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

Assignment Prompt & Instructions

**files (3)**

– ## feedback.docx

– ## CapstonePartIIintrucctions.docx

– ## MSNCapstoneProject.edited1.docx

**## feedback.docx**

Overall, you are on the right track. Use one clinical setting to make it a realistic Capstone.

**## CapstonePartIIintrucctions.docx**

Capstone Part II: Review of Literature

**CAPSTONE: PART II due 10/4/2025 by 11:59pm**

1. Review of Literature:

– Review and discuss literature: Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else's opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence.

2. Analyze and apply knowledge directly to your PICOT- The studies that you cite in this section must relate directly to your PICOT question.

3. Provide precise body of evidence for your Practice Change- Include Nurses as leaders in this project, statistics, cost, impact on healthcare.

4. Discuss objectives for your practice change, Why is change necessary?

5. Discuss where the problem exists, why it exists, what is the preposition for change. Include information from your PICOT.

6. Apply all that is relevant to the problem. For example: Pros vs Cons, current state of problem

NOTE: It should not reflect your opinion, but rather Evidence Based Practice should be applied

-After completing a literature search on interventions addressing your chosen health problem, write a review that evaluates the strengths and weaknesses of all the sources you have found, compare anc constrast.

-Use appropriate APA 7th Ed. Scholarly, peer-reviewed, and research articles cited should be within the last five years.

-This section should be minimum 4-6 pages long (not including the title and reference page).

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

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

**Rubric Capstone II.docx**

**Submission**

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CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Integration of
Knowledge
25 points
Thoroughly selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
25
Briefly selected and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
20
Vaguely selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
15
Did not select and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
0
Topic Focus
25 points
The health problem
is focused narrowly
enough for the
scope of this
assignment. A topic
statement provides
direction for the
paper. The topic is
consistently well
thought out,
thorough offers
insight into the topic,
and includes cited
evidence to support
the topic.
25
The health problem
is focused but
lacks direction. The
paper is about a
specific topic, but
the writer has not
established a
position. The topic
is somewhat well
thought out, offers
limited insight into
the topic, but does
not include cited
evidence to support
the topic.
20
The health problem
is too broad for the
scope of this
assignment.
15
The health problem
is unclear or
unrelated to the
discussion topic
with little or no
supporting
evidence.
0
Depth of
Discussion and
Cohesiveness
25 points
In-depth discussion
and elaboration in all
sections of the
paper.
Ties together
information from all
sources. Paper flows
from one issue to
the next with no
headings. The
author’s writing
demonstrates an
understanding of the
relationship among
material obtained
from all sources
Mostly, it ties
together information
from all sources.
In-depth discussion
and elaboration in
most sections of
the paper.
Mostly, it ties
together
information from all
sources. Paper
flows with only
some
disjointedness. The
author’s writing
demonstrates an
understanding of
the relationship
among material
obtained from all
sources.
The writer has
omitted content.
Quotations from
others outweigh the
writer’s own ideas
excessively.
Sometimes ties
together
information from all
sources. The paper
does not flow.
Disjointedness is
apparent. The
author’s writing
does not
demonstrate an
understanding of
the relationship
between material
obtained from all
sources.
Cursory discussion
in all the sections
of the paper or brief
discussion in only a
few sections.
It does not tie
together
information. Paper
does not flow and
appears to be
created from
disparate issues.
Headings are
necessary to link
concepts. Writing
does not
demonstrate an
understanding of
any relationship.

25 20
15
0
Spelling and
Grammar
10 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
Required word count
has been met.
8
More than 5 but
fewer than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
6
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 50 words
below the minimum
required count.
5
An unacceptable
number of spelling
and/or grammar
mistakes.
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
10 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 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
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.
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.

**## MSNCapstoneProject.edited1.docx**

2

**Nurse-Led Renal Diet Education to Improve Dietary Adherence in Hospitalized Adult Patients with Chronic Kidney Disease**

Yailin Ramirez

Florida National University

MSN Capstone Project-DAX-DL01

Dr. Carmen Lazo

May 21, 2026

**Nurse-Led Renal Diet Education to Improve Dietary Adherence in Hospitalized Adult Patients With Chronic Kidney Disease**

Chronic kidney disease is a progressive disease of the kidneys in which, over time, they lose their ability to properly filter waste and excess water from the blood, resulting in serious and life-threatening complications. CKD affects more than 1 in 10 adults in the United States, with approximately 37 million adults, or 14% of the adult population, estimated to have the condition, and many individuals remaining undiagnosed until advanced stages of disease progression (CDC, 2026).The cost of CKD to Medicare in 2022 alone was over 86 billion dollars (NIH, 2025). At the local level, adults in Spartanburg County, South Carolina, are affected by several risk factors associated with CKD, including diabetes, hypertension, poverty, limited health literacy, and reduced access to nutritional education. These factors may contribute to poor disease self-management and difficulty adhering to renal dietary recommendations.

The practice problem this paper investigates is the poor adherence of hospitalized adult renal patients to their diet. Failure to follow dietary recommendations for kidney disease, particularly sodium, potassium, phosphorus, and fluid, can lead to an imbalance of electrolytes, fluid overload, and more rapid progression of disease. Non-adherence is also associated with preventable hospital readmissions and higher health care costs (Surasura et al., 2024). The purpose of this capstone project is to evaluate whether a nurse-led renal diet education intervention using a simplified one-page handout improves dietary adherence among hospitalized adult renal patients in a community hospital setting over an eight-week period.

**PICOT**

Patient compliance with severe diet changes is a major factor in the management of CKD. While it is well recognized that nutrition is an important component in slowing the progression of disease and preventing complications from the hospital environment, there is a lack of knowledge and practical means for many renal patients to follow the nutritional recommendations in a consistent manner. This lack of patient education is a major and correctable clinical issue. The guiding question for this capstone project is:
_In hospitalized adult renal patients with CKD (P), does providing nurse-led education using a simplified one-page renal diet handout (I), compared to usual care with no structured dietary education (C), improve dietary adherence (O) over eight weeks (T)?_

The population includes hospitalized adult patients diagnosed with chronic kidney disease (CKD) receiving inpatient care in a community hospital setting within Spartanburg County, South Carolina. This population is especially vulnerable as care of CKD involves adherence to complex dietary limitations affecting salt, potassium, phosphorus and fluid intake . CKD patients often have many chronic illnesses, such as diabetes, hypertension, and socioeconomic determinants of health, including low health literacy, lack of access to nutritional counseling, and financial constraints, may adversely impact diet adherence and health consequences. Therefore, it is necessary to have simple and systematic education in order to successfully treat the disease after discharge.

The proposed intervention is a one-page education handout adapted in a simplified format with a nurse-led bedside education session. The handout offers simple information on how to limit sodium, potassium, phosphorus, and fluids. This session is designed to be about 15-20 minutes in length and is provided by the bedside nurse or advanced practice nurse during hospitalization. An educational intervention targeting specific components of CKD management, such as dietary restrictions and knowledge assessment at pre- and post-intervention, is found to be an effective element of a comprehensive CKD management program (Atraca et al., 2025).

