Advanced Practice Nurses: Roles in the Hemodialysis Unit

Advanced Practice Nurses:
Roles in the Hemodialysis Unit
Carol M. Headley
Barry Wall
If the ESRD annual growth rate
continues to increase at 9% (current
rate), then an estimated 6,40 0
additional nephrologists will be
necessary in 10 years. This would
require a three-fold increase in the
current number of nephrologists in
training (Ad Hoc Committee, 1997 ) .
Proposals for addressing the shortage
have suggested the merit of advanced
practice nurses (APNs) (Anderson,
Torres, Bitter, Anderson, & Briefel,
1999; Bolton, 1998; Mundinger,
1994; Sox, Ginsburg, & Scott, 1994 ) .
A PNs are recognized as an entity of
specialized nursing that includes
nurse practitioners, clinical nurse specialists,
certified nurse-midwives, and
nurse anesthetists. For the purpose of
this article, APNs will refer to the
merging roles of the nurse practitioner
(NP) and clinical nurse specialist
( CNS).
Id e n t i fication of the APN
Graduate nursing curricula are
beginning to integrate both the NP
and CNS programs into either an
advanced practice or masters degree.
Sperhac and Strodtbeck (1997) discuss
the successful unification of the CNS
and NP programs for the maternalchild
graduate-nursing program at
Rush University, College of Nu r s i n g ,
in Chicago, Illinois. The APN should
possess an academic degree above a
baccalaureate and an active registered
nurse license in the United States or its
territories (Mirr, 1995). Additional cer-
Carol M. Headley, MSN, RN, CNN, is Nurse
Clinician, Nephrology Section, Department of
Nephrology Veterans Affairs Medical Center,
Memphis, TN.
Barry Wall, MD, is Associate Professor of
Medicine/Associate Chief, Nephrology Section,
Department of Nephrology Veterans Affairs
Medical Center, Memphis, TN.
tification may be required to assure
that APNs practicing in a specific area
(e.g., nephrology) have met predetermined
standards for that specialty
(Ellis & Hartley, 1992). APN practice
continues to lack uniformity among
states due to a lack of statutory congruence
concerning prescriptive authority,
reimbursement, and recognition as
primary care providers (Chmielewski,
Ho l e chek, McWilliams, Powers, & Tu ,
1996 ) .
Prescriptive privileges for APN s
vary among states and among different
employment arenas (Pearson, 1996 ) .
Certain states grant prescriptive
authority to NPs without reference to
the CNS, while other states refer to
Newly diagnosed cases of end stage renal disease (ESRD) have increased by 9% each year
since 1970. It has been estimated that there will need to be a significant increase in the
number of nephrologists to care for the ESRD population by the year 2010. Recent reports
have advocated the use of advanced practice nurses (APN) to collaborate with nephrolo -
gists to meet increasing patient care demands. Clinical evidence has supported the finan -
cial and clinical advantages of APN utilization in nephrology. The renal community has
stressed an outcome-based practice with a provision of guidelines to improve morbidity
and mortality in ESRD. Reimbursement and mortality have been linked to identification
of quality care delivery. APNs can be instrumental in assuring that quality patient care is
delivered across the ESRD continuum through several different roles: clinician, educator,
consultant, researcher, administrator, and case manager.
G o a l
Recognize the role of the advanced practice nurse in the hemodialysis
u n i t .
O b j e c t i v e s
After reading this article the reader will be able to:
1. Identify several barriers and facilitators to advanced practice nursing
in nephrology.
2. Give a brief synopsis of the history of advanced practice nursing.
3. Discuss three reasons for advocating advanced practice nursing in
n e p h r o l o g y.
4. Describe the roles of an advanced practice nurse (APN) in the
hemodialysis unit.
This offering for 2.0 contact hours is being provided by the American Nephrology Nurses’
Association (ANNA), which is accredited as a provider and approver of continuing education in
nursing by the American Nurses’ Credentialing Center-Commission on Accreditation (ANCC-
COA). This educational activity is approved by most states and specialty organizations that
recognize the ANCC-COA accreditation process. ANNA is an approved provider of continuing
education in nursing by the California Board of Registered Nursing, BRN Provider No. 00910; the
Florida Board of Nursing, BRN Provider No. 27F0441; the Alabama Board of Nursing, BRN
Provider No. P0324; and the Kansas State Board of Nursing, Provider No. LT0148-0738. This
offering is accepted for RN and LPN relicensure in Kansas.
