ORIGINAL ARTICLE
The effect of aromatherapy on haemodialysis patients’ pruritus Mehtap Cu¨rcani and Mehtap Tan
Aims and objectives. To determine the effect of aromatherapy on pruritus observed in haemodialysis patients. Background. Although the prevalence of pruritus in kidney failure has decreased in the recent years, pruritus is a difficult and serious problem which concerns the majority of haemodialysis patents and is hard to cure. Design. A prospective, pretest–post-test quasi-experimental design was used. Methods. The research is quasi-experimental clinical trial conducted as pretest and post-test with control groups between January 2011–April 2012, in haemodialysis units of hospitals in Erzurum. The collection of the data is achieved using a questionnaire to detect the patients’ individual and pruritus score scale and to clarify certain laboratory parameters regarding the pruritus. Chi-square analysis and t-test are used for the analysis of data. Results. The experimental group’s mean post-test pruritus scores (720 314) were found to be lower than that of control group patients (1000 247), and a highly significant difference was found between the groups (p < 0001). In the between-groups comparisons of experimental and control group’s laboratory parameters, the experimental group’s post-test blood urea nitrogen levels (11826 3676) were found to be lower than that of control group patients (13880 4869), and the between-groups difference was found to be statistically significant (p < 005). Conclusions. The results demonstrate that aromatherapy was found to decrease the pruritus problem of haemodialyses patients and led to positive changes in some laboratory parameters related to pruritus. Relevance to clinical practice. One of the roles of health professionals is to advise individuals, who are living on this problem, using the nonpharmacological methods in checking the itching. By preventing or reducing uraemic pruritus, aromatherapy may also improve quality of life in this patient group.
What does this paper contribute to the wider global clinical community?
• The results of this study have
•
•
practical implications in nursing practice for haemodialyses patients who suffer from pruritus. Nurses are ideal practitioners of complementary therapies and are positioned to contribute to the research base regarding the use of aromatherapy in health care. Using aromatherapy for management of patient’s pruritus is a simple and effective treatment that causes no harm and avoids overuse of pharmaceuticals.
Key words: aromatherapy, haemodialysis, nursing, pruritus, Turkey Accepted for publication: 25 January 2014
Authors: Mehtap Cu¨rcani, Assistant Professor, Department of Internal Medicine Nursing, Faculty of Health Science, Atatu¨rk University, Erzurum; Mehtap Tan, PhD, Professor, Department of Internal Medicine Nursing, Faculty of Health Science, Atatu¨rk University, Erzurum, Turkey
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Correspondence: Mehtap Cu¨rcani, Department of Internal Medicine Nursing, Faculty of Health Science, Atatu¨rk University, Erzurum, Turkey. Telephone: +90 442 231 27 48. E-mail: [email protected]
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365, doi: 10.1111/jocn.12579
Original article
The effect of aromatherapy
Introduction
Background
Kidney failure is an important health problem, both in the world and in Turkey. According to the 2010 data of Turkish Nephrology Association, there are approximately 62,903 patients with kidney failure and 49,505 of those are receiving haemodialysis (HD) (Turkish Society of Nephrology 2010). The study also found that many haemodialysis patients suffer from symptoms such as pruritus, insomnia, fatigue, muscle ache, dry skin and muscle spasms, which can dramatically affect quality of life in this patient group (Pisoni et al. 2006). Pruritus is one of the most common and disturbing symptoms of end-stage renal disease (ESRD), with a prevalence between 20–90% (Patel et al. 2007, Narita et al. 2008, Kuypers 2009, Asßıcıoglu et al. 2011). Pruritus can compromise physical and mental abilities as well as the quality of sleep. In this manner, pruritus compromises quality of life considerably, with reports in the literature of increased mortality in those who have pruritus (Pisoni et al. 2006, Keithi-Reddy et al. 2007). A 2009 survey of HD patients in Turkey showed that two-thirds experienced symptoms of pruritus daily and that four-fifths had suffered from pruritus for over once a week (Yılmaz 2009). From further studies in Turkey, 80–83% of haemodialysis patients experience pruritus (Onsun et al. 1990, Balevi & Uysal 2000). In Turkey, a study has reported the prevalence of pruritus in 80 HD patients to be 410%, in which 179 and 410% reported severe, moderate and mild pruritus, respectively (Yılmaz 2009). According to various studies, severe and obvious pruritus affects 15–49% of patients with chronic renal failure and 50–90% of patients under HD. The symptoms are more frequent in patients under HD than in those under peritoneal dialysis (42 vs. 32%) (Kurban et al. 2008). In Iran, a study has reported the prevalence of pruritus in 167 HD patients to be 419%, in which 371, 114 and 514% reported severe, moderate and mild pruritus, respectively (Akhyani et al. 2005). Although there has been a growing interest in aromatherapy, the actual effect of aromatherapy on uraemic pruritus in patients with chronic renal failure has been insufficiently documented in the nursing literature. Despite the common occurrence of patients with CRF experiencing pruritus, research on effective nursing intervention for these complications has been limited. Thus, the aim of this research is to study the effect of aromatherapy on pruritus relief in HD patients.