The comparison intervention is usual care, consisting of standard discharge instructions without structured or nurse-led dietary education. Currently, many hospitalized renal patients receive generalized education that lacks the individualization and clarity needed to produce meaningful dietary behavior change.

The expected outcome is a change in dietary adherence measured by a validated dietary adherence questionnaire at baseline and at 8 weeks. Improved adherence is expected to reduce electrolyte abnormalities, prevent fluid overload, and decrease unplanned hospital readmissions (Surasura et al., 2024).

The timeframe for this project is eight weeks. This is enough time for the intervention to be delivered while hospitalized and for patients to transfer the dietary education to the post-hospital environment, while compliance is assessed at the end of the 8-week period.

**Vulnerable Population and Setting**

The population being addressed in this capstone project includes hospitalized adult patients diagnosed with chronic kidney disease (CKD) receiving inpatient care in a community hospital setting within Spartanburg County, South Carolina. This population is considered vulnerable because CKD management requires adherence to complex dietary restrictions involving sodium, potassium, phosphorus, and fluid intake. Additionally, many patients experience multiple chronic conditions, including diabetes, hypertension, and cardiovascular disease, which may complicate disease self-management. In Spartanburg County, social and economic disparities, including poverty, limited access to specialty care, reduced access to renal nutrition counseling, and lower health literacy, may contribute to poor disease management and increased risk for complications and hospital readmissions.

Social determinants of health are a key factor in determining the dietary behaviors and health outcomes of this population. Low health literacy is widely reported in people with CKD and is linked to weak self-care in the disease, poor health outcomes, higher mortality, and a lower quality of life (Billany et al., 2023). A significant number of people in this context are poorly educated, do not have the same access to nutritional advice, and have difficulties in buying foods suitable for the kidneys due to their financial situation. Additionally, increased scores in health literacy are significantly associated with enhanced self-care behaviors among patients with CKD, such as diet management and follow-up of clinical recommendations (Yu et al., 2021). These findings underscore the importance of easy-to-use educational resources to assist in educating patients on the difference between recommendations and understanding.

This vulnerable population has well-defined risk factors. Advanced CKD patients have to deal with multiple medications, comorbid conditions, and dietary restrictions, making them more susceptible to non-adherence. Surasura et al. (2024) further verified that poor self-management and low compliance with the CKD treatment plan, including diet components, significantly contribute to hospital readmission in CKD patients. For this population, change is vital as preventable readmissions, reduced quality of life, and increasing health care costs are the result of failure to address dietary non-adherence, as documented. A low-cost nurse-led educational intervention delivered during hospitalization represents a timely and feasible opportunity to reduce these outcomes and empower patients in their own care.

**Proposal and Intervention Plan**

**The Intervention.** The intervention is a brief, 15-20-minute nurse-led bedside education session for each eligible hospitalized adult CKD patient. The session is facilitated with a one-page handout that has basic information on how to control sodium, potassium, phosphorus, and fluid. The handout is written at a low literacy level to ensure accessibility. Jagodage et al. (2024) showed that structured education sessions delivered face-to-face to CKD patients are linked to better dietary adherence and self-management outcomes than other unstructured usual care approaches.

**Resources Needed.** Minimal resources are required the estimated budget for this intervention is minimal because the educational materials consist of a one-page handout produced at low printing cost. Estimated expenses include approximately $20 for educational handout printing, $10 for questionnaire materials, and no additional staffing costs because the intervention will be incorporated into routine nursing workflow. The estimated total cost of implementation is approximately $30–$40, making the intervention feasible and sustainable in a community hospital setting.

**Feasibility for the Advanced Practice Nurse.** This is an advanced practice intervention that can be incorporated into the hospital workflow. The simplicity of its cost, resource, and time make it a viable and sustainable element to ongoing nursing practice in a community hospital setting.

**Those Involved.** Bedside registered nurse, advanced practice nurse, and dietary staff (when available) are the primary individuals involved. Charge nurses will assist in consistent implementation during the intervention period, across shifts.

**Timeline**

Weeks 1 & 2 will be used for staff preparation. In this stage, the one-page handout is finalized, and nursing staff are given a brief training in conducting the education session, and baseline dietary adherence data are obtained from enrolled patients.

Weeks 3-6 are the active implementation phase, in which the nurse-led education session and renal diet handout are provided at the bedside to all eligible hospitalized adult CKD patients.

The outcome measurement and evaluation occur in weeks 7 and 8 when post-intervention dietary adherence questionnaires are completed, data are analyzed, and the effectiveness of the intervention is evaluated to inform practice decisions.

**Theoretical Framework**

Self-Care Deficit Nursing Theory by Dorothea Orem is the main theory that forms the basis for this capstone project. The focus of the Orem theory is on the patient's self-care abilities, which are assumed to be within the patient's control and responsibility, and the role of the nurse when the patient cannot meet these needs on his/her own. After discharge, patients face complex dietary restrictions, but many do not know or feel confident in how to do this effectively within the context of CKD. Changsieng et al. (2023) demonstrated statistically significant improvement in knowledge, dietary adherence, and self-care agency among patients who received supportive-educative programs from nurses using Orem's theory compared with those who received conventional care. In this project, the nurse-led education session and one-page handout are direct representations of the supportive-educative model of nursing by Orem, which emphasizes the reduction of the self-care deficit by providing relevant and actionable dietary information for the patients.

This project will be implemented and evaluated using the Iowa Model of Evidence-Based Practice. The Iowa Model is designed to assist nurses in working systematically, beginning with identifying an issue or opportunity, stating the purpose, forming a team, assembling, appraising, and synthesizing the body of evidence, designing and piloting the practice change, integrating and sustaining the practice change, and disseminating (Cullen et al., 2022). The Iowa Model Revised is a well-defined framework for Iowa nurses to use in converting a quality improvement project into a nursing evidence-based practice development project, and has been successfully used in hemodialysis and nephrology settings to develop nursing interventions that aim for improving patient outcomes. This capstone focuses on the Iowa Model guiding the entire process, including identifying poor dietary adherence as a clinical issue and measuring post-intervention adherence scores for the nurse-led handout intervention.

Together, these two frameworks strengthen the foundation of this capstone. The patient-centred design of the educational intervention and the role of the nurse in closing the self-care gap is guided by Orem's theory and substantiated by the Iowa Model, which offers evidence-based, systematic, and rigorous design and evaluation of the project. Both concepts are consistent with the ultimate aim of increasing adherence to good dietary habits and enhancing the quality of nursing for hospitalized CKD patients.