This article DOES NOT qualify for the fundamental nursing education requirement to take the
CNN Examination.
To receive continuing education credit, you must read the information in this article, complete
and return the answer form on page 186 and appropriate fee to the ANNA National Office. Please
refer to the answer form for the appropriate fee and address of the National Office.
NEPHROLOGY NURSING JOURNAL April 2000 Vol. 27, No. 2 177

oth as a “midlevel provider.”
Restrictions for APNs range from limiting
prescriptive selection to a specified
formulary, to co-signature requirement
by a physician (MD) for controlled
substances, to no prescriptive
provision (Pearson, 1996). The lack of
a uniform regulatory body for APNs is
recognized as an obstacle to defining
the clinical role of APNs, particularly
in regards to prescriptive authority
(Chmielewski et al., 1996 ) .
A PN recognition and reimbursement
as a primary care provider
( PCP) are often discussed simultaneo
u s l y. A PCP is one who assumes
independent responsibility for a provided
service and contracts with a
hospital or agency for pay (Be y e r s ,
Gunn, Egging, & Thomas, 1997). In
contrast, collaborative practice
involves physician oversight and
many states base reimbursement on
the type of practices (collaborative vs.
independent). Currently, 13 states
and the District of Columbia reimburse
NPs without physician collaboration
(Ventura, 1998). Barriers still
exist for APNs, but substantial
progress has been made over the past
25 years.
A PN Historical Pe r s p e c t i ve s
Nearly 25 years ago, both the government
and private sector recognized
the need for APNs to assist with intensifying
health care demands. The
Department of Health, Education, and
Welfare established an interdisciplinary
committee to examine the
expanding role of nurses in health
care. These findings gave impetus for
federal funding of graduate nursing
programs (Kitzman, 1983). Ad v a n c e d
practice degrees were emphasized in
ambulatory care settings and were limited
to adult, obstetric, and pediatric
primary care. Certified nurse midwives
and certified registered nurse
anesthetists were delineated separately
because of their unique practice.
Advanced practice specialization in
other clinical areas emerged in the
1990s (Berger et al., 1996 ) .
The need for nephrology APN s
was recognized almost 25 years ago
even though specialized training was
178
not yet available. Shapiro (1976 )
designed a program to assist dialysis
nurses in returning to school for an
advanced practice degree in 1976 .
After obtaining academic credentials,
additional training related to the
unique needs of the nephrology
patients was offered. These APN s
were subsequently employed in satellite
dialysis units. Ne p h r o l o g i s t s
directly supervised APNs, such that
any prescribed therapy by an APN
required a physician co-signature.
Fiscal analysis demonstrated economic
benefit, since each APN assisted in
managing 50 chronic dialysis patients
at a cost significantly below that
w h i ch physicians would incur
(Shapiro, 1976).
Today’s cost-conserving climate of
health care has focused on the economic
impact of using APNs to provide
some services given by MD s
( Berger et al., 1996). The savings
would be largely due to salary differentials,
with the APN being paid less
than the MD. Cost savings of APN s
has not been limited to salary differentials,
as APNs have been reported
to prescribe less expensive but equally
effective diagnostic or therapeutic
interventions than MDs (Salkever,
Skinner, Steinwachs, & Katz, 1982 ) .
Kassirer (1994) disputes this finding
and suggests that APNs do not order
sophisticated diagnostic tests (e.g.,
magnetic resonance imaging) because
of their lack of familiarity with these
tests and that this may jeopardize
patient care. Bolton (1998) confirms
the economic benefit of APNs in
nephrology and emphasizes additional
APN qualities including: subspecialty
expertise, competency, flexibility,
and positive patient reception.
Today, some APNs are able to function
as PCPs and have established
nurse managed clinics, reimbursed at
the same rates as physicians (Ve n t u r a ,
1998 ) .
A PN Me r i t
The proposed shortage of available
nephrologists to care for the growing
ESRD population is a significant
incentive for APN sanction.