Pruritus is one of the commonest problems in patients with end-stage renal failure undergoing HD. Pruritus is an irritating symptom which can directly affect the life quality of patients with chronic renal failure. In such patients, physical and mental abilities as well as sleep quality are impaired by pruritus, hence the interference in life quality of the patient. Furthermore, an increase in mortality in patients with pruritus has been reported in some studies (Melo et al. 2009). Because of the poorly understood pathophysiological mechanisms of uraemic pruritus, the treatments for this condition have largely been empirical, and no treatment has been shown to have sufficient efficacy and safety (Asßıcıo glu et al. 2011). Various treatments have been proposed to alleviate pruritus in patients with ESRD including venous injection of lidocaine or heparin, oral administration of cholestyramine, activated charcoal and azelastine HCI, a low-protein diet, magnesium-free dialysis, parathyroidectomy, renal transplantation, acupuncture, acupressure, ultraviolet therapy and aromatherapy (Chou 2000, Mıllıkan 2003, Shapiro & Stockard 2003, Zucker et al. 2003, Ada et al. 2005, Arıcan 2005, Kim et al. 2010). However, available treatments have failed to relieve the symptom, and kidney transplant remains the definite treatment for the problem. A study by Morton et al. examined pruritus scores in patients, and physiological measures were used to indicate the levels of pruritus in patients with CRF. Physiological measures included were skin pH, stratum corneum hydration (SCH) and several biochemical markers that had been used as the indicators related to pruritus in patients with CRF in previous studies: blood urea nitrogen (BUN), creatinine (Cr), sodium (Na), potassium (K), phosphorus (P) and calcium (Ca) (Yosipovitch et al. 1993, Morton et al. 1996, Carmichael et al. 1988). Aromatherapy is also one of these complementary medicine methods increasingly used in the twenty-first century. Many of the effects of essential oils used in aromatherapy have been reported in animal experiments, including relaxation, anti-inflammation, analgesia, disinfection, antioxidation and decreasing the blood urea level. Although there is an increasing inclination towards employing aromatherapy, the real effect of aromatherapy on uraemic pruritus in patients with chronic kidney failure is not well established (Ro et al. 2002). Nurses are increasingly incorporating complementary therapies into their practices. Aromatherapy is one of the most popular therapies. Aromatherapy was proposed as a noninvasive nursing intervention to alleviate pruritus in patients with CRF undergoing HD. The basis of aromatherapy is essential oils, which are chemically active
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
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substances with a long history of safe traditional use and a growing evidence base to support their use in nursing care (Buckle 2001, Dunning 2005, Tseng 2005). The use of essential oils in the medical field goes back more than 6000 years to the Greco-Roman era (Keville & Green 1997). There are more than 200 types of essential oils with distinctive chemical compositions and characteristics. Aromatherapy involves using pure essential oils derived from plants (Lawless 1994). A variety of methods exist for applying aromatherapy including bathing, massage, irrigation of the skin, cold and hot compresses, facial steam bath and inhalation. Because essential oils consist of simple, small molecules capable of rapid absorption through hair follicles, massage is an effective method of applying aromatherapy (Lavabre 1990). Aromatherapy was effectively found in literature when it was applied for pruritus for 2–6 weeks (Walsh 1996, Anderson et al. 2000, Ro et al. 2002, Magin et al. 2006, Shahgholian et al. 2010). It is stated in many studies that aromatherapy oils are beneficial to such dermatological diseases as pruritus, psoriasis, eczema, acne, head lice, burn and alopecia (Walsh 1996, Hay et al. 1998, Anderson et al. 2000, Lahlou et al. 2000, Ro et al. 2002, Al-Waili 2003, Magin et al. 2006, Roh et al. 2007, Shahgholian et al. 2010). On the other hand, it is noted that the number of studies on the effect of aromatherapy for uraemic pruritus in patients with chronic renal failure is insufficient in nursing literature.
Methods Design and sample The research is quasi-experimental clinical trial conducted as pretest–post-test with control groups between January 2011–April 2012, in haemodialysis units of hospitals in Erzurum, eastern Turkey. The research consists of 134 patients receiving dialysis treatment in haemodialysis units of relevant hospitals. All patients with pruritus who underwent HD three times a week for three to five hours in each session participated in this study. In selection of the sample group, below criteria are taken into consideration. Patients: • Receiving three- to five-hour HD treatment three times a week. • Had pruritus during the past two weeks before sampling. • Had not used any pruritus relieving medication before and during sampling. • Had no dermatological problem other than uraemic pruritus.
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• •
Without open wounds at the region of application. Between the age of 18–65 are included in the study. To exclude those in the control group from influences of those in the study group, patients who received HD on Mondays, Wednesdays and Fridays were included in the experimental group (n = 40), while those who received HD on Tuesdays, Thursdays and Saturdays were included in the control group (n = 40).
Instruments The collection of the data is achieved using a questionnaire. The questionnaire prepared by the researches in the light of literature consists of patients age, gender, duration of HD and laboratory parameters (haemoglobin (Hb), haematocrit (Hct), albumin (ALB), calcium (Ca), phosphorus (P), BUN, creatinine (Cr) and parathyroid hormone (PTH) and Kt/V values) (Walsh 1996, Anderson et al. 2000, Ro et al. 2002, Magin et al. 2006, Shahgholian et al. 2010). A modified scale of the Pruritus Score Scale was used to measure the severity, location and frequency of pruritus using the following scales (Ro et al. 2002, Shahgholian et al. 2010): • Severity: visual analogue scale (VAS) is performed to evaluate the severity of the pruritus. VAS is a scale developed by Huskisson (1974), which is used to convert some data that cannot be expressed numerically into quantitative state (Huskisson 1974, Huskısson et al. 1976). In this study, a form with a 10-cm line, which reads ‘no pruritus’ (zero points) at one end and ‘very severe pruritus’ (10 points) at the other, is given to define the severity of pruritus, and then, the patient is asked to mark his/her condition on the line. The severity of the pruritus is determined by measuring the length with a standard ruler from the point of no pruritus to the point where the patient marked. • Location: one or two sites on the body (one point), three or more sites or the entire body (two points). • Frequency: infrequent (zero points), sometimes present (one point), often present (two points) and present all day (three points). The pruritus scores ranges from 0–15, with 15 indicating the most severe pruritus.
Intervention The researcher first washes his/her hands thoroughly. To eliminate waste from the subject’s skin surface and to help the skin absorb the oil more easily, the applicable area is
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
Original article
washed gently with a cotton pad dampened in region of the pruritus. Patients in experimental group received a six-week aromatherapy by the investigators during dialysis sessions three times a week for a period of 7–15 minutes for each region of the pruritus (not applied to the arm with fistula). To that end, in this study, aromatherapy was applied for six weeks. In the study, lavender, tea tree, almond and jojoba oils are mixed and used for therapeutic purposes. Lavender and tea tree oils are prepared in the ratio 1:1, and then, the mixture is diluted with almond and jojoba oil in the ratio 4:1 producing a 5% solution. The pH of the mixture was measured as 65 with Metler Toledo MP220 pH metre (Mettler Toledo, Austin, TX, USA). All the participants had a skin test before undergoing massage with the oil to make sure they were not allergic to the oil. We stopped the treatment immediately if a patient exhibits allergic reaction. Patients in control groups have been provided with normal nursing care, and they are not attended by the investigators. Post-test data are collected after six weeks following the pretests of the patients in experimental and control groups, by re-evaluating the scores of pruritus and recording the necessary laboratory results.
Data collection The study was approved by the Ethical Committee of the Health Science Institute of the Ataturk University. Written and verbal consents from the hospitals to be included in the research are provided prior to the study. Patients willing to participate are accounted for the research. Before collection of the data, patients’ questions are answered, and then written and verbal consents are obtained after they are informed (informed consent doctrine). The data are gathered from face-to-face meetings of researchers with the patients in HD unit. To collect pretest data, questionnaires are given to patients in experimental and control groups, requisite laboratory results are recorded (Hb, Hct, ALB, Ca, P, BUN, Cr, PTH and Kt/V) and pruritus scores are determined. Post-test data are collected after six weeks following the pretests of the patients in experimental and control groups, by re-evaluating the scores of pruritus and recording the necessary laboratory results.
Analysis of data The analysis of data is performed on computers via SPSS version 15.00 (Statistical Package for Social Science) software © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
The effect of aromatherapy
package (SPSS, Inc., Chicago, IL, USA). Chi-square analysis and t-test are used for the analysis of data.