**Conclusion**

Nonadherence to diet among hospitalized patients with adult CKD is an important and expensive clinical issue that is linked to electrolyte disturbances, fluid overload, CKD progression, and avoidable hospitalizations. This capstone project's purpose is to develop an educational intervention for nurses, with a simplified one-page renal diet handout, to be implemented over an 8-week period among hospitalized adult patients with CKD in a community hospital setting as a feasible and evidence-based intervention to fill this gap. The intervention is based on Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence-Based Practice, ensuring both patient-centered design and systematic implementation. The proposed dietary adherence outcome is attainable and measurable in the specified time period. Addressing this problem carries far-reaching implications for CKD patients, including improved quality of life, reduced burden on the healthcare system, and fewer costly and preventable hospitalizations.

**References**

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), 30–30. 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

Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H. S., & Wagner, M. (2022). Iowa implementation for sustainability framework.
_Implementation Science_,
_17_(1), 1–20. https://doi.org/10.1186/s13012-021-01157-5

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

NIDDK. (2023).
_Kidney disease statistics for the United States_. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease

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.
_Curēus_. 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

**## MSNCapstoneProject.edited1.docx**

2

**Nurse-Led Renal Diet Education to Improve Dietary Adherence in Hospitalized Adult Patients with Chronic Kidney Disease**

Yailin Ramirez

Florida National University

MSN Capstone Project-DAX-DL01

Dr. Carmen Lazo

May 21, 2026

**Nurse-Led Renal Diet Education to Improve Dietary Adherence in Hospitalized Adult Patients With Chronic Kidney Disease**

Chronic kidney disease is a progressive disease of the kidneys in which, over time, they lose their ability to properly filter waste and excess water from the blood, resulting in serious and life-threatening complications. CKD affects more than 1 in 10 adults in the United States, with approximately 37 million adults, or 14% of the adult population, estimated to have the condition, and many individuals remaining undiagnosed until advanced stages of disease progression (CDC, 2026).The cost of CKD to Medicare in 2022 alone was over 86 billion dollars (NIH, 2025). At the local level, adults in Spartanburg County, South Carolina, are affected by several risk factors associated with CKD, including diabetes, hypertension, poverty, limited health literacy, and reduced access to nutritional education. These factors may contribute to poor disease self-management and difficulty adhering to renal dietary recommendations.

The practice problem this paper investigates is the poor adherence of hospitalized adult renal patients to their diet. Failure to follow dietary recommendations for kidney disease, particularly sodium, potassium, phosphorus, and fluid, can lead to an imbalance of electrolytes, fluid overload, and more rapid progression of disease. Non-adherence is also associated with preventable hospital readmissions and higher health care costs (Surasura et al., 2024). The purpose of this capstone project is to evaluate whether a nurse-led renal diet education intervention using a simplified one-page handout improves dietary adherence among hospitalized adult renal patients in a community hospital setting over an eight-week period.

**PICOT**

Patient compliance with severe diet changes is a major factor in the management of CKD. While it is well recognized that nutrition is an important component in slowing the progression of disease and preventing complications from the hospital environment, there is a lack of knowledge and practical means for many renal patients to follow the nutritional recommendations in a consistent manner. This lack of patient education is a major and correctable clinical issue. The guiding question for this capstone project is:
_In hospitalized adult renal patients with CKD (P), does providing nurse-led education using a simplified one-page renal diet handout (I), compared to usual care with no structured dietary education (C), improve dietary adherence (O) over eight weeks (T)?_

The population includes hospitalized adult patients diagnosed with chronic kidney disease (CKD) receiving inpatient care in a community hospital setting within Spartanburg County, South Carolina. This population is especially vulnerable as care of CKD involves adherence to complex dietary limitations affecting salt, potassium, phosphorus and fluid intake . CKD patients often have many chronic illnesses, such as diabetes, hypertension, and socioeconomic determinants of health, including low health literacy, lack of access to nutritional counseling, and financial constraints, may adversely impact diet adherence and health consequences. Therefore, it is necessary to have simple and systematic education in order to successfully treat the disease after discharge.

The proposed intervention is a one-page education handout adapted in a simplified format with a nurse-led bedside education session. The handout offers simple information on how to limit sodium, potassium, phosphorus, and fluids. This session is designed to be about 15-20 minutes in length and is provided by the bedside nurse or advanced practice nurse during hospitalization. An educational intervention targeting specific components of CKD management, such as dietary restrictions and knowledge assessment at pre- and post-intervention, is found to be an effective element of a comprehensive CKD management program (Atraca et al., 2025).

The comparison intervention is usual care, consisting of standard discharge instructions without structured or nurse-led dietary education. Currently, many hospitalized renal patients receive generalized education that lacks the individualization and clarity needed to produce meaningful dietary behavior change.

The expected outcome is a change in dietary adherence measured by a validated dietary adherence questionnaire at baseline and at 8 weeks. Improved adherence is expected to reduce electrolyte abnormalities, prevent fluid overload, and decrease unplanned hospital readmissions (Surasura et al., 2024).

The timeframe for this project is eight weeks. This is enough time for the intervention to be delivered while hospitalized and for patients to transfer the dietary education to the post-hospital environment, while compliance is assessed at the end of the 8-week period.

**Vulnerable Population and Setting**

The population being addressed in this capstone project includes hospitalized adult patients diagnosed with chronic kidney disease (CKD) receiving inpatient care in a community hospital setting within Spartanburg County, South Carolina. This population is considered vulnerable because CKD management requires adherence to complex dietary restrictions involving sodium, potassium, phosphorus, and fluid intake. Additionally, many patients experience multiple chronic conditions, including diabetes, hypertension, and cardiovascular disease, which may complicate disease self-management. In Spartanburg County, social and economic disparities, including poverty, limited access to specialty care, reduced access to renal nutrition counseling, and lower health literacy, may contribute to poor disease management and increased risk for complications and hospital readmissions.

Social determinants of health are a key factor in determining the dietary behaviors and health outcomes of this population. Low health literacy is widely reported in people with CKD and is linked to weak self-care in the disease, poor health outcomes, higher mortality, and a lower quality of life (Billany et al., 2023). A significant number of people in this context are poorly educated, do not have the same access to nutritional advice, and have difficulties in buying foods suitable for the kidneys due to their financial situation. Additionally, increased scores in health literacy are significantly associated with enhanced self-care behaviors among patients with CKD, such as diet management and follow-up of clinical recommendations (Yu et al., 2021). These findings underscore the importance of easy-to-use educational resources to assist in educating patients on the difference between recommendations and understanding.

This vulnerable population has well-defined risk factors. Advanced CKD patients have to deal with multiple medications, comorbid conditions, and dietary restrictions, making them more susceptible to non-adherence. Surasura et al. (2024) further verified that poor self-management and low compliance with the CKD treatment plan, including diet components, significantly contribute to hospital readmission in CKD patients. For this population, change is vital as preventable readmissions, reduced quality of life, and increasing health care costs are the result of failure to address dietary non-adherence, as documented. A low-cost nurse-led educational intervention delivered during hospitalization represents a timely and feasible opportunity to reduce these outcomes and empower patients in their own care.

