[Solved] Assigment .Apa seven . All instructions attached.

Assignment Prompt & Instructions

**files (3)**

– ## FinalCapstone.docx

– ## MSN_Capstone_Part_II_Literature_Review.docx

– MSNCapstoneProject.edited1.docx

**## FinalCapstone.docx**

Final Capstone: Part I, II, III Cohesively Due 10/18/2025 by 11:59pm

1.Implementation/Conclusion

– Implement the change you are proposing- This should be a cohesive paper and continuation of Part I and Part II. Present as a cohesive paper to include Part I, II, III as per APA essay format.

2. Describe the practice change and setting clearly; is it in the community, organizational, clinic setting? Be detailed about the reason why you are seeking change.

3. Discuss how you would implement and assess the change; this should include time frame, setting (be specific), participants, barriers, external and internal factors.

-Timeline should be presented as a chart or essay format.* Do not use bullet points.

*Do not use direct implementation of Human Subjects in your proposal. This requires IRB

approval and CITI training which we will not use for this Capstone.

4. How would you evaluate the change process?

-The change must be measurable before and after the implementation.

-How would you measure or evaluate? Is there a tool to measure?

5. The literature review must support your change and implementation. Use leadership qualities and skills that will be utilized for successful completion of the project. What leasdership/management skills will you use?

6. Discuss who will be invited to the proposal: who are the stakeholders? Be specific about why you chose the team and what each of their role will be.

-How will you present the information to your stakeholders? Include cost and budget.

OVERALL: The conclusion should have your Part I, II, II all put together in a thorough APA format.

-Use appropriate APA 7th Ed. format

-Scholarly, peer-reviewed, and research articles cited should be within the last five years.

-This section should be minimum 3-4 pages long (not including the title and reference page).

-The final Capstone project should be a minimum of 8 pages.

-Use proper in-text citations with a properly formatted reference list.

-All papers must be written in the 3rd person.

CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Implementation of
the practice change
20 Points
Thoroughly
presented the
change proposal.
Included setting,
time frame,
population,
stakeholders, Pros
and cons/barriers.
20
Briefly presented
the change
proposal. Briefly
Included setting,
time frame,
stakeholders. Pros
and cons.
15
Vaguely presented
the change
proposal. Vaguely
Included setting,
time frame,
stakeholders, Pros
and cons.
10
Did not present the
change proposal.
0
Change proposal
was measured and
realistic.
20 Points
Thoroughly used an
appropriate
measurement tool.
Provided realistic
outcomes.
Discussed how it
will be used and
implemented.
20
Briefly used an
appropriate
measurement tool.
Provided realistic
outcomes.
15
Vaguely used an
appropriate
measurement tool.
Provided realistic
outcomes.
10
Did not use an
appropriate
measurement tool.
Provided realistic
outcomes.
0
Depth of
Discussion and
Cohesiveness
20 Points
Thoroughly, In-
depth discussion
and elaboration in
all sections of the
paper. Follows
criteria provided in
addition to
leadership,
management,
budget and
statistics.
20
Briefly, In-depth
discussion and
elaboration in most
sections of the
paper.
15
Vaguely, In-depth
discussion and
elaboration in most
sections of the
paper.
10
Did not use In-
depth discussion
and elaboration in
most sections of
the paper.
0
Conclusion
25 Points
Thoroughly, Ties
together
information from all
sources of Part I,
II,III. Followed
feedback and
comments given
from faculty.
25
Briefly, Ties
together
information from all
sources of Part I,
II,III
20
Vaguely, Ties
together
information from all
sources of Part I,
II,III
15
Does not Tie
together
information from all
sources of Part I,
II,III
0
Spelling and
Grammar
5 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
More than 5 but
fewer than 10
grammatical,
spelling,
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
An unacceptable
number of spelling
and/or grammar
mistakes.

Required word
count has been
met.
5
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
4
Required word
count is 50 words
below the minimum
required count.
3
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
5 points
Over 5 current
sources, of which
at least 3 are peer-
review journal
articles or scholarly
books. Sources
include both
general background
sources and
specialized
sources. Special-
interest sources
and popular
literature and
acknowledged as
such if they are
cited. All websites
utilized are
authoritative.
5
5 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
4
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
3
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books.
Not all websites
utilized are credible,
and/or sources are
not current.
0
Citations
5 points
Fewer than 5
incomplete
citations and/or
quotations, and
APA format errors
5
More than 5 but
fewer than 10
incomplete
citations and/or
quotations, and
APA format errors.
4
More than 10
incomplete
citations and/or
quotations, or APA
format errors.
3
The citation style is
inconsistent or
incorrect. It does
not cite sources

**## MSN_Capstone_Part_II_Literature_Review.docx**

**Part II: Review of Literature**

Yailin Ramirez

Florida National University

MSN Capstone Project—DAX-DL01

Dr. Carmen Lazo

June 5, 2026

**Review of Literature**

Non-adherence to nutrition is one of the most challenging and problematic clinical issues for nephrology nurses, particularly in adult patients with chronic kidney disease (CKD). This problem is exacerbated in a community hospital environment that provides care to adult inpatients and where community factors such as low health literacy, poverty, and access to renal nutrition counseling are present in Spartanburg County, South Carolina. The PICOT question for this capstone project is: For hospitalized adult renal patients who have CKD, is the provision of nurse-led education based on a simplified 1-page renal diet handout compared to usual care (no structured dietary education) associated with increased dietary adherence within 8 weeks? The findings of the synthesis of the available primary research and systematic reviews strongly reflect the effectiveness of structured, nurse-led dietary education in improving adherence outcomes in patients with renal disease and end-stage renal disease (ESRD), as well as highlight some key issues within current practice, missing evidence and conflicting views of the link between patient knowledge and behaviour change.

