Nephrology Nursing and Dialysis Final Exam Review

Final Exam Logistics and Post-Exam Requirements

• Exam Performance Standards: A passing score of $80\%$ or greater is required to pass the final exam. On the exam, candidates must be able to recognize the correct answer even if they cannot recall it independently.

• Study Materials: Notes and flashcards are encouraged for study purposes however they are strictly prohibited during the actual exam.

• Testing Locations: The exam can be administered at a facility, hospital, or business office. Health System Administrators (HSA) will assist in locating an appropriate quiet spot.

• Assignment Eligibility: Passing the exam is not the sole requirement for receiving an independent assignment. Other professional components must be completed first.

• Prerequisites for Independent Assignment:     * Training Hours: All specific training hour requirements must be met; some students may require additional time at the bedside with a preceptor.     * Training Binder: Must be 100% complete.     * STAR Learning Courses: All modules must be finished. If the system shows less than $100\%$ completion, students should provide their transcript to a preceptor or manager to identify missing modules.     * Skills Checklist: Must be completed, signed, and attested to in STAR Learning by both the student and the manager.     * Clinical Training Classes: All sessions must be attended and completed.     * Verification of Competency Form: This form is located in the training binder and is ultimately uploaded to the digital teammate lab.

Nursing Scope of Practice and Functions

• Standard of Care: The reasonable and prudent standard of care for nephrology nursing serves as the guiding principle.

• Nurse vs. Patient Care Technician (PCT) Scope: Both the nurse and the PCT must operate within their specific scopes of practice, which are defined by standardized clinical criteria and oversight.

• Independent Nursing Functions: These are actions a nurse can take without an explicit order from a physician. Examples include general patient care and technical skills.

• Delegated Medical Functions: These are tasks explicitly directed by a physician. This includes physician orders and protocols (which are essentially physician orders adopted beforehand).

• Delegation to PCTs: A nurse can delegate tasks to a PCT if the tasks meet the following criteria:     * They are technical in nature.     * They fit within the PCT scope of practice.     * They have predictable results.     * They carry minimal or standard risk.     * Note: If vital signs are expected to be unpredictable (e.g., severe hypertension or hypotension), the task should remain with the nurse as it requires advanced assessment.

Nutritional and Physiological Indicators

• Optimal Nutrition in Dialysis: Defined by the following clinical markers:     * Albumin levels $\ge 4.0\,g/dL$.     * Stable and desirable target weight.     * Adequate fat stores and muscle mass.     * Appropriate appetite and intake.

• Hyperkalemia (High Potassium):     * Causes: Consuming high-potassium foods, hemolysis, loss of residual kidney function, specific medications, missed or shortened dialysis treatments, trauma/bleeding, infection (driving potassium out of cells), DKA (uncontrolled blood sugar), and constipation.     * Symptoms: Extreme muscle weakness, abnormal heart rhythm, and potential cardiac arrest.     * Dietary Sources: Chocolate, tomatoes, potatoes, and various fruits/vegetables.

• Hypoalbuminemia (Low Albumin):     * Non-Nutritional Causes: Infection, inflammation, GI bleeding or other blood loss, liver disease, diabetes, fluid overload (dilution), metabolic acidosis, and protein loss during dialysis (especially in Peritoneal Dialysis due to loss in effluent).     * Clinical Impact: Low albumin is directly linked to higher rates of hospitalization and death.

• High-Phosphorus Foods: Dairy products (cheese, milk), meat, soda/colas, fast food, canned items, chocolate, dried beans, peas, and nuts.

• Phosphorus Binders: These medications act like a "sponge" or a "magnet" to absorb or attract phosphorus. They must be taken with food to be effective.

• Calcium Imbalances: Symptoms of hypocalcemia (low calcium) include muscle spasms, numbness, confusion, and seizures.

• Renal Vitamins: These are water-soluble vitamins that are typically removed during the dialysis process. Therefore, they should be taken after treatment to ensure absorption.

Principles of Renal Replacement Therapy

• Efficacy: Hemodialysis replaces approximately $15\%$ of kidney function. This replacement is entirely excretory; it does not replace endocrine functions.

• Excretory Functions of the Kidney:     * Waste removal (e.g., BUN, toxins).     * Electrolyte balance.     * Acid-base balance (pH regulation).     * Fluid removal.

• Endocrine Functions of the Kidney:     * Blood pressure regulation (via the RAS system).     * Red blood cell production (via Erythropoietin).     * Vitamin D and Calcium regulation (activation of Vitamin D for intestinal absorption).     * Note: These functions must be managed by medications (binders, Epogen, iron, ACE inhibitors) rather than the dialyzer.

• Dialysis Mechanism Terms:     * Semipermeable Membrane: A barrier that allows the exchange of some substances but not all (e.g., removes toxins but keeps essential large proteins).     * Filtration: Fluid passing through a membrane controlled by hydrostatic pressure. In clinical terms, this occurs in the glomerulus and is non-specific in measured volume.     * Ultrafiltration: Controlled fluid removal by the manipulation of hydrostatic pressure.     * Convection: Also known as "Solute Drag," where solutes are dragged across a membrane along with the fluid.     * Diffusion: Movement of solutes from an area of higher concentration to lower concentration.     * Osmosis: Movement of fluid from an area of lower solute concentration to an area of higher solute concentration.