**Proposal and Intervention Plan**

**The Intervention.** The intervention is a brief, 15-20-minute nurse-led bedside education session for each eligible hospitalized adult CKD patient. The session is facilitated with a one-page handout that has basic information on how to control sodium, potassium, phosphorus, and fluid. The handout is written at a low literacy level to ensure accessibility. Jagodage et al. (2024) showed that structured education sessions delivered face-to-face to CKD patients are linked to better dietary adherence and self-management outcomes than other unstructured usual care approaches.

**Resources Needed.** Minimal resources are required the estimated budget for this intervention is minimal because the educational materials consist of a one-page handout produced at low printing cost. Estimated expenses include approximately $20 for educational handout printing, $10 for questionnaire materials, and no additional staffing costs because the intervention will be incorporated into routine nursing workflow. The estimated total cost of implementation is approximately $30–$40, making the intervention feasible and sustainable in a community hospital setting.

**Feasibility for the Advanced Practice Nurse.** This is an advanced practice intervention that can be incorporated into the hospital workflow. The simplicity of its cost, resource, and time make it a viable and sustainable element to ongoing nursing practice in a community hospital setting.

**Those Involved.** Bedside registered nurse, advanced practice nurse, and dietary staff (when available) are the primary individuals involved. Charge nurses will assist in consistent implementation during the intervention period, across shifts.

**Timeline**

Weeks 1 & 2 will be used for staff preparation. In this stage, the one-page handout is finalized, and nursing staff are given a brief training in conducting the education session, and baseline dietary adherence data are obtained from enrolled patients.

Weeks 3-6 are the active implementation phase, in which the nurse-led education session and renal diet handout are provided at the bedside to all eligible hospitalized adult CKD patients.

The outcome measurement and evaluation occur in weeks 7 and 8 when post-intervention dietary adherence questionnaires are completed, data are analyzed, and the effectiveness of the intervention is evaluated to inform practice decisions.

**Theoretical Framework**

Self-Care Deficit Nursing Theory by Dorothea Orem is the main theory that forms the basis for this capstone project. The focus of the Orem theory is on the patient's self-care abilities, which are assumed to be within the patient's control and responsibility, and the role of the nurse when the patient cannot meet these needs on his/her own. After discharge, patients face complex dietary restrictions, but many do not know or feel confident in how to do this effectively within the context of CKD. Changsieng et al. (2023) demonstrated statistically significant improvement in knowledge, dietary adherence, and self-care agency among patients who received supportive-educative programs from nurses using Orem's theory compared with those who received conventional care. In this project, the nurse-led education session and one-page handout are direct representations of the supportive-educative model of nursing by Orem, which emphasizes the reduction of the self-care deficit by providing relevant and actionable dietary information for the patients.

This project will be implemented and evaluated using the Iowa Model of Evidence-Based Practice. The Iowa Model is designed to assist nurses in working systematically, beginning with identifying an issue or opportunity, stating the purpose, forming a team, assembling, appraising, and synthesizing the body of evidence, designing and piloting the practice change, integrating and sustaining the practice change, and disseminating (Cullen et al., 2022). The Iowa Model Revised is a well-defined framework for Iowa nurses to use in converting a quality improvement project into a nursing evidence-based practice development project, and has been successfully used in hemodialysis and nephrology settings to develop nursing interventions that aim for improving patient outcomes. This capstone focuses on the Iowa Model guiding the entire process, including identifying poor dietary adherence as a clinical issue and measuring post-intervention adherence scores for the nurse-led handout intervention.

Together, these two frameworks strengthen the foundation of this capstone. The patient-centred design of the educational intervention and the role of the nurse in closing the self-care gap is guided by Orem's theory and substantiated by the Iowa Model, which offers evidence-based, systematic, and rigorous design and evaluation of the project. Both concepts are consistent with the ultimate aim of increasing adherence to good dietary habits and enhancing the quality of nursing for hospitalized CKD patients.

**Conclusion**

Nonadherence to diet among hospitalized patients with adult CKD is an important and expensive clinical issue that is linked to electrolyte disturbances, fluid overload, CKD progression, and avoidable hospitalizations. This capstone project's purpose is to develop an educational intervention for nurses, with a simplified one-page renal diet handout, to be implemented over an 8-week period among hospitalized adult patients with CKD in a community hospital setting as a feasible and evidence-based intervention to fill this gap. The intervention is based on Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence-Based Practice, ensuring both patient-centered design and systematic implementation. The proposed dietary adherence outcome is attainable and measurable in the specified time period. Addressing this problem carries far-reaching implications for CKD patients, including improved quality of life, reduced burden on the healthcare system, and fewer costly and preventable hospitalizations.

**References**

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), 30–30. 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

Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H. S., & Wagner, M. (2022). Iowa implementation for sustainability framework.
_Implementation Science_,
_17_(1), 1–20. https://doi.org/10.1186/s13012-021-01157-5

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

NIDDK. (2023).
_Kidney disease statistics for the United States_. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease

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.
_Curēus_. 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

**## feedback.docx**

Overall, you are on the right track. Use one clinical setting to make it a realistic Capstone.

**## CapstonePartIIintrucctions.docx**

Capstone Part II: Review of Literature

**CAPSTONE: PART II due 10/4/2025 by 11:59pm**

1. Review of Literature:

– Review and discuss literature: Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else's opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence.

2. Analyze and apply knowledge directly to your PICOT- The studies that you cite in this section must relate directly to your PICOT question.

3. Provide precise body of evidence for your Practice Change- Include Nurses as leaders in this project, statistics, cost, impact on healthcare.

4. Discuss objectives for your practice change, Why is change necessary?

5. Discuss where the problem exists, why it exists, what is the preposition for change. Include information from your PICOT.

6. Apply all that is relevant to the problem. For example: Pros vs Cons, current state of problem

NOTE: It should not reflect your opinion, but rather Evidence Based Practice should be applied

-After completing a literature search on interventions addressing your chosen health problem, write a review that evaluates the strengths and weaknesses of all the sources you have found, compare anc constrast.

-Use appropriate APA 7th Ed. Scholarly, peer-reviewed, and research articles cited should be within the last five years.

-This section should be minimum 4-6 pages long (not including the title and reference page).