Results All the patients fulfilling the inclusion criteria completed this study. Table 1 presents a comparison of experimental and control groups with respect to the informative characteristics of patients involved in the study. It is concluded that there is no statistically significant difference (p > 005) between these groups regarding the gender, age, duration of HD, score of pruritus and pretest conclusions of laboratory results of the patients in the experimental and control groups, and that both groups are alike (Table 1). Table 2 gives the comparison of the pretest–post-test pruritus score of patients between and within the groups. In the within-group comparisons of the experimental group patients’ pruritus scores, the patients’ mean prearomatherapy pruritus scores were 975 267, while this value became 720 314 after the aromatherapy, and the difference was found to be highly significant (p < 0001). The mean pretest pruritus score of the control group patients was found to be 973 232, whereas the posttest pruritus score was found to be 1000 247, and the difference was not found to be statistically significant (p > 005). The between-groups comparison of experimental and control groups’ pruritus scores revealed no significant differences between the pretest scores of the experimental and control groups (p > 005). The experimental group’s mean post-test pruritus scores (720 314) were found to be lower than that of control group patients (1000 247), and a highly significant difference was found between the groups (p < 0001, Table 2). These findings indicate that there is a decline in the pruritus scores of patients in experimental group, which suggests an improvement and an increase in scores of control patients although it is not statistically significant. Table 3 gives the within- and between-group comparison of pretest and post-test levels of laboratory parameters of patients in experimental and control groups. In the withingroup comparisons of the experimental and control groups’ pretest and post-test laboratory parameters, a significant increase was observed in the experimental group’s Hct levels; a decrease was observed in BUN and PTH levels, while a significant increase was observed in the control group’s P and BUN levels (p < 005, Table 3). In the between-groups comparisons of experimental and control group’s laboratory parameters, the experimental
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M Cu¨rcani and M Tan Table 1 Comparison of experimental and control groups with respect to the informative characteristics of the patients Experimental Features Sex Female Male
Control
n
%
n
%
p
15 25 X SD
375 625
21 19 X SD
525 475
v2 = 1818 p = 0178
Age (years)
4518 1494
5108 1168
Haemodialysis (month)
4975 3899
4798 4401
973 232
975 267
1060 193
1123 125
Hct
3075 559
3281 360
Ca
862 068
852 133
P
552 162
540 114
Albumin
397 077
396 068
12738 4825
13233 4815
1176 2143
949 576
47206 41691
41018 28713
170 089
167 037
Pruritus scores Laboratory parameters (mg/dl) Hb
Blood urea nitrogen Cr Parathyroid hormone Kt/V
t = 1968 p = 0053 t = 0191 p = 0849 t = 0045 p = 0964 t = 1722 p = 0089 t = 1965 p = 0053 t = 0406 p = 0686 t = 0387 p = 0700 t = 0074 p = 0941 t = 0459 p = 0647 t = 0649 p = 0518 t = 0773 p = 0442 t = 0228 p = 0820
p < 005, t = independent samples t-test.
Table 2 Within- and between-group comparison of the mean pretest/post-test pruritus scores of the patients in experimental and control groups Pruritus scores
Groups
Pretest X SD
Post-test X SD
Experimental Control t p
975 267 973 232 0045 0964
720 314 1000 247 4433 0000
t
p 7053 1638
0000 0109
p < 005, t = independent samples t-test.
group’s post-test BUN levels (11826 3676 mg/dl) were found to be lower than that of control group patients (13880 4869 mg/dl) and the between-groups difference was found to be statistically significant (p < 005, Table 3).
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Discussion Although not a peril on its own, pruritus causes physical and mental fatigue in many patients as well as insomnia, chronic fatigue, social isolation, anger–anxiety–depression and a decline in self-respect, self-care ability and quality of life (Melo et al. 2009, Shahgholian et al. 2010). Uraemic pruritus does not have a definite and effective treatment as is the case with other diseases with no clear aetiology. This uncertainty in treatment for the pruritus allows the use of various complementary and alternative medicine (CAM) therapies, one of which being aromatherapy (Mıllıkan 2003). The use of CAM treatments in dermatology spreads worldwide. According to the literature, the frequency of CAM use is 41% in Taiwan (Chen & Chang 2003), 265% in Germany (Sch€ afer et al. 2002), 257% in Singapore (See et al. 2011) and 21% in Turkey (Esßer et al. 2010). The frequency of aromatherapy use on patients applying for © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
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Table 3 Within- and between-group comparison of pretest and post-test levels of laboratory parameters of patients in experimental and control groups Pretest X SD Hb Experimental Control t p Hct Experimental Control t p Ca Experimental Control t p P Experimental Control t p Albumin Experimental Control t p Blood urea nitrogen Experimental Control t p Cr Experimental Control t p Parathyroid hormone Experimental Control t p Kt/V Experimental Control t p
Post-test X SD
t
p
1123 125 1060 193 1722 0089
1122 155 1102 202 0495 0622
005 1584
096 0121
3075 559 3281 360 1965 0053
3263 533 3347 476 0741 0461
2655 1086
0011 0284
852 133 862 068 0406 0686
892 091 857 068 1949 0055
1875 0438
0068 0664
552 162 540 114 0387 07
573 186 611 149 1011 0315
1177 2888
0246 0006
396 068 397 077 0074 0941
395 042 412 112 086 0393
0007 1172
0994 0248
13233 4815 12738 4825 0459 0647
11826 3676 13880 4869 2129 0036
2887 2233
0006 0031
1176 2143 949 576 0649 0518
858 262 897 500 0436 0664
0981 0459
0333 0649
47206 41691 41018 28713 0773 0442
35571 32486 35706 24837 0021 0983
3011 1659
0005 0105
167 037 170 089 0228 082
174 022 206 148 1365 0176
1234 1637
0225 011
p < 005, t = independent samples t-test.