There has been ample literature documenting the burden of poor food intake in CKD. In this population, poor self-management and poor adherence to the CKD treatment plan, such as dietary elements, are significant factors for preventable hospital re-admission (Surasura et al., 2024). In 2022, the cost of CKD to Medicare was greater than $86 billion, highlighting the economic need for preventive interventions (NIH, 2025). National and local statistical data further support the need for a structured renal diet education intervention. At the national level, more than 1 in 10 U.S. adults, or approximately 37 million people, are estimated to have chronic kidney disease (CKD), and about 87% of adults with CKD are unaware that they have the condition (Centers for Disease Control and Prevention [CDC], 2026). This burden is highly relevant to hospitalized renal patients because CKD is strongly associated with diabetes and hypertension; approximately 38% of adults with diabetes and 21% of adults with high blood pressure are estimated to have CKD (CDC, 2026). At the state level, South Carolina reported a CKD prevalence of 5.2% among adults in 2024, compared with 4.0% nationally, ranking the state 47th for this measure (America’s Health Rankings, 2026). Locally, the 2024 Spartanburg County Community Health Needs Assessment reported that 12% of Spartanburg County adults were living with diabetes, slightly higher than the U.S. average of 10%, and 14.8% of residents, or 49,977 individuals, lived below the federal poverty level in 2022 (Live Healthy Spartanburg, 2024). These local and national statistics demonstrate that CKD risk factors, poverty, and limited health literacy may interfere with renal diet adherence. Therefore, a nurse-led, plain-language renal diet handout is appropriate for Spartanburg Regional Medical Center because it addresses a measurable health need in the local population.

Restrictions in CKD are multifaceted, meaning that patients need to restrict sodium, potassium, phosphorus and fluid intake all at once – often a very demanding and difficult set of restrictions for patients who may not have high health literacy. Billany et al. (2023) completed a systematic review showing that there is a significant association between low health literacy and poor self-management behaviors, poor health outcomes, and increased mortality in CKD patients. The findings are directly relevant to the target population in Spartanburg County where educational attainment and access to specialty care is below the national average.

One of the main variables in the problem is health literacy as well as one of the variables in the proposed solution. Lambert et al. (2024) carried out a quasi-experimental study to compare a health literacy informed approach to care in outpatient nephrology dietetic clinics. The updated model of care consisted of plain language materials, a renal diet question prompt sheet, and teach back techniques. A significant increase in patient understanding, dietary self-management confidence and satisfaction with the educational encounter were identified in the study. These results support the low-literacy, plain-language one-page handout approach recommended in this capstone and confirm the importance of this type of communication to ensure higher rates of patient participation in renal diet recommendations. A systematic review of effectiveness of Teach-Back methodology in patient education in CKD by Jagodage et al. (2023) revealed that teach-back led patient education programs, especially when delivered in a face-to-face format, were found to be effective in improving the dietary adherence and self-management outcomes among CKD patients when compared with non-structured usual care approaches. Both studies suggest the format and delivery that is advocated in this project.

Several randomized controlled trials (RCTs) have directly shown the effectiveness of the structured, nurse-led education in the CKD and ESRD patient population. Arad et al. (2021) performed an RCT with 66 patients with hemodialysis divided into two groups: those who received a nurse-led education program plus telephone follow-up and those who received usual care. At 1 and 3 months after intervention, results proved statistically significant in the intervention group in terms of dietary adherence, fluid restriction adherence, and laboratory values. The four-domain adherence measure employed was the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ), which has been validated and is applicable to the outcome measurement suggested in this capstone. Likewise, Dsouza et al. (2023) carried out an RCT study with 160 hemodialysis patients in a tertiary hospital in the southern part of India. The intervention group were given structured education sessions and a printed educational booklet, while the control group were given standard care. Post intervention assessment showed that there was a statistically significant improvement in the intervention group (restriction adherence and dietary adherence) with no change in the control group. Most importantly, the difference in knowledge did not correlate with the difference in adherence in the intervention group in this study, a pattern seen in several studies, with implications for this project.

One of the ongoing debates in the CKD dietary adherence research literature is whether there is a connection between dietary knowledge acquisition and changes in behavior. There have been several studies that show that patients can be more aware of the restrictions of their diet for the kidneys, but not necessarily change their own diet. This disconnect was noted by Dsouza et al. (2023) and Arad et al. (2021) also reported that the association between knowledge scores and adherence scores was not statistically significant. The available evidence indicates that educational interventions should include behaviour change techniques, including providing simplified information, setting goals and teach back, to have an impact and to produce lasting dietary adherence. This one-page handout is meant to be actionable and not just informational, so this concern is addressed. However, Yu et al. (2021) argued that health literacy, as opposed to knowledge, showed greater predictive power for self-care behaviors in the context of CKD, including diet adherence. Greater scores in each of the health literacy domains (access, understanding, appraisal, and action) were significantly correlated with higher levels of dietary self-management. These results support the need for patient education materials to be tailored to patient health literacy level, as this was key to the design of the simplified handout in this project.

Nursing profession is the key element in providing and maintaining dietary education to patients with CKD in hospital. Nurses are the first and most common health care professional to encounter hospitalized patients offering an opportunity to provide bedside education that is timely, individualized, and repeated through interaction. In a cluster-randomized controlled trial (cRCT) in community hospitals conducted by Changsieng et al. (2023), a supportive-educative program by a nurse using Orem's theory of self-care was found to be statistically significantly effective in increasing dietary adherence, self-care agency and glycated hemoglobin (HbA1C) reduction. Atraca et al. (2025) also found that nurse-led education that focuses on the self-care of CKD disease yielded tangible outcomes in self-care ability and disease knowledge in various clinical scenarios. There is also literature that supports the feasibility and cost-effectiveness of such interventions. The cost to implement this capstone in the community is estimated to be 30-40 dollars, just for printing the one page handout and questionnaire materials, no additional staff member needed, the intervention will be integrated into routine nursing practice. This makes it very easy and environmentally friendly to implement in community hospitals with limited resources.

Although the evidence for effective nurse-led educational interventions is sound, there are still a number of limitations and gaps to be addressed. The most rigorous RCTs were conducted abroad, in dialysis centers instead of an inpatient hospital setting, and with populations with socioeconomic and cultural backgrounds that could be significantly different from those of CKD patients in Spartanburg County, SC. This capstone project addresses an important evidence gap – translating results from dialysis populations to pre-dialysis hospitalized inpatients. Furthermore, only a few studies have analyzed the sustainability of adherence improvement over 3-month periods, and issues regarding the long-term effect remain unclear. Although this project has a short time period of 8 weeks, it encompasses immediate and early post-discharge adherence behavior, and will serve as a stepping stone to longer term follow-up investigations. The lack of systematic and personalized education of patients' diet in many community hospitals is not consistent with the evidence and is a correctable gap. The change proposed for this capstone is clear, feasible, and supported by evidence: Providing a brief, nurse-led bedside educational session with a simplified one-page renal diet handout will optimize dietary adherence in the hospitalized adult patient with CKD which will result in fewer preventable readmissions and further evidence-based quality improvement by the advanced practice nurse at Spartanburg Regional Medical Center.