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

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

**Rubric Capstone II.docx**

**Submission**

Text Editor

_Word count: 0_

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CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Integration of
Knowledge
25 points
Thoroughly selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
25
Briefly selected and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
20
Vaguely selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
15
Did not select and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
0
Topic Focus
25 points
The health problem
is focused narrowly
enough for the
scope of this
assignment. A topic
statement provides
direction for the
paper. The topic is
consistently well
thought out,
thorough offers
insight into the topic,
and includes cited
evidence to support
the topic.
25
The health problem
is focused but
lacks direction. The
paper is about a
specific topic, but
the writer has not
established a
position. The topic
is somewhat well
thought out, offers
limited insight into
the topic, but does
not include cited
evidence to support
the topic.
20
The health problem
is too broad for the
scope of this
assignment.
15
The health problem
is unclear or
unrelated to the
discussion topic
with little or no
supporting
evidence.
0
Depth of
Discussion and
Cohesiveness
25 points
In-depth discussion
and elaboration in all
sections of the
paper.
Ties together
information from all
sources. Paper flows
from one issue to
the next with no
headings. The
author’s writing
demonstrates an
understanding of the
relationship among
material obtained
from all sources
Mostly, it ties
together information
from all sources.
In-depth discussion
and elaboration in
most sections of
the paper.
Mostly, it ties
together
information from all
sources. Paper
flows with only
some
disjointedness. The
author’s writing
demonstrates an
understanding of
the relationship
among material
obtained from all
sources.
The writer has
omitted content.
Quotations from
others outweigh the
writer’s own ideas
excessively.
Sometimes ties
together
information from all
sources. The paper
does not flow.
Disjointedness is
apparent. The
author’s writing
does not
demonstrate an
understanding of
the relationship
between material
obtained from all
sources.
Cursory discussion
in all the sections
of the paper or brief
discussion in only a
few sections.
It does not tie
together
information. Paper
does not flow and
appears to be
created from
disparate issues.
Headings are
necessary to link
concepts. Writing
does not
demonstrate an
understanding of
any relationship.

25 20
15
0
Spelling and
Grammar
10 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
Required word count
has been met.
8
More than 5 but
fewer than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
6
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 50 words
below the minimum
required count.
5
An unacceptable
number of spelling
and/or grammar
mistakes.
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
10 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 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
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.
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.

**## MSNCapstoneProject.edited1.docx**

2

**Nurse-Led Renal Diet Education to Improve Dietary Adherence in Hospitalized Adult Patients with Chronic Kidney Disease**

Yailin Ramirez

Florida National University

MSN Capstone Project-DAX-DL01

Dr. Carmen Lazo

May 21, 2026

**Nurse-Led Renal Diet Education to Improve Dietary Adherence in Hospitalized Adult Patients With Chronic Kidney Disease**

Chronic kidney disease is a progressive disease of the kidneys in which, over time, they lose their ability to properly filter waste and excess water from the blood, resulting in serious and life-threatening complications. CKD affects more than 1 in 10 adults in the United States, with approximately 37 million adults, or 14% of the adult population, estimated to have the condition, and many individuals remaining undiagnosed until advanced stages of disease progression (CDC, 2026).The cost of CKD to Medicare in 2022 alone was over 86 billion dollars (NIH, 2025). At the local level, adults in Spartanburg County, South Carolina, are affected by several risk factors associated with CKD, including diabetes, hypertension, poverty, limited health literacy, and reduced access to nutritional education. These factors may contribute to poor disease self-management and difficulty adhering to renal dietary recommendations.

The practice problem this paper investigates is the poor adherence of hospitalized adult renal patients to their diet. Failure to follow dietary recommendations for kidney disease, particularly sodium, potassium, phosphorus, and fluid, can lead to an imbalance of electrolytes, fluid overload, and more rapid progression of disease. Non-adherence is also associated with preventable hospital readmissions and higher health care costs (Surasura et al., 2024). The purpose of this capstone project is to evaluate whether a nurse-led renal diet education intervention using a simplified one-page handout improves dietary adherence among hospitalized adult renal patients in a community hospital setting over an eight-week period.

**PICOT**

Patient compliance with severe diet changes is a major factor in the management of CKD. While it is well recognized that nutrition is an important component in slowing the progression of disease and preventing complications from the hospital environment, there is a lack of knowledge and practical means for many renal patients to follow the nutritional recommendations in a consistent manner. This lack of patient education is a major and correctable clinical issue. The guiding question for this capstone project is:
_In hospitalized adult renal patients with CKD (P), does providing nurse-led education using a simplified one-page renal diet handout (I), compared to usual care with no structured dietary education (C), improve dietary adherence (O) over eight weeks (T)?_

The population includes hospitalized adult patients diagnosed with chronic kidney disease (CKD) receiving inpatient care in a community hospital setting within Spartanburg County, South Carolina. This population is especially vulnerable as care of CKD involves adherence to complex dietary limitations affecting salt, potassium, phosphorus and fluid intake . CKD patients often have many chronic illnesses, such as diabetes, hypertension, and socioeconomic determinants of health, including low health literacy, lack of access to nutritional counseling, and financial constraints, may adversely impact diet adherence and health consequences. Therefore, it is necessary to have simple and systematic education in order to successfully treat the disease after discharge.

The proposed intervention is a one-page education handout adapted in a simplified format with a nurse-led bedside education session. The handout offers simple information on how to limit sodium, potassium, phosphorus, and fluids. This session is designed to be about 15-20 minutes in length and is provided by the bedside nurse or advanced practice nurse during hospitalization. An educational intervention targeting specific components of CKD management, such as dietary restrictions and knowledge assessment at pre- and post-intervention, is found to be an effective element of a comprehensive CKD management program (Atraca et al., 2025).

The comparison intervention is usual care, consisting of standard discharge instructions without structured or nurse-led dietary education. Currently, many hospitalized renal patients receive generalized education that lacks the individualization and clarity needed to produce meaningful dietary behavior change.

The expected outcome is a change in dietary adherence measured by a validated dietary adherence questionnaire at baseline and at 8 weeks. Improved adherence is expected to reduce electrolyte abnormalities, prevent fluid overload, and decrease unplanned hospital readmissions (Surasura et al., 2024).

The timeframe for this project is eight weeks. This is enough time for the intervention to be delivered while hospitalized and for patients to transfer the dietary education to the post-hospital environment, while compliance is assessed at the end of the 8-week period.

**Vulnerable Population and Setting**

The population being addressed in this capstone project includes hospitalized adult patients diagnosed with chronic kidney disease (CKD) receiving inpatient care in a community hospital setting within Spartanburg County, South Carolina. This population is considered vulnerable because CKD management requires adherence to complex dietary restrictions involving sodium, potassium, phosphorus, and fluid intake. Additionally, many patients experience multiple chronic conditions, including diabetes, hypertension, and cardiovascular disease, which may complicate disease self-management. In Spartanburg County, social and economic disparities, including poverty, limited access to specialty care, reduced access to renal nutrition counseling, and lower health literacy, may contribute to poor disease management and increased risk for complications and hospital readmissions.

Social determinants of health are a key factor in determining the dietary behaviors and health outcomes of this population. Low health literacy is widely reported in people with CKD and is linked to weak self-care in the disease, poor health outcomes, higher mortality, and a lower quality of life (Billany et al., 2023). A significant number of people in this context are poorly educated, do not have the same access to nutritional advice, and have difficulties in buying foods suitable for the kidneys due to their financial situation. Additionally, increased scores in health literacy are significantly associated with enhanced self-care behaviors among patients with CKD, such as diet management and follow-up of clinical recommendations (Yu et al., 2021). These findings underscore the importance of easy-to-use educational resources to assist in educating patients on the difference between recommendations and understanding.