Nephrologists have reported spending
38% of their total ESRD practice time
devoted to primary care (Bender &
Holley, 1996). A recent outcomebased
study that compared NPs to
MDs in a ambulatory care setting concluded
that primary care provided by
NPs was equal to that of MDs. NP s
maintained the same authority and
responsibilities delegated to their MD
counterparts, with random patient
assignments (Mundinger et al., 20 0 0 ) .
Most nephrologists spend a significant
proportion of their time in the care of
non-ESRD patients (Ad Hoc
Committee, 1997). APNs have been
advocated in the management of
patients pre-ESRD as well as in the
care of dialysis patients, allowing
nephrologists to have a more diversified
practice (Bolton, 1998). Bolton
( 1998) described a successful collaborative
practice model utilizing a NP in
the care of pre-ESRD and ESRD
patients. Collaborative practice
between a MD and APN is comprised
of joint commitments to patient care
with an integration of talents and skills
(Chmielewski et al., 1996).
Nephrology APNs in a collaborative
practice maintain a great deal of autonomy
in providing primary care with
support from nephrologists for specific
needs (e.g., admitting privileges) that
the APN may not be able to provide
(Steinman, 1999 ) .
The United States Renal Data
System (USRDS) reports an annual
death rate of approximately 25%
(higher than any industrialized country)
for ESRD. Age and comorbid illnesses
modify individual mortality
rates (Agodoa, Wolfe, & Port, 1999 ) .
European nephrologists have suggested
that American nephrologists spend
less time with patients and that this
may be a factor in the higher mortality
rates (Suki, 1999). With the predicted
shortage of nephrologists over the next
10 years, nephrologists will have less
time with individual patients; such
decreased patient contact time could
adversely affect patient mortality.
Bolton (1998) made a comparative
analysis of nephrologists and NPs in
reference to time spent with patients.
The average pages/calls received by
the NP was twice that of nephrologists
NEPHROLOGY NURSING JOURNAL April 2000 Vol. 27, No. 2

per month. Patients called NPs first for
minor illnesses because the NP was
perceived as more sympathetic and
willing to allot more time to address
their needs (Bolton, 1998). A Ne w
York dialysis unit recently conducted a
survey to find out nurses’ perceptions
of an APN colleague. APN availability
and accountability for dialysis orders,
emergency evaluations, and preventive
and health maintenance were considered
to be the most valuable contributions
of APNs. APN availability was
considered to be an improvement
over orders written by the nephrologist
that rotated through the unit on a
monthly basis (Izzo, 1982 ) .
Debate continues over the care of
dialysis patients by APNs as compared
to physician assistants (PA). An
editorial by Suki (1999) explored
n e p h r o l o g i s t /PA collaborative practice
issues, but never identified APN s
as a possible alternative. Retention of
international nephrology fellows and
recruitment of medical school graduates
into the nephrology subspecialty
were considered preferred alternatives
to addressing the shortage of
nephrologists (Suki, 1999). Ach i e v ement
of these proposals is not likely
when there is a lack of evidence for a
change in current trends.
Conservative estimates of ESRD
prevalence rates and workforce
requirements still estimate a significant
shortage of nephrologists in 10
years (Ad Hoc Committee, 1997 ) .
Numerous authors, however, have
supported the utilization of NPs over
PAs in collaborative practice agreements
(Beyers et al., 1997; Bolton,
1998; Sox et al., 1994). NPs were recommended
over PAs because NP s
were thought to require less supervision
than PAs (Bolton, 1998; Sox et
al., 1994) and were considered to
have more direct patient care experience
(Ventura, 1998). Watts and
Chmielewski conducted a survey of
nephrology APNs with 45 respondents;
the majority possessed over 10
years of nursing experience (as cited
in Chmielewski et al., 1996). To d a y ,
NPs (20.7%) outnumber PAs (8.9%)
in collaborative practice with
nephrologists (Anderson et al., 1999 ) .
Considering the complex nature of
patients with ESRD, clinical experience
is essential to providing quality
c a r e .
ESRD patients’ unique interrelated
considerations include adequacy of
dialysis, management of anemia, electrolyte
disturbances, renal osteodystrophy,
access patency, dietary considerations,
treatment of comorbid conditions,
and rehabilitative initiatives.
