care. The practical part promotes skills acquisition to promote healthy 
access to AVF. This study will replicate Sousa’s educational model with slight modification to 
align with the local context.  While Sousa (2021) implemented the educational model for AVF 
self-care behaviors in a group format, in the current study the educational model will be 
delivered on a one-on-one basis. This modification is sought to accommodate the cultural 
difference, language proficiency, literacy level and individual patient need. Furthermore, 
individualized approach is tailored to ensure the clear and effective communication while 
respecting cultural norm.  
 Timing of the intervention will set based on the overall health status of patients. Patient 
will be given the option of rescheduling if not feeling well at given time. Each participant will 
receive individualized didactic instruction and personalized practical training before the dialysis 
procedure start (Annexure 9,11). These two sessions will be delivered on separate days within 
the same week.  The primary investigator will be responsible for the intervention delivery. The 
sessions will take place in a private conference room at each dialysis unit. 
The didactic session. The purpose of this session is to educate patients on AVF self-care 
maintenance. Participants will explore the AVF concept, their perceptions of AVF, their current 
care practices, and the individual responsible for their AVF care at home. Next, patients will be 
educated on fistula, its functionality, its significance in dialysis patients, and its impact on social, 
emotional and mental health. Any concerns about self-care behaviors will be addressed. The 
session will conclude within a total duration of 25-30 minutes before the dialysis. Teaching 
methods that will be utilized in this session are oral presentations and discussions. The didactic 
sessions will be scheduled when patients are in hemodynamically stable condition and can 
engage in discussions.   
The practical session. The purpose of the practical session is to build skills that promote 
AVF self-care assessment and monitoring. The session will conclude within 20 to 25 minutes. In 
this session, participants will be shown how to assess and monitor AVF skill using a checklist 

18 
 
(Annexure 8). The checklist will serve dual purposes: first, as a teaching guide to teach the skill 
to the participants and second, for patients to demonstrate their understanding through return 
demonstration. The assessment will be step-wise process starting with inspection, palpation and 
auscultation. The details step-wise process is: 
1-Inspection serves the purpose of identifying any situation that may compromise the 
AVF functioning, such as skin color changes, temperature changes at the AV fistula site 
indicative of signs of infection (signs of drainage, redness, fever or tenderness at the incision 
site) etc.  
2- Palpation serves the purpose of training the participants to identify the thrill of their 
fistula. A continuous purring or vibration should be present, diminishing in strength when further 
from anastomosis. 
3-Auscultation serves the purpose of training the participants to listen the bruits sounds of 
their AVFs. The participants will be encouraged to listen to their bruit sounds (a sound which is 
heard over AVF) with a stethoscope.  A continuous low-pitched bruit should be audible.  A 
teaching stethoscope will be utilized for auscultation. Participants will be encouraged to talk 
about the difficulties at any point of the session in the last five minutes. At the end of this 
session, participants will have a return demonstration of skill, verbalizing potential changes in 
the appearance, thrill and bruit sound of AVF. Moreover, they will articulate the significance of 
monitoring AVF in their daily life activities and outline their plan of action to detect any changes 
in the AVF.  The primary investigator will observe and mark the checklist during the 
participants' return demonstration. If the participants are unable to redemonstrate accurately, they 
will be given time to practice the skill according to their feasibility and have redemonstration. 
This observation and marking aim to ensure that the participants comprehend and follow the 
technique. The practical session will be offered before dialysis. Patients will be instructed to 
follow this assessment daily at home for their AVF assessment utilizing the provided checklist. 
The checklist will be provided to the patients in the Urdu language, facilitating their ability to 
memorize and refer to the steps when performing their AVF assessment at home.  
Teaching methods utilized in the session will include teach-back, demonstration and back 
demonstration techniques.   

19 
 
Assessment Checklist for AVF 
 
The primary investigator developed the assessment checklist after reviewing the 
literature. This assessment checklist will be utilized in the teaching-learning and assessment 
process of the intervention’s practical part (session two). This checklist includes the steps of 
inspection, palpation and auscultation. The checklist consists of 27 items, with the yes/ no 
responses. The maximum score on the checklist is 27 and the minimum is 0.  The first draft of 
the checklist (Annexure 8) will be sent to the experts (Two educationists, one senior nurse 
manager and two nephrologists) for evaluation on clarity and relevance. Educationist must have 
five years’ experience of classroom and clinical teaching. Nurse manager and nephrologist must 
have experience of working in dialysis units. Experts will be informed to delete the irrelevant 
items and add new ones, justifying additions and deletions. Moreover, they will be requested to 
review the weightage of each item. Feedback will be integrated, and this checklist will undergo 
pilot testing after consensus development. Subsequently, reliability will be calculated. The 
bilingual translator will then translate the checklist into Urdu. The CVI will be calculated. 
Follow-up. The purpose of the follow-up is to assess the effectiveness of intervention and 
sustainability in the self-care behaviors of participants. There will be two follow-up assessments: 
the 2nd, and 6th week post-intervention. Follow-up sessions will be completed during patients’ 
routine dialysis schedules in the dialysis units. Each patient will complete the ASBHD-AVF and 
HARQ. Each follow-up time will be approximately 15-20 minutes. If patients do not come for 
their routine dialysis for three scheduled days during the follow-up weeks, they will receive a 
phone call to inquire about their status by primary investigator. Throughout the intervention and 
follow-up periods, the usual questions will be addressed by PI. Patients will be advised to 
complete the checklist daily after assessing their AVF. Daily assessment of the AVF using the 
checklist will serve to reinforce their behaviors. Patients will also be instructed to promptly 
report any observed changes in their AVF to health care providers. A reminder for the 
assessment of AVF and marking on the checklist will be provided through WhatsApp message to 
the patient. Participants will not be allowed to communicate through WhatsApp. 
Pilot Testing of Intervention  
Before the actual research begins, the PI will conduct pilot testing of the intervention on 
10% of the sample in the same setting and population where the actual study is planned to take 
place. Based on the findings of the pilot testing, modifications may be made in the intervention.  

20 
 
Fidelity of the Intervention  
Intervention fidelity is referred to how accurately intervention is implemented according 
to its original design. Moreover, it also ensures that the intervention is applied consistently across 
all participants (Horner, 2012). Horner (2012) outline five key areas that will be focused on to 
enhance the fidelity of intervention.   
Standardized intervention dose: To ensure consistent intervention dose for all the 
participants, primary investigator will strictly follow a detailed manual of operation (Annexure 
10). Moreover, adherence to the lesson plan (Annexure 9) for both didactic and practical sessions 
will be ensured uphold consistency.   
Standardized interventionist training:  The practice and implementation of the 
intervention on simulated patients will enhance the investigator’s proficiency.    
Monitoring intervention delivery:  Each session will follow a standardized format based 
on a predetermined lesson plan (Annexure 9). Additionally, a randomly selected intervention 
session will be audio-taped for quality assurance. 
 Evaluating participant understanding of information provided: A teach-back strategy will 
be employed to reinforce understanding. This will allow the investigator to determine the level of 
comprehension among participants.  
 Ensuring participant’s use the skill taught. Participants will be required to demonstrate 
their newly acquired AVF skill at the end of the session will help to ensure the learning has taken 
place. To further verify, the correct application of skill, a checklist will be used by patients 
during assessment of AVF at their homes.  
Outcome measures: 
Primary outcome of this study will be self-care behaviors related to AVF and secondary 
outcome will be AVF quality of life. Primary and secondary outcome will be compared by using 
the independent T test.  
Sampling  
Participants will initially be recruited using consecutive sampling techniques. This 
method involves enrolling the eligible participants in a specific order, allowing for the 
calculation of response rates, and using clinical information until the desired sample size is 
achieved (Bujang et al., 2022; Thewes et al., 2018).  Hemodialysis patients who meet the 
inclusion criteria will be invited to participate in the study.  

21 
 
Sample size 
The sample size was calculated by using G* power (Faul et al., 2009). The parameters 
used for sample size calculation were: alpha= 0.05, β=0.15; power 1- β=0.85, with an allocation 
ratio of 1:1 and effect size =0.4. Effect size is determined by reviewing the previous RCTs or the 
meta-analysis, pilot testing and taking the expert feedback (opinion seeking) (Rothwell, 2018). 
However, only one RCT is found on the relevant topic with small sample size, therefore effect 
size is determined by opinion seeking method. Hence the calculated sample size is 228, with 114 
participants in each group.  However, attrition rates can significantly affect the later stages of the 
study, so factoring them into the initial sample size calculation can enhance the validity and 
reliability of the study (Hui et al., 2013).In behavioral and educational interventions, the most 
common reasons for attrition are patients’ withdrawal and clinical deterioration. Hence, after 
adjusting the anticipated 20% attrition rate, the final calculated sample size will be 274 
participants, with 137 in each group. To minimize the loss to follow-up in this RCT multiple 
strategies will be implemented.  First, the researcher will recruit a larger sample to overcome 
potential loss to follow-up, incorporating a 20% attrition rate into the sample size calculation.  
Second, the research assistant contacted the participants at follow-up points via phone 
calls. Third, an intention to treat analysis will be applied when analyzing the results. The 
intention-to-treat analysis method ensures that data from all randomized patients are included in 
the analysis, regardless of their dropout from the study at any stage (Andrade, 2022).  
 
Random Allocation  
Consented patients will be randomized into a control group and experimental group, 
within each hemodialysis unit. Randomization is an optimal approach utilized in RCTs, to 
minimize the influence of extraneous variables and the risk of biases (Baghbaninaghadehi, 
2016).   
Data analyst will assist with permuted block randomization procedure will be used to 
separate random scheme in both setting (A) and (B). The sealed envelopes will be prepared by 
data analyst, shuffled, numbered serial, and placed in a locked drawer in both units (A and B), 
and only research assistant can access it. After consenting and completing baseline assessment, 
the research assistant will open a sealed envelope to reveal the patient’s group assignment. The 
patient will then be assigned to specific group accordingly.  Research assistant will ensure that 

22 
 
intervention and control groups’ patients will have dialysis in separate rooms or wards to prevent 
contamination in intervention.  
Blinding   
Blinding is a methodological indicator in RCTs to minimize biases (Monaghan et al., 
2021). Blinding will be implemented at two levels. First, baseline data will be collected before 
randomization to prevent bias in data collection and maintain patient blinding regarding their 
group assignment.  Second, the PI will not be involved in the data collection process to ensure 
objectivity. A research assistant will be responsible for data collection process and an 
independent data analyst will perform the data analysis to further minimize potential biases.    
Data Collection Tools 
Demographic and Socioeconomical  
Information will be collected on demographic and socioeconomical status using a form 
developed for this purpose (Annexure 5).  
Clinical History. Data will be collected on current health conditions, hemodialysis 
frequency, dialysis duration, AVF duration and on Charlton’s Comorbidity Index. Charlton 
comorbidity index predicts the survival rates in 10 years in patients with multiple comorbidities. 
The use of this index enables to identification of comorbidities in hemodialysis patients and 
assess their impact on the study outcomes (Brusselaers, & Lagergren, 2017).  
Assessment of Self-care Behaviors with AVF in Hemodialysis Patients  
The primary outcome of this study is AVF self-care behaviors. This outcome will be 
assessed using the Self-care Behaviors Scale with Arteriovenous Fistula in Hemodialysis patients 
(ASBHD-AVF) (Annexure 6a). The ASBHD-AVF is a 16 items self- assessment scale 
developed by Sousa et al (2015) to assess the self-care behaviors of AVF of hemodialysis 
patients. The scale consists of two subscales: 1) management of signs and symptoms (6 items) 
and 2) prevention from complications (10 items). Response options consist of a five-point Likert 
scale ranging from 1 (never develop the self-care) to 5 (always develop the self-care). The 
minimum score is 16 and a maximum score is 80.  A higher score reflects a higher frequency of 
self-care behaviors. The overall reported reliability of this tool is 0.72 and CVI is 1 (Sousa, 
2015). Permission to use the tool was obtained from author (Annexure 6b). This tool had been 
used in different countries such as Portugal, Iraq, China and Turkey.  The tool will be translated 

23 
 
and administered in Urdu language. The process of translation of tools ASBHD-AVF and 
Hemodialysis Access-related Quality of Life is described in the below section. 
Hemodialysis Access related Quality of Life 
The secondary outcome of this study is Quality of Life related to AVF. This outcome will 
be assessed using the Hemodialysis Access-related Quality of Life (HARQ) (Annexure 7a) 
which is a self-administered tool develop by (Nordyke, 2020). This tool includes six domains 
and specific scales are used to assess various domains that impact a patient's quality of life. In 
symptoms domain two numerical rating scale is used, that is (0-10) to measure the severity of 
pain related to the hemodialysis access, and Likert-type scale (0= not at all bothered, 1= 
sometime bothered, 2= moderately bothered, 3=very much bothered, 4= extremely bothered) for 
bleeding, bruises, needle-stick pain, swelling, and numbness.  Likewise, the emotional domain is 
assessed using a same Likert-type scale and evaluates how the hemodialysis access affects 
emotional aspect of the patients. The physical functioning domain evaluates how the 
hemodialysis access affects daily physical activities and overall mobility levels using a Likert-
type scale 0 to 4 (0=cannot do, 1= quite a lot, 2= somewhat, 3= very little, 4= not at all). The 
social and role functioning domain evaluates how the hemodialysis VA affects patients’ social 
activity using a Likert-type scale 0 to 4 (0=never, 1= rarely,2= sometime, 3=often, 4=always). In 
addition, the sleep domain evaluates how the hemodialysis access affects sleep of the patients 
using a Likert-type scale (0= none of the time 1= a little of the time, 2= some of the time, 3= 
most of the time, 4= all of the time). Lastly, care related burden domain is assessed using a 
Likert-type scale 0 to 4 (0=never, 1= rarely, 2= sometime, 3=often, 4=always). However, the 
psychometric properties of this are not reported. Permission to use the tool is obtained from the 
author (Annexure 7b).  The tool will be translated and administered in Urdu.  
Translation Process. The ASBHD-AVF and the HARQ tools will be translated into 
Urdu and validated to ensure they are appropriately adapted to the local context according to the 
Sousa & Rojjanasrirat, (2011) guideline. The translation is a seven steps process. First five steps 
of translation will be implemented. Steps 6 and 7 will not be implemented as it requires bilingual 
experts and large sample size which is beyond the scope of this study.  Step-1 is translation of 
original instrument from English to Urdu, step-2: comparison of the two translated version, step 
3: blind back translation to English, Step-4: comparison of two back translated version, step-5: 
pilot testing of the Urdu version tool. Two independent bilingual translators, fluent in both 