This vulnerable population has well-defined risk factors. Advanced CKD patients have to deal with multiple medications, comorbid conditions, and dietary restrictions, making them more susceptible to non-adherence. Surasura et al. (2024) further verified that poor self-management and low compliance with the CKD treatment plan, including diet components, significantly contribute to hospital readmission in CKD patients. For this population, change is vital as preventable readmissions, reduced quality of life, and increasing health care costs are the result of failure to address dietary non-adherence, as documented. A low-cost nurse-led educational intervention delivered during hospitalization represents a timely and feasible opportunity to reduce these outcomes and empower patients in their own care.

**Proposal and Intervention Plan**

**The Intervention.** The intervention is a brief, 15-20-minute nurse-led bedside education session for each eligible hospitalized adult CKD patient. The session is facilitated with a one-page handout that has basic information on how to control sodium, potassium, phosphorus, and fluid. The handout is written at a low literacy level to ensure accessibility. Jagodage et al. (2024) showed that structured education sessions delivered face-to-face to CKD patients are linked to better dietary adherence and self-management outcomes than other unstructured usual care approaches.

**Resources Needed.** Minimal resources are required the estimated budget for this intervention is minimal because the educational materials consist of a one-page handout produced at low printing cost. Estimated expenses include approximately $20 for educational handout printing, $10 for questionnaire materials, and no additional staffing costs because the intervention will be incorporated into routine nursing workflow. The estimated total cost of implementation is approximately $30–$40, making the intervention feasible and sustainable in a community hospital setting.

**Feasibility for the Advanced Practice Nurse.** This is an advanced practice intervention that can be incorporated into the hospital workflow. The simplicity of its cost, resource, and time make it a viable and sustainable element to ongoing nursing practice in a community hospital setting.

**Those Involved.** Bedside registered nurse, advanced practice nurse, and dietary staff (when available) are the primary individuals involved. Charge nurses will assist in consistent implementation during the intervention period, across shifts.

**Timeline**

Weeks 1 & 2 will be used for staff preparation. In this stage, the one-page handout is finalized, and nursing staff are given a brief training in conducting the education session, and baseline dietary adherence data are obtained from enrolled patients.

Weeks 3-6 are the active implementation phase, in which the nurse-led education session and renal diet handout are provided at the bedside to all eligible hospitalized adult CKD patients.

The outcome measurement and evaluation occur in weeks 7 and 8 when post-intervention dietary adherence questionnaires are completed, data are analyzed, and the effectiveness of the intervention is evaluated to inform practice decisions.

**Theoretical Framework**

Self-Care Deficit Nursing Theory by Dorothea Orem is the main theory that forms the basis for this capstone project. The focus of the Orem theory is on the patient's self-care abilities, which are assumed to be within the patient's control and responsibility, and the role of the nurse when the patient cannot meet these needs on his/her own. After discharge, patients face complex dietary restrictions, but many do not know or feel confident in how to do this effectively within the context of CKD. Changsieng et al. (2023) demonstrated statistically significant improvement in knowledge, dietary adherence, and self-care agency among patients who received supportive-educative programs from nurses using Orem's theory compared with those who received conventional care. In this project, the nurse-led education session and one-page handout are direct representations of the supportive-educative model of nursing by Orem, which emphasizes the reduction of the self-care deficit by providing relevant and actionable dietary information for the patients.

This project will be implemented and evaluated using the Iowa Model of Evidence-Based Practice. The Iowa Model is designed to assist nurses in working systematically, beginning with identifying an issue or opportunity, stating the purpose, forming a team, assembling, appraising, and synthesizing the body of evidence, designing and piloting the practice change, integrating and sustaining the practice change, and disseminating (Cullen et al., 2022). The Iowa Model Revised is a well-defined framework for Iowa nurses to use in converting a quality improvement project into a nursing evidence-based practice development project, and has been successfully used in hemodialysis and nephrology settings to develop nursing interventions that aim for improving patient outcomes. This capstone focuses on the Iowa Model guiding the entire process, including identifying poor dietary adherence as a clinical issue and measuring post-intervention adherence scores for the nurse-led handout intervention.

Together, these two frameworks strengthen the foundation of this capstone. The patient-centred design of the educational intervention and the role of the nurse in closing the self-care gap is guided by Orem's theory and substantiated by the Iowa Model, which offers evidence-based, systematic, and rigorous design and evaluation of the project. Both concepts are consistent with the ultimate aim of increasing adherence to good dietary habits and enhancing the quality of nursing for hospitalized CKD patients.

**Conclusion**

Nonadherence to diet among hospitalized patients with adult CKD is an important and expensive clinical issue that is linked to electrolyte disturbances, fluid overload, CKD progression, and avoidable hospitalizations. This capstone project's purpose is to develop an educational intervention for nurses, with a simplified one-page renal diet handout, to be implemented over an 8-week period among hospitalized adult patients with CKD in a community hospital setting as a feasible and evidence-based intervention to fill this gap. The intervention is based on Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence-Based Practice, ensuring both patient-centered design and systematic implementation. The proposed dietary adherence outcome is attainable and measurable in the specified time period. Addressing this problem carries far-reaching implications for CKD patients, including improved quality of life, reduced burden on the healthcare system, and fewer costly and preventable hospitalizations.

**References**

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), 30–30. 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

Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H. S., & Wagner, M. (2022). Iowa implementation for sustainability framework.
_Implementation Science_,
_17_(1), 1–20. https://doi.org/10.1186/s13012-021-01157-5

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

NIDDK. (2023).
_Kidney disease statistics for the United States_. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease

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.
_Curēus_. 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

**## feedback.docx**

Overall, you are on the right track. Use one clinical setting to make it a realistic Capstone.

**## CapstonePartIIintrucctions.docx**

Capstone Part II: Review of Literature

**CAPSTONE: PART II due 10/4/2025 by 11:59pm**

1. Review of Literature:

– Review and discuss literature: Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else's opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence.

2. Analyze and apply knowledge directly to your PICOT- The studies that you cite in this section must relate directly to your PICOT question.

3. Provide precise body of evidence for your Practice Change- Include Nurses as leaders in this project, statistics, cost, impact on healthcare.

4. Discuss objectives for your practice change, Why is change necessary?

5. Discuss where the problem exists, why it exists, what is the preposition for change. Include information from your PICOT.

6. Apply all that is relevant to the problem. For example: Pros vs Cons, current state of problem

NOTE: It should not reflect your opinion, but rather Evidence Based Practice should be applied

-After completing a literature search on interventions addressing your chosen health problem, write a review that evaluates the strengths and weaknesses of all the sources you have found, compare anc constrast.

-Use appropriate APA 7th Ed. Scholarly, peer-reviewed, and research articles cited should be within the last five years.

-This section should be minimum 4-6 pages long (not including the title and reference page).