**References**

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), 119. https://doi.org/10.1186/s12882-021-02319-9

Atraca, E., Solinho, L., Pires, S., Braga, V., Gomes, I., & Ramos, A. (2025). An educational nursing program to improve self-care in chronic kidney disease: A multiple case study. Journal of Ageing and Longevity, 5(3), 30. https://doi.org/10.3390/jal5030030

Billany, R. E., Thopte, A., Adenwalla, S. F., March, D. S., Burton, J. O., & Graham-Brown, M. P. M. (2023). Associations of health literacy with self-management behaviours and health outcomes in chronic kidney disease: A systematic review. Journal of Nephrology, 36(5). https://doi.org/10.1007/s40620-022-01537-0

Changsieng, P., Pichayapinyo, P., Lagampan, S., & Lapvongwatana, P. (2023). Implementation of self-care deficits assessment and a nurse-led supportive education program in community hospitals for behavior change and HbA1c reduction: A cluster randomized controlled trial. Journal of Primary Care & Community Health, 14. https://doi.org/10.1177/21501319231181106

Dsouza, B., Prabhu, R., Unnikrishnan, B., Ballal, S., Mundkur, S. C., Sekaran, V. C., Shetty, A., & Moreira, P. (2023). Effect of educational intervention on knowledge and level of adherence among hemodialysis patients: A randomized controlled trial. Global Health, Epidemiology and Genomics, 2023, 4295613. https://doi.org/10.1155/2023/4295613

Jagodage, H., McGuire, A., Seib, C., & Bonner, A. (2023). Effectiveness of teach-back for chronic kidney disease patient education: A systematic review. Journal of Renal Care, 50(2). https://doi.org/10.1111/jorc.12462

Lambert, K., Tulissio, N., & Cosier, D. (2024). Impact of a health literacy sensitive model of care in outpatient nephrology dietetic clinics. Journal of Human Nutrition and Dietetics, 37(6), 1516–1537. https://doi.org/10.1111/jhn.13373

NIH. (2025). Healthcare expenditures for persons with CKD. USRDS. https://usrds-adr.niddk.nih.gov/2024/chronic-kidney-disease/6-healthcare-expenditures-for-persons-with-ckd

Surasura, A., Kumar, B. G. S. K. P., Chinamanagonda, S., Durga, D., & Gubbala, S. (2024). Understanding hospital readmissions: Insights, patterns, and interventions for improvement in chronic kidney disease. Cureūs. https://doi.org/10.7759/cureus.59524

Yu, P.-S., Tsai, Y.-C., Chiu, Y.-W., Hsiao, P.-N., Lin, M.-Y., Chen, T.-H., Wang, S.-L., Kung, L.-F., Hsiao, S.-M., Hwang, S.-J., & Kuo, M.-C. (2021). The relationship between subtypes of health literacy and self-care behavior in chronic kidney disease. Journal of Personalized Medicine, 11(6), 447.
[https://doi.org/10.3390/jpm11060447](https://doi.org/10.3390/jpm11060447)

America’s Health Rankings. (2026).
_Chronic kidney disease in South Carolina_. United Health Foundation.
[https://www.americashealthrankings.org/explore/measures/CKD/SC](https://www.americashealthrankings.org/explore/measures/CKD/SC?utm_source=chatgpt.com)

Centers for Disease Control and Prevention. (2026).
_Chronic kidney disease in the United States_.
[https://www.cdc.gov/kidney-disease/php/data-research/index.html](https://www.cdc.gov/kidney-disease/php/data-research/index.html?utm_source=chatgpt.com)

Live Healthy Spartanburg. (2024).
_Spartanburg County community health needs assessment_.
[https://www.livehealthyspartanburg.org/s/Live-Healthy-Spartanburg-2024-CHNA.pdf](https://www.livehealthyspartanburg.org/s/Live-Healthy-Spartanburg-2024-CHNA.pdf?utm_source=chatgpt.com)

**MSNCapstoneProject.edited1.docx**

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**MSNCapstoneProject.edited1.docx**

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**## FinalCapstone.docx**

Final Capstone: Part I, II, III Cohesively Due 10/18/2025 by 11:59pm

1.Implementation/Conclusion

– Implement the change you are proposing- This should be a cohesive paper and continuation of Part I and Part II. Present as a cohesive paper to include Part I, II, III as per APA essay format.

2. Describe the practice change and setting clearly; is it in the community, organizational, clinic setting? Be detailed about the reason why you are seeking change.

3. Discuss how you would implement and assess the change; this should include time frame, setting (be specific), participants, barriers, external and internal factors.

-Timeline should be presented as a chart or essay format.* Do not use bullet points.

*Do not use direct implementation of Human Subjects in your proposal. This requires IRB

approval and CITI training which we will not use for this Capstone.

4. How would you evaluate the change process?

-The change must be measurable before and after the implementation.

-How would you measure or evaluate? Is there a tool to measure?

5. The literature review must support your change and implementation. Use leadership qualities and skills that will be utilized for successful completion of the project. What leasdership/management skills will you use?

6. Discuss who will be invited to the proposal: who are the stakeholders? Be specific about why you chose the team and what each of their role will be.

-How will you present the information to your stakeholders? Include cost and budget.

OVERALL: The conclusion should have your Part I, II, II all put together in a thorough APA format.

-Use appropriate APA 7th Ed. format

-Scholarly, peer-reviewed, and research articles cited should be within the last five years.

-This section should be minimum 3-4 pages long (not including the title and reference page).

-The final Capstone project should be a minimum of 8 pages.

-Use proper in-text citations with a properly formatted reference list.

-All papers must be written in the 3rd person.

CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Implementation of
the practice change
20 Points
Thoroughly
presented the
change proposal.
Included setting,
time frame,
population,
stakeholders, Pros
and cons/barriers.
20
Briefly presented
the change
proposal. Briefly
Included setting,
time frame,
stakeholders. Pros
and cons.
15
Vaguely presented
the change
proposal. Vaguely
Included setting,
time frame,
stakeholders, Pros
and cons.
10
Did not present the
change proposal.
0
Change proposal
was measured and
realistic.
20 Points
Thoroughly used an
appropriate
measurement tool.
Provided realistic
outcomes.
Discussed how it
will be used and
implemented.
20
Briefly used an
appropriate
measurement tool.
Provided realistic
outcomes.
15
Vaguely used an
appropriate
measurement tool.
Provided realistic
outcomes.
10
Did not use an
appropriate
measurement tool.
Provided realistic
outcomes.
0
Depth of
Discussion and
Cohesiveness
20 Points
Thoroughly, In-
depth discussion
and elaboration in
all sections of the
paper. Follows
criteria provided in
addition to
leadership,
management,
budget and
statistics.
20
Briefly, In-depth
discussion and
elaboration in most
sections of the
paper.
15
Vaguely, In-depth
discussion and
elaboration in most
sections of the
paper.
10
Did not use In-
depth discussion
and elaboration in
most sections of
the paper.
0
Conclusion
25 Points
Thoroughly, Ties
together
information from all
sources of Part I,
II,III. Followed
feedback and
comments given
from faculty.
25
Briefly, Ties
together
information from all
sources of Part I,
II,III
20
Vaguely, Ties
together
information from all
sources of Part I,
II,III
15
Does not Tie
together
information from all
sources of Part I,
II,III
0
Spelling and
Grammar
5 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
More than 5 but
fewer than 10
grammatical,
spelling,
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
An unacceptable
number of spelling
and/or grammar
mistakes.

Required word
count has been
met.
5
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
4
Required word
count is 50 words
below the minimum
required count.
3
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
5 points
Over 5 current
sources, of which
at least 3 are peer-
review journal
articles or scholarly
books. Sources
include both
general background
sources and
specialized
sources. Special-
interest sources
and popular
literature and
acknowledged as
such if they are
cited. All websites
utilized are
authoritative.
5
5 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
4
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
3
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books.
Not all websites
utilized are credible,
and/or sources are
not current.
0
Citations
5 points
Fewer than 5
incomplete
citations and/or
quotations, and
APA format errors
5
More than 5 but
fewer than 10
incomplete
citations and/or
quotations, and
APA format errors.
4
More than 10
incomplete
citations and/or
quotations, or APA
format errors.
3
The citation style is
inconsistent or
incorrect. It does
not cite sources

**## MSN_Capstone_Part_II_Literature_Review.docx**

**Part II: Review of Literature**

Yailin Ramirez

Florida National University

MSN Capstone Project—DAX-DL01

Dr. Carmen Lazo

June 5, 2026

**Review of Literature**

Non-adherence to nutrition is one of the most challenging and problematic clinical issues for nephrology nurses, particularly in adult patients with chronic kidney disease (CKD). This problem is exacerbated in a community hospital environment that provides care to adult inpatients and where community factors such as low health literacy, poverty, and access to renal nutrition counseling are present in Spartanburg County, South Carolina. The PICOT question for this capstone project is: For hospitalized adult renal patients who have CKD, is the provision of nurse-led education based on a simplified 1-page renal diet handout compared to usual care (no structured dietary education) associated with increased dietary adherence within 8 weeks? The findings of the synthesis of the available primary research and systematic reviews strongly reflect the effectiveness of structured, nurse-led dietary education in improving adherence outcomes in patients with renal disease and end-stage renal disease (ESRD), as well as highlight some key issues within current practice, missing evidence and conflicting views of the link between patient knowledge and behaviour change.

There has been ample literature documenting the burden of poor food intake in CKD. In this population, poor self-management and poor adherence to the CKD treatment plan, such as dietary elements, are significant factors for preventable hospital re-admission (Surasura et al., 2024). In 2022, the cost of CKD to Medicare was greater than $86 billion, highlighting the economic need for preventive interventions (NIH, 2025). National and local statistical data further support the need for a structured renal diet education intervention. At the national level, more than 1 in 10 U.S. adults, or approximately 37 million people, are estimated to have chronic kidney disease (CKD), and about 87% of adults with CKD are unaware that they have the condition (Centers for Disease Control and Prevention [CDC], 2026). This burden is highly relevant to hospitalized renal patients because CKD is strongly associated with diabetes and hypertension; approximately 38% of adults with diabetes and 21% of adults with high blood pressure are estimated to have CKD (CDC, 2026). At the state level, South Carolina reported a CKD prevalence of 5.2% among adults in 2024, compared with 4.0% nationally, ranking the state 47th for this measure (America’s Health Rankings, 2026). Locally, the 2024 Spartanburg County Community Health Needs Assessment reported that 12% of Spartanburg County adults were living with diabetes, slightly higher than the U.S. average of 10%, and 14.8% of residents, or 49,977 individuals, lived below the federal poverty level in 2022 (Live Healthy Spartanburg, 2024). These local and national statistics demonstrate that CKD risk factors, poverty, and limited health literacy may interfere with renal diet adherence. Therefore, a nurse-led, plain-language renal diet handout is appropriate for Spartanburg Regional Medical Center because it addresses a measurable health need in the local population.

Restrictions in CKD are multifaceted, meaning that patients need to restrict sodium, potassium, phosphorus and fluid intake all at once – often a very demanding and difficult set of restrictions for patients who may not have high health literacy. Billany et al. (2023) completed a systematic review showing that there is a significant association between low health literacy and poor self-management behaviors, poor health outcomes, and increased mortality in CKD patients. The findings are directly relevant to the target population in Spartanburg County where educational attainment and access to specialty care is below the national average.

One of the main variables in the problem is health literacy as well as one of the variables in the proposed solution. Lambert et al. (2024) carried out a quasi-experimental study to compare a health literacy informed approach to care in outpatient nephrology dietetic clinics. The updated model of care consisted of plain language materials, a renal diet question prompt sheet, and teach back techniques. A significant increase in patient understanding, dietary self-management confidence and satisfaction with the educational encounter were identified in the study. These results support the low-literacy, plain-language one-page handout approach recommended in this capstone and confirm the importance of this type of communication to ensure higher rates of patient participation in renal diet recommendations. A systematic review of effectiveness of Teach-Back methodology in patient education in CKD by Jagodage et al. (2023) revealed that teach-back led patient education programs, especially when delivered in a face-to-face format, were found to be effective in improving the dietary adherence and self-management outcomes among CKD patients when compared with non-structured usual care approaches. Both studies suggest the format and delivery that is advocated in this project.