24 
 
languages (English, Urdu) with the understanding of both cultures will translate the tools into 
Urdu language. Both translators will have distinct background. Translator 1 must have 
understanding of medical terminologies and the content area of the instrument. And second 
translator will be familiar with colloquial phrases, slang, jargon, and idiomatic and emotional 
expression. Translators will be brief about tool and translation process by primary investigator 
before starting the process.  Translations done by both translators will be compared. Next, an 
independent bilingual translator will translate these Urdu translated tools back into the English 
language. The research team and translators will compare the translation and back translation 
copies of the tools. Moreover, the tools will be pilot-tested on 10% of the population of the same 
setting and Cronbach alpha will be calculated.   
Data Collection 
The primary and secondary outcomes will be assessed at: baseline, after the completion 
of the intervention, and follow-up data will be collected at the second and sixth weeks after 
intervention is completed. The research assistant (RA) will receive training on study procedures.  
Training of Research Assistant 
A manual of operation (Annexure 10) is developed by primary researcher and will be 
used to train the research assistant. The research assistant will be trained about the baseline 
assessment, randomization, and assignment allocation and pilot testing. Initially, time will be 
given to read and understand the tools, its possible responses, scoring method. Then primary 
researcher will perform a role play while considering all the elements of study. Research 
assistant will practice it multiple times on a simulated patients until she/he become proficient. 
Concern and questions will be addressed.  
Data Management and Analysis         
Double data entry will be employed to ensure the accuracy of the data. The data will be 
checked for missing values, outliers, and logical inconsistencies. Data will be analyzed using the 
Statistical Package of Social Science (SPSS) version 25. Descriptive statistics, means and 
standard deviations will be used for the continuous variables, (age, income, dialysis duration, 
AVF Duration) while frequencies and percentages will be utilized for categorical demographic 
data (gender, educational level, hemodialysis frequency, items of self-care behavior scale, QOL).  
Important demographic data will be presented in the table to confirm randomization and assess 
the equal distribution of the groups. The normality of the data will be checked. An Independent t- 

25 
 
test will be applied to compare the differences between the groups. In case normality not achieve 
then Mann-witney U test will be applied. Mean scores and frequencies will be calculated for 
overall, each dimension, and for each item for both the outcomes.  
Ethical Consideration 
Approval to conduct the study will be obtained from the institutional review board (IRB) 
and the Ethical Committee of the institution (Shifa International Hospital). Furthermore, 
permission to collect patient data will be obtained from the head of hemodialysis units. 
Permission for using the tools already have been taken from the authors. The purpose of the 
study will be shared with study participants before collecting data. Informed consent will be 
obtained from eligible and patients interested in the study (Annexure 2). The participants’ 
autonomy will be ensured by using informed consent. No known risks are involved in this 
research, and the benefits of the study will be explained. However, patients may feel 
overwhelmed during the data collection process. Data collection process will be scheduled and 
divided into two slots according to participant’s ease. Patients will be allowed to ask any 
questions related to the study. A serial code instead of the participant's name will be assigned to 
participants’ data sheets. Participants’ names and ID numbers will be kept confidential. Contact 
information will be kept with primary investigator during the intervention and follow-up duration 
which will not be shared with anyone. On a personal laptop, a data folder will be created and 
secured with a password. Only the research team will have access to the data. The participants 
have a right to withdraw from the study at any time of data collection. The intervention will be 
implemented in the control group after the data collection.  
Summary  
This chapter outlines the primary methodology of the study. Moreover, the didactic 
approach underpinning the intervention, the intervention plan, follow-up procedures, and the 
intervention’s fidelity are discussed. 
 
 
 
 
 
 

26 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
References 
Abbafati, C., Abbas, K. M., Abbasi, M., Abbasifard, M., Abbasi-Kangevari, M., Abbastabar, H.,  
Abd-Allah, F., Abdelalim, A., Abdollahi, M., Abdollahpour, I., Abedi, A., Abedi, P., 
Abegaz, K. H., Abolhassani, H., Abosetugn, A. E., Aboyans, V., Abrams, E. M., Abreu, 
L. G., Abrigo, M. R. M., … Murray, C. J. L. (2020). Global burden of 369 diseases and 
injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global 
Burden of Disease Study 2019. The Lancet, 396(10258), 1204–1222. 
https://doi.org/10.1016/S0140-6736(20)30925-9 
Abbasi Abianeh, N., Abdollah Zargar, S., Amirkhani, A., & Adelipouramlash, A. (2020). The  

27 
 
effect of self-care education through teach back method on the quality of life in 
hemodialysis patients. Nephrologie et Therapeutique, 16(4), 197–200. 
https://doi.org/10.1016/j.nephro.2020.01.002 
Adib-Hajbagheri, M., Molavizadeh, N., Alavi, N. M., & Abadi, M. H. M. (2014). Factors 
   
associated with complications of vascular access site in hemodialysis patients in Isfahan  
Aliasghar hospital. Iranian Journal of Nursing and Midwifery Research, 19(2), 208–214.  
http://www.ncbi.nlm.nih.gov/pubmed/24834093%0Ahttp://www.pubmedcentral.nih.gov/
articlerender.fcgi?artid=PMC4020033 
Aljuaid1, M. M., , Nawaf Najim Alzahrani1 , Abdulrahman Abdulaziz Alshehri1, L. H. A., 
Faisal Sultan Alosaimi1, N. W. A., Asiri1, O. A., & Atalla2, A. A. (2020). Complications of 
arteriovenous fistula in dialysis patients: Incidence and risk factors in Taif city, KSA. 
Journal of Family Medicine and Primary Care, 9(1). https://doi.org/DOI: 
10.4103/jfmpc.jfmpc_848_19 
Almasri, J., Alsawas, M., Mainou, M., Mustafa, R. A., Wang, Z., Woo, K., Cull, D. L., & Murad,  
M. H. (2016). Outcomes of vascular access for hemodialysis: A systematic review and 
meta-analysis. Journal of Vascular Surgery, 64(1), 236–243 
Alsaqri, S. H., Edison, J. S., Alshammari, S., & Ahmad, H. H. (2019). The effectiveness of   
instructional module on self-care practices of arteriovenous fistula among hemodialysis 
patients at Hail region, Saudi Arabia. International Journal of Advanced and Applied 
Sciences, 6(2), 87–93. https://doi.org/10.21833/ijaas.2019.02.013 
Arad, M., Goli, R., Parizad, N., Vahabzadeh, D., & Baghaei, R. (2021). Do the patient education 
program and nurse-led telephone follow-up improve treatment adherence in hemodialysis 
patients? A randomized controlled trial. BMC Nephrology, 22(1), 1–13. 
https://doi.org/10.1186/s12882-021-02319-9 
Arnault, D. Saint. (2018). Defining and Theorizing about Culture: The Evolution of the Cultural  
Determinants of Help-Seeking, Revised. Nursing Research, 67(2), 161–168. 
https://doi.org/10.1097/NNR.0000000000000264 
Asano, M., Thumma, J., Oguchi, K., Pisoni, R. L., Akizawa, T., Akiba, T., Fukuhara, S.,  
Kurokawa, K., Ethier, J., Saran, R., & Saito, A. (2013). Vascular access care and 
treatment practices associated with outcomes of arteriovenous fistula: International 

28 
 
comparisons from the dialysis outcomes and practice patterns study vitamin D. Nephron - 
Clinical Practice, 124(1–2), 23–30. https://doi.org/10.1159/000353733 
Atalla, H. R. A., Soliman, G. H., & Sallam, S. A. E. G. (2019). Effectiveness of Nursing 
Intervention Regarding Newly Placed Arteriovenous Fistula Self-Care on Level of 
Knowledge , Practice , and Attitude among Hemodialysis Patients. Journal of Nursing and 
Health Science, 8(3), 35–46. https://doi.org/10.9790/1959-0803063546 
Avanji, F. S. I., Alavi, N. M., Akbari, H., & Saroladan, S. (2021). Self-Care and Its Predictive  
Factors in Hemodialysis Patients. Journal of Caring Sciences, 10(3), 153–159. 
https://doi.org/10.34172/jcs.2021.022 
Bahri, N., Saljooghi, S., Noghabi, A. D., & Moshki, M. (2018). Effectiveness of the teach-back  
method in improving self-care activities in postmenopausal women. Przeglad 
Menopauzalny, 17(1), 5–10. https://doi.org/10.5114/pm.2018.74896 
Bakarman.A.W, Felimban.K.M, Atta.M.M, B. S. . (2019). The Effect of an Educational 
Program on Quality of Life in Patients Undergoing Hemodialysis in Western Saudia 
Arabia. 
Balamuthusamy, S., Miller, L. E., Clynes, D., Kahle, E., Knight, R. A., & Conway, P. T. (2020). 
American Association of Kidney Patients survey of patient preferences for hemodialysis 
vascular access. Journal of Vascular Access, 21(2), 230–236. 
https://doi.org/10.1177/1129729819870962 
Banerjee, D., Winocour, P., Chowdhury, T. A., De, P., Wahba, M., Montero, R., Fogarty, 
D., Frankel, A. H., Karalliedde, J., Mark, P. B., Patel, D. C., Pokrajac, A., Sharif, A., 
Zac-Varghese, S., Bain, S., & Dasgupta, I. (2022). Management of hypertension and 
renin-angiotensin-aldosterone system blockade in adults with diabetic kidney 
disease: Association of British Clinical Diabetologists and the Renal Association UK 
guideline update 2021. BMC Nephrology, 23(1), 1–31. 
https://doi.org/10.1186/s12882-021-02587-5 
Barnett, T., Li Yoong, T., Pinikahana, J., & Si-Yen, T. (2008). Fluid compliance among 
patients having haemodialysis: Can an educational programme make a difference? 
Journal of Advanced Nursing, 61(3), 300–306. https://doi.org/10.1111/j.1365-
2648.2007.04528.x 

29 
 
Başer, E., & Mollaoğlu, M. (2019). The effect of a hemodialysis patient education 
program on fluid control and dietary compliance. Hemodialysis International, 23(3), 
392–401. https://doi.org/10.1111/hdi.12744 
Beerappa, H., & Chandrababu, R. (2019). Adherence to dietary and fluid restrictions 
among patients undergoing hemodialysis: An observational study. Clinical 
Epidemiology and Global Health, 7(1), 127–130. 
https://doi.org/10.1016/j.cegh.2018.05.003 
Bellg, A. J., Resnick, B., Minicucci, D. S., Ogedegbe, G., Ernst, D., Borrelli, B., Hecht, J., Ory, 
M., Orwig, D., & Czajkowski, S. (2004). Enhancing treatment fidelity in health behaviors 
change studies: Best practices and recommendations from the NIH Behaviors Change 
Consortium. Health Psychology, 23(5), 443–451. https://doi.org/10.1037/0278-
6133.23.5.443 
Bello, A. K., Levin, A., Lunney, M., Osman, M. A., Ye, F., Ashuntantang, G. E., Bellorin-Font, 
E., Benghanem Gharbi, M., Davison, S. N., Ghnaimat, M., Harden, P., Htay, H., Jha, V., 
Kalantar-Zadeh, K., Kerr, P. G., Klarenbach, S., Kovesdy, C. P., Luyckx, V. A., Neuen, 
B. L., … Johnson, D. W. (2019). Status of care for end stage kidney disease in countries 
and regions worldwide: International cross sectional survey. The BMJ, 367. 
https://doi.org/10.1136/bmj.l5873 
Bello, A. K., Levin, A., Tonelli, M., Okpechi, I. G., Feehally, J., Harris, D., Jindal, K., Salako, B. 
L., Rateb, A., Osman, M. A., Qarni, B., Saad, S., Lunney, M., Wiebe, N., Ye, F., & 
Johnson, D. W. (2017). Assessment of global kidney health care status. JAMA - Journal 
of the American Medical Association, 317(18), 1864–1881. 
https://doi.org/10.1001/jama.2017.4046 
Bikbov, B., Purcell, C. A., Levey, A. S., Smith, M., Abdoli, A., Abebe, M., Adebayo, O. M.,  
Afarideh, M., Agarwal, S. K., Agudelo-Botero, M., Ahmadian, E., Al-Aly, Z., Alipour, 
V., Almasi-Hashiani, A., Al-Raddadi, R. M., Alvis-Guzman, N., Amini, S., Andrei, T., 
Andrei, C. L., … Murray, C. J. L. (2020). Global, regional, and national burden of 
chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of 
Disease Study 2017. The Lancet, 395(10225), 709–733. https://doi.org/10.1016/S0140-
6736(20)30045-3 
Blessy. P, V. (2020). l Follwo-up study on the Effect of Cognitive Behavioral Therapy on 