dermatology clinics is 86% in USA and 53% in Germany (Ernst 2000). Several studies argue that aromatherapy oils are beneficial to many dermatological diseases such as itch, psoriasis, eczema, acne, head lice and alopecia (Walsh 1996, Hay et al. 1998, Anderson et al. 2000, Lahlou et al. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
2000, Ro et al. 2002, Al-Waili 2003, Magin et al. 2006, Herro & Jacob 2010, Shahgholian et al. 2010). In this research, tea tree oils and lavender oils are mixed together with sweet almond and jojoba oils, and the aromatherapy with the application of the suspension
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is observed to cause a decrease in the level of pruritus. According to the literature, studies conducted using tea tree oils suggest better results with less adverse effects in such dermatological problems as acne, dandruff, head lice, eczema and uraemic itch in contrast with other conventional treatments (Walsh 1996, Anderson et al. 2000, Ro et al. 2002, Satchell et al. 2002, Shahgholian et al. 2010). Lavender flowers had been used in ancient Greece and by Romans in water of common baths to prevent infection as well as to cleanse and tend to wounds such as bites, burns (including sunburns), laceration and to treat acne, psoriasis, fungal infections and cold sore (Lis-Balchin & Hart 1999, Mei-Yu et al. 2012). Several studies suggest that lavender oil is effective in many dermatological diseases (Walsh 1996, Anderson et al. 2000, Ro et al. 2002, Shahgholian et al. 2010). Ro et al. (2002) conducted a study with 29 HD patients used aromatherapy with lavender and tea tree oil three times a week for four weeks. They observed that the itchiness scores of the patients in experimental group are declined, the difference of which is statistically significant from the control group (Ro et al. 2002). Shahgholian et al. (2010) reported that they prepared a solution of mint, lavender and tea tree oils diluted to 5% with sweet almond oil to be used on 24 patients to observe the effects of aromatherapy on itchiness of HD patients. Following the two-week application of aromatherapy, it is claimed that the itchiness scores of patients in experimental group are decreased, and the difference from the control group is statistically significant (Shahgholian et al. 2010). Uraemia itself is mainly at fault for uraemic itch; however, it is not solely responsible for the itch. Although the reasons are not clear, it is suggested that secondary hyperthyroidism and the alterations in divalent ion concentrations such as calcium, phosphate and magnesium may cause the uraemic itch. It is also claimed that the accumulation of divalent ions, such as calcium, phosphate, magnesium on the skin, has a potential role on the pathogenesis of uraemic itch by affecting the itch centre and receptors (Narita et al. 2008). Some studies suggest that there is a close relation between high serum calcium (>102 mg/dl), high serum phosphorus (>55 mg/dl) and high serum CaxP (>80 mg2/dl2) levels, and the uraemic itch (Momose et al. 2004, Pisoni et al. 2006). It is stated in the literature that secondary hyperparathyroidism is also important in the aetiology of uraemic itch, which lessens following a parathyroidectomy and that increased parathormone levels augment histamine
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release by inducing mast cells (Chou 2000, Pisoni et al. 2006). As a result of the study, BUN and PTH levels of the patients treated with aromatherapy in experimental group are observed to fall (Table 3). Ro et al. (2002) state in their research regarding HD patients that BUN levels of the patients in the experimental group, who are treated with aromatherapy, decline with respect to the patients in the control group inasmuch as the difference is statistically significant; therefore, aromatherapy is effective and a method of use of patients in HD however inconclusive it was regarding other laboratory parameters related to the itch.
Conclusions After applying aromatherapy regularly for six weeks, surveys of the participants revealed significantly reduced severity of pruritus. This study confirmed that aromatherapy is effective treatment for pruritus. However, we acknowledge that our study has several limitations, such as nonrandomised design and the lack of an equivalent-treatment control group to estimate the superior effectiveness of aromatherapy massage. Therefore, it is not clear whether the positive effects were due to the aromatherapy, the massage or both (e.g. identical results may have been achieved using only massage, or using aromatherapy and massage). Further randomised studies should be carried out that include more objective measures, such as hormonal changes associated with climacteric women, to explain the possible mechanism of reduction in menopausal symptoms.
Relevance to clinical practice The itch should be monitored by the nurses by determining the frequency–intensity–localisation of the itch of dialysis patients in HD units. An initiative regarding the inclusion of complementary therapies such as aromatherapy in nursing practice within HD units should be taken, and the use of aromatherapy should be spread. Aromatherapy and other alternative medicine therapies should be included in nursing education programmes. Another issue is educating patients on the effectiveness of aromatherapy for treating pruritus. To improve quality of life in haemodialysis patients, guidelines for instructing patients in the proper application of aromatherapy to relieve itching should also be developed. Similar studies should be conducted with larger sample groups and for extended periods of time, results of which then should be compared.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
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The effect of aromatherapy
Acknowledgements Financial support for this study was provided by Scientific Research Project (No. BAP-2011/65). Curcani did some of the work for this study at the Research Institute of Health Sciences at Ataturk University as part of a PhD thesis.
Disclosure
ethical_1author.html), as follows: (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflict of interest
The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/
None.
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M Cu¨rcani and M Tan Complementary Therapies in Medicine 14, 62–76. Mei-Yu H, May-Hua L, Yang-Kao W, Yung-Sheng H & Hsiao-Chuan W (2012) Effect of lavender essential oil on LPS-stimulated inflammation. American Journal of Chinese Medicine 40, 845–849. Melo NC, Elias RM, Castro MC, Romao JE Jr & Abensur H (2009) Pruritus in hemodialysis patients: the problem remains. Hemodialysis International 13, 38–42. Mıllıkan ME (2003) Alternative therapy in pruritus. Dermatologic Therapy 16, 175–180. Momose A, Kudo S, Sato M, Saito H, Nagai K, Katabira Y & Funyu T (2004) Calcium ions are abnormally distributed in the skin of haemodialysis patients with uraemic pruritus. Nephrology, Dialysis, Transplantation 19, 2061– 2066. Morton CA, Lafferty M, Hau C, Henderson I, Jones M & Lowe JG (1996) Pruritus and skin hydration during dialysis. Nephrology, Dialysis, Transplantation 11, 2031–2036. Narita I, Alchi B, Omori K, Sato F, Ajiro J, Saga D, Kondo D, Skatsume M, Maruyama S, Kazama JJ, Akazawa K & Gejyo F (2006) Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients. Kidney International 69, 1626–1632. Narita I, Iguchi S & Omori K (2008) Uremic pruritus in chronic hemodialysis patients. Journal of Nephrology 21, 161–165. Onsun N, Balsever Y, Karakullukcßu F, Nisßancı P, Atılganoglu U & Bozfakioglu F (1990) Hemodiyalitik kronik b€ obrek yetmezligi olgularında derma-
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tolojik bulgular. [Dermatological sings in chronic renal failure patients]. 13. Ulusal Dermatoloji Kongresi. Adana € C Basıevi. 631– ß ukurova Universitesi 634. Patel TS, Freedman BI & Yosipovitch G (2007) An update on pruritus associated with CKD. American Journal of Kidney Diseases 50, 11–20. Pisoni RL, Wikstr€ om B, Elder SJ, Akizawa T, Asano Y, Keen ML, Saran R, Mendelssohn DC, Young EW & Port FK (2006) Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrology, Dialysis, Transplantation 21, 3495– 3505. Ro YJ, Ha HC & Kim CG (2002) The effects of aromatherapy on pruritus in patients undergoing hemodialysis. Dermatology Nursing 14, 231–256. Roh YS, Cho H, Oh JO & Yoon CJ (2007) Effects of skin rehabilitation massage therapy on pruritus, skin status, and depression in burn survivors. Journal of Korean Academy of Nursing 37, 221–226. Satchell AC, Saurajen A, Bell C & Barnetson RS (2002) Treatment of dandruff with 5% tea tree oil shampoo. Journal of the American Academy of Dermatology 47, 852–855. Sch€afer T, Riehle A, Wichmann HE & Ring J (2002) Alternative medicine in allergies prevalence, patterns of use, and costs. Allergy 57, 694– 706. See A, Teo B, Kwan R, Lim R, Lee J, Tang MB & Verkooijen HM (2011) Use of complementary and alternative medicine among dermatology outpatients in Singapore. Australasian Journal of Dermatology 52, 7–13.
