Advanced Practice Nurses: Roles in the Hemodialysis Unit

More documents

Recommendations

Info

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 constructed, 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- NEPHROLOGY NURSING JOURNAL April 2000 Vol. 27, No. 2 181
Page 1 and 2: Advanced Practice Nurses: Roles in
Page 3: per month. Patients called NPs firs
Page 7 and 8: For example, utilization of the sta

Advanced Practice Nurses: Roles in the Hemodialysis Unit

Create successful ePaper yourself

Delete template?

Save as template?