30 
 
Hemodialysis Adherence (pp. 58–65). 
Blok, A. C. (2017). A Middle-Range Explanatory Theory of Self-Management Behavior for  
Collaborative Research and Practice. Nursing Forum, 52(2), 138–146. 
https://doi.org/10.1111/nuf.12169 
Browne, L. D., Dawood, M., Leahy, F., Ryan, M. C., White, E., O’Sullivan, A., O’Sullivan, L., 
& Stack, A. G. (2022). Differential Impact of Central Venous Catheters versus 
Arteriovenous Fistulae on Quality of Life among Irish Haemodialysis Patients. 
Kidney360, 3(6), 1065–1072. https://doi.org/10.34067/KID.0006622021 
Brusselaers, N., & Lagergren, J. (2017). The Charlson comorbidity index in registry-based 
research. Methods of information in medicine, 56(05), 401-406. 
Bujang, M. A., Sidik, T. M. I. T. A. B., & Sa’at, N. (2022). Application of Consecutive Sampling 
Technique in a Clinical Survey for an Ordered Population: Does it Generate Accurate 
Statistics? Philippine Statistician, 71(1), 87–98. 
Campos, E., Cuevas-Budhart, M. A., Cedillo-Flores, R., Candelario-López, J., Jiménez, R.,  
Flores-Almonte, A., Ramos-Sanchez, A., & Divino Filho, J. C. (2024). Is central venous 
catheter in haemodialysis still the main factor of mortality after hospitalization? BMC 
Nephrology, 25(1), 1–5. https://doi.org/10.1186/s12882-023-03433-6 
Caputo, B. C., Leong, B., Sibona, A., Jhajj, S., Kohne, C., Gabel, J., Shih, W., Abou Zamzam, A.  
M., Bianchi, C., & Teruya, T. H. (2021). Arteriovenous fistula maturation: Physical exam 
versus flow study. Annals of Vascular Surgery, 77, 16–24. 
https://doi.org/10.1016/j.avsg.2021.05.022 
Carney, F. E. (2020). The impact of chronic kidney. Nature Reviews, 16(May), 2020.Chen, J.,  
Zhao, H., Hao, S., Xie, J., Ouyang, Y., & Zhao, S. (2018). Motivational interviewing to 
improve the self-care behaviors for patients with chronic heart failure: A randomized 
controlled trial. International Journal of Nursing Sciences, 5(3), 213–217. 
https://doi.org/10.1016/j.ijnss.2018.04.012 
Castro Júnior, A. R. de, Matias, D. M. de M., Machado, E. F. S., Melo, R. P. de, Tavares, T. D. J. 
L., & Vieira, D. V. F. (2020). Individual home care for patients with arteriovenous fistula. 
Revista de Enfermagem UFPE on Line, 14. https://doi.org/10.5205/1981-8963.2020.244317 
Chen, H. C., Lin, H. C., Chen, H. H., Mai, F. Der, Liu, Y. C., Lin, C. M., Chang, C. C., 

31 
 
Tsai, H. Y., & Yang, C. P. (2014). Innovative strategy with potential to increase 
hemodialysis efficiency and safety. Scientific Reports, 4, 1–5. 
https://doi.org/10.1038/srep04425 
Cheng, T. Y., Tarng, D. C., Liao, Y. M., & Lin, P. C. (2017). Effects of systematic 
nursing instruction on a low-phosphorus diet, serum phosphorus level and pruritus of 
patients on haemodialysis. Journal of Clinical Nursing, 26(3–4), 485–494. 
https://doi.org/10.1111/jocn.13471 
Cho, M. K., & Kang, Y. (2021). Effect of self-care intervention for controlling interdialytic  
weight gain among patients on haemodialysis: A systematic review and meta-analysis. 
Journal of Clinical Nursing, 30(15–16), 2348–2365. https://doi.org/10.1111/jocn.15773 
Clementino, D. C., de, Q. S., do Carmo da, C. B., Carvalho, D. M. A., dos Santos Renato, & do, 
N. F. (2018). Hemodialysis Patients: the Importance of Self-Care With the Arteriovenous 
Fistula. Journal of Nursing UFPE / Revista de Enfermagem UFPE, 12(7), 1841–1852. 
http://search.ebscohost.com/login.aspx?direct=true&db=jlh&AN=130496818&site=ehost-
live 
Cochrane. (2020). RevMan 5.4 User Guide. 4(May), 1–175. 
Cocchieri, A., Riegel, B., D’Agostino, F., Rocco, G., Fida, R., Alvaro, R., & Vellone, E. (2015). 
Describing self-care in Italian adults with heart failure and identifying determinants of poor 
self-care. European Journal of Cardiovascular Nursing, 14(2), 126–136. 
https://doi.org/10.1177/1474515113518443 
Costa Pessoa, N. R., de Souza Soares Lima, L. H., dos Santos, G. A., de Queiroz Frazão, C. M. 
F., Sousa, C. N., & Ramos, V. P. (2020). Self-care actions for the maintenance of the 
arteriovenous fistula: An integrative review. International Journal of Nursing Sciences, 
7(3), 369–377. https://doi.org/10.1016/j.ijnss.2020.06.007 
Cukor etal. (2014). Psychosocial Intervention Improves Depression,Quality of Life, and 
 Fluid Adherence in Hemodialysis. J AM Soc Nephrology, 25, 196–206 
Deif, H. I. A., Elsawi, K., Selim, M., & NasrAllah, M. M. (2015). Effect of an 
Educational Program on Adherence to Therapeutic Regimen among Chronic 
Kidney Disease Stage 5 (CKD5) Patients under Maintenance Hemodialysis. 
Journal of Education and Practice, 6(5), 21–34 

32 
 
Devi, K. M., & Sengupta, M. (2022). Effect of self-instructional module on knowledge regarding 
care of arteriovenous fistula among hemodialysis patients in selected hospitals, Guwahati, 
Assam. Indian Journal of Health Sciences and Biomedical Research kleu, 15(3), 270-274. 
Dickson, V. V., Melkus, G. D. E., Dorsen, C., Katz, S., & Riegel, B. (2014). Improving heart  
failure self-care through a community-based skill-building intervention: A study protocol. 
Journal of Cardiovascular Nursing, 30(4), S14–S24. 
https://doi.org/10.1097/JCN.0000000000000161 
Dickson, V. V., Melkus, G. D. E., Katz, S., Levine-Wong, A., Dillworth, J., Cleland, C. M., &  
Riegel, B. (2014). Building skill in heart failure self-care among community dwelling 
older adults: Results of a pilot study. Patient Education and Counseling, 96(2), 188–196. 
https://doi.org/10.1016/j.pec.2014.04.018 
Domenick Sridharan, N., Fish, L., Yu, L., Weisbord, S., Jhamb, M., Makaroun, M. S., & Yuo, T.  
H. (2018). The associations of hemodialysis access type and access satisfaction with 
health-related quality of life. Journal of Vascular Surgery, 67(1), 229–235. 
https://doi.org/10.1016/j.jvs.2017.05.131 
Ebrahimi, H., Sadeghi, M., Amanpour, F., & Dadgari, A. (2016). Influence of nutritional 
education on hemodialysis patients’ knowledge and quality of life. Saudi Journal 
of Kidney Diseases and Transplantation : An Official Publication of the Saudi 
Center for Organ Transplantation, Saudi Arabia, 27(2), 250–255. 
https://doi.org/10.4103/1319-2442.178253 
Farrington, C. A., Robbin, M. L., Lee, T., Barker-Finkel, J., & Allon, M. (2020). Early predictors  
 of arteriovenous fistula maturation: A novel perspective on an enduring problem. 
Journal of the American Society of Nephrology, 31(7), 1617–1627. 
https://doi.org/10.1681/ASN.2019080848 
Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Statistical power analyses using G*  
Power 3.1: Tests for correlation and regression analyses. Behaviors Research Methods, 
41(4), 1149–1160 
Field, M., Khawaja, A. Z., Ellis, J., Nieto, T., Hodson, J., & Inston, N. (2019). The vascular  
access questionnaire: A single centre UK experience. BMC Nephrology, 20(1). 
https://doi.org/10.1186/s12882-019-1493-9 
Fletcher, B. R., Damery, S., Aiyegbusi, O. L., Anderson, N., Calvert, M., Cockwell, P., 

33 
 
Ferguson, J., Horton, M., Paap, M. C. S., Sidey-Gibbons, C., Slade, A., Turner, N., & Kyte, 
D. (2022). Symptom burden and health-related quality of life in chronic kidney disease: A 
global systematic review and meta-analysis. PLoS Medicine, 19(4), 1–25. 
https://doi.org/10.1371/journal.pmed.1003954 
Gabriel Antunes Sousa Silva1*, Nicole Nogueira Cardoso1, Andressa Ribeiro da Costa1, M., 
Amaral Medeiros1, Yasser Nader Abed1, Laís Celi Mendes Rezende1, M. C. C., Raquel 
Braga Rossi1, Mariana Rodrigues de Paulo3, Mariana Rossi Silva da Paixão3, G., Oliveira 
de Moura Rigonato3, João Victor de Jesus Franco4, Lucas Paes de Rezende5, R., & Sabino, 
F. B. and B. C. N. (2021). Open Access Level Of Knowledge About Self-Care With Avf In 
Frequent Chronic Kidney Patients In A Hemodialysis Clinic In Southwestern Goiano. 11, 
50789–50793. 
Ghadam, M. S., Poorgholami, F., Badiyepeymaie Jahromi, Z., Parandavar, N., Kalani, N., 
& Rahmanian, E. (2015). Effect of Self-Care Education by Face-to-Face Method 
on the Quality of Life in Hemodialysis Patients (Relying on Ferrans and Powers 
Questionnaire). Global Journal of Health Science, 8(6), 121–127. 
https://doi.org/10.5539/gjhs.v8n6p121 
Ghazi, I. N., & Mohammed, W. K. (2022). Application of Self-Care Behaviour Scale for Arterio 
Venous Fistula Among Hemodialysis Patients. Pakistan Journal of Medical and Health 
Sciences, 16(5), 786–789. https://doi.org/10.53350/pjmhs22165786 
Ghiasvand, F., Riazi, H., Hajian, S., Kazemi, E., & Firoozi, A. (2017). The effect of a self-care  
program based on the teach back method on the postpartum quality of life. Electronic 
Physician, 9(4), 4180–4189. https://doi.org/10.19082/4180 
Gomes, A., Schmidt, R., & Wish, J. (2013). Re-envisioning fistula first in a patient-centered  
culture. In Clinical Journal of the American Society of Nephrology (Vol. 8, Issue 10, pp. 
1791–1797). https://doi.org/10.2215/CJN.03140313 
Grifey, R. T., Shin, N., Jones, S., Aginam, N., Gross, M., Kinsella, Y., Williams, J. A.,  
Carpenter, C. R., Goodman, M., & Kaphingst, K. A. (2015). The impact of teach-back on 
comprehension of discharge instructions and satisfaction among emergency patients with 
limited health literacy: A randomized, controlled study. Journal of Communication in 
Healthcare, 8(1), 10–21. https://doi.org/10.1179/1753807615Y.0000000001 
Griva, K., Nandakumar, M., Ng, J. an H., Lam, K. F. Y., McBain, H., & Newman, S. P. 

34 
 
(2018). Hemodialysis Self-management Intervention Randomized Trial (HED-
SMART): A Practical Low-Intensity Intervention to Improve Adherence and 
Clinical Markers in Patients Receiving Hemodialysis. American Journal of Kidney 
Diseases, 71(3), 371–381. https://doi.org/10.1053/j.ajkd.2017.09.014 
Hashemi, S., Tayebi, A., Rahimi, A., & Einollahi, B. (2018). An Investigation of the 
Effect of Continuous Care Model on Compliance with Dietary and Fluid Restrictions 
in Hemodialysis Patients: A Clinical Trial Study. Medical - Surgical Nursing 
Journal, In Press(In Press). https://doi.org/10.5812/msnj.87353 
He, X., & Liu, Y. (2023). Effects of arteriovenous fistulas and central venous catheters on the 
cardiac function and prognosis of patients on maintenance hemodialysis. Pakistan Journal 
of Medical Sciences, 39(3), 780–784. https://doi.org/10.12669/pjms.39.3.7151 
He, Z. (2023). Observation of the Nursing Intervention Effects on Arteriovenous Fistula in 
Hemodialysis Patients. MEDS Clinical Medicine, 4(9), 29-35. 
Henedy, W. M. (2019). Effect of Designed Nursing Intervention Protocol on Postoperative 
Arteriovenous Fistula Complications and Maturation among Patients with End ,Stage Renal 
Disease. International Journal of Novel Research in Healthcare and Nursing, 6(2), 226–
239. 
Hill, N. R., Fatoba, S. T., Oke, J. L., Hirst, J. A., O’Callaghan, C. A., Lasserson, D. S., & 
Hobbs, F. D. R. (2016). Global prevalence of chronic kidney disease - A systematic 
review and meta-analysis. PLoS ONE, 11(7), 1–18. 
https://doi.org/10.1371/journal.pone.0158765 
Hirakata, H., Tomo, T., & Akizawa, T. (2015). 2011 update Japanese Society for Dialysis  
 
Therapy Guidelines of Vascular Access Construction and Repair for Chronic  
Horner, S. D. (2012). Best practices for improving intervention fidelity that every nurse should 
know. Journal for Specialists in Pediatric Nursing, 17(2), 171. 
Hugtenburg, J. G., Timmers, L., Elders, P. J. M., Vervloet, M., & van Dijk, L. (2013). 
Definitions, variants, and causes of nonadherence with medication: A challenge for 
tailored interventions. Patient Preference and Adherence, 7, 675–682. 
https://doi.org/10.2147/PPA.S29549 
Hui, D., Glitza, I., Chisholm, G., Yennu, S., & Bruera, E. (2013). Attrition rates, reasons, and 

35 
 
predictive factors in supportive care and palliative oncology clinical trials. Cancer, 119(5), 
1098–1105. https://doi.org/10.1002/cncr.27854 
Hussein, W. F., Mohammed, H., Browne, L., Plant, L., & Stack, A. G. (2018). Prevalence and 
correlates of central venous catheter use among haemodialysis patients in the Irish health 
system - A national study. BMC Nephrology, 19(1), 13–16. https://doi.org/10.1186/s12882-
018-0873-x 
Ibeas, J., Roca-Tey, R., Vallespín, J., Moreno, T., Moñux, G., Martí-Monrós, A., del Pozo, J. L., 
Gruss, E., de Arellano, M. R., Fontseré, N., Arenas, M. D., Merino, J. L., García-Revillo, 
J., Caro, P., López-Espada, C., Giménez-Gaibar, A., Fernández-Lucas, M., Valdés, P., 
Fernández-Quesada, F., … Barba, Á. (2017). Spanish Clinical Guidelines on Vascular 
Access for Haemodialysis. Nefrologia, 37(Suppl 1), 1–191. 
https://doi.org/10.1016/S2013-2514(19)30100-2 
Imtiaz, S., & Alam, A. (2021). Is haemodialysis the most feasible dialysis modality for Pakistan?  
Journal of the Pakistan Medical Association, 71(2 A), 528–530. 
https://doi.org/10.47391/JPMA.129 
Imtiaz, S., & Alam, A. (2023). Epidemiology and demography of Chronic Kidney Disease in  
Pakistan- A review of Pakistani literature. Pakistan Journal of Kidney Diseases, 7(1), 2–
7. https://doi.org/10.53778/pjkd71209 
Ince, S. Ç., Günüşen, N. P., Özerdem, A., & Özışık, S. (2017). Diabetes Self-Care Views of  
Individuals With Severe Mental Illness and Comorbid Type 2 Diabetes and of Those 
Only With Type 2 Diabetes. Archives of Psychiatric Nursing, 31(4), 386–393. 
https://doi.org/10.1016/j.apnu.2017.04.011 
Iqbal, Q. T. A., Shareef, A., Afzal, A., & Ashraf, S. (2018). Arteriovenous Fistula Care: 
Knowledge, Attitude And Practice In Esrd Patients On Hemodialysis. The Professional 
Medical Journal, 25(09), 1426-1431. 
Isik.K, E. . (2020). The Effect of Home Care Based on hte Neuman System Modelon 
Symptomatic Relief and Quality of Life in Patients Undergoing Hemodialysis (pp. 
1809–1816) 
Jaarsma, T., Strömberg, A., Dunbar, S. B., Fitzsimons, D., Lee, C., Middleton, S., Vellone, E., 