Shahgholian N, Dehghan M, Mortazavi M, Gholami F & Valiani M (2010) Effect of aromatherapy on pruritus relief in hemodialysis patients. Iranian Journal of Nursing and Midwifery Research 15, 240–244. Shapiro R & Stockard H (2003) Successful treatment of uremic pruritus: the acupuncture approach revisited. Dialysis & Transplantation 32, 8–10. Tseng YH (2005) Aromatherapy in nursing practice. Hu Li Za Zhi [The Journal of Nursing] 52, 11–15. Turkish Society of Nephrology (2010) Dialysis Population Statistical of Turkish. Available at: http://www.tsn. org.tr/ (accessed 3 February 2012). Walsh D (1996) Using aromatherapy in the management of psoriasis. Nursing Standard 11, 53–56. Yılmaz S (2009) Diyalize giren hastalarda gı ve ßs iddeti ile IL-2, ILpruritus sıklı 6, tnf-a ve leptin du¨zeyleri arasındaki ilisßkinin arasßtırılması (Investigation of Association Between Frequency and Intensity of Pruritus and Serum IL-2, IL-6, TNF-a and Leptin Levels in Dialysis Patients). Uzmanlık Tezi, Isparta, Tu¨rkiye. Unpublished Master’s Thesis, Institute of Health Science, Isparta, Turkey. Yosipovitch G, Tur E, Morduchowicz G & Borner G (1993) Skin surface pH, moisture, and pruritus in hemodialysis patients. Nephrology, Dialysis, Transplantation 8, 1129–1132. Zucker I, Yosipovitch G, David M, Gafter U & Boner G (2003) Prevalence and characterization of uremic pruritus in patients undergoing hemodialysis: uremic pruritus is still a major problem for patients with end-stage renal disease. Journal of the American Academy of Dermatology 49, 842–846.
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Original article
The effect of aromatherapy
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© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
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The effect of aromatherapy on haemodialysis patients’ pruritus Mehtap Cu¨rcani and Mehtap Tan
Aims and objectives. To determine the effect of aromatherapy on pruritus observed in haemodialysis patients. Background. Although the prevalence of pruritus in kidney failure has decreased in the recent years, pruritus is a difficult and serious problem which concerns the majority of haemodialysis patents and is hard to cure. Design. A prospective, pretest–post-test quasi-experimental design was used. Methods. The research is quasi-experimental clinical trial conducted as pretest and post-test with control groups between January 2011–April 2012, in haemodialysis units of hospitals in Erzurum. The collection of the data is achieved using a questionnaire to detect the patients’ individual and pruritus score scale and to clarify certain laboratory parameters regarding the pruritus. Chi-square analysis and t-test are used for the analysis of data. Results. The experimental group’s mean post-test pruritus scores (720 314) were found to be lower than that of control group patients (1000 247), and a highly significant difference was found between the groups (p < 0001). In the between-groups comparisons of experimental and control group’s laboratory parameters, the experimental group’s post-test blood urea nitrogen levels (11826 3676) were found to be lower than that of control group patients (13880 4869), and the between-groups difference was found to be statistically significant (p < 005). Conclusions. The results demonstrate that aromatherapy was found to decrease the pruritus problem of haemodialyses patients and led to positive changes in some laboratory parameters related to pruritus. Relevance to clinical practice. One of the roles of health professionals is to advise individuals, who are living on this problem, using the nonpharmacological methods in checking the itching. By preventing or reducing uraemic pruritus, aromatherapy may also improve quality of life in this patient group.
What does this paper contribute to the wider global clinical community?
• The results of this study have
•
•
practical implications in nursing practice for haemodialyses patients who suffer from pruritus. Nurses are ideal practitioners of complementary therapies and are positioned to contribute to the research base regarding the use of aromatherapy in health care. Using aromatherapy for management of patient’s pruritus is a simple and effective treatment that causes no harm and avoids overuse of pharmaceuticals.
Key words: aromatherapy, haemodialysis, nursing, pruritus, Turkey Accepted for publication: 25 January 2014
Authors: Mehtap Cu¨rcani, Assistant Professor, Department of Internal Medicine Nursing, Faculty of Health Science, Atatu¨rk University, Erzurum; Mehtap Tan, PhD, Professor, Department of Internal Medicine Nursing, Faculty of Health Science, Atatu¨rk University, Erzurum, Turkey
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Correspondence: Mehtap Cu¨rcani, Department of Internal Medicine Nursing, Faculty of Health Science, Atatu¨rk University, Erzurum, Turkey. Telephone: +90 442 231 27 48. E-mail: [email protected]
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365, doi: 10.1111/jocn.12579
Original article
The effect of aromatherapy
Introduction
Background
Kidney failure is an important health problem, both in the world and in Turkey. According to the 2010 data of Turkish Nephrology Association, there are approximately 62,903 patients with kidney failure and 49,505 of those are receiving haemodialysis (HD) (Turkish Society of Nephrology 2010). The study also found that many haemodialysis patients suffer from symptoms such as pruritus, insomnia, fatigue, muscle ache, dry skin and muscle spasms, which can dramatically affect quality of life in this patient group (Pisoni et al. 2006). Pruritus is one of the most common and disturbing symptoms of end-stage renal disease (ESRD), with a prevalence between 20–90% (Patel et al. 2007, Narita et al. 2008, Kuypers 2009, Asßıcıoglu et al. 2011). Pruritus can compromise physical and mental abilities as well as the quality of sleep. In this manner, pruritus compromises quality of life considerably, with reports in the literature of increased mortality in those who have pruritus (Pisoni et al. 2006, Keithi-Reddy et al. 2007). A 2009 survey of HD patients in Turkey showed that two-thirds experienced symptoms of pruritus daily and that four-fifths had suffered from pruritus for over once a week (Yılmaz 2009). From further studies in Turkey, 80–83% of haemodialysis patients experience pruritus (Onsun et al. 1990, Balevi & Uysal 2000). In Turkey, a study has reported the prevalence of pruritus in 80 HD patients to be 410%, in which 179 and 410% reported severe, moderate and mild pruritus, respectively (Yılmaz 2009). According to various studies, severe and obvious pruritus affects 15–49% of patients with chronic renal failure and 50–90% of patients under HD. The symptoms are more frequent in patients under HD than in those under peritoneal dialysis (42 vs. 32%) (Kurban et al. 2008). In Iran, a study has reported the prevalence of pruritus in 167 HD patients to be 419%, in which 371, 114 and 514% reported severe, moderate and mild pruritus, respectively (Akhyani et al. 2005). Although there has been a growing interest in aromatherapy, the actual effect of aromatherapy on uraemic pruritus in patients with chronic renal failure has been insufficiently documented in the nursing literature. Despite the common occurrence of patients with CRF experiencing pruritus, research on effective nursing intervention for these complications has been limited. Thus, the aim of this research is to study the effect of aromatherapy on pruritus relief in HD patients.