Kassirer (1994) noted that NPs were
rated superior to physicians in patient
satisfaction and in patient compliance
with health promotion and maintenance,
but maintained a lack of support
for APNs as PCPs. Mundinger
( 1994) considered diagnosis and treatment
by NPs and physicians to be simi
l a r. NPs, however, were more likely to
expand treatment to include patient
education, counseling, and health
maintenance interventions. The nature
and perpetuity of diseases/impairments
affecting ESRD patients (e.g.,
hypertension, renal osteodystrophy,
anemia, electrolyte imbalances)
require continuous therapeutic monitoring
to assure adequate management
(Daugirdas, 1994 ) .
The Department of Veterans
Affairs issued a policy promoting
employment of APNs because it was
felt that APNs could effectively manage
up to 80% of patient care requirements
(Ventura, 1998). Experienced
A PNs in the hemodialysis unit should
be able to successfully address the
majority of patient care issues, but
their practice may best be conveyed in
collaboration with one or more
nephrologists. A major barrier to
nephrologists acceptance of APNs is
related to quality of care concerns
( Beyers et al., 1997). Lack of clarity in
defining APN roles has led to concerns
among both nurses and physicians
regarding competency (Chmielewski
et al., 1996). The American Nu r s e s ’
Association has defined a graduate
level degree as a requirement for identification
of APNs (American Nu r s e s ’
Association, 1996).
A PN in the Hemodialysis Un i t
The following section will address
roles of APNs in the care of
hemodialysis patients, emphasizing
utilization of a collaborative team
a p p r o a ch which includes, nephrologist,
dietician, social worker, psych o lo
g i s t / p s y chiatrist, vascular access surgeon,
interventional radiologist, dialysis
nurse, and APN .
Maintaining effective communication
among all members of the team
is essential to quality care, and the
A PN must assume a pivotal role. It is
difficult to separate APN roles (clinician,
educator, consultant, counselor,
administrator, and research e r )
because of their overlapping nature.
Some APNs function as administrators
and others practice as case managers,
having 24-hour accountability
for patients in the caseload (Berger et
al., 1996). This article will explore the
A PN as a clinician, educator, consultant,
and research e r. A scenario will
be given for each role to illustrate
A PN involvement and emphasize the
need for a collaborative practice.
Cl i n i c i a n
Nephrology APNs institute treatment
options for a variety of patient
problems and initiate preventive
measures to avert development of
complications. Hemodialysis patients
are subject to unique problems not
often observed with other chronic illnesses.
Hematological, nutritional,
endocrine, musculoskeletal, and
immune response abnormalities are
just a few of the universal problems
associated with chronic dialysis therapy
(Daugirdas, 1994). There is a predominance
of cardiovascular disease
in the ESRD population, such that
chronic renal failure has been
described as a vasculopathic state
(Luke, 1998). Cardiovascular disease
has been identified as the cause of up
to 50% of deaths in ESRD (Ritz &
Querfeld, 1986), with cardiac arrests,
acute myocardial infarction, and cardiac
arrhythmia accounting for one
third of all ESRD deaths (Luke,
1998). Hypertension and diabetes
mellitus account for the cause of
approximately two thirds of ESRD
cases. Because of the magnitude of
the problem of cardiovascular disease,
nephrology practice must incor-
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porate treatment of all modifiable cardiac
risk factors. Modifiable risk factors
include smoking cessation,
improved hypertension, diabetes
mellitus, and hyperlipidemia treatment.
Additional modifiable factors
unique to renal failure include management
of secondary hyperparathyroidism
and anemia. Abnormal calcium
and phosphorus metabolism have
been associated with the development
of vascular calcifications and
atherosclerotic heart disease (Block ,
Hulbert-Shearon, Levin, & Po r t ,
1998; Rostand, Sanders, Katharine,
Rutsky, & Fraser, 1988; Terman et al.,
1971). Recent clinical evidence has
concluded that the relative risk of
death for hemodialysis patients is significantly
greater for those with a
hematocrit less than 30% (Co l l i n s ,
Ma, Xia, & Ebben, 1997). This
increased attention to cardiovascular
risk factors further expands the role of
the nephrology team as primary care
providers. The APN can provide
valuable input into the day-to-day
management of each of these risk fact
o r s .