36 
 
Freedland, K. E., & Riegel, B. (2020). Self-care research: How to grow the evidence 
base? International Journal of Nursing Studies, 105. 
https://doi.org/10.1016/j.ijnurstu.2020.103555 
Jager, K. J., & Fraser, S. D. S. (2017). The ascending rank of chronic kidney disease in the  
global burden of disease study. Nephrology Dialysis Transplantation, 32(February), 
ii121–ii128. https://doi.org/10.1093/ndt/gfw330 
Jeffs, E., Ream, E., Shewbridge, A., Cowan-Dickie, S., Crawshaw, D., Huit, M., & Wiseman, T. 
(2015). Exploring patient perception of success and benefit in self-management of breast 
cancer-related arm lymphoedema. European Journal of Oncology Nursing, 20, 173–183. 
https://doi.org/10.1016/j.ejon.2015.08.001 
Joanna Briggs Institute, & JBI. (2022). Checklist for systematic reviews and research 
syntheses. Joanna Briggs Institute. https://jbi.global/critical-appraisal-tools 
Johnsson, N., Strandberg, S., Tuvesson, H., Fagerström, C., Ekstedt, M., & Lindberg, C. (2023). 
Delineating and clarifying the concept of self-care monitoring: a concept analysis. In 
International Journal of Qualitative Studies on Health and Well-being (Vol. 18, Issue 1). 
Taylor and Francis Ltd. https://doi.org/10.1080/17482631.2023.2241231 
Katrachanca, S. M., & Koleske, A. J. (2017). 乳鼠心肌提取 HHS Public Access. Physiology &  
 
Behavior, 176(5), 139–148. https://doi.org/10.1016/j.jneb.2015.08.012 
Ke, C., Liang, J., Liu, M., Liu, S., & Wang, C. (2022). Burden of chronic kidney disease and its 
risk-attributable burden in 137 low-and middle-income countries, 1990–2019: results from 
the global burden of disease study 2019. BMC Nephrology, 23(1), 1–12. 
https://doi.org/10.1186/s12882-021-02597-3 
Khumukcham Monali Devi, M. S. (2022). Effect of Vitex trifolia Linn and Solanum nigrum Linn 
on oxidative. Indian Journal of Health Sciences and Biomedical Research KLEU, Volume 
15,(Issue 3), 269–275. https://doi.org/10.4103/kleuhsj.%0Akleuhsj_92_22 
Kim, D. H., Park, J. I., Lee, J. P., Kim, Y. L., Kang, S. W., Yang, C. W., Kim, N. H., Kim, Y. S.,  
& Lim, C. S. (2020). The effects of vascular access types on the survival and quality of 
life and depression in the incident hemodialysis patients. Renal Failure, 42(1), 30–39. 
https://doi.org/10.1080/0886022X.2019.1702558 
Kim, H., & Cho, M. K. (2021). Factors influencing self-care behavior and treatment adherence in
 
hemodialysis patients. International Journal of Environmental Research and Public  

37 
 
 
Health, 18(24), 12934. 
Kong, D., Zuo, M., & Chen, M. (2021). Self-management behaviorsof older adults with  
chronic diseases: Comparative analysis based on the daily activity abilities. Australian 
Journal of Primary Health, 27(3), 186–193. https://doi.org/10.1071/PY20159 
Kukita, K., Ohira, S., Amano, I., Naito, H., Azuma, N., Ikeda, K., Kanno, Y., Satou, T., Sakai, 
S., Sugimoto, T., Takemoto, Y., Haruguchi, H., Minakuchi, J., Miyata, A., Murotani, N., 
Hirakata, H., Tomo, T., & Akizawa, T. (2015). 2011 update Japanese Society for Dialysis 
Therapy Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis. 
Therapeutic Apheresis and Dialysis, 19(S1), 1–39. https://doi.org/10.1111/1744-
9987.12296 
Kukita, K., Ohira, S., Amano, I., Naito, H., Azuma, N., Ikeda, K., Kanno, Y., Satou, T., Sakai,  
S., Sugimoto, T., Takemoto, Y., Haruguchi, H., Minakuchi, J., Miyata, A., Murotani, N., 
Hemodialysis. Therapeutic Apheresis and Dialysis, 19(S1), 1–39. 
https://doi.org/10.1111/1744- 
 
9987.12296 
Lazarus, E. R. (2019). Effectiveness of education and exercise on quality of life among  
patients undergoing hemodialysis. Clinical Epidemiology and Global Health, 7(3), 
402–408. https://doi.org/10.1016/j.cegh.2018.07.003 
Lee, K. Y. (2017). A unified pathogenesis for kidney diseases, including genetic diseases 
and cancers, by the protein-homeostasis-system hypothesis. Kidney Research and 
Clinical Practice, 36(2), 132–144. https://doi.org/10.23876/j.krcp.2017.36.2.132 
Levac, D., Colquhoun, H., O'brien,K.K (2010). Scoping studies: advancing the methodology. 
Representing and Intervening. 
https://doi.org/http://www.implementationscience.com/content/5/1/69 Implementation 
Li, Q., & Yin, Z. (2021). Effect of self-management and thrombus monitoring on patients with  
autogenous arteriovenous fistula. American Journal of Translational Research, 13(10), 
11806–11813 
Lin, S. J., Chang, S. C., Tung, C. W., Hsu, Y. C., Shih, Y. H., Wu, Y. L., Chou, T. C., & Lin, C.  
 
L. (2021). Timing of the first cannulation and survival of arteriovenous grafts in 
 hemodialysis patients: a multicenter retrospective cohort study. Renal Failure, 43(1), 
 1416–1424. https://doi.org/10.1080/0886022X.2021.1988638 

38 
 
Liu, L., Liu, Y. P., Wang, J., An, L. W., & Jiao, J. M. (2016). Use of a knowledge-attitude- 
 
behaviour education programme for Chinese adults undergoing maintenance 
haemodialysis: Randomized controlled trial. Journal of International Medical Research, 
44(3), 557–568. https://doi.org/10.1177/0300060515604980 
Lok, C. E., Huber, T. S., Lee, T., Shenoy, S., Yevzlin, A. S., Abreo, K., Allon, M., Asif, A.,  
Astor, B. C., Glickman, M. H., Graham, J., Moist, L. M., Rajan, D. K., Roberts, C., 
Vachharajani, T. J., & Valentini, R. P. (2020). KDOQI Clinical Practice Guideline for 
Vascular Access: 2019 Update. American Journal of Kidney Diseases, 75(4), S1–S164. 
https://doi.org/10.1053/j.ajkd.2019.12.001 
Lukman, N. A., Leibing, A., & Merry, L. (2020). Self-Care Experiences of Adults with Chronic 
Disease in Indonesia: An Integrative Review. International Journal of Chronic Diseases, 
2020, 1–17. https://doi.org/10.1155/2020/1379547 
Maguire, I. C., Browne, L. D., Dawood, M., Leahy, F., Ryan, M. C., White, E., O’Sullivan, A., 
O’Sullivan, L., & Stack, A. G. (2022). Differential Impact of Central Venous Catheters 
versus Arteriovenous Fistulae on Quality of Life among Irish Haemodialysis Patients. 
Kidney360, 3(6), 1065–1072. https://doi.org/10.34067/kid.0006622021 
Martínez, N., Connelly, C. D., Pérez, A., & Calero, P. (2021). Self-care: A concept analysis.  
International Journal of Nursing Sciences, 8(4), 418–425. 
https://doi.org/10.1016/j.ijnss.2021.08.007 
Martins, M., & Moura, S. (2023). Analisar o autocuidado com a fístula arteriovenosa. Revista de 
Enfermagem Referência, VI Série(No2), 1–10. https://doi.org/10.12707/rvi23.11.29211 
Marzband, R., & Zakavi, A. A. (2015). A Concept Analysis of Self-Care Based on Islamic  
 
Sources. 
Matarese, M., Lommi, M., De Marinis, M. G., & Riegel, B. (2018a). A Systematic Review and  
Integration of Concept Analyses of Self-Care and Related Concepts. Journal of Nursing 
Scholarship, 50(3), 296–305. https://doi.org/10.1111/jnu.12385 
Mills, K. T., Xu, Y., Zhang, W., Bundy, J. D., Chen, C. S., Kelly, T. N., Chen, J., & He, J. 
(2015). A systematic analysis of worldwide population-based data on the global burden of 
chronic kidney disease in 2010. Kidney International, 88(5), 950–957. 
https://doi.org/10.1038/ki.2015.230 
Mital Parikh, Maulin Shah, Maoulik kumar P Modi, Jay Darji, Dishant Vaddoriya, U. S. (2022). 

39 
 
Impact of vascular access type on health-related quality of life in patients undergoing 
hemodialysis: A cross-sectional observational study. Indian Journal of Vascular and 
Endovascular Surgery, 7(1), 63. https://doi.org/10.4103/ijves.ijves_47_19 
Moher, D. (2010). Consolidated Standards of Reporting Trials Group. CONSORT 2010 
explanation and elaboration: updated guidelines for reporting parallel group randomized 
trials. J Clin Epidemiol, 63, e1-e37. 
Monaghan, T. F., Agudelo, C. W., Rahman, S. N., Wein, A. J., Lazar, J. M., Everaert, K., & 
Dmochowski, R. R. (2021). Blinding in clinical trials: Seeing the big picture. Medicina 
(Lithuania), 57(7), 1–13. https://doi.org/10.3390/medicina57070647 
Mor, M. K., Sevick, M. A., Shields, A. M., Green, J. A., Palevsky, P. M., Arnold, R. M.,  
Fine, M. J., & Weisbord, S. D. (2014). Sexual function, activity, and satisfaction 
among women receiving maintenance hemodialysis. Clinical Journal of the 
American Society of Nephrology, 9(1), 128–134. 
https://doi.org/10.2215/CJN.05470513 
Mudeshwar, H., & Anjum, F. (2021). Hemodialysis - StatPearls - NCBI Bookshelf. In  
StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK563296 
Murali, K. M., Mullan, J., Roodenrys, S., Hassan, H. C., Lambert, K., & Lonergan, M. 
(2019). Strategies to improve dietary, fluid, dialysis or medication adherence in 
patients with end stage kidney disease on dialysis: A systematic review and meta-
analysis of randomized intervention trials. In PLoS ONE (Vol. 14, Issue 1). Public 
Library of Science. https://doi.org/10.1371/journal.pone.0211479 
Napalkov, P., Felici, D. M., Chu, L. K., Jacobs, J. R., & Begelman, S. M. (2013). Incidence of  
catheter-related complications in patients with central venous or hemodialysis catheters: 
A health care claims database analysis. BMC Cardiovascular Disorders, 13(1), 1. 
https://doi.org/10.1186/1471-2261-13-86 
Naseri-Salahshour, V., Sajadi, M., Nikbakht-Nasrabadi, A., Davodabady, F., & Fournier, 
A. (2020). The effect of nutritional education program on quality of life and serum 
electrolytes levels in hemodialysis patients: A single-blind randomized controlled 
trial. Patient Education and Counseling, 103(9), 1774–1779. 
https://doi.org/10.1016/j.pec.2020.03.021 

40 
 
Neuen, B. L., Chadban, S. J., Demaio, A. R., Johnson, D. W., & Perkovic, V. (2017). Chronic  
kidney disease and the global NCDs agenda. BMJ Global Health, 2(2), 7–10. 
https://doi.org/10.1136/bmjgh-2017-000380 
Nordyke, R. J., Nicholson, G., Gage, S. M., Lithgow, T., Himmelfarb, J., Rivara, M. B., Hays, R. 
 D., Woo, K., & Peipert, J. D. (2020). Vascular access-specific health-related quality of 
 life impacts among hemodialysis patients: Qualitative development of the hemodialysis 
access-related quality of life (HARQ) instrument. BMC Nephrology, 21(1), 1–10. 
https://doi.org/10.1186/s12882-020-1683-5\ 
Ok, E., & Kutlu, Y. (2021). The Effect of Motivational Interviewing on Adherence to 
Treatment and Quality of Life in Chronic Hemodialysis Patients: A Randomized 
Controlled Trial. Clinical Nursing Research, 30(3), 322–333. 
https://doi.org/10.1177/1054773820974158 
Önsöz, H. B., & Yeşilbalkan, Ö. U. (2013). Reliability and validity of the turkish version 
of the dialysis symptom index in chronic hemodialysis patients. Turkish Nephrology, 
Dialysis and Transplantation Journal, 22(1), 60–67. 
https://doi.org/10.5262/tndt.2013.1001.08 
Ozen, N., Tosun, N., Cinar, F. I., Bagcivan, G., Yilmaz, M. I., Askin, D., Mut, D., Ozen, V.,  
Yenicesu, M., & Zajm, E. (2017). Investigation of the knowledge and attitudes of patients 
who are undergoing hemodialysis treatment regarding their arteriovenous fistula. Journal 
of Vascular Access, 18(1), 64–68. https://doi.org/10.5301/jva.5000618 
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. 
D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., 
Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, 
E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: An updated 
guideline for reporting systematic reviews. The BMJ, 372. 
https://doi.org/10.1136/bmj.n71 
Patient information for care of the arteriovenous dialysis access fistula (AVF). (n.d.) 
Pasyar, N., Rambod, M., Sharif, F., Rafii, F., & Pourali-Mohammadi, N. (2015). Improving 
adherence and biomedical markers in hemodialysis patients: The effects of relaxation 
therapy. Complementary Therapies in Medicine, 23(1), 38–45. 