Several randomized controlled trials (RCTs) have directly shown the effectiveness of the structured, nurse-led education in the CKD and ESRD patient population. Arad et al. (2021) performed an RCT with 66 patients with hemodialysis divided into two groups: those who received a nurse-led education program plus telephone follow-up and those who received usual care. At 1 and 3 months after intervention, results proved statistically significant in the intervention group in terms of dietary adherence, fluid restriction adherence, and laboratory values. The four-domain adherence measure employed was the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ), which has been validated and is applicable to the outcome measurement suggested in this capstone. Likewise, Dsouza et al. (2023) carried out an RCT study with 160 hemodialysis patients in a tertiary hospital in the southern part of India. The intervention group were given structured education sessions and a printed educational booklet, while the control group were given standard care. Post intervention assessment showed that there was a statistically significant improvement in the intervention group (restriction adherence and dietary adherence) with no change in the control group. Most importantly, the difference in knowledge did not correlate with the difference in adherence in the intervention group in this study, a pattern seen in several studies, with implications for this project.

One of the ongoing debates in the CKD dietary adherence research literature is whether there is a connection between dietary knowledge acquisition and changes in behavior. There have been several studies that show that patients can be more aware of the restrictions of their diet for the kidneys, but not necessarily change their own diet. This disconnect was noted by Dsouza et al. (2023) and Arad et al. (2021) also reported that the association between knowledge scores and adherence scores was not statistically significant. The available evidence indicates that educational interventions should include behaviour change techniques, including providing simplified information, setting goals and teach back, to have an impact and to produce lasting dietary adherence. This one-page handout is meant to be actionable and not just informational, so this concern is addressed. However, Yu et al. (2021) argued that health literacy, as opposed to knowledge, showed greater predictive power for self-care behaviors in the context of CKD, including diet adherence. Greater scores in each of the health literacy domains (access, understanding, appraisal, and action) were significantly correlated with higher levels of dietary self-management. These results support the need for patient education materials to be tailored to patient health literacy level, as this was key to the design of the simplified handout in this project.

Nursing profession is the key element in providing and maintaining dietary education to patients with CKD in hospital. Nurses are the first and most common health care professional to encounter hospitalized patients offering an opportunity to provide bedside education that is timely, individualized, and repeated through interaction. In a cluster-randomized controlled trial (cRCT) in community hospitals conducted by Changsieng et al. (2023), a supportive-educative program by a nurse using Orem's theory of self-care was found to be statistically significantly effective in increasing dietary adherence, self-care agency and glycated hemoglobin (HbA1C) reduction. Atraca et al. (2025) also found that nurse-led education that focuses on the self-care of CKD disease yielded tangible outcomes in self-care ability and disease knowledge in various clinical scenarios. There is also literature that supports the feasibility and cost-effectiveness of such interventions. The cost to implement this capstone in the community is estimated to be 30-40 dollars, just for printing the one page handout and questionnaire materials, no additional staff member needed, the intervention will be integrated into routine nursing practice. This makes it very easy and environmentally friendly to implement in community hospitals with limited resources.

Although the evidence for effective nurse-led educational interventions is sound, there are still a number of limitations and gaps to be addressed. The most rigorous RCTs were conducted abroad, in dialysis centers instead of an inpatient hospital setting, and with populations with socioeconomic and cultural backgrounds that could be significantly different from those of CKD patients in Spartanburg County, SC. This capstone project addresses an important evidence gap – translating results from dialysis populations to pre-dialysis hospitalized inpatients. Furthermore, only a few studies have analyzed the sustainability of adherence improvement over 3-month periods, and issues regarding the long-term effect remain unclear. Although this project has a short time period of 8 weeks, it encompasses immediate and early post-discharge adherence behavior, and will serve as a stepping stone to longer term follow-up investigations. The lack of systematic and personalized education of patients' diet in many community hospitals is not consistent with the evidence and is a correctable gap. The change proposed for this capstone is clear, feasible, and supported by evidence: Providing a brief, nurse-led bedside educational session with a simplified one-page renal diet handout will optimize dietary adherence in the hospitalized adult patient with CKD which will result in fewer preventable readmissions and further evidence-based quality improvement by the advanced practice nurse at Spartanburg Regional Medical Center.

**References**

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), 119. https://doi.org/10.1186/s12882-021-02319-9

Atraca, E., Solinho, L., Pires, S., Braga, V., Gomes, I., & Ramos, A. (2025). An educational nursing program to improve self-care in chronic kidney disease: A multiple case study. Journal of Ageing and Longevity, 5(3), 30. https://doi.org/10.3390/jal5030030

Billany, R. E., Thopte, A., Adenwalla, S. F., March, D. S., Burton, J. O., & Graham-Brown, M. P. M. (2023). Associations of health literacy with self-management behaviours and health outcomes in chronic kidney disease: A systematic review. Journal of Nephrology, 36(5). https://doi.org/10.1007/s40620-022-01537-0

Changsieng, P., Pichayapinyo, P., Lagampan, S., & Lapvongwatana, P. (2023). Implementation of self-care deficits assessment and a nurse-led supportive education program in community hospitals for behavior change and HbA1c reduction: A cluster randomized controlled trial. Journal of Primary Care & Community Health, 14. https://doi.org/10.1177/21501319231181106

Dsouza, B., Prabhu, R., Unnikrishnan, B., Ballal, S., Mundkur, S. C., Sekaran, V. C., Shetty, A., & Moreira, P. (2023). Effect of educational intervention on knowledge and level of adherence among hemodialysis patients: A randomized controlled trial. Global Health, Epidemiology and Genomics, 2023, 4295613. https://doi.org/10.1155/2023/4295613

Jagodage, H., McGuire, A., Seib, C., & Bonner, A. (2023). Effectiveness of teach-back for chronic kidney disease patient education: A systematic review. Journal of Renal Care, 50(2). https://doi.org/10.1111/jorc.12462