The renal community has placed
emphasis on aggressive disease management
to address the high mortality
risks of ESRD. The National Kidney
Foundation Dialysis Outcomes Quality
Initiative Clinical Practice Guidelines
have given support to the establishment
of certain expectations of care for
ESRD patients (National Kidney
Foundation, 1997). Reimbursement initiatives
for dialysis have associated
accountability for quality of care
(Hannah, Levin, London, & Osheroff,
1999). Evidence-based medicine has
documented that implementation of
clinical practice guidelines can reduce
mortality and improve quality of life
( National Kidney Foundation, 1997 ) .
The ability to adequately manage all of
the clinical aspects of hemodialysis
patients may be monumental for a
nephrologist with a diversified practice.
An APN in the hemodialysis unit that
possesses critical thinking, advanced
knowledge, and expert skills may facilitate
implementation of clinical practice
guidelines and, therefore, effect an
improved patient quality of life.
180
The APN will often refer patients
for treatment or diagnostic procedures.
APNs may also be trained to
perform certain invasive procedures
(transplant kidney biopsies, femoral
and internal jugular catheter placements).
Anderson and colleagues
( 1999) reported that out of 53 surveyed
PAs, 35% routinely perform
femoral cannulization and 5.7% performed
internal jugular/subclavian
vein cannulizations. In the first
author’s experience, the number of
A PNs doing procedures was not identified
in this study, but APNs have
been acknowledged in providing temporary
access placement in several
dialysis units. APNs have been delineated
as access coordinators for all
identified problems (Steinman, 1999 ) ,
w h i ch should include provision of
temporary access. APNs have been
reported as possessing as much skill
as physicians in the performance of
specific invasive procedures
(Kassirer, 1994). Maintaining vascular
accesses for chronic dialysis patients
is a frequent cause for patient hospitalization
and is attributed to the high
costs of ESRD care (Hannah et al.,
1999). Often, a patient will present to
the dialysis unit with a thrombosed or
infected access and require hospitalization.
APNs may be able to
decrease associated costs by providing
temporary vascular access, allowing
for uninterrupted dialysis while
coordinating further treatment on an
outpatient basis. If the access is determined
to pose an immediate threat
(e.g., infection), then hospitalization is
u n a v o i d a b l e .
A PNs may be instrumental in
expediting vascular access placement,
allowing time necessary for maturity
prior to beginning chronic dialysis. It
has been recommended that an arteriovenous
fistula be constructed 4
months before the need for dialysis
(Hannah et al., 1999). Contact with
the vascular surgeon may be delayed
for many reasons. An APN may be
able to make a preliminary examination
that would expedite care.
Diminished peripheral pulses place a
patient at increased risk for isch e m i a
(hand or foot) once an access is con-
structed, or an identified umbilical
hernia may indicate the need for surgical
repair prior to Te n ck h o f f
catheter placement and initiation of
peritoneal dialysis. Recognition of
these findings on physical examination
and coordinating treatment will
avoid possible delays in access placement.
Patients with a history of central
venous catheters may require
venography prior to arteriovenous fistula
or arteriovenous graft surgery
( Schwab et al., 1988). The APN can
often assist the vascular access surgeon
in obtaining necessary presurgical
evaluations. Continuous monitoring
of access parameters and close
communication with dialysis nurses
will allow the APN to coordinate necessary
radiographic study and treatment
of identifiable stenosis with
angioplasty, stent placement, or surgical
revision.
The acute and chronic hemodialysis
unit based in a hospital setting may
allow APNs opportunities (e.g., performance
of invasive procedures)
thwarted by satellite clinics. APN s
who perform procedures must realize
that certain risks are associated with
any invasive procedure and know
what measures to be taken if complications
arise. Certain advantages exist
for those units that employ an APN
skilled in the placement of catheters
for acute dialysis. Femoral vein
catheter placement for temporary
access in a chronic dialysis patient
with a thrombosed vascular access
may obviate the need for central line
placement prior to access thrombolysis
or surgical thrombectomy. In
many circumstances, the APN can
offer valuable skill in performing procedures
that have less associated risk
than alternative treatments. Two scenarios
will be presented to demonstrate
the clinical role of an APN in an
acute and chronic hemodialysis unit
based in a primary care hospital.
A PN clinical scenario 1. A 64 -
year-old chronic dialysis patient presented
for his regular treatment complaining
of chest pain and palpitations.