41 
 
https://doi.org/10.1016/j.ctim.2014.10.011 
Pecoits-Filho, R., Okpechi, I. G., Donner, J. A., Harris, D. C. H., Aljubori, H. M., Bello, A. K.,  
Bellorin-Font, E., Caskey, F. J., Collins, A., Cueto-Manzano, A. M., Feehally, J., Goh, B. 
L., Jager, K. J., Nangaku, M., Rahman, M., Sahay, M., Saleh, A., Sola, L., Turan 
Kazancioglu, R., … Johnson, D. W. (2020). Capturing and monitoring global differences 
in untreated and treated end-stage kidney disease, kidney replacement therapy modality, 
and outcomes. Kidney International Supplements, 10(1), e3–e9. 
https://doi.org/10.1016/j.kisu.2019.11.001 
Peipert, J. D., Nair, D., Klicko, K., Schatell, D. R., & Hays, R. D. (2019). Kidney disease quality 
of life 36-item short form survey (KDQOL-36) normative values for the United States 
dialysis population and new single summary score. Journal of the American Society of 
Nephrology, 30(4), 654–663. https://doi.org/10.1681/ASN.2018100994 
Pessoa, N. R. C., & Linhares, F. M. P. (2015). Hemodialysis patients with arteriovenous fistula: 
knowledge, attitude and practice. Escola Anna Nery - Revista de Enfermagem, 19(1). 
https://doi.org/10.5935/1414-8145.20150010 
Peters, M. D. J., Godfrey, C., McInerney, P., Khalil, H., Larsen, P., Marnie, C., Pollock, D., 
Tricco, A. C., & Munn, Z. (2022). Best practice guidance and reporting items for the 
development of scoping review protocols. JBI Evidence Synthesis, 20(4), 953–968. 
https://doi.org/10.11124/JBIES-21-00242 
Peters, M. D., Godfrey, C., Mcinerney, P., Munn, Z., & Tricco, A. C. (2020). Chapter 11: 
Scoping reviews. JBI Manual for Evidence Synthesis, January 2022, 12–13. 
https://doi.org/10.46658/jbimes-20-12 
Pisoni, R. L., Zepel, L., Fluck, R., Lok, C. E., Kawanishi, H., Süleymanlar, G., Wasse, H.,  
Tentori, F., Zee, J., Li, Y., Schaubel, D., Burke, S., & Robinson, B. (2018). International 
Differences in the Location and Use of Arteriovenous Accesses Created for 
Hemodialysis: Results From the Dialysis Outcomes and Practice Patterns Study 
(DOPPS). American Journal of Kidney Diseases, 71(4), 469–478. 
https://doi.org/10.1053/j.ajkd.2017.09.012 
Rafiee Vardanjani, L., Parvin, N., & Mahmoodi Shan, G. (2016). The effects of an 

42 
 
individual, multistep intervention on adherence to treatment in hemodialysis 
patients. Disability and Rehabilitation, 38(8), 768–772. 
https://doi.org/10.3109/09638288.2015.1061601 
Rashid, N., Aamer, M., Malik, U., Arif, N., Akram, M. W., & Irshad, A. (2018). Arteriovenous  
Fistula (AVF) Self-Care: A Study at a Tertiary Care Hospital in Lahore, Pakistan. Annals 
of King Edward Medical University, 24(1). 
Ravani, P., Palmer, S. C., Oliver, M. J., Quinn, R. R., MacRae, J. M., Tai, D. J., Pannu, N. I., 
Thomas, C., Hemmelgarn, B. R., Craig, J. C., Manns, B., Tonelli, M., Strippoli, G. F. M., & 
James, M. T. (2013). Associations between hemodialysis access type and clinical outcomes: 
A systematic review. Journal of the American Society of Nephrology, 24(3), 465–473. 
https://doi.org/10.1681/ASN.2012070643 
Ray.S.P., D., Namira, S., Rupnawar, A., Shinde, A., Rathod, V., & Rasal, S. (2021). A study to 
assess the knowledge regarding arteriovenous fistula and its care among dialysis patient in 
selected hospitals of Pune city. Drugs and Cell Therapies in Haematology, 10(1), 1. (ISSN: 
2281-4876) 
Riegel, B., Dunbar, S. B., Fitzsimons, D., Freedland, K. E., Lee, C. S., Middleton, S., Stromberg, 
 A., Vellone, E., Webber, D. E., & Jaarsma, T. (2021). Self-care research: Where are we  
now? Where are we going? International Journal of Nursing Studies, 116.  
https://doi.org/10.1016/j.ijnurstu.2019.103402 
Riegel, B., Jaarsma, T., & Strömberg, A. (2012). A middle-range theory of self-care of chronic  
illness. Advances in Nursing Science, 35(3), 194–204. 
https://doi.org/10.1097/ANS.0b013e318261b1ba 
Riegel, B., Jaarsma, T., Lee, C. S., & Strömberg, A. (2019). Integrating symptoms into the  
middle-range theory of self-care of chronic illness. Advances in Nursing Science, 42(3),  
206–215. https://doi.org/10.1097/ANS.0000000000000237 
Robert, R. R., & Petersen, S. (2013). Critical thinking at the bedside: Providing safe passage to  
patients. MEDSURG Nursing, 22(2), 2013. 
Sabiu, G., & Gallieni, M. (2023). Pathophysiology of Arteriovenous Fistula Maturation and  
Nonmaturation. Clinical Journal of the American Society of Nephrology : CJASN, 18(1), 
8–10. https://doi.org/10.2215/CJN.13101122 
Şahan, S., Yıldız, A., Özdemir, C., & Günay İsmailoğlu, E. (2023). The effect of video-based  

43 
 
fistula care education on hemodialysis patients’ self-care behaviors: A randomized 
controlled study. Therapeutic Apheresis and Dialysis, 27(6), 1095–1102. 
https://doi.org/10.1111/1744-9987.14058 
Santoro, D., Benedetto, F., Mondello, P., Pipitò, N., Barillà, D., Spinelli, F., Ricciardi, C. A.,  
Cernaro, V., & Buemi, M. (2014). Vascular access for hemodialysis: Current 
perspectives. International Journal of Nephrology and Renovascular Disease, 7, 281–
294. https://doi.org/10.2147/IJNRD.S46643 
Schmidli, J., Widmer, M. K., Basile, C., de Donato, G., Gallieni, M., Gibbons, C. P., Haage, P.,  
Hamilton, G., Hedin, U., Kamper, L., Lazarides, M. K., Lindsey, B., Mestres, G.,  
Pegoraro, M., Roy, J., Setacci, C., Shemesh, D., Tordoir, J. H. M., van Loon, M., …  
Roca-Tey, R. (2018). Editor’s Choice – Vascular Access: 2018 Clinical Practice  
Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of  
Vascular and Endovascular Surgery, 55(6), 757–818. 
https://doi.org/10.1016/j.ejvs.2018.02.001 
Shafi, S. T., Saleem, M., Anjum, R., Abdullah, W., & Shafi, T. (2018). Refusal of hemodialysis  
by hospitalized chronic kidney disease patients in Pakistan. Saudi Journal of Kidney 
Diseases and Transplantation : An Official Publication of the Saudi Center for Organ 
Transplantation, Saudi Arabia, 29(2), 401–408. https://doi.org/10.4103/1319-
2442.229270 
Shen, D., Huang, W., Wei, S., Zhu, Y., & Shi, B. (2023). The impact of Teach-back method on  
preoperative anxiety and surgical cooperation in elderly patients undergoing outpatient 
ophthalmology surgery: A randomized clinical trial. Medicine (United States), 102(8), 
E32931. https://doi.org/10.1097/MD.0000000000032931 
Shuk-hang, L., & Alexander, M. (2001). Dietary and fluid compliance in Chinese 
hemodialysis patients. - PubMed - NCBI. Int J Nurs Stud, 39, 39 (7): 695-704. 
http://www.ncbi.nlm.nih.gov/pubmed/12231026 
Sousa, C. N., Marujo, P., Teles, P., Lira, M. N., Dias, V. F. F., & Novais, M. E. L. M. (2020).  
Self-Care Behavior Profiles With Arteriovenous Fistula in Hemodialysis Patients. 
Clinical Nursing Research, 29(6), 363–367. https://doi.org/10.1177/1054773818787110 
Sousa, C. N., Marujo, P., Teles, P., Lira, M. N., & Novais, M. E. L. M. (2017). Self-Care on  

44 
 
Hemodialysis: Behaviors With the Arteriovenous Fistula. Therapeutic Apheresis and 
Dialysis, 21(2), 195–199. https://doi.org/10.1111/1744-9987.12522 
Sousa, C. N., Paquete, A. R. C., Teles, P., Pinto, C. M. C. B., Dias, V. F. F., Ribeiro, O. M. P. L.,  
Manzini, C. S. S., Nicole, A. G., Souza, L. H., & Ozen, N. (2021). Investigating the 
Effect of a Structured Intervention on the Development of Self-Care Behaviors With 
Arteriovenous Fistula in Hemodialysis Patients. Clinical Nursing Research, 30(6), 866–
874. https://doi.org/10.1177/1054773820974834 
Sousa, C. N., Teles, P., Dias, V. F. F., Apóstolo, J. L. A., Figueiredo, M. H. J. S., & Martins, M.  
M. (2014). Physical examination of arteriovenous fistula: The influence of professional 
experience in the detection of complications. Hemodialysis International, 18(3), 695-699. 
Sousa, H., Bártolo, A., Ribeiro, O., & Figueiredo, D. (2022). A family-centred perspective on the 
arteriovenous fistula in end-stage renal disease: Findings from dyadic interviews. 
Scandinavian Journal of Caring Sciences, 36(2), 426–438. 
https://doi.org/10.1111/scs.13055 
Stavert, B. M., Monaro, S., Tienstra, L., Naganathan, V., & Aitken, S. J. (2022). Protocol for a 
qualitative study exploring haemodialysis dependent patients’ arteriovenous fistula 
experience, values and concerns in Sydney, Australia. BMJ Open, 12(6), 1–7. 
https://doi.org/10.1136/bmjopen-2021-058152 
Stephen B. Hulley, Steven R. Cummings, Warren S. Browner, Deborah G. Grady, T. B. N. 
(2013). Designing Clinical Research. 
Stolic, R. (2013). Most important chronic complications of arteriovenous fistulas for 
hemodialysis. Medical Principles and Practice, 22(3), 220–228. 
https://doi.org/10.1159/000343669 
Sultan. B, Froelicher. E.S (In press). Effectiveness of Patient Education on  
Adherence to Treatment Regimen and Quality of Life in Hemodialysis Patients: A 
Systematic Review and Meta-Analysis. Minerva Journal of Nephrology and Urology 
  
Sultan. B, Yasmin. T & Pienaar. A. J, (2023). Exploring the Experiences of hemodialysis 
patients and describe nurse’s perception regarding arteriovenous fistula care in 
hemodialysis units of Islamabad and Lahore. (Unpublished manuscript). Shifa College of 
Nursing, Shifa Tameer-e-Millat University. 

45 
 
Tao WW, Tao XM, Wang Y, Bi SH. Psycho-social and educational interventions for  
enhancing adherence to dialysis in adults with end-stage renal disease: A meta-
analysis. J Clin Nurs. 2020;29(15–16):2834–48.  
Thewes, B., Rietjens, J. A. C., van den Berg, S. W., Compen, F. R., Abrahams, H., Poort, H., van 
de Wal, M., Schellekens, M. P. J., Peters, M. E. W. J., Speckens, A. E. M., Knoop, H., & 
Prins, J. B. (2018). One way or another: The opportunities and pitfalls of self-referral and 
consecutive sampling as recruitment strategies for psycho-oncology intervention trials. 
Psycho-Oncology, 27(8), 2056–2059. https://doi.org/10.1002/pon.4780 
Trask, M. A., Marchuk, S., Rozon, C., Puyat, J. H., Costantini, L., Mackay, M., & Ocampo, L. L.  
(2016). The Evaluation of an Orientation Program of Self-Care Abilities for Patients on 
Hemodialysis. In Nephrology nursing journal : journal of the American Nephrology 
Nurses’ Association (Vol. 43, Issue 6, pp. 501–534). 
Toulabi, T., Kalaveh, S. M., Ghasemi, F., & Anbari, K. (2016). The impact of 
multidisciplinary rehabilitation on the quality of life of hemodialysis patients in Iran. 
Journal of the Formosan Medical Association, 115(7), 553–559. 
https://doi.org/10.1016/j.jfma.2015.05.013 
Tsay, S. L. (2003). Self-efficacy training for patients with end-stage renal disease. 
Journal of Advanced Nursing, 43(4), 370–375. https://doi.org/10.1046/j.1365-
2648.2003.02725.x 
Urquhart-Secord, R., Craig, J. C., Hemmelgarn, B., Tam-Tham, H., Manns, B., Howell, M., ... &  
Tong, A. (2016). Patient and caregiver priorities for outcomes in hemodialysis: an 
international nominal group technique study. American Journal of Kidney 
Diseases, 68(3), 444-454. 
Verberne, W. R., Das-Gupta, Z., Allegretti, A. S., Bart, H. A., Van Biesen, W., García-García,  
G., ... & Bos, W. J. W. (2019). Development of an international standard set of value-
based outcome measures for patients with chronic kidney disease: a report of the 
International Consortium for Health Outcomes Measurement (ICHOM) CKD Working 
Group. American journal of kidney diseases, 73(3), 372-384. 
Victoria, A. (2015). Family Support, Social and Demographic Correlations of Non-
Adherence among Haemodialysis Patients. American Journal of Nursing Science, 

