NEPHROLOGY SERVICE

STUDENT PACK

This pack contains learning objectives for student nurses whilst on placement within the nephrology service. These learning objectives should be utilised as a framework to structure the student’s placement within the nephrology service and should be used in conjunction with the student’s own personal objectives.

The students should receive the support of their mentor within all three areas of the service:

Haemodialyis Unit: 3 days.

Peritoneal Dialysis Unit: 2 days.

Renal Ward: rest of placement.

General Objectives of Placement within the nephrology service.For the students to develop an understanding of:

All types of dialysis. Acute and chronic renal failure. Care of patients undergoing haemodialysis, peritoneal dialysis and with

acute renal failure in the ward and dialysis setting. The wider issues surrounding patients with end stage renal failure such as

psychological issues, transplantation and patient education.

Students will not be expected to complete the whole package within their short time within the nephrology service. They will be expected to highlight areas of interest and utilise the package to guide their learning.

STUDENT NAME

RENAL WARD-COMM DATE

HD-DATE 3DAYS

CAPD-DATE2DAYS

RENAL THERAPIES –PRESENTATIONS1ST SESSION 2NDSESSION

First Day

The student will be:

1. Allocated a mentor.

1. Orientated to nephrology service -all three areas.

2. Orientated to location of all fire points.

3. Orientated to location of all emergency equipment.

4. Instructed regarding the emergency procedures within the department.

5. Introduced to department personnel i.e. Nurses, Doctors, Ward Assistants.

6. Informed by mentor of the student's role within each placement.

7. Given the opportunity to discuss personal and unit specific objectives for placement and complete the learning contract with their mentor.

How to use this package:

The package is designed to be a directed study package which will guide and facilitate students learning whilst on placement within the department. The package is separated into 4 sections:

General section. Care of the patient within the renal ward. Care of the patient within haemodialysis. Care of the patient within peritoneal dialysis.

The aim of the package is that while students are in each of the areas they will complete the relevant section by referring to the references provided and by encouraging the student to utilise the knowledge and experience of the nurses in that area. Study time will be provided by each of the areas and should be negotiated with your mentor or the nurse in charge.

All the references stated within the text are available within the department.

By the end of the placement you should have completed all of your personal and most of the overall objectives set within this package.

General Section

Anatomy and Physiology

1 How many kidneys does a person usually have and where are they situated in the body?

2. What are their approx. shape and size?

3. Describe how urine is formed naming the three processes involved.

4. Name the 7 functions of the kidney and briefly explain how these functions occur.

Pathophysiology/Signs and Symptoms

1. Describe what clinical changes happen to a person as each of above functions begin to fail.

Disease Processes

There are the 7 main causes of chronic renal failure:

}> Glomerulonephritis }> Diabetes }> Hypertension }> Pyelonephritis }> Renal calculi }> Congenital/hereditary abnormalities }> Tumours

Give a brief description of each and how they lead to renal failure.

Diet and Fluid Restrictions for Chronic Patients

1. Why do dialysis patients require a special diet and fluid restrictions?

2. What are their main restrictions and what are the consequences of not adhering to them?

3. What are the different dietary restrictions between haemodialysis and peritoneal dialysis patients and explain why they are different

Transplantation

The third treatment option for patients with renal failure is transplantation.

1 Can all patients receive a transplant?

2. What would prevent a patient from going on the transplant list?

3. How are donor kidneys matched to the patient?

4. Does having a kidney transplant mean that patients can now lead a normal life? Yes/No

5. What are the side effects and long term complications of immuno- suppressant drugs?

Patient Education

1 What educational information is available within the Renal Dialysis Unit for the following patients?

~ Pre dialysis patients ~ Haemodialysis patients ~ Peritoneal dialysis patients ~ Patients with acute renal failure.

2. How is this information provided to the patients?

3. Do you feel that this is the best format for the information to be given? Discuss this with your mentor.

Psychological aspects of renal failure

The following list highlights potential psychological problems which some renal patients may require help or guidance with:

Coping with a chronic illness - depression, dependence on machines, early death, medication.

Lifestyle changes - diet, work, exercise, money.

Body Image- coping with a permanent A-V fistula, a central line or a peritoneal dialysis catheter.

Relationships- new relationships, marriage, sexual problems, children.

Discuss with your mentor the impact these may have on a patient and their family. Suggest some coping strategies or referrals that may help the patient/family to cope.

Anaemia

Anaemia is a common and debilitating problem experienced by many patients with renal failure.

1 Why is anaemia common in patients with renal failure?

2. What are the signs and symptoms of anaemia?

3. What 3 treatments do we use to combat anaemia -discuss the pros and cons of each?

References:

Akyol, M., et al, (2000). Transplant Guide -Kidney transplant your questions answered. Lothian University Hospitals NHS Trust.

Any anatomy and physiology text book.

British National Formulary

McQuat, J. Scott, J., (2001). Nutrition and Dialysis. Ninewells Hospital Pre dialysis information leaflet.

Stanton, D., (1999). 'The Use of Erythropoietin in End Stage Renal Failure'. British Journal of Homecare. Jan/Feb, pp.9-15.

Stein, A., & Wild, J., (2000). Kidney failure explained. 1st edition, London: Class Publishing.

Caring for a renal patient within the ward setting

Aim The aim of this section is to facilitate the students learning and provide them with the knowledge to discuss and describe the investigations, care and treatments and investigations for patients within the renal ward setting. This section of the pack has been devised with the understanding that the student has an insight into renal physiology and pathophysiology.

Objectives

By completing this section of the student will be able to:

. Discuss the causes of acute and chronic renal failure.

Describe the specific signs of acute