He had a past history of recurrent
paroxysmal supraventricular
t a chycardia (PSVT), but no history of
NEPHROLOGY NURSING JOURNAL April 2000 Vol. 27, No. 2

coronary artery disease. His PS V T
had been treated with multiple antiarrhythmic
agents including digoxin
0 .125 mg every other day and verapamil
240 mg every day. His initial
vital signs included heart rate of 168
beats/minute, blood pressure 140 / 72
mmHg, and a respiratory rate of
22/minute. The patient was given
oxygen and placed on a cardiac monitor,
which confirmed the presence of
paroxysmal supraventricular tach ycardia.
Blood was obtained for routine
chemistries and for levels of
digoxin and verapamil. After conferring
with the on-call nephrologist, a
total of 5 mg of intravenous verapamil
was administered. This resulted
in no change in heart rate, however,
blood pressure decreased to 110 / 60
mmHg. After phone consultation
with the on-call cardiologist, adenosine
(6 mg) was administered intrav
e n o u s l y. This was accompanied by
an abrupt termination of the PS V T
with return of normal sinus rhythm.
Initial laboratory evaluation confirmed
the presence of therapeutic
blood levels of digoxin and verapamil.
Given the symptomatic nature
of the PSVT and its refractoriness to
standard anti-arrhythmic therapy, the
patient underwent electrophysiologic
studies with surgical ablation of a reentrant
pathway. He has subsequently
been able to discontinue all antiarrhythmics
without recurrence of
PS V T. In this case, the data collected
by the APN during the acute arrhythmia
(documentation of symptoms,
vital signs, blood levels of antiarrhythmic
agents, electrocardiac
monitor tracings confirming the
PSVT, and conversion with adenosine)
were the critical data used to
document the need for surgical ablative
therapy in this patient.
A PN clinical scenario 2. A 74 -
year-old man with ESRD receiving
hemodialysis presented for his sch e duled
dialysis treatment and was found
to have a thrombosed brach i o a x i l l a r y
arteriovenous graft. Initial evaluation
of the graft indicated no evidence of
infection. Laboratory findings included
serum potassium of 6.2 mEq/L .
He was 5.4 kg above his established
dry weight and had a history of recurrent
pulmonary edema due to
i s chemic cardiomyopathy. These
findings confirmed the need for
urgent dialysis. Femoral vein
catheters were placed by the APN to
permit immediate dialysis. The APN
relayed the access history to the interventional
radiologist who sch e d u l e d
the patient to have graft thrombolysis
the following day. The patient had a
history of prior thrombosis of this
access associated with a significant
stenosis of the brachiocephalic vein,
w h i ch had been previously angioplastied.
The vascular access surgeon and
interventional radiologist were both
consulted by the APN to determine
the optimal treatment option to salvage
the patient’s present access
because of limited availability of alternative
access sites.
A prophylactic treatment plan was
discussed with the interventional radiologist
regarding the patient’s history
of allergy to radiocontrast media. The
patient was currently residing in a
nursing home, requiring the APN to
communicate with the nursing home
staff and to write orders for the management
of the patient, which included:
(a) keeping the patient in bed for
the next 4 hours, (b) observing the
right groin pressure dressing for any
signs of bleeding or development of
hematoma hourly for 4 hours and
recording, (c) giving 30 mg prednisone
po at 9 p.m. tonight and in the
a.m., (d) giving 50 mg diphenhydramine
in the a.m., and e) providing
a clear liquid breakfast in a.m. The
patient was brought to the interventional
radiological suite, as directed,
and had successful thrombolysis of
his access with percutaneous transluminal
angioplasty of the brach i ocephalic
vein stenosis without complic
a t i o n s .
This complicated patient was
managed successfully as an outpatient,
even though he was currently
residing in a nursing home. This case
emphasizes the complexity of management
of thrombosed vascular
accesses, which continues to be the
most common indication for hospitalization
and surgical intervention in
chronic hemodialysis patients. The
possible avoidance of hospitalization
and associated expenditures is an
example of the economic benefits of
the availability of an APN who is
trained to perform temporary vascular
access for acute dialysis.
E d u c a t o r
A PNs in the hemodialysis unit
have a responsibility for staff and
patient education. Patient education is
imperative at the pre-ESRD level of
patient care. Many patients do not
receive adequate information regarding
dialysis access, such as the need to
preserve arm veins for future vascular
access (Hannah et al., 1999). Early
education has the potential to avert
long-term access problems and
reduce costs (Schwab et al., 1998 ) .