46 
 
4(2), 60. https://doi.org/10.11648/j.ajns.s.2015040201.21 
Victoria Alikari, R. (2015). The Effect of Nursing Counseling on Improving Knowledge, 
Adherence to Treatment and Quality of Life of Patients Undergoing Hemodialysis. 
International Journal of Caring Sciences, 8(2), 514. 
Wang, J., Yue, P., Huang, J., Xie, X., Ling, Y., Jia, L., Xiong, Y., & Sun, F. (2018). 
Nursing Intervention on the Compliance of Hemodialysis Patients with End-Stage 
Renal Disease: A Meta-Analysis. In Blood Purification (Vol. 45, Issues 1–3, pp. 
102–109). S. Karger AG. https://doi.org/10.1159/000484924 
Wang, R., Tang, C., Chen, X., Zhu, C., Feng, W., Li, P., & Lu, C. (2016). Poor sleep and 
reduced quality of life were associated with symptom distress in patients receiving 
maintenance hemodialysis. Health and Quality of Life Outcomes, 14(1), 1–8. 
https://doi.org/10.1186/s12955-016-0531-6 
Welch, J. L., Siek, K. A., Connelly, K. H., Astroth, K. S., McManus, M. S., Scott, L., 
Heo, S., & Kraus, M. A. (2010). Merging health literacy with computer technology: 
Self-managing diet and fluid intake among adult hemodialysis patients. Patient 
Education and Counseling, 79(2), 192–198. 
https://doi.org/10.1016/j.pec.2009.08.016 
Wilemen, Vari, E. (2015). Evidence of Improved Fluid Managment in Patient Receiving 
Hemodialysis Following a Self Affirimation Theory-Based Intervention: A 
Randomize Control Trial. 
 Yang F, Griva K, Lau T, Vathsala A, Lee E, Ng HJ, et al. Health-related quality of life of  
Asian patients with end-stage renal disease (ESRD) in Singapore. Qual Life Res. 
2015;24(9):2163–71. 
Yang, M. miao, Zhao, H. hua, Ding, X. qiang, Zhu, G. hong, Yang, Z. hua, Ding, L., Yang, X. 
hao, Zhao, Y., Chen, L., Yang, R. mei, Fang, J., & Sousa, C. N. (2019). Self-Care Behavior 
of Hemodialysis Patients With Arteriovenous Fistula in China: A Multicenter, Cross-
Sectional Study. Therapeutic Apheresis and Dialysis, 23(2), 167–172. 
https://doi.org/10.1111/1744-9987.12770 
Yangöz, Ş. T., Özer, Z., & Boz, İ. (2021). Comparison of the effect of educational and self- 

47 
 
management interventions on adherence to treatment in hemodialysis patients: A 
systematic review and meta-analysis of randomized controlled trials. International 
Journal of Clinical Practice, 75(5). https://doi.org/10.1111/ijcp.13842 
Yeh, L. M., Chiu, S. Y. H., & Lai, P. C. (2019). The Impact of Vascular Access Types on 
Hemodialysis Patient Long-term Survival. Scientific Reports, 9(1), 1–8. 
https://doi.org/10.1038/s41598-019-47065-z 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Annexures 
Annexure 1 
Information Sheet for Head of Departments 
I am Bushra Sultan student of Doctor of Philosophy of Nursing (Ph. D) at Shifa Tameer-
e- Millat. The research study is the academic requirement of my Ph.D. degree.  The study will be 
supervised by Dr. Khairunnisa Dhamani. The purpose of this study is to assess the Effectiveness 
of Skill Building Education on Arteriovenous Fistula Self-care Behavior and quality of life 
among Patients on Hemodialysis. I will invite all the hemodialysis patient who have AVF came 
in the hemodialysis units to participate in this research.  
This research will involve the skill building educational intervention which mean that 
patients will be trained to assess and care their own AVF at home.  Participants will be instructed 
to perform that assessment on daily basis. There are no potential risks associated with this study. 
Participants will have the following benefits 
1. They will get more knowledge and information to care your AVF at home  
2. They will be able to learn AVF assessment skill. They can apply that skill at home on AVF on 
regular basis. This activity will help them to prevent from AVF complication and indirectly 
improve the quality of life 
3. Their participation will allow us to test this intervention on real hemodialysis patients and include 
it as a protocol in hemodialysis units for the future patients.  
 
Thank you for your cooperation. If you have any concerns or questions about the study, 
please feel free to contact  
Bushra Sultan (primary investigator)  
Mobile Number: 03315116190 
Email address: bushra.scn@stmu.edu.pk 
 
 
 
 
 

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Annexure 2  
Medical Record Screening Form 
Date of Screening:    ____________________ Screen by: ________________________ 
Participant ID or Medical record (M.R) number: ________________________ 
Reviewed by (Name/ID): 
Eligibility Criteria: 
1. Age: aged 18 years or above. 
o __ Eligible 
o __ Not Eligible 
o __ Not Applicable 
2. Diagnosis:  diagnosed with end-stage renal disease__  
o ___Eligible (Specify: ______________________) 
o __ Not Eligible 
o __ Not Applicable 
3.      Hemodialysis: on hemodialysis through an arteriovenous fistula  
a. __ Eligible (Specify: ______________________) 
b. __ Not Eligible 
c. __ Not Applicable 
3.     Can read and understand the Urdu language. 
a. __ Eligible  
b. __ Not Eligible (Specify condition: ______________________) 
c. __ Not Applicable 
Overall Eligibility Status: 
a. __ Eligible 
b. __ Not Eligible (Specify reason: ______________________) 
Notes/Comments: 
 
 
 

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Annexure 3   
Participants Needed for Research Study on AVF Self-Care and Quality of Life! 
I am Bushra Sultan student of Ph. D at Shifa Tameer-e- Millat  
I am conducting a study as a requirement of my Ph.D. degree 
What’s the study about? We are conducting a study to explore how educational interventions 
focused on AVF self-care can impact overall health and well-being. The study aims to empower 
patients with the knowledge and skills needed to better manage their AVF and improve their 
quality of life. 
The study will be supervised by Dr. Khairunnisa Dhamani. The study is approved by IRB 
Who can participate? 
 
Adults 18 years or older 
 
Currently receiving hemodialysis with an AVF 
 
Willing to participate in a brief educational program 
 
Able to provide informed consent 
What’s involved? 
 
A skill-building educational session focused on AVF self-care 
 
Routine care information for patients 
 
Follow-up assessments to monitor health and well-being 
Thank you for your cooperation. If you have any concerns or questions about the study, 
please feel free to contact Bushra Sultan (primary investigator) at the below-given details. Ph.D 
student, Shifa College of Nursing, and Islamabad, Pakistan  
Mobile Number: 03315116190 
Email address: bushra.scn@stmu.edu.pk 
 
 
 
 
 
 

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Annexure 4  
Consent form for Participants 
Study Title: Effectiveness of Skill Building Education on Arteriovenous Fistula Self-care 
Behaviour and quality of life among Patients on Haemodialysis  
Principal Investigator (PI): Bushra Sultan 
Supervisor: Prof. Khairunnisa Dhamani 
Co-supervisor:  Prof. Kawkab Shishani 
Committee member: Muhammad Ishtiaq 
Organization: Shifa College of Nursing, Shifa Tameer e Millat, Islamabad.  
Introduction 
I am Bushra Sultan student of Doctor of Philosophy of Nursing (Ph. D) at Shifa Tameer 
e Millat. The research study is the academic requirement of my Ph.D degree.  The study will be 
supervised by Dr. Khairunnisa Dhamani. I am inviting you to participate in this research. This 
research will be related to the arteriovenous fistula care in hemodialysis patients. Before taking 
decision of participation in this study you can seek clarification.    
Do not be concerned by the length of this template. It is long only because it contains guidance 
and explanations which are for you to participants in your research.  
Purpose of the Study 
AVF is a common and lifelong vascular access for the hemodialysis patients. It is created 
via surgery and become a part of patient body. Every time for hemodialysis you required a 
functional AVF. However, its functionality could be compromise due to lack of awareness and 
carelessness. Therefore, I am doing this research to train hemodialysis patients to take care their 
fistula at home. This study aims to assess the Effectiveness of Skill Building Education on 
Arteriovenous Fistula Self-care Behavior and quality of life among Patients on Hemodialysis.  
Right to withdrawal 
I will invite all the hemodialysis patient who have AVF came in the hemodialysis units to 
participate in this research. Your participation in this research will be entirely voluntary. 
Whether you want to participate or not, your services in the dialysis units will continue and will 
not be change. If you participate, and withdraw from study on any phase of this research, you 
can. 
 

52 
 
Procedure 
If you are interested to participate in this study, following procedure will be completed in 
the research process. A data (two survey form) related to self-care and quality of life of your 
AVF will be taken after you give consent for participation. The time duration for data collection 
(survey form) will be approximately 30 minutes. Afterward you will assign to either intervention 
group or the control group by selecting a sealed envelope. Participants in one group will receive 
the routine care of dialysis and other group will receive the skill building educational 
intervention. Neither you, nor I will know, you are in which group. Your record will be saved in 
the files but that file will not be open until the intervention completed.  
Type of intervention This research will involve the skill building educational intervention 
which mean that patients will be trained to assess and care their own AVF at home.  The 
intervention of this study will be divided into two teaching sessions. In session one, you will be 
asked to explain your experience of caring AVF at home and then information will be provided 
to you regarding your AVF care. Session one will be completed in 25min. In the next session, 
AVF assessment skill will be taught by demonstration and then you will have return 
demonstration which will be completed in 20 min. During intervention implementation phase 
there may be some word that you do not understand. Please ask me to stop, I will take time to 
explain and clarifies you. Moreover, you will be instructed to perform that assessment on daily 
basis. Data will be collected on the same form after intervention, then after 2, 4 weeks of 
intervention implementation. During the time frame of intervention and follow-up you can ask 
any question, queries on daily basis.  
Possible Discomfort and Risk 
There are no potential risks associated with this study. If you do not feel comfortable you 
can refuse without any hesitation. The data collection will be instantly halted and resumed with 
your permission when you feel comfortable. As the data will be collected on two survey forms 
that may cause minimal discomfort or burden to you. 
Benefits 
If you participate in this research, you will have the following benefits 
1. You will get more knowledge and information to care your AVF at home  
2. You will be able to learn AVF assessment skill. You can apply that skill at home on your 
AVF on regular basis. This activity will help to prevent yourself form AVF complication and 
indirectly improve the quality of life 

53 
 
3. Your participation will allow us to test this intervention on real hemodialysis patients and 
include it as a protocol in hemodialysis units for the future patients.  
Confidentiality 
To maintain anonymity, codes will be used for each individual. A password-protected 
copy on the personal laptop will be used to save data and keep hard copies of the data under lock 
and key. The information you provide will be accessible only to the thesis committee. Your 
name will not be reflected anywhere during transcribing the data, thesis writing, and publication 
Contact Information 
Thank you for your cooperation. If you have any concerns or questions about the study, 
please feel free to contact Bushra Sultan (primary investigator) at the below-given details. Ph.D 
student, Shifa College of Nursing, and Islamabad, Pakistan  
Mobile Number: 03315116190 
Email address: bushra.scn@stmu.edu.pk 
Agreement to Participation 
I have read and understood the information provided in the form for the study participants. I 
agree to participate in the study. I had an opportunity to ask any question. I have a right to 
withdraw from the study at any stage. I agree that the study’s findings may be published but will 
not show my identity.  
 
Participant Name: _____________________________  
Participant’s Signature or thumb impression: _________________________  
Email: _______________________________ 
Mobile Number ______________________ 
Date: _________________________________________ 
 
 
 
Annexure 5 
Personal and Clinical Information Sheet 

54 
 
Name__________________________________________Phone number 
_____________________ 
Address_______________________________________________________________________
______________________________________________________________________________
____Email 
address____________________________________________________________________ 
Family member name, _____________________  Email address, ________________________ 
Phone number, ____________________________ 
Patient age _________     Gender,_________         Educational 
level________________________ Employment,___________________________           Income 
_____________________________        Any other earning source, total income) 
______________________________________and  
 
Clinical characteristic  
 Current disease________________________________, Hemodialysis frequency ____________ 
Dialysis duration, ______________________________ 
When dialysis treatment was started:     __________________________________________ 
Time of Dialysis start from AVF_________________________________________________   
Charlton’s Comorbidity Index  
 
 
 
 
 
 
 
 
 
 

55 
 
Annexure 6a 
Assessment of Self-care Behaviors with AVF in Hemodialysis Patients 
 
S 
 
1 2 3 4 5 
1. 
I address the nurse when I have cramps during hemodialysis 
 
 
 
 
 
2. 
I do compression of puncture sites with the fingers. 
 
 
 
 
 
3. 
I address the nurse when I get a headache and chest during hemodialysis. 
 
 
 
 
 
4. 
I apply ointment when hematoma occurs. 
 
 
 
 
 
5. 
I feel the thrill at the site of the fistula twice a day 
 
 
 
 
 
6. 
I do compression at home at puncture site if bleeding occurs. 
 
 
 
 
 
7. 
I check every day if the hand of the fistula arm cools. 
 
 
 
 
 
8. 
I observe signs of redness and swelling at the puncture sites. 
 
 
 
 
 
9 
I protect the fistula arm from scratches, cuts and wounds. 
 
 
 
 
 
 
10. I check every day if the color of the hand from the fistula arm changes. 
 
 
 
 
 
11. I protect the fistula arm from bumps and shocks 
 
 
 
 
 
 
12. I allow blood sampling in the fistula arm* 
 
 
 
 
 
 
13. I address the nurse if the hand of the fistula arm starts to hurt. 
 
 
 
 
 
 
14. I avoid getting into places with different temperatures 
 
 
 
 
 
15 
I immediately go to hospital or a clinic if fistula has not thrill. 
 
 
 
 
 
16 
I address nurses if the hand of the fistula arm appears with wounds 
 
 
 
 
 
1= “Never develop this self-care”  
2= Rarely  
3=Sometime  
4=Often 
5= Always develop this self-care” 
 
 

56 
 
Annexure 6b:  
Permission for Self-care Behaviors tool 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Annexure 7a: 
Hemodialysis Access Related Quality of Life Tool 
Va

57 
 
 
 
 

58 
 
 
 

59 
 
 

60 
 
 
 

61 
 
 
 

62 
 
 
 
 

63 
 
 
 
 
 
 
 
 
 

64 
 
Annexure 7b:  
Permission for HARQ Tool 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

65 
 
Annexure 8  
Checklist for Assessment of Arteriovenous Fistula 
 
Items  
Yes (1) 
No (0) 
1 
Have you felt any changes in your fistula  
 
 
 
LOOK  
 
 
2 
Inspection 
Observe for fistula for the following  
 
 
3 
Location of fistula  
 Radio cephalic  
 Brachiocephalic  
 Upper arm transpose basilic 
 
 
 
Infection/ Inflammation  
 
 
4 
4.1 
4.2 
4.3 
Do you observe any swelling around or on fistula? 
If yes from how long this swelling is ________________ 
Have you performed any intervention for swelling  
What intervention you perform any of these intervention  
4.3.1                                                         Hot fomentation (1) 
4.3.2                                                         Cold fomentation (2) 
4.3.3                                                         Bandage (3) 
4.3.4                                                         Arm elevation (4) 
4.3.5                                                         Other (5) 
 
 
5 
Do you observe redness around or on fistula? 
 
 
6 
 
6.1 
6.2 
 
 
 
 
 
 
6.3 
Are you feeling pain at fistula side? 
If yes then  
 What is the intensity of the pain?  Scoring will be on pain 
scale  
 What intervention you perform to relieve the pain  
6.2.1                                                     Hot fomentation (1) 
6.2.2                                                    Cold fomentation (2) 
6.2.3                                                     Bandage (3) 
6.2.4                                                     Arm elevation (4) 
6.2.5                                                     Ointment painkiller (5) 
6.2.6                                                     Oral analgesic (6) 
 Has it impacted your daily life activities?  
 