Pruritus is one of the commonest problems in patients with end-stage renal failure undergoing HD. Pruritus is an irritating symptom which can directly affect the life quality of patients with chronic renal failure. In such patients, physical and mental abilities as well as sleep quality are impaired by pruritus, hence the interference in life quality of the patient. Furthermore, an increase in mortality in patients with pruritus has been reported in some studies (Melo et al. 2009). Because of the poorly understood pathophysiological mechanisms of uraemic pruritus, the treatments for this condition have largely been empirical, and no treatment has been shown to have sufficient efficacy and safety (Asßıcıo glu et al. 2011). Various treatments have been proposed to alleviate pruritus in patients with ESRD including venous injection of lidocaine or heparin, oral administration of cholestyramine, activated charcoal and azelastine HCI, a low-protein diet, magnesium-free dialysis, parathyroidectomy, renal transplantation, acupuncture, acupressure, ultraviolet therapy and aromatherapy (Chou 2000, Mıllıkan 2003, Shapiro & Stockard 2003, Zucker et al. 2003, Ada et al. 2005, Arıcan 2005, Kim et al. 2010). However, available treatments have failed to relieve the symptom, and kidney transplant remains the definite treatment for the problem. A study by Morton et al. examined pruritus scores in patients, and physiological measures were used to indicate the levels of pruritus in patients with CRF. Physiological measures included were skin pH, stratum corneum hydration (SCH) and several biochemical markers that had been used as the indicators related to pruritus in patients with CRF in previous studies: blood urea nitrogen (BUN), creatinine (Cr), sodium (Na), potassium (K), phosphorus (P) and calcium (Ca) (Yosipovitch et al. 1993, Morton et al. 1996, Carmichael et al. 1988). Aromatherapy is also one of these complementary medicine methods increasingly used in the twenty-first century. Many of the effects of essential oils used in aromatherapy have been reported in animal experiments, including relaxation, anti-inflammation, analgesia, disinfection, antioxidation and decreasing the blood urea level. Although there is an increasing inclination towards employing aromatherapy, the real effect of aromatherapy on uraemic pruritus in patients with chronic kidney failure is not well established (Ro et al. 2002). Nurses are increasingly incorporating complementary therapies into their practices. Aromatherapy is one of the most popular therapies. Aromatherapy was proposed as a noninvasive nursing intervention to alleviate pruritus in patients with CRF undergoing HD. The basis of aromatherapy is essential oils, which are chemically active
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substances with a long history of safe traditional use and a growing evidence base to support their use in nursing care (Buckle 2001, Dunning 2005, Tseng 2005). The use of essential oils in the medical field goes back more than 6000 years to the Greco-Roman era (Keville & Green 1997). There are more than 200 types of essential oils with distinctive chemical compositions and characteristics. Aromatherapy involves using pure essential oils derived from plants (Lawless 1994). A variety of methods exist for applying aromatherapy including bathing, massage, irrigation of the skin, cold and hot compresses, facial steam bath and inhalation. Because essential oils consist of simple, small molecules capable of rapid absorption through hair follicles, massage is an effective method of applying aromatherapy (Lavabre 1990). Aromatherapy was effectively found in literature when it was applied for pruritus for 2–6 weeks (Walsh 1996, Anderson et al. 2000, Ro et al. 2002, Magin et al. 2006, Shahgholian et al. 2010). It is stated in many studies that aromatherapy oils are beneficial to such dermatological diseases as pruritus, psoriasis, eczema, acne, head lice, burn and alopecia (Walsh 1996, Hay et al. 1998, Anderson et al. 2000, Lahlou et al. 2000, Ro et al. 2002, Al-Waili 2003, Magin et al. 2006, Roh et al. 2007, Shahgholian et al. 2010). On the other hand, it is noted that the number of studies on the effect of aromatherapy for uraemic pruritus in patients with chronic renal failure is insufficient in nursing literature.
Methods Design and sample The research is quasi-experimental clinical trial conducted as pretest–post-test with control groups between January 2011–April 2012, in haemodialysis units of hospitals in Erzurum, eastern Turkey. The research consists of 134 patients receiving dialysis treatment in haemodialysis units of relevant hospitals. All patients with pruritus who underwent HD three times a week for three to five hours in each session participated in this study. In selection of the sample group, below criteria are taken into consideration. Patients: • Receiving three- to five-hour HD treatment three times a week. • Had pruritus during the past two weeks before sampling. • Had not used any pruritus relieving medication before and during sampling. • Had no dermatological problem other than uraemic pruritus.
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• •
Without open wounds at the region of application. Between the age of 18–65 are included in the study. To exclude those in the control group from influences of those in the study group, patients who received HD on Mondays, Wednesdays and Fridays were included in the experimental group (n = 40), while those who received HD on Tuesdays, Thursdays and Saturdays were included in the control group (n = 40).
Instruments The collection of the data is achieved using a questionnaire. The questionnaire prepared by the researches in the light of literature consists of patients age, gender, duration of HD and laboratory parameters (haemoglobin (Hb), haematocrit (Hct), albumin (ALB), calcium (Ca), phosphorus (P), BUN, creatinine (Cr) and parathyroid hormone (PTH) and Kt/V values) (Walsh 1996, Anderson et al. 2000, Ro et al. 2002, Magin et al. 2006, Shahgholian et al. 2010). A modified scale of the Pruritus Score Scale was used to measure the severity, location and frequency of pruritus using the following scales (Ro et al. 2002, Shahgholian et al. 2010): • Severity: visual analogue scale (VAS) is performed to evaluate the severity of the pruritus. VAS is a scale developed by Huskisson (1974), which is used to convert some data that cannot be expressed numerically into quantitative state (Huskisson 1974, Huskısson et al. 1976). In this study, a form with a 10-cm line, which reads ‘no pruritus’ (zero points) at one end and ‘very severe pruritus’ (10 points) at the other, is given to define the severity of pruritus, and then, the patient is asked to mark his/her condition on the line. The severity of the pruritus is determined by measuring the length with a standard ruler from the point of no pruritus to the point where the patient marked. • Location: one or two sites on the body (one point), three or more sites or the entire body (two points). • Frequency: infrequent (zero points), sometimes present (one point), often present (two points) and present all day (three points). The pruritus scores ranges from 0–15, with 15 indicating the most severe pruritus.