Patient selection of a dialysis modality
should also be given adequate time
to insure selection of the most appropriate
dialysis modality. An APN can
assist the patient and family in making
this critical decision.
The realization of the impending
need for chronic dialysis may be
overwhelming to patients and families.
The APN can alleviate this anxiety
by educating the patient and family
about the requirements and expectations
that accompany chronic dialysis
therapy. Medications and dietary
changes differ depending on dialysis
m o d a l i t y. The APN can highlight
these differences, allowing patients
the opportunity for a more informed
decision. The APN must communicate
with the dietician regarding the
patient’s cultural dietary preferences
that may impact dialysis modality
selection (e.g., vegetarians with a relatively
low dietary protein intake may
not thrive on peritoneal dialysis).
A PNs may recognize the need for
early social worker involvement if
cultural obstacles and economic disadvantages
exist that would impact
the transition to chronic dialysis.
A PNs may also assess discussions
concerning transplant interest and
candidacy at the pre-ESRD level of
c a r e .
Patient compliance can be directly
impacted by the APNs efforts at edu-
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cation. Continuous education regarding
medication adjustments and dialysis
prescriptions is warranted to augment
compliance once the patient is
on maintenance dialysis. Co m m o n l y
prescribed drugs for hemodialysis
patients include vitamin D analogues,
phosphate binders, erythropoietin,
iron supplements, antihypertensives,
and insulin, which necessitate rigorous
and repetitive analyses to ensure
appropriate management. The
USRDS reported that hemodialysis
patients beginning dialysis in 1996
and 1997 were prescribed a median
of 8 different medications. (USRDS ,
1997). The complexity of prescribed
medication regimens and recent
emphasis for quality care suggest the
need for an educator willing to consider
patient’s preferences, family situations,
and environment. APN s
have been credited with possessing
s u ch skills (Brown & Grimes, 1993).
A PNs may also be responsible for
staff education including the integration
of clinical research findings into
clinical practice. Critically evaluating
the suitability of available educational
resources for both patients and staff is
an important aspect of the APN as an
educator (Berger et al., 1996 ) .
A PN educator scenario. A 68 -
year-old chronic hemodialysis patient
with evidence of severe secondary
hyperparathyroidism (intact PTH –
24X upper limit of normal) was found
to have a markedly elevated calcium/phosphorus
product on monthly
laboratory testing that necessitated
discontinuation of calcitriol therapy.
He denied constipation or gastric
intolerance, but admitted noncompliance
with the prescribed amount of
phosphate binder. A family conference
was arranged that included the
dietician, patient’s wife, APN, and
nephrologist. The difficulty with his
compliance was determined to be
associated with his illiteracy and
physical inability to open the bottles
related to weakness in his hands. The
patient’s wife worked full-time and
was not at home to assist him in taking
medications during the day. The
A PN provided education to the wife
regarding medical indications for
182
dietary phosphate binders and prescribed
delivery with use of a pillbox
o r g a n i z e r. The wife was able to continue
to work while leaving the pillbox
organizer within the patient’s
r e a ch. The following month, the
patient’s calcium and phosphorus
product improved, allowing resumption
of calcitriol therapy, thus, potentially
avoiding surgical management
of his severe hyperparathyroid disease.
Co n s u l t a n t
It is difficult to separate consultant
from educator because the APN will
often consult as an educator.
Consultants offer support and guidance
to patients, co-workers, and subspecialty
colleagues (Beyers et al.,
1997). An APN may offer advice to
colleagues regarding the appropriateness
of referrals to the nephrology
clinic. The vascular surgeon may consult
the APN regarding a patient’s
ability to care for an access.
Determination of access maturity and
likelihood of successful cannulation
will often be referred to the APN. The
following two scenarios will offer
insight into the variability of APNs as
consultant. One scenario will focus on
the APN consultant in a psych o s o c i a l
situation and the following related to
clinical nephrology expertise.
A PN consultant scenario 1. A
79-year-old male who had been on
hemodialysis for 13 years was confronted
with the problem of driving
15 miles to the dialysis center. The
A PN consulted the social worker
regarding the possibility of the patient
moving to a nearby apartment complex,
which would allow the patient
to walk to his scheduled dialysis
appointments. The social worker met
with the patient and he agreed to
obtain residence at the apartment
complex in close proximity to the
dialysis unit. The social worker reconsulted
the APN regarding his subsequent
denial for residency because
of an arrest record involving bootlegging
whiskey 30 years previously.