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

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

**Rubric Capstone II.docx**

**Submission**

Text Editor

_Word count: 0_

**Drag files here**

Maximum size: 512 MB

**or**

**Details & Information**

CRITERIA OUTSTANDING VERY GOOD GOOD UNACCEPTABLE
Integration of
Knowledge
25 points
Thoroughly selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
25
Briefly selected and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
20
Vaguely selected
and present an
appropriate
Evidence Based
Practice for the
health problem and
change.
15
Did not select and
present an
appropriate
Evidence Based
Practice for the
health problem and
change.
0
Topic Focus
25 points
The health problem
is focused narrowly
enough for the
scope of this
assignment. A topic
statement provides
direction for the
paper. The topic is
consistently well
thought out,
thorough offers
insight into the topic,
and includes cited
evidence to support
the topic.
25
The health problem
is focused but
lacks direction. The
paper is about a
specific topic, but
the writer has not
established a
position. The topic
is somewhat well
thought out, offers
limited insight into
the topic, but does
not include cited
evidence to support
the topic.
20
The health problem
is too broad for the
scope of this
assignment.
15
The health problem
is unclear or
unrelated to the
discussion topic
with little or no
supporting
evidence.
0
Depth of
Discussion and
Cohesiveness
25 points
In-depth discussion
and elaboration in all
sections of the
paper.
Ties together
information from all
sources. Paper flows
from one issue to
the next with no
headings. The
author’s writing
demonstrates an
understanding of the
relationship among
material obtained
from all sources
Mostly, it ties
together information
from all sources.
In-depth discussion
and elaboration in
most sections of
the paper.
Mostly, it ties
together
information from all
sources. Paper
flows with only
some
disjointedness. The
author’s writing
demonstrates an
understanding of
the relationship
among material
obtained from all
sources.
The writer has
omitted content.
Quotations from
others outweigh the
writer’s own ideas
excessively.
Sometimes ties
together
information from all
sources. The paper
does not flow.
Disjointedness is
apparent. The
author’s writing
does not
demonstrate an
understanding of
the relationship
between material
obtained from all
sources.
Cursory discussion
in all the sections
of the paper or brief
discussion in only a
few sections.
It does not tie
together
information. Paper
does not flow and
appears to be
created from
disparate issues.
Headings are
necessary to link
concepts. Writing
does not
demonstrate an
understanding of
any relationship.

25 20
15
0
Spelling and
Grammar
10 points
Fewer than 5
grammatical,
spelling,
capitalization, or
punctuation errors.
Required word count
has been met.
8
More than 5 but
fewer than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 25 words
below the minimum
required count.
6
More than 10
grammatical,
spelling,
capitalization &
punctuation errors
Required word
count is 50 words
below the minimum
required count.
5
An unacceptable
number of spelling
and/or grammar
mistakes.
Required word
count is more than
50 words below the
minimum required
count.
0
Sources
10 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 current sources,
of which at least 2
are peer-review
journal articles or
scholarly books. All
websites utilized
are authoritative.
Fewer than 5
current sources or
fewer than 2 of 5
are peer-reviewed
journal articles or
scholarly books. All
websites utilized
are credible.
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.
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
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**## MSNCapstoneProject.edited1.docx**

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**Nurse-Led Renal Diet Education to Improve Dietary Adherence in Hospitalized Adult Patients with Chronic Kidney Disease**

Yailin Ramirez

Florida National University

MSN Capstone Project-DAX-DL01

Dr. Carmen Lazo

May 21, 2026

**Nurse-Led Renal Diet Education to Improve Dietary Adherence in Hospitalized Adult Patients With Chronic Kidney Disease**

Chronic kidney disease is a progressive disease of the kidneys in which, over time, they lose their ability to properly filter waste and excess water from the blood, resulting in serious and life-threatening complications. CKD affects more than 1 in 10 adults in the United States, with approximately 37 million adults, or 14% of the adult population, estimated to have the condition, and many individuals remaining undiagnosed until advanced stages of disease progression (CDC, 2026).The cost of CKD to Medicare in 2022 alone was over 86 billion dollars (NIH, 2025). At the local level, adults in Spartanburg County, South Carolina, are affected by several risk factors associated with CKD, including diabetes, hypertension, poverty, limited health literacy, and reduced access to nutritional education. These factors may contribute to poor disease self-management and difficulty adhering to renal dietary recommendations.

The practice problem this paper investigates is the poor adherence of hospitalized adult renal patients to their diet. Failure to follow dietary recommendations for kidney disease, particularly sodium, potassium, phosphorus, and fluid, can lead to an imbalance of electrolytes, fluid overload, and more rapid progression of disease. Non-adherence is also associated with preventable hospital readmissions and higher health care costs (Surasura et al., 2024). The purpose of this capstone project is to evaluate whether a nurse-led renal diet education intervention using a simplified one-page handout improves dietary adherence among hospitalized adult renal patients in a community hospital setting over an eight-week period.

**PICOT**

Patient compliance with severe diet changes is a major factor in the management of CKD. While it is well recognized that nutrition is an important component in slowing the progression of disease and preventing complications from the hospital environment, there is a lack of knowledge and practical means for many renal patients to follow the nutritional recommendations in a consistent manner. This lack of patient education is a major and correctable clinical issue. The guiding question for this capstone project is:
_In hospitalized adult renal patients with CKD (P), does providing nurse-led education using a simplified one-page renal diet handout (I), compared to usual care with no structured dietary education (C), improve dietary adherence (O) over eight weeks (T)?_

The population includes hospitalized adult patients diagnosed with chronic kidney disease (CKD) receiving inpatient care in a community hospital setting within Spartanburg County, South Carolina. This population is especially vulnerable as care of CKD involves adherence to complex dietary limitations affecting salt, potassium, phosphorus and fluid intake . CKD patients often have many chronic illnesses, such as diabetes, hypertension, and socioeconomic determinants of health, including low health literacy, lack of access to nutritional counseling, and financial constraints, may adversely impact diet adherence and health consequences. Therefore, it is necessary to have simple and systematic education in order to successfully treat the disease after discharge.

The proposed intervention is a one-page education handout adapted in a simplified format with a nurse-led bedside education session. The handout offers simple information on how to limit sodium, potassium, phosphorus, and fluids. This session is designed to be about 15-20 minutes in length and is provided by the bedside nurse or advanced practice nurse during hospitalization. An educational intervention targeting specific components of CKD management, such as dietary restrictions and knowledge assessment at pre- and post-intervention, is found to be an effective element of a comprehensive CKD management program (Atraca et al., 2025).

The comparison intervention is usual care, consisting of standard discharge instructions without structured or nurse-led dietary education. Currently, many hospitalized renal patients receive generalized education that lacks the individualization and clarity needed to produce meaningful dietary behavior change.

The expected outcome is a change in dietary adherence measured by a validated dietary adherence questionnaire at baseline and at 8 weeks. Improved adherence is expected to reduce electrolyte abnormalities, prevent fluid overload, and decrease unplanned hospital readmissions (Surasura et al., 2024).

The timeframe for this project is eight weeks. This is enough time for the intervention to be delivered while hospitalized and for patients to transfer the dietary education to the post-hospital environment, while compliance is assessed at the end of the 8-week period.