Intervention The researcher first washes his/her hands thoroughly. To eliminate waste from the subject’s skin surface and to help the skin absorb the oil more easily, the applicable area is
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
Original article
washed gently with a cotton pad dampened in region of the pruritus. Patients in experimental group received a six-week aromatherapy by the investigators during dialysis sessions three times a week for a period of 7–15 minutes for each region of the pruritus (not applied to the arm with fistula). To that end, in this study, aromatherapy was applied for six weeks. In the study, lavender, tea tree, almond and jojoba oils are mixed and used for therapeutic purposes. Lavender and tea tree oils are prepared in the ratio 1:1, and then, the mixture is diluted with almond and jojoba oil in the ratio 4:1 producing a 5% solution. The pH of the mixture was measured as 65 with Metler Toledo MP220 pH metre (Mettler Toledo, Austin, TX, USA). All the participants had a skin test before undergoing massage with the oil to make sure they were not allergic to the oil. We stopped the treatment immediately if a patient exhibits allergic reaction. Patients in control groups have been provided with normal nursing care, and they are not attended by the investigators. Post-test data are collected after six weeks following the pretests of the patients in experimental and control groups, by re-evaluating the scores of pruritus and recording the necessary laboratory results.
Data collection The study was approved by the Ethical Committee of the Health Science Institute of the Ataturk University. Written and verbal consents from the hospitals to be included in the research are provided prior to the study. Patients willing to participate are accounted for the research. Before collection of the data, patients’ questions are answered, and then written and verbal consents are obtained after they are informed (informed consent doctrine). The data are gathered from face-to-face meetings of researchers with the patients in HD unit. To collect pretest data, questionnaires are given to patients in experimental and control groups, requisite laboratory results are recorded (Hb, Hct, ALB, Ca, P, BUN, Cr, PTH and Kt/V) and pruritus scores are determined. Post-test data are collected after six weeks following the pretests of the patients in experimental and control groups, by re-evaluating the scores of pruritus and recording the necessary laboratory results.
Analysis of data The analysis of data is performed on computers via SPSS version 15.00 (Statistical Package for Social Science) software © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
The effect of aromatherapy
package (SPSS, Inc., Chicago, IL, USA). Chi-square analysis and t-test are used for the analysis of data.
Results All the patients fulfilling the inclusion criteria completed this study. Table 1 presents a comparison of experimental and control groups with respect to the informative characteristics of patients involved in the study. It is concluded that there is no statistically significant difference (p > 005) between these groups regarding the gender, age, duration of HD, score of pruritus and pretest conclusions of laboratory results of the patients in the experimental and control groups, and that both groups are alike (Table 1). Table 2 gives the comparison of the pretest–post-test pruritus score of patients between and within the groups. In the within-group comparisons of the experimental group patients’ pruritus scores, the patients’ mean prearomatherapy pruritus scores were 975 267, while this value became 720 314 after the aromatherapy, and the difference was found to be highly significant (p < 0001). The mean pretest pruritus score of the control group patients was found to be 973 232, whereas the posttest pruritus score was found to be 1000 247, and the difference was not found to be statistically significant (p > 005). The between-groups comparison of experimental and control groups’ pruritus scores revealed no significant differences between the pretest scores of the experimental and control groups (p > 005). The experimental group’s mean post-test pruritus scores (720 314) were found to be lower than that of control group patients (1000 247), and a highly significant difference was found between the groups (p < 0001, Table 2). These findings indicate that there is a decline in the pruritus scores of patients in experimental group, which suggests an improvement and an increase in scores of control patients although it is not statistically significant. Table 3 gives the within- and between-group comparison of pretest and post-test levels of laboratory parameters of patients in experimental and control groups. In the withingroup comparisons of the experimental and control groups’ pretest and post-test laboratory parameters, a significant increase was observed in the experimental group’s Hct levels; a decrease was observed in BUN and PTH levels, while a significant increase was observed in the control group’s P and BUN levels (p < 005, Table 3). In the between-groups comparisons of experimental and control group’s laboratory parameters, the experimental
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M Cu¨rcani and M Tan Table 1 Comparison of experimental and control groups with respect to the informative characteristics of the patients Experimental Features Sex Female Male
Control
n
%
n
%
p
15 25 X SD
375 625
21 19 X SD
525 475
v2 = 1818 p = 0178
Age (years)
4518 1494
5108 1168
Haemodialysis (month)
4975 3899
4798 4401
973 232
975 267
1060 193
1123 125
Hct
3075 559
3281 360
Ca
862 068
852 133
P
552 162
540 114
Albumin
397 077
396 068
12738 4825
13233 4815
1176 2143
949 576
47206 41691
41018 28713
170 089
167 037
Pruritus scores Laboratory parameters (mg/dl) Hb
Blood urea nitrogen Cr Parathyroid hormone Kt/V
t = 1968 p = 0053 t = 0191 p = 0849 t = 0045 p = 0964 t = 1722 p = 0089 t = 1965 p = 0053 t = 0406 p = 0686 t = 0387 p = 0700 t = 0074 p = 0941 t = 0459 p = 0647 t = 0649 p = 0518 t = 0773 p = 0442 t = 0228 p = 0820
p < 005, t = independent samples t-test.
Table 2 Within- and between-group comparison of the mean pretest/post-test pruritus scores of the patients in experimental and control groups Pruritus scores
Groups
Pretest X SD
Post-test X SD
Experimental Control t p
975 267 973 232 0045 0964
720 314 1000 247 4433 0000
t
p 7053 1638
0000 0109
p < 005, t = independent samples t-test.
group’s post-test BUN levels (11826 3676 mg/dl) were found to be lower than that of control group patients (13880 4869 mg/dl) and the between-groups difference was found to be statistically significant (p < 005, Table 3).