Lambert, K., Tulissio, N., & Cosier, D. (2024). Impact of a health literacy sensitive model of care in outpatient nephrology dietetic clinics. Journal of Human Nutrition and Dietetics, 37(6), 1516–1537. https://doi.org/10.1111/jhn.13373

NIH. (2025). Healthcare expenditures for persons with CKD. USRDS. https://usrds-adr.niddk.nih.gov/2024/chronic-kidney-disease/6-healthcare-expenditures-for-persons-with-ckd

Surasura, A., Kumar, B. G. S. K. P., Chinamanagonda, S., Durga, D., & Gubbala, S. (2024). Understanding hospital readmissions: Insights, patterns, and interventions for improvement in chronic kidney disease. Cureūs. https://doi.org/10.7759/cureus.59524

Yu, P.-S., Tsai, Y.-C., Chiu, Y.-W., Hsiao, P.-N., Lin, M.-Y., Chen, T.-H., Wang, S.-L., Kung, L.-F., Hsiao, S.-M., Hwang, S.-J., & Kuo, M.-C. (2021). The relationship between subtypes of health literacy and self-care behavior in chronic kidney disease. Journal of Personalized Medicine, 11(6), 447.
[https://doi.org/10.3390/jpm11060447](https://doi.org/10.3390/jpm11060447)

America’s Health Rankings. (2026).
_Chronic kidney disease in South Carolina_. United Health Foundation.
[https://www.americashealthrankings.org/explore/measures/CKD/SC](https://www.americashealthrankings.org/explore/measures/CKD/SC?utm_source=chatgpt.com)

Centers for Disease Control and Prevention. (2026).
_Chronic kidney disease in the United States_.
[https://www.cdc.gov/kidney-disease/php/data-research/index.html](https://www.cdc.gov/kidney-disease/php/data-research/index.html?utm_source=chatgpt.com)

Live Healthy Spartanburg. (2024).
_Spartanburg County community health needs assessment_.
[https://www.livehealthyspartanburg.org/s/Live-Healthy-Spartanburg-2024-CHNA.pdf](https://www.livehealthyspartanburg.org/s/Live-Healthy-Spartanburg-2024-CHNA.pdf?utm_source=chatgpt.com)

**MSNCapstoneProject.edited1.docx**

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**## FinalCapstone.docx**

Final Capstone: Part I, II, III Cohesively Due 10/18/2025 by 11:59pm

1.Implementation/Conclusion

– Implement the change you are proposing- This should be a cohesive paper and continuation of Part I and Part II. Present as a cohesive paper to include Part I, II, III as per APA essay format.

2. Describe the practice change and setting clearly; is it in the community, organizational, clinic setting? Be detailed about the reason why you are seeking change.

3. Discuss how you would implement and assess the change; this should include time frame, setting (be specific), participants, barriers, external and internal factors.

-Timeline should be presented as a chart or essay format.* Do not use bullet points.

*Do not use direct implementation of Human Subjects in your proposal. This requires IRB

approval and CITI training which we will not use for this Capstone.

4. How would you evaluate the change process?

-The change must be measurable before and after the implementation.

-How would you measure or evaluate? Is there a tool to measure?

5. The literature review must support your change and implementation. Use leadership qualities and skills that will be utilized for successful completion of the project. What leasdership/management skills will you use?

6. Discuss who will be invited to the proposal: who are the stakeholders? Be specific about why you chose the team and what each of their role will be.

-How will you present the information to your stakeholders? Include cost and budget.

OVERALL: The conclusion should have your Part I, II, II all put together in a thorough APA format.

-Use appropriate APA 7th Ed. format

-Scholarly, peer-reviewed, and research articles cited should be within the last five years.

-This section should be minimum 3-4 pages long (not including the title and reference page).

-The final Capstone project should be a minimum of 8 pages.

-Use proper in-text citations with a properly formatted reference list.

-All papers must be written in the 3rd person.

CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Implementation of
the practice change
20 Points
Thoroughly
presented the
change proposal.
Included setting,
time frame,
population,
stakeholders, Pros
and cons/barriers.
20
Briefly presented
the change
proposal. Briefly
Included setting,
time frame,
stakeholders. Pros
and cons.
15
Vaguely presented
the change
proposal. Vaguely
Included setting,
time frame,
stakeholders, Pros
and cons.
10
Did not present the
change proposal.
0
Change proposal
was measured and
realistic.
20 Points
Thoroughly used an
appropriate
measurement tool.
Provided realistic
outcomes.
Discussed how it
will be used and
implemented.
20
Briefly used an
appropriate
measurement tool.
Provided realistic
outcomes.
15
Vaguely used an
appropriate
measurement tool.
Provided realistic
outcomes.
10
Did not use an
appropriate
measurement tool.
Provided realistic
outcomes.
0
Depth of
Discussion and
Cohesiveness
20 Points
Thoroughly, In-
depth discussion
and elaboration in
all sections of the
paper. Follows
criteria provided in
addition to
leadership,
management,
budget and
statistics.
20
Briefly, In-depth
discussion and
elaboration in most
sections of the
paper.
15
Vaguely, In-depth
discussion and
elaboration in most
sections of the
paper.
10
Did not use In-
depth discussion
and elaboration in
most sections of
the paper.
0
Conclusion
25 Points
Thoroughly, Ties
together
information from all
sources of Part I,
II,III. Followed
feedback and
comments given
from faculty.
25
Briefly, Ties
together
information from all
sources of Part I,
II,III
20
Vaguely, Ties
together
information from all
sources of Part I,
II,III
15
Does not Tie
together
information from all
sources of Part I,
II,III
0
Spelling and
Grammar
5 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
More than 5 but
fewer than 10
grammatical,
spelling,
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
An unacceptable
number of spelling
and/or grammar
mistakes.