The APN drafted a letter to the apartment
manager explaining the
patient’s medical condition and
emphasized his long-term sobriety
and compliance with maintenance
hemodialysis. The patient was subsequently
accepted as a resident and he
currently walks to each dialysis treatm
e n t .
A PN consultant scenario 2. T h e
hemodialysis APN was consulted by
a colleague in the adjoining spinal
cord injury unit regarding a patient
with chronic renal insufficiency (baseline
serum creatinine 2.4 mg/dL) and
elevated serum potassium (5.6
m E q /L). The patient was a 46 - y e a r -
old paraplegic man with a history of
obstructive uropathy due to
nephrolithiasis. His PCP consulted
the APN regarding a recent rise in
serum potassium concentration without
a change in serum creatinine concentration.
The APN reviewed possible
causes of an abrupt hyperkalmia
and gave the clinician several points
of investigation in his attempt to
determine the etiology. Dietary factors
were emphasized including attention
given to salt substitutes, which
contain potassium chloride. The
patient reported recent use of a salt
substitute containing potassium ch l oride
to his food in an effort to comply
with a low sodium diet. The hyperkalemia
resolved after discontinuation
of this product.
R e s e a rc h e r
A PNs engage in both formal
r e s e a r ch, as primary investigators,
and in research utilization that often
demonstrates the need for changes in
policies, procedures, or equipment to
insure continuous quality improvement.
It is well known that research
efforts can have an impact on current
practices and may contribute to
career fulfillment (Berger et al., 1996 ) .
A PNs have served as principal investigators
and co-investigators in multiple
clinical investigations (Bolton,
1998; Mundinger, 1994). Pu r ch a s i n g
decisions (e.g., temporary and permanent
dialysis catheters) are often
based on a thorough review of
r e s e a r ch literature. Formal research
has and should be conducted by
A PNs, particularly in demonstrating
the effectiveness of their own practice.
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For example, utilization of the standardized
mortality ratio (SMR) in
dialysis units that employ APNs may
offer objective evidence supporting
the beneficial role of APN s .
A P N re s e a rcher scenario.
Problems with inadequate blood flow
rates and increased infection rates
were noted in patients requiring the
use of a permanent venous catheter
for vascular access in a chronic dialysis
unit. An effort was made by the
A PN to identify the cause of these
problems by retrospectively and
prospectively reviewing the dialysis
records of all patients using permanent
venous dialysis catheters in the
c e n t e r. The site of the placement of
the catheters (operating room by vascular
access surgeon versus interventional
radiology suite by radiologist)
was shown to have no effect on the
frequency of access related problems.
After 6 months of data collection, it
was concluded that the catheter per se
was the most likely problem, rather
than procedures concerning site care
or the place of catheter insertion. The
A PN reviewed product information
concerning recently marketed
catheters, which were reported to
have improved performance and
lower infection rates. The new
catheter was purchased and a policy
was instituted for catheters to be
placed by the interventional radiologist
unless circumstances existed that
warranted the patient being brought
to the operating room (e.g., general
anesthesia requirement). There was
an immediate reduction in catheter
infections and inadequate blood flows
documented with the use of the
improved dialysis catheter. The findings
of this small study were reported
to the hospital infectious disease committee
and tracking of catheter-related
problems continues to be a part of
this dialysis unit’s quality assurance
p r o g r a m .
Co n c l u s i o n
There are many different roles for
an APN within the specialty of
n e p h r o l o g y. This discussion was limited
to roles that may be found in the
hemodialysis unit. The integration of
A PNs into the ESRD team can
potentially decrease patient expenditures
by decreasing the need for hospitalization
and costly diagnostic and
therapeutic interventions related to
inadequate pre-ESRD care or to suboptimal
ESRD maintenance therapy.
The APN can build a network of
resources that will expedite delivery
of care. Utilization of nephrology
A PNs will help meet demands of outcome-based
dialysis initiatives.
Nephrology APNs are strategic members
of the renal team and allow for
provision of holistic patient care
d e l i v e r y.
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