 
 
Steal syndrome 
 
 

66 
 
7 
Do you feel any change in the temperature at fistula side or at that hand? 
 
8 
Do you feel any numbness or change in sensation at fistula side or at hand  
 
9 
Do you feel tingling sensation at hand  
 
10 
Do you feel any changes in the strength of your hand or arm 
 
11 
Do you feel any difficult in performing the daily activities with the fistula 
arm or hand 
 
12 
Do you feel any discoloration at fistula side? 
 
13 
Dou you have ischemia of finger and nail 
 
14 
Is there any change in the skin integrity at fistula side 
 Skin rash 
 
 
15 
Is there any scar at fistula side  
 
 
16 
Is there any formation of clot 
 
 
17 
Observe for aneurysm  
 
 
18 
Is there any hematoma  
 
 
 
19 
Perform Arm elevation test 
Is your fistula being collapse on arm elevation? 
If No, report to doctor 
 
Ask the patient to raise or elevate the fistula arm above the level of the 
heart.  
Normal finding: The fistula should collapse or become flat on elevation of 
arm and return back to normal when arm at horizontal or lower to the 
body.  
Note: In the presence of a significant stenosis, blood drainage is hampered 
and the AVF may not collapse and usually becomes hyper pulsatile.  
 
 
 
20 
20.1 
20.2 
20.3 
Inspect for central vein stenosis 
Have you compared both arm(extremities) 
Are your both arms being of equal size 
Is the fistula arm is swollen  
Have you observed colla lateral vein in the fistula arm.  
 
 
 
21 
Aneurysm and pseudoaneurysm 
 Observe for aneurysm  
 
 
 
22 
Palpation (feel) 
 Palpate the pulses (Radial, ulnar, brachial) 
 
 
23 
Perform Allen test  
 
 

67 
 
 
24 
Check the capillary refill 
Is the capillary refill less than 3sec. 
 
 
 
25 
Perform Augmentation test 
Is the augmentation test normal? 
 
The augmentation test is done by occluding the access completely by 
palpation several centimeters beyond the arterial anastomosis.  
The test is normal when the portion of the access upstream from the 
palpation (occlusion) demonstrates augmentation of the pulse. 
Pulse is expected to increase in intensity and thrill should disappear after 
AVF occlusion. 
 
 
 
26 
Feel for Accessory veins 
Do you feel the accessory veins on palpation? 
 
Normally on examination the thrill that is palpable over the arterial 
anastomosis disappear completely when the downstream or the outflow of 
the fistula is manually occluded.  
If the thrill does not disappear with manual occlusion of the outflow, then 
one should suspect an extra channel or extra outflow channel that we call 
an accessory vein which may be present between anastomosis and the 
points of occlusion. In presence to accessory vein despite occlusion the 
thrill persists especially if the accessory vein is large.  
 
 
 
27 
 
27.1 
27.2 
Auscultation 
Is the bruits sound being normal over the fistula and along the entire length 
of the arm? 
Is the sound is same along on the fistula and on the entire length of the arm  
Have you listened sound other than bruits 
If yes Report to doctor 
 
Bruits is sound or the murmur is heard over the fistula  
Listen along the entire length of the arm.  
 
 
 
Assessment after hemodialysis (After 2-3hrs) 
S 
Items 
Yes (1) 
No (0) 
1 
Do you feel erythema, swelling at fistula site 
 
 
2 
Do you feel tenderness at a fistula site 
 
 
3 
Do you feel a persistent extremity swelling  
 
 

68 
 
4 
Do you feel a prolonged bleeding after needle withdrawal  
 
 
5 
Do you feel an altered pulse or thrill in the fistula  
 
 
6 
Do you feel an altered bruit in the fistula  
 
 
7 
Do you feel an absence of bruits in the fistula  
 
 
8 
Do you feel an absence of thrills in the fistula 
 
 
 
I confirm that the fistula or graft is officially abandoned for further use 
and is not safely salvageable (by Health care professional) 
 
 
Note: This assessment can be performed by the patient him/herself or by the caregiver. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

69 
 
Annexure 9 
Teaching Plan 
Sessions Time 
Content 
Strategy 
Facilitator 
1 
 
25min 
This session will focus on the self- care maintenance of AVF:  
1. Patients will be inquired about their AVF concept, their 
subjective feelings about AVF, care practices at home, their pattern 
of dialysis, and who is responsible for their AVF care at home           
2. Information related to the general concept of fistula 
maintenance, its functionality, its significance in dialysis patients, 
specific instruction needs to be considered in daily life activities, 
and its impact on social, emotion and mental health will be 
covered. Patients' concerns and quarries about their self-care 
behaviors will be clarified in this session. 
 
 
 
 
Teach-
back, 
PPT, 
 
 
 
 
Primary 
Investigato
r 
Plan for practical session 
2 
20min 
Demonstration of Skill 
This session will focus on the self- care monitoring of AVF, the 
importance of self-care monitoring in daily routines, and 
assessment of AVF. The skill will be demonstrated by following 
three steps: inspection, palpation and auscultation following a skill 
checklist. 
Demonstr
ation Re-
demonstr
ation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

70 
 
Annexure 10 
Manual of Operation 
Introduction 
The purpose of this Manual of operation is to provide a guideline for the principal 
investigator and member of research team. It serves as an extensive document that outline the 
fundamental processes, procedures, and guideline to conduct the study. It provides a clear 
instruction for the implementation of the intervention.  
Manual of operation content and organization 
Research team responsibilities 
 Responsibilities of primary investigator are the development of protocol, initial plan and 
intervention of the study. 
 Implementation of feedback and refinement of protocol 
 Taking the IRB approval 
 Meeting with HOD and staff of dialysis units, translators.  
 Facilitation of translators  
 Training of research assistant  
 Pilot test the tool and intervention 
 Actual implementation of intervention  
 Provision of data to data analyst 
 Finalization of study finding 
Responsibilities of supervisor, co-supervisor and team 
Provision of feedback and guidance ongoing basis 
Study Protocol 
Study protocol will be attached as an appendix 
Meeting with dialysis head and staff  
A meeting will be held with the head of dialysis units. The purpose of this meeting will be to 
share the information related to the research process, intervention and pilot testing. An 
information sheet is developed to share with them (Annexure). Moreover, a permission will be 
taken to conduct research in the dialysis unit. That letter of permission will be attached as an 
annexure to show to institution review board.  
Tools Translation and validation 
Written in protocol 

71 
 
Ethical Approval  
Ethical approval will be taken from institution review board. After ethical approval tools and 
intervention will be pilot tested. 
Psychometric properties of Tools  
Tools will be sent to 5 experts for review. Content validity index will be calculated. Feedback 
will be incorporated and tool will be finalized.  The primary investigator will pilot test the tool in 
10% of population of same setting (dialysis units) where the actual study will be conducted. 
Reliability of tool will be calculated.  
Eligibility criteria of 10% population 
4. 
Patients diagnosed with end-stage renal disease on hemodialysis through an 
arteriovenous fistula 
5. 
Have aged 18 years or above 
6. 
Who can read and understand the Urdu language. 
Meeting with dialysis staff 
A meeting will be held at the time of pilot testing with the dialysis unit team leader. The 
purpose of this meeting is to not only discuss the research process, intervention but also taking 
the permission of using their room for the purpose of education session for patients. Moreover, 
having a setting of dialysis treatment of interventional and control group in a separate rooms or 
wards.   
Training of research assistant 
A research assistant will be trained for the data collection process. The research assistant 
will be briefed about the pilot testing, consent from, baseline assessment, randomization, and 
sealed envelope. Both the tools in Urdu language, and consent form will be share with research 
assistant. Time will be given to read and understand the tools, its possible responses, scoring 
method. Concern and questions will be entertained. First, the research assistant will take a 
consent from the participant, then base line assessment will be done. Later on, a sealed envelope 
will be handed over to participants and assign in a particular group.  
Intervention pilot testing 
Intervention will be pilot tested at the same time with the tools by the primary 
investigator.  
Results will be finalized and modification made according to the finding of pilot testing. 

72 
 
Communication Plan  
Ongoing communication will be required among the primary investigator, research 
assistant, dialysis unit team leader/staff and other member of the research team to ensure that the 
study progress and other emerging issues deal properly.  
Intervention  
Intervention of the study will be implemented by primary investigator.  Each patient will 
receive two educational sessions individually. The detail of intervention is explained in protocol.  
Data Analysis 
Data will be analyzed by data analyst. However, the final writing and explanation of 
finding will be done by the primary investigator.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

73 
 
Annexure 11 
Assessment Guide 
Empowering patients and Caregivers: A guide for AVF assessment  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

74 
 
Purpose 
This guide or manual will serve a comprehensive resource for the hemodialysis patients 
and their caregiver to manage the arteriovenous fistula. This guideline typically provides 
information, and instruction to ensure the proper care and handling of AVF. Moreover, it guides 
the patients and caregiver to ensure the normal functioning of AVF and identify the abnormality 
or changes in the normal functioning of AVF.  
 
 
 
 
 
  
 
 
 
 
 
 
 

75 
 
Table of Content 
 
Content                                                                                                      Page No 
 
AVF concepts                                                                                                 4 
AVF examination 
Inspection  
 
 
 
 
 
 
 
 
6-13 
Palpation  
 
 
 
 
 
 
 
 
13-15 
Auscultation  
 
 
 
 
 
 
 
16 
Checklist for AVF assessment  
 
 
 
 
 
17-19 
Checklist for AVF assessment after dialysis   
 
 
 
19 
General points for consideration 
 
 
 
 
 
20 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

76 
 
Arteriovenous Fistula  
Arteriovenous fistula (AVF) can be surgically created by vascular specialist for the 
hemodialysis access. Arteriovenous fistula is the abnormal connection between the artery and 
vein (Abreo et al., 2019). The AVF blood flow from the artery directly into the vein, increasing 
the blood pressure and amount of blood flow through the vein. The increase flow and pressure 
cause the vein to enlarge because increase blood flow and pressure is required for the 
hemodialysis treatment.  
Arteriovenous fistula depends on the location in the body. Typically, it is created in the 
extremities, upper extremities are most prefer than lower extremities.  
Fistula  
Arteries and veins 
Upper 
extremity  
Radio cephalic, 
Radial artery and cephalic vein at the wrist 
Forearm-Basilic 
Radial or ulnar artery and basilic vein at the wrist 
 
Radial artery and antecubital vein  
 
Radial artery and median antebrachial vein 
Brachial-cephalic 
Brachial artery and cephalic vein the proximal forearm 
Brachial-basilic 
Brachial artery and basilic vein in the upper arm 
Lower 
Extremity 
Femoral 
Femoral artery or femoral vein  
Transpose 
femoral 
Femoral artery and saphenous vein  
superficial artery and saphenous with femoral or 
popliteal vein 
 
AVF become a part of patient body. Having fistula is a visual reminder of their disease. The 
experience and anticipation of complication with their access can a key source of stress and 
interruption to the routine of hemodialysis patients. Therefore, daily care is required to keep the 
fistula functional. The first step in the fistula care is the assessment of fistula and act according to 
the changes in the normal functioning. When the patients able to know the normal functionality 
of the fistula they better able to detect the any changes in the normal functioning and prevent 
them from complication.  
 
 
Arteriovenous Fistula examination 
 
AVF require daily inspection and care.  
Physical examination of the arteriovenous access is an accurate diagnostic tool that can be 
quickly performed by the patient. It can provide valuable information to detect or rule out normal 
or abnormal functioning of AVFs 
 
 
Arteriovenous fistula examination involve LOOK, LISTEN and FEEL.  

77 
 
                                                               
 
LOOK 
Inspection  
Location of Fistula  
 
 

78 
 
 
 
 
 
 
Observe for fistula for the following  
1. Sign of infection and inflammation. If sign of infection and inflammation is present then 
then observe for cardinal symptom. Pain, redness, swelling, loss of function, increase in 
temperature. 
 Assess Pain scale  
 What is a location of pain? 
 What is the intensity of the pain? 

79 
 
 Is it rotating? 
 Is it associated with any other symptom? 
 How it relieves? 
 How this impacts your daily life activities? 
 Redness & swelling is local or it in whole arm 
 Does the patient is able move AVF arm? 
 Compare temperature of AVF side with area of AVF arm 
2. Rule out for the Steal syndrome in inspection:  
 Evaluate for any discoloration at fistula, (discoloration of the hand, the hand may appear 
dusky, and have bluish tinge or pale in color). 
 Evaluate for ischemia of finger and nail 
 Check the temperature at fistula side or at that hand 
 Check for numbness or change in sensation at AVF side or at hand  
 Presence of tingling sensation at hand  
 Check for any changes in the strength of your hand or arm 
 Evaluate for any difficulty in performing the daily activities with the fistula arm or hand 
 Check the skin integrity at fistula side 
 Evaluate for the presence of scars at fistula side  
3. Observe for aneurysm  
4. Observe for hematoma  
 
 
 
 
Perform arm elevation test 
Arm elevation test 
It is a simple noninvasive test that can easily be perform to rule out the stenosis. It is low cost, 
convenient and quick test that can help to save patients form the unwarranted invasive 
procedures. This test is performed by elevating the patient access arm above the level of heart. 
Normally, the elevation leads to the collapse of fistula. Gravity causes the blood within the AVF 
to drain. thus, causing the fistula to collapse. In case of stenosis the fistula will not collapse and 
become hyper pulsatile.  