Dialysis Machine and Monitoring Procedures

• Conductivity: Measures the electrolyte concentration in the dialysate solution (e.g., sodium, potassium, calcium).

• pH: Measures the acid-base balance of the dialysate.

• Water System Testing: The Reverse Osmosis (RO) system must run for a minimum of $15\,min$ before testing. Chlorine and Chloramines must measure less than or equal to $0.1\,ppm$.

• Monitoring Standards:     * Assessments: Must be documented prior to treatment initiation.     * Every 15 Minutes: Documentation must include blood pressure, heart rate, visible access checks, and confirmed tubing connections.     * Common Documentation Reasons: Proof of care rendered, permanent legal record, continuity of data, and communication tool among the healthcare team.

• Pressure Monitoring:     * High Venous Pressure Causes: Kinks/clots after the transducer, needle malposition, infiltration, stenosis, or excessively high blood flow rates.     * Low Venous Pressure Causes: Separation of blood tubing from the needle/catheter, drop in blood pump speed, blockage before the monitoring site, or saline infusion (saline is less viscous than blood).     * High Arterial Pressure Causes: Kinks/clamps, hypotension (pulling against low volume), or high blood flow rates.     * Low Arterial Pressure Causes: Separation of tubing, air entering the system, saline infusion, or decreased pump speed.

Infection Control and Hepatitis B

• Hand Hygiene: The single most important intervention in preventing infection. It prevents the transfer of organisms and reduces hand contamination.

• Gloves: Serve as a barrier for body fluids and reduce the risk of contamination.

• Transmission: The most common route of infection in dialysis is contact transmission (via hands).

• MRSA: Can remain on surfaces for days; plastic and vinyl are especially favorable for survival.

• Vascular Access Infection: The most common infectious complication for hemodialysis patients.

• Hepatitis B Protocols:     * Teammates cannot care for a Hepatitis B positive (infected) patient and a susceptible patient simultaneously.     * Machines used by patients with unknown status must undergo internal disinfection (e.g., citric thermal disinfection).     * Lab Interpretation: A surface antibody result of $4$ without a surface antigen result is insufficient to determine status; the patient is considered "unknown."     * A Surface Antigen-positive patient can dialyze with other positive patients or immune patients (with appropriate barriers like curtains and gown/glove changes).

Vascular Access and AKI

• Physical Exam of Access: Always listen for the Bruit and feel for the Thrill.

• KDOQI Rule of 6s for Fistulas:     * At least $6\,weeks$ post-op.     * At least $0.6\,cm$ wide.     * At least $0.6\,cm$ (or less) below the skin surface.     * Blood flow within the vessel must be at least $600\,ml/min$.

• BEST TIPS Checklist: Includes monitoring for complications like Stenosis and Steele Syndrome.

• Stenosis: Characterized by a "Water Hammer" sound at the inflow and a high-pitched "Whistle" at the outflow.

• Steele Syndrome: Symptoms include decreased blood flow beyond the access (unilateral), numbness, severe pain, pallor, or weak pulses.

• Acute Kidney Injury (AKI):     * RIFLE Criteria: Risk, Injury, Failure, Loss, and End-Stage Kidney Disease.     * Definitions: Oliguria is < 400\,ml of urine in $24\,hours$. Anuria is < 100\,ml in $24\,hours$ (or zero in $12\,hours$).     * Management Goals: Reverse the cause, maintain nutrition, manage fluid/waste, and protect residual kidney function by avoiding hypovolemia.

Clinical Complications and Emergencies

• Anemia: Chronic patients experience anemia due to decreased erythropoietin production, iron deficiency, shortened RBC lifespan in uremic environments, and blood loss (GI bleeds or dialysis loss).

• Hypovolemia: Results from attempting to remove too much fluid. It causes organ stunning, ischemia, and increased mortality.

• Disinfectant Reaction: Telltale sign is burning at the venous needle. Other signs include respiratory distress, itching, flushing, and chest pain.

• Fluid Overload (Chronic): Leads to Hypertension, Left Ventricular Hypertrophy (enlarged heart), and cerebrovascular disease.

• Chest Pain (Angina): Initial response is to lower the blood flow rate to $150\,ml/min$, turn off or decrease the UF, and provide oxygen as ordered.

• Air Embolism: Immediately STOP the pump and clamp the lines. Then place the patient on their left side in Trendelenburg position.

• Power Failure: The patient's blood can be returned via a hand crank. Crucial: The venous line must be disengaged from the white clamp, or pressure will build up and prevent return.

Calculations and Safety Reminders

• SBAR Communication: Situation, Background, Assessment, Recommendation.

• Fluid Goal Calculation Example:     * Tea (10 oz): $10 \times 30 = 300\,ml$     * Prime/Rinse: $400\,ml$     * Antibiotic: $100\,ml$     * Physician Removal Order: $2200\,ml$     * Total UF Goal: $300 + 400 + 100 + 2200 = 3000\,ml$     * Hourly UFR (for a 3-hour treatment): $3000 / 3 = 1000\,ml/hr$

• Blood Loss "Never Event" Reminders:     1. Direct line of sight (access visible).     2. Tape is secure.     3. Pretreatment mental status assessment.     4. Nurse report.     5. Machine location (ensure slack in lines).