**Vulnerable Population and Setting**

The population being addressed in this capstone project includes hospitalized adult patients diagnosed with chronic kidney disease (CKD) receiving inpatient care in a community hospital setting within Spartanburg County, South Carolina. This population is considered vulnerable because CKD management requires adherence to complex dietary restrictions involving sodium, potassium, phosphorus, and fluid intake. Additionally, many patients experience multiple chronic conditions, including diabetes, hypertension, and cardiovascular disease, which may complicate disease self-management. In Spartanburg County, social and economic disparities, including poverty, limited access to specialty care, reduced access to renal nutrition counseling, and lower health literacy, may contribute to poor disease management and increased risk for complications and hospital readmissions.

Social determinants of health are a key factor in determining the dietary behaviors and health outcomes of this population. Low health literacy is widely reported in people with CKD and is linked to weak self-care in the disease, poor health outcomes, higher mortality, and a lower quality of life (Billany et al., 2023). A significant number of people in this context are poorly educated, do not have the same access to nutritional advice, and have difficulties in buying foods suitable for the kidneys due to their financial situation. Additionally, increased scores in health literacy are significantly associated with enhanced self-care behaviors among patients with CKD, such as diet management and follow-up of clinical recommendations (Yu et al., 2021). These findings underscore the importance of easy-to-use educational resources to assist in educating patients on the difference between recommendations and understanding.

This vulnerable population has well-defined risk factors. Advanced CKD patients have to deal with multiple medications, comorbid conditions, and dietary restrictions, making them more susceptible to non-adherence. Surasura et al. (2024) further verified that poor self-management and low compliance with the CKD treatment plan, including diet components, significantly contribute to hospital readmission in CKD patients. For this population, change is vital as preventable readmissions, reduced quality of life, and increasing health care costs are the result of failure to address dietary non-adherence, as documented. A low-cost nurse-led educational intervention delivered during hospitalization represents a timely and feasible opportunity to reduce these outcomes and empower patients in their own care.

**Proposal and Intervention Plan**

**The Intervention.** The intervention is a brief, 15-20-minute nurse-led bedside education session for each eligible hospitalized adult CKD patient. The session is facilitated with a one-page handout that has basic information on how to control sodium, potassium, phosphorus, and fluid. The handout is written at a low literacy level to ensure accessibility. Jagodage et al. (2024) showed that structured education sessions delivered face-to-face to CKD patients are linked to better dietary adherence and self-management outcomes than other unstructured usual care approaches.

**Resources Needed.** Minimal resources are required the estimated budget for this intervention is minimal because the educational materials consist of a one-page handout produced at low printing cost. Estimated expenses include approximately $20 for educational handout printing, $10 for questionnaire materials, and no additional staffing costs because the intervention will be incorporated into routine nursing workflow. The estimated total cost of implementation is approximately $30–$40, making the intervention feasible and sustainable in a community hospital setting.

**Feasibility for the Advanced Practice Nurse.** This is an advanced practice intervention that can be incorporated into the hospital workflow. The simplicity of its cost, resource, and time make it a viable and sustainable element to ongoing nursing practice in a community hospital setting.

**Those Involved.** Bedside registered nurse, advanced practice nurse, and dietary staff (when available) are the primary individuals involved. Charge nurses will assist in consistent implementation during the intervention period, across shifts.

**Timeline**

Weeks 1 & 2 will be used for staff preparation. In this stage, the one-page handout is finalized, and nursing staff are given a brief training in conducting the education session, and baseline dietary adherence data are obtained from enrolled patients.

Weeks 3-6 are the active implementation phase, in which the nurse-led education session and renal diet handout are provided at the bedside to all eligible hospitalized adult CKD patients.

The outcome measurement and evaluation occur in weeks 7 and 8 when post-intervention dietary adherence questionnaires are completed, data are analyzed, and the effectiveness of the intervention is evaluated to inform practice decisions.

**Theoretical Framework**

Self-Care Deficit Nursing Theory by Dorothea Orem is the main theory that forms the basis for this capstone project. The focus of the Orem theory is on the patient's self-care abilities, which are assumed to be within the patient's control and responsibility, and the role of the nurse when the patient cannot meet these needs on his/her own. After discharge, patients face complex dietary restrictions, but many do not know or feel confident in how to do this effectively within the context of CKD. Changsieng et al. (2023) demonstrated statistically significant improvement in knowledge, dietary adherence, and self-care agency among patients who received supportive-educative programs from nurses using Orem's theory compared with those who received conventional care. In this project, the nurse-led education session and one-page handout are direct representations of the supportive-educative model of nursing by Orem, which emphasizes the reduction of the self-care deficit by providing relevant and actionable dietary information for the patients.

This project will be implemented and evaluated using the Iowa Model of Evidence-Based Practice. The Iowa Model is designed to assist nurses in working systematically, beginning with identifying an issue or opportunity, stating the purpose, forming a team, assembling, appraising, and synthesizing the body of evidence, designing and piloting the practice change, integrating and sustaining the practice change, and disseminating (Cullen et al., 2022). The Iowa Model Revised is a well-defined framework for Iowa nurses to use in converting a quality improvement project into a nursing evidence-based practice development project, and has been successfully used in hemodialysis and nephrology settings to develop nursing interventions that aim for improving patient outcomes. This capstone focuses on the Iowa Model guiding the entire process, including identifying poor dietary adherence as a clinical issue and measuring post-intervention adherence scores for the nurse-led handout intervention.

Together, these two frameworks strengthen the foundation of this capstone. The patient-centred design of the educational intervention and the role of the nurse in closing the self-care gap is guided by Orem's theory and substantiated by the Iowa Model, which offers evidence-based, systematic, and rigorous design and evaluation of the project. Both concepts are consistent with the ultimate aim of increasing adherence to good dietary habits and enhancing the quality of nursing for hospitalized CKD patients.

**Conclusion**

Nonadherence to diet among hospitalized patients with adult CKD is an important and expensive clinical issue that is linked to electrolyte disturbances, fluid overload, CKD progression, and avoidable hospitalizations. This capstone project's purpose is to develop an educational intervention for nurses, with a simplified one-page renal diet handout, to be implemented over an 8-week period among hospitalized adult patients with CKD in a community hospital setting as a feasible and evidence-based intervention to fill this gap. The intervention is based on Orem's Self-Care Deficit Nursing Theory and the Iowa Model of Evidence-Based Practice, ensuring both patient-centered design and systematic implementation. The proposed dietary adherence outcome is attainable and measurable in the specified time period. Addressing this problem carries far-reaching implications for CKD patients, including improved quality of life, reduced burden on the healthcare system, and fewer costly and preventable hospitalizations.

**References**

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), 30–30. 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

Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H. S., & Wagner, M. (2022). Iowa implementation for sustainability framework.
_Implementation Science_,
_17_(1), 1–20. https://doi.org/10.1186/s13012-021-01157-5

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

NIDDK. (2023).
_Kidney disease statistics for the United States_. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease

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.
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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