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Discussion Although not a peril on its own, pruritus causes physical and mental fatigue in many patients as well as insomnia, chronic fatigue, social isolation, anger–anxiety–depression and a decline in self-respect, self-care ability and quality of life (Melo et al. 2009, Shahgholian et al. 2010). Uraemic pruritus does not have a definite and effective treatment as is the case with other diseases with no clear aetiology. This uncertainty in treatment for the pruritus allows the use of various complementary and alternative medicine (CAM) therapies, one of which being aromatherapy (Mıllıkan 2003). The use of CAM treatments in dermatology spreads worldwide. According to the literature, the frequency of CAM use is 41% in Taiwan (Chen & Chang 2003), 265% in Germany (Sch€ afer et al. 2002), 257% in Singapore (See et al. 2011) and 21% in Turkey (Esßer et al. 2010). The frequency of aromatherapy use on patients applying for © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
Original article
The effect of aromatherapy
Table 3 Within- and between-group comparison of pretest and post-test levels of laboratory parameters of patients in experimental and control groups Pretest X SD Hb Experimental Control t p Hct Experimental Control t p Ca Experimental Control t p P Experimental Control t p Albumin Experimental Control t p Blood urea nitrogen Experimental Control t p Cr Experimental Control t p Parathyroid hormone Experimental Control t p Kt/V Experimental Control t p
Post-test X SD
t
p
1123 125 1060 193 1722 0089
1122 155 1102 202 0495 0622
005 1584
096 0121
3075 559 3281 360 1965 0053
3263 533 3347 476 0741 0461
2655 1086
0011 0284
852 133 862 068 0406 0686
892 091 857 068 1949 0055
1875 0438
0068 0664
552 162 540 114 0387 07
573 186 611 149 1011 0315
1177 2888
0246 0006
396 068 397 077 0074 0941
395 042 412 112 086 0393
0007 1172
0994 0248
13233 4815 12738 4825 0459 0647
11826 3676 13880 4869 2129 0036
2887 2233
0006 0031
1176 2143 949 576 0649 0518
858 262 897 500 0436 0664
0981 0459
0333 0649
47206 41691 41018 28713 0773 0442
35571 32486 35706 24837 0021 0983
3011 1659
0005 0105
167 037 170 089 0228 082
174 022 206 148 1365 0176
1234 1637
0225 011
p < 005, t = independent samples t-test.
dermatology clinics is 86% in USA and 53% in Germany (Ernst 2000). Several studies argue that aromatherapy oils are beneficial to many dermatological diseases such as itch, psoriasis, eczema, acne, head lice and alopecia (Walsh 1996, Hay et al. 1998, Anderson et al. 2000, Lahlou et al. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
2000, Ro et al. 2002, Al-Waili 2003, Magin et al. 2006, Herro & Jacob 2010, Shahgholian et al. 2010). In this research, tea tree oils and lavender oils are mixed together with sweet almond and jojoba oils, and the aromatherapy with the application of the suspension
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is observed to cause a decrease in the level of pruritus. According to the literature, studies conducted using tea tree oils suggest better results with less adverse effects in such dermatological problems as acne, dandruff, head lice, eczema and uraemic itch in contrast with other conventional treatments (Walsh 1996, Anderson et al. 2000, Ro et al. 2002, Satchell et al. 2002, Shahgholian et al. 2010). Lavender flowers had been used in ancient Greece and by Romans in water of common baths to prevent infection as well as to cleanse and tend to wounds such as bites, burns (including sunburns), laceration and to treat acne, psoriasis, fungal infections and cold sore (Lis-Balchin & Hart 1999, Mei-Yu et al. 2012). Several studies suggest that lavender oil is effective in many dermatological diseases (Walsh 1996, Anderson et al. 2000, Ro et al. 2002, Shahgholian et al. 2010). Ro et al. (2002) conducted a study with 29 HD patients used aromatherapy with lavender and tea tree oil three times a week for four weeks. They observed that the itchiness scores of the patients in experimental group are declined, the difference of which is statistically significant from the control group (Ro et al. 2002). Shahgholian et al. (2010) reported that they prepared a solution of mint, lavender and tea tree oils diluted to 5% with sweet almond oil to be used on 24 patients to observe the effects of aromatherapy on itchiness of HD patients. Following the two-week application of aromatherapy, it is claimed that the itchiness scores of patients in experimental group are decreased, and the difference from the control group is statistically significant (Shahgholian et al. 2010). Uraemia itself is mainly at fault for uraemic itch; however, it is not solely responsible for the itch. Although the reasons are not clear, it is suggested that secondary hyperthyroidism and the alterations in divalent ion concentrations such as calcium, phosphate and magnesium may cause the uraemic itch. It is also claimed that the accumulation of divalent ions, such as calcium, phosphate, magnesium on the skin, has a potential role on the pathogenesis of uraemic itch by affecting the itch centre and receptors (Narita et al. 2008). Some studies suggest that there is a close relation between high serum calcium (>102 mg/dl), high serum phosphorus (>55 mg/dl) and high serum CaxP (>80 mg2/dl2) levels, and the uraemic itch (Momose et al. 2004, Pisoni et al. 2006). It is stated in the literature that secondary hyperparathyroidism is also important in the aetiology of uraemic itch, which lessens following a parathyroidectomy and that increased parathormone levels augment histamine
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release by inducing mast cells (Chou 2000, Pisoni et al. 2006). As a result of the study, BUN and PTH levels of the patients treated with aromatherapy in experimental group are observed to fall (Table 3). Ro et al. (2002) state in their research regarding HD patients that BUN levels of the patients in the experimental group, who are treated with aromatherapy, decline with respect to the patients in the control group inasmuch as the difference is statistically significant; therefore, aromatherapy is effective and a method of use of patients in HD however inconclusive it was regarding other laboratory parameters related to the itch.
Conclusions After applying aromatherapy regularly for six weeks, surveys of the participants revealed significantly reduced severity of pruritus. This study confirmed that aromatherapy is effective treatment for pruritus. However, we acknowledge that our study has several limitations, such as nonrandomised design and the lack of an equivalent-treatment control group to estimate the superior effectiveness of aromatherapy massage. Therefore, it is not clear whether the positive effects were due to the aromatherapy, the massage or both (e.g. identical results may have been achieved using only massage, or using aromatherapy and massage). Further randomised studies should be carried out that include more objective measures, such as hormonal changes associated with climacteric women, to explain the possible mechanism of reduction in menopausal symptoms.
Relevance to clinical practice The itch should be monitored by the nurses by determining the frequency–intensity–localisation of the itch of dialysis patients in HD units. An initiative regarding the inclusion of complementary therapies such as aromatherapy in nursing practice within HD units should be taken, and the use of aromatherapy should be spread. Aromatherapy and other alternative medicine therapies should be included in nursing education programmes. Another issue is educating patients on the effectiveness of aromatherapy for treating pruritus. To improve quality of life in haemodialysis patients, guidelines for instructing patients in the proper application of aromatherapy to relieve itching should also be developed. Similar studies should be conducted with larger sample groups and for extended periods of time, results of which then should be compared.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
Original article
The effect of aromatherapy
Acknowledgements Financial support for this study was provided by Scientific Research Project (No. BAP-2011/65). Curcani did some of the work for this study at the Research Institute of Health Sciences at Ataturk University as part of a PhD thesis.
Disclosure
ethical_1author.html), as follows: (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflict of interest
The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/
None.
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© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3356–3365
Original article
The effect of aromatherapy
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