80 
 
 
Arm elevation test. (A) Left forearm (radial artery to cephalic vein) arteriovenous fistula (AVF) 
in a patient on hemodialysis. The AVF is visibly raised, well distended, and aneurysmal. (B) 
Elevation of the arm above the heart level leads to the collapse of the AVF. Full collapse of the 
most distal aneurysm is clearly seen while the proximal aneurysms partially collapse. 
Inspect for central vein stenosis 
In case of central venous stenosis, the access arm will be swollen. Presence of collateral vein are 
also sign of central venous stenosis. Patient arm will be compared for the inspection of central 
venous stenosis.  
                                                                                        
 
                                                                                                        Collateral Vein 
 
Inspect for Aneurysm  

81 
 
 Arteriovenous fistula aneurysms are defined by an expansion of the intimal, medial and 
adventitial layers of the vessel wall to a diameter of more than 18 mm. Treatment of 
arteriovenous fistula aneurysm is indicated if there is pain, risk of hemorrhage and flow 
disturbance (either low or high flow). 
 
 
 
 

82 
 
 
 
Palpation (Feel) 
Palpation involves the assessment of Inflow (augmentation test), out flow (hyper pulsatile pulse 
and absence of thrill) and feel for accessory vein 
The normal AVF is soft and compressible. AVF should be palpated form the area of anastomosis 
to the subclavian vein. In doing so, the character of the pulse and quality of thrill could be 
evaluated.  
Pulse 
Normally the pulse is soft and compressible. As a rule of thumb, having pulse is bad, 
indicating downstream stenosis.  The degree of hyperpulsatility is proportional to the severity of 
the stenosis. 
Juxta-anastomosis vein stenosis is the most common site for stenosis. Juxta-anastomosis mean 
close to the anastomosis. Juxta-anastomosis is site where there is a surgical mobilization of the 
vein and this mobilization leads to small trauma or ischemia of the vein. Early diagnosis by 
palpation of the anastomosis and the distal outflow vein help in the stenotic lesion.  
Normally the AVF is soft and compressible. With juxta anastomosis, the water hammer pulse is 
felt at the anastomosis.  
Water hammer pulse is very forceful pulse that is felt at the anastomosis. The pulse goes away 
rather abruptly as the side of stenosis encountered, about this level the pulse is very week and the 
vein is poorly developed. An unusually weak pulse (hypopulsatile access) or "flat access" 
suggests the presence of a stenotic lesion located in the inflow side of the access. 
 
 
Thrill 

83 
 
 A thrill is a palpable vibration indicating the blood flow within the AVF. It could be check by 
using the palm of the hand. A Normal thrill is diffuse, continuous and machinery like vibration 
of sensation with a systolic and diastolic component. A thrill is most obvious at the arterial 
anastomosis, but it can be palpable over the course of AVF.  
The absence of a thrill indicates a lack of flow, which along with the absence of any pulse is 
characteristic of a thrombosed access. 
 
Check the Augmentation of the fistula 
Augmentation test is performed to assess the adequacy of inflow pressure. It is the assessment of 
arterial flow or arterial inflow. The outflow vein is manually occluded few centimeters proximal 
to the anastomosis. The segment between the arterial anastomosis and the occlusion become 
hyper pulsatile because of the arterial pressure is transmitted across patent anastomosis.  
In inflow stenosis the arterial pressure is not adequately transmitted and the segment between the 
occlusion and the anastomosis remains weekly pulsatile.  
Pulse is expected to increase in intensity and thrill should disappear after AVF occlusion. 
Absence of thrill distal to outflow stenosis 
With outflow stenosis the fistula become pulsatile firm and losses the thrill. Absence of thrill 
distal to stenosis this distal segment become firm does not collapse with the arm elevation and 
there is no thrill. Distal to the stenosis the segment is hyper pulsatile 
 
Feel for Accessory veins 
Accessory vein sometime prevents the maturation of the fistula. The accessory vein especially in 
the juxta-anastomosis segment that is a segment closer to the anastomosis in the outflow track 
can leads to loss of pressure head into the main channel that is useful for cannulation. Normally 
on examination the thrill that is palpable over the arterial anastomosis disappear completely 
when the downstream or the outflow of the fistula is manually occluded.  
If the thrill does not disappear with manual occlusion of the outflow, then one should suspect an 
extra channel or extra outflow channel that we call an accessory vein which may be present 
between anastomosis and the points of occlusion. In presence to accessory vein despite occlusion 
the thrill persists especially if the accessory vein is large.  
Normally the thrill that is palpable over the arterial anastomosis is disappear completely when 
the downstream fistula is manually occluded.  
Capillary refill 
Check the capillary refill of the hand and finger. It should be less than 3sec. 
 

84 
 
 
 
 
Auscultation 
Auscultation is the last step of AVF examination. On auscultation the bruit are sound or the 
murmur is heard over the fistula. It should be listened along the entire length of the arm.  
 
 
 
 
 
 

85 
 
Checklist for Assessment of Arteriovenous Fistula 
 
Items  
Yes (1) 
No (0) 
1 
Have you felt any changes in your fistula  
 
 
 
LOOK  
 
 
2 
Inspection 
Observe for fistula for the following  
 
 
3 
Location of fistula  
 Radio cephalic  
 Brachiocephalic  
 Upper arm transpose basilic 
 
 
 
Infection/ Inflammation  
 
 
4 
4.1 
4.2 
4.3 
Do you observe any swelling around or on fistula? 
If yes from how long this swelling is ________________ 
Have you performed any intervention for swelling  
What intervention you perform any of these intervention  
4.3.1                                                         Hot fomentation (1) 
4.3.2                                                         Cold fomentation (2) 
4.3.3                                                         Bandage (3) 
4.3.4                                                         Arm elevation (4) 
4.3.5                                                         Other (5) 
 
 
5 
Do you observe redness around or on fistula? 
 
 
6 
 
6.1 
6.2 
 
 
 
 
 
 
6.3 
Are you feeling pain at fistula side? 
If yes then  
 What is the intensity of the pain?  Scoring will be on pain 
scale  
 What intervention you perform to relieve the pain  
6.2.1                                                     Hot fomentation (1) 
6.2.2                                                    Cold fomentation (2) 
6.2.3                                                     Bandage (3) 
6.2.4                                                     Arm elevation (4) 
6.2.5                                                     Ointment painkiller (5) 
6.2.6                                                     Oral analgesic (6) 
 Has it impacted your daily life activities?  
 
 
 
Steal syndrome 
 
 
7 
Do you feel any change in the temperature at fistula side or at that hand? 
 

86 
 
8 
Do you feel any numbness or change in sensation at fistula side or at hand  
 
9 
Do you feel tingling sensation at hand  
 
10 
Do you feel any changes in the strength of your hand or arm 
 
11 
Do you feel any difficult in performing the daily activities with the fistula 
arm or hand 
 
12 
Do you feel any discoloration at fistula side? 
 
13 
Dou you have ischemia of finger and nail 
 
14 
Is there any change in the skin integrity at fistula side 
 Skin rash 
 
 
15 
Is there any scar at fistula side  
 
 
16 
Is there any formation of clot 
 
 
17 
Observe for aneurysm  
 
 
18 
Is there any hematoma  
 
 
 
19 
Perform Arm elevation test 
Is your fistula being collapse on arm elevation? 
If No, report to doctor 
 
Ask the patient to raise or elevate the fistula arm above the level of the 
heart.  
Normal finding: The fistula should collapse or become flat on elevation of 
arm and return back to normal when arm at horizontal or lower to the 
body.  
Note: In the presence of a significant stenosis, blood drainage is hampered 
and the AVF may not collapse and usually becomes hyper pulsatile.  
 
 
 
20 
20.1 
20.2 
20.3 
Inspect for central vein stenosis 
Have you compared both arm(extremities) 
Are your both arms being of equal size 
Is the fistula arm is swollen  
Have you observed colla lateral vein in the fistula arm.  
 
 
 
21 
Aneurysm and pseudoaneurysm 
 Observe for aneurysm  
 
 
 
22 
Palpation (feel) 
 Palpate the pulses (Radial, ulnar, brachial) 
 
 
23 
Perform Allen test  
 
 
 
Check the capillary refill 
 
 

87 
 
24 
Is the capillary refill less than 3sec. 
 
25 
Perform Augmentation test 
Is the augmentation test normal? 
 
The augmentation test is done by occluding the access completely by 
palpation several centimeters beyond the arterial anastomosis.  
The test is normal when the portion of the access upstream from the 
palpation (occlusion) demonstrates augmentation of the pulse. 
Pulse is expected to increase in intensity and thrill should disappear after 
AVF occlusion. 
 
 
 
26 
Feel for Accessory veins 
Do you feel the accessory veins on palpation? 
 
Normally on examination the thrill that is palpable over the arterial 
anastomosis disappear completely when the downstream or the outflow of 
the fistula is manually occluded.  
If the thrill does not disappear with manual occlusion of the outflow, then 
one should suspect an extra channel or extra outflow channel that we call 
an accessory vein which may be present between anastomosis and the 
points of occlusion. In presence to accessory vein despite occlusion the 
thrill persists especially if the accessory vein is large.  
 
 
 
27 
 
27.1 
27.2 
Auscultation 
Is the bruits sound being normal over the fistula and along the entire length 
of the arm? 
Is the sound is same along on the fistula and on the entire length of the arm  
Have you listened sound other than bruits 
If yes Report to doctor 
 
Bruits is sound or the murmur is heard over the fistula  
Listen along the entire length of the arm.  
 
 
 
Assessment after hemodialysis (After 2-3hrs) 
S 
Items 
Yes (1) 
No (0) 
1 
Do you feel erythema, swelling at fistula site 
 
 
2 
Do you feel tenderness at a fistula site 
 
 
3 
Do you feel a persistent extremity swelling  
 
 
4 
Do you feel a prolonged bleeding after needle withdrawal  
 
 

88 
 
5 
Do you feel an altered pulse or thrill in the fistula  
 
 
6 
Do you feel an altered bruit in the fistula  
 
 
7 
Do you feel an absence of bruits in the fistula  
 
 
8 
Do you feel an absence of thrills in the fistula 
 
 
 
I confirm that the fistula or graft is officially abandoned for further use 
and is not safely salvageable (by Health care professional) 
 
 
 
Note: This assessment can be perform by the patient him/herself or by the caregiver. 
 
DOs and DON’T OF Fistula Care 
Cleanliness is important to keep the fistula uninfected. Wash it with soap and water daily.  
Any restriction in the blood flow can lead to clotting or fistula blockage.  
Avoid tight clothing  
Avoid tight jewelry over the access area 
Do not carry heavy item with the access arm 
Do not sleep over access arm  
Do not check your blood pressure form the access arm.  
Do not give sample from the access arm.  
Attend regular follow-up appointment Engage in gentle exercise as recommended by the health 
care provider. This can help promote blood flow and overall vascular health. 
 
 
Reference 
Abreo, K., Amin, B. M., & Abreo, A. P. (2019). Physical examination of the hemodialysis 
arteriovenous fistula to detect early dysfunction. Journal of Vascular Access, 20(1), 7–11. 
https://doi.org/10.1177/1129729818768183 
Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates _ Surgery _ 
JAMA Surgery _ JAMA Network. (n.d.). 
Beathard, G. A. (2022). Physical examination of the mature hemodialysis arteriovenous fistula. 
https://www.uptodate.com/contents/physical-examination-of-the-mature-hemodialysis-
arteriovenous-
fistula/print?search=fistolaarterovenosa&so…1/13OfficialreprintfromUpToDatewww.uptod
ate.com 
Before beginning dialysis, stop to LOOK, LISTEN, AND FEEL. (n.d.). 3773. 
Coentrão, L., Faria, B., & Pestana, M. (2012a). Physical examination of dysfunctional 
arteriovenous fistulae by non-interventionalists: a skill worth teaching. Nephrology, 
Dialysis, Transplantation : Official Publication of the European Dialysis and Transplant 
Association - European Renal Association, 27(5), 1993–1996. 
https://doi.org/10.1093/ndt/gfr532 
Coentrão, L., Faria, B., & Pestana, M. (2012b). Physical examination of dysfunctional 
arteriovenous fistulae by non-interventionalists: a skill worth teaching. In Nephrology, 

89 
 
dialysis, transplantation : official publication of the European Dialysis and Transplant 
Association - European Renal Association (Vol. 27, Issue 5, pp. 1993–1996). 
https://doi.org/10.1093/ndt/gfr532 
Infec, B. (n.d.). Basic Infection Prevention Booklet. 
Jayroe H, Foley KJayroe, H., & Foley, K. (2022). Arteriovenous Fistula - StatPearls - NCBI 
Bookshelf. In StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK559213/ 
Taylor, M. J., Hanson, C. S., Casey, J. R., Craig, J. C., Harris, D., & Tong, A. (2016). “You know 
your own fistula, it becomes a part of you”-Patient perspectives on vascular access: A 
semistructured interview study. Hemodialysis International, 20(1), 5–14. 
https://doi.org/10.1111/hdi.12340 
Woo, K. (2019). Arteriovenous fistula creation for hemodialysis and its complications. In 
UpToDate (pp. 1–31). https://www.lib.utdo.ir/contents/arteriovenous-fistula-creation-for-
hemodialysis-and-its-complications?search=Arteriovenous fistula creation for hemodialysis 
and its 
complications&source=search_result&selectedTitle=1~150&usage_type=default&display_r
ank=1 
(Abreo et al., 2019; Arteriovenous Fistula Maturation, Functional Patency, and Intervention  
Rates _ Surgery _ JAMA Surgery _ JAMA Network, n.d.; Before Beginning Dialysis, Stop to 
LOOK, LISTEN, AND FEEL, n.d.; Beathard, 2022; Coentrão et al., 2012a, 2012b; Infec, n.d.; 
Jayroe H, Foley KJayroe & Foley, 2022; Taylor et al., 2016; Woo, 2019)