Required word
count has been
met.
5
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
4
Required word
count is 50 words
below the minimum
required count.
3
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
5 points
Over 5 current
sources, of which
at least 3 are peer-
review journal
articles or scholarly
books. Sources
include both
general background
sources and
specialized
sources. Special-
interest sources
and popular
literature and
acknowledged as
such if they are
cited. All websites
utilized are
authoritative.
5
5 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
4
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
3
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books.
Not all websites
utilized are credible,
and/or sources are
not current.
0
Citations
5 points
Fewer than 5
incomplete
citations and/or
quotations, and
APA format errors
5
More than 5 but
fewer than 10
incomplete
citations and/or
quotations, and
APA format errors.
4
More than 10
incomplete
citations and/or
quotations, or APA
format errors.
3
The citation style is
inconsistent or
incorrect. It does
not cite sources

**## MSN_Capstone_Part_II_Literature_Review.docx**

**Part II: Review of Literature**

Yailin Ramirez

Florida National University

MSN Capstone Project—DAX-DL01

Dr. Carmen Lazo

June 5, 2026

**Review of Literature**

Non-adherence to nutrition is one of the most challenging and problematic clinical issues for nephrology nurses, particularly in adult patients with chronic kidney disease (CKD). This problem is exacerbated in a community hospital environment that provides care to adult inpatients and where community factors such as low health literacy, poverty, and access to renal nutrition counseling are present in Spartanburg County, South Carolina. The PICOT question for this capstone project is: For hospitalized adult renal patients who have CKD, is the provision of nurse-led education based on a simplified 1-page renal diet handout compared to usual care (no structured dietary education) associated with increased dietary adherence within 8 weeks? The findings of the synthesis of the available primary research and systematic reviews strongly reflect the effectiveness of structured, nurse-led dietary education in improving adherence outcomes in patients with renal disease and end-stage renal disease (ESRD), as well as highlight some key issues within current practice, missing evidence and conflicting views of the link between patient knowledge and behaviour change.

There has been ample literature documenting the burden of poor food intake in CKD. In this population, poor self-management and poor adherence to the CKD treatment plan, such as dietary elements, are significant factors for preventable hospital re-admission (Surasura et al., 2024). In 2022, the cost of CKD to Medicare was greater than $86 billion, highlighting the economic need for preventive interventions (NIH, 2025). National and local statistical data further support the need for a structured renal diet education intervention. At the national level, more than 1 in 10 U.S. adults, or approximately 37 million people, are estimated to have chronic kidney disease (CKD), and about 87% of adults with CKD are unaware that they have the condition (Centers for Disease Control and Prevention [CDC], 2026). This burden is highly relevant to hospitalized renal patients because CKD is strongly associated with diabetes and hypertension; approximately 38% of adults with diabetes and 21% of adults with high blood pressure are estimated to have CKD (CDC, 2026). At the state level, South Carolina reported a CKD prevalence of 5.2% among adults in 2024, compared with 4.0% nationally, ranking the state 47th for this measure (America’s Health Rankings, 2026). Locally, the 2024 Spartanburg County Community Health Needs Assessment reported that 12% of Spartanburg County adults were living with diabetes, slightly higher than the U.S. average of 10%, and 14.8% of residents, or 49,977 individuals, lived below the federal poverty level in 2022 (Live Healthy Spartanburg, 2024). These local and national statistics demonstrate that CKD risk factors, poverty, and limited health literacy may interfere with renal diet adherence. Therefore, a nurse-led, plain-language renal diet handout is appropriate for Spartanburg Regional Medical Center because it addresses a measurable health need in the local population.

Restrictions in CKD are multifaceted, meaning that patients need to restrict sodium, potassium, phosphorus and fluid intake all at once – often a very demanding and difficult set of restrictions for patients who may not have high health literacy. Billany et al. (2023) completed a systematic review showing that there is a significant association between low health literacy and poor self-management behaviors, poor health outcomes, and increased mortality in CKD patients. The findings are directly relevant to the target population in Spartanburg County where educational attainment and access to specialty care is below the national average.

One of the main variables in the problem is health literacy as well as one of the variables in the proposed solution. Lambert et al. (2024) carried out a quasi-experimental study to compare a health literacy informed approach to care in outpatient nephrology dietetic clinics. The updated model of care consisted of plain language materials, a renal diet question prompt sheet, and teach back techniques. A significant increase in patient understanding, dietary self-management confidence and satisfaction with the educational encounter were identified in the study. These results support the low-literacy, plain-language one-page handout approach recommended in this capstone and confirm the importance of this type of communication to ensure higher rates of patient participation in renal diet recommendations. A systematic review of effectiveness of Teach-Back methodology in patient education in CKD by Jagodage et al. (2023) revealed that teach-back led patient education programs, especially when delivered in a face-to-face format, were found to be effective in improving the dietary adherence and self-management outcomes among CKD patients when compared with non-structured usual care approaches. Both studies suggest the format and delivery that is advocated in this project.

Several randomized controlled trials (RCTs) have directly shown the effectiveness of the structured, nurse-led education in the CKD and ESRD patient population. Arad et al. (2021) performed an RCT with 66 patients with hemodialysis divided into two groups: those who received a nurse-led education program plus telephone follow-up and those who received usual care. At 1 and 3 months after intervention, results proved statistically significant in the intervention group in terms of dietary adherence, fluid restriction adherence, and laboratory values. The four-domain adherence measure employed was the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ), which has been validated and is applicable to the outcome measurement suggested in this capstone. Likewise, Dsouza et al. (2023) carried out an RCT study with 160 hemodialysis patients in a tertiary hospital in the southern part of India. The intervention group were given structured education sessions and a printed educational booklet, while the control group were given standard care. Post intervention assessment showed that there was a statistically significant improvement in the intervention group (restriction adherence and dietary adherence) with no change in the control group. Most importantly, the difference in knowledge did not correlate with the difference in adherence in the intervention group in this study, a pattern seen in several studies, with implications for this project.

One of the ongoing debates in the CKD dietary adherence research literature is whether there is a connection between dietary knowledge acquisition and changes in behavior. There have been several studies that show that patients can be more aware of the restrictions of their diet for the kidneys, but not necessarily change their own diet. This disconnect was noted by Dsouza et al. (2023) and Arad et al. (2021) also reported that the association between knowledge scores and adherence scores was not statistically significant. The available evidence indicates that educational interventions should include behaviour change techniques, including providing simplified information, setting goals and teach back, to have an impact and to produce lasting dietary adherence. This one-page handout is meant to be actionable and not just informational, so this concern is addressed. However, Yu et al. (2021) argued that health literacy, as opposed to knowledge, showed greater predictive power for self-care behaviors in the context of CKD, including diet adherence. Greater scores in each of the health literacy domains (access, understanding, appraisal, and action) were significantly correlated with higher levels of dietary self-management. These results support the need for patient education materials to be tailored to patient health literacy level, as this was key to the design of the simplified handout in this project.

Nursing profession is the key element in providing and maintaining dietary education to patients with CKD in hospital. Nurses are the first and most common health care professional to encounter hospitalized patients offering an opportunity to provide bedside education that is timely, individualized, and repeated through interaction. In a cluster-randomized controlled trial (cRCT) in community hospitals conducted by Changsieng et al. (2023), a supportive-educative program by a nurse using Orem's theory of self-care was found to be statistically significantly effective in increasing dietary adherence, self-care agency and glycated hemoglobin (HbA1C) reduction. Atraca et al. (2025) also found that nurse-led education that focuses on the self-care of CKD disease yielded tangible outcomes in self-care ability and disease knowledge in various clinical scenarios. There is also literature that supports the feasibility and cost-effectiveness of such interventions. The cost to implement this capstone in the community is estimated to be 30-40 dollars, just for printing the one page handout and questionnaire materials, no additional staff member needed, the intervention will be integrated into routine nursing practice. This makes it very easy and environmentally friendly to implement in community hospitals with limited resources.

Although the evidence for effective nurse-led educational interventions is sound, there are still a number of limitations and gaps to be addressed. The most rigorous RCTs were conducted abroad, in dialysis centers instead of an inpatient hospital setting, and with populations with socioeconomic and cultural backgrounds that could be significantly different from those of CKD patients in Spartanburg County, SC. This capstone project addresses an important evidence gap – translating results from dialysis populations to pre-dialysis hospitalized inpatients. Furthermore, only a few studies have analyzed the sustainability of adherence improvement over 3-month periods, and issues regarding the long-term effect remain unclear. Although this project has a short time period of 8 weeks, it encompasses immediate and early post-discharge adherence behavior, and will serve as a stepping stone to longer term follow-up investigations. The lack of systematic and personalized education of patients' diet in many community hospitals is not consistent with the evidence and is a correctable gap. The change proposed for this capstone is clear, feasible, and supported by evidence: Providing a brief, nurse-led bedside educational session with a simplified one-page renal diet handout will optimize dietary adherence in the hospitalized adult patient with CKD which will result in fewer preventable readmissions and further evidence-based quality improvement by the advanced practice nurse at Spartanburg Regional Medical Center.

**References**

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), 119. https://doi.org/10.1186/s12882-021-02319-9

Atraca, E., Solinho, L., Pires, S., Braga, V., Gomes, I., & Ramos, A. (2025). An educational nursing program to improve self-care in chronic kidney disease: A multiple case study. Journal of Ageing and Longevity, 5(3), 30. https://doi.org/10.3390/jal5030030

Billany, R. E., Thopte, A., Adenwalla, S. F., March, D. S., Burton, J. O., & Graham-Brown, M. P. M. (2023). Associations of health literacy with self-management behaviours and health outcomes in chronic kidney disease: A systematic review. Journal of Nephrology, 36(5). https://doi.org/10.1007/s40620-022-01537-0

Changsieng, P., Pichayapinyo, P., Lagampan, S., & Lapvongwatana, P. (2023). Implementation of self-care deficits assessment and a nurse-led supportive education program in community hospitals for behavior change and HbA1c reduction: A cluster randomized controlled trial. Journal of Primary Care & Community Health, 14. https://doi.org/10.1177/21501319231181106

Dsouza, B., Prabhu, R., Unnikrishnan, B., Ballal, S., Mundkur, S. C., Sekaran, V. C., Shetty, A., & Moreira, P. (2023). Effect of educational intervention on knowledge and level of adherence among hemodialysis patients: A randomized controlled trial. Global Health, Epidemiology and Genomics, 2023, 4295613. https://doi.org/10.1155/2023/4295613

Jagodage, H., McGuire, A., Seib, C., & Bonner, A. (2023). Effectiveness of teach-back for chronic kidney disease patient education: A systematic review. Journal of Renal Care, 50(2). https://doi.org/10.1111/jorc.12462

Lambert, K., Tulissio, N., & Cosier, D. (2024). Impact of a health literacy sensitive model of care in outpatient nephrology dietetic clinics. Journal of Human Nutrition and Dietetics, 37(6), 1516–1537. https://doi.org/10.1111/jhn.13373

NIH. (2025). Healthcare expenditures for persons with CKD. USRDS. https://usrds-adr.niddk.nih.gov/2024/chronic-kidney-disease/6-healthcare-expenditures-for-persons-with-ckd

Surasura, A., Kumar, B. G. S. K. P., Chinamanagonda, S., Durga, D., & Gubbala, S. (2024). Understanding hospital readmissions: Insights, patterns, and interventions for improvement in chronic kidney disease. Cureūs. https://doi.org/10.7759/cureus.59524

Yu, P.-S., Tsai, Y.-C., Chiu, Y.-W., Hsiao, P.-N., Lin, M.-Y., Chen, T.-H., Wang, S.-L., Kung, L.-F., Hsiao, S.-M., Hwang, S.-J., & Kuo, M.-C. (2021). The relationship between subtypes of health literacy and self-care behavior in chronic kidney disease. Journal of Personalized Medicine, 11(6), 447.
[https://doi.org/10.3390/jpm11060447](https://doi.org/10.3390/jpm11060447)

America’s Health Rankings. (2026).
_Chronic kidney disease in South Carolina_. United Health Foundation.
[https://www.americashealthrankings.org/explore/measures/CKD/SC](https://www.americashealthrankings.org/explore/measures/CKD/SC?utm_source=chatgpt.com)

Centers for Disease Control and Prevention. (2026).
_Chronic kidney disease in the United States_.
[https://www.cdc.gov/kidney-disease/php/data-research/index.html](https://www.cdc.gov/kidney-disease/php/data-research/index.html?utm_source=chatgpt.com)

Live Healthy Spartanburg. (2024).
_Spartanburg County community health needs assessment_.
[https://www.livehealthyspartanburg.org/s/Live-Healthy-Spartanburg-2024-CHNA.pdf](https://www.livehealthyspartanburg.org/s/Live-Healthy-Spartanburg-2024-CHNA.pdf?utm_source=chatgpt.com)

**MSNCapstoneProject.edited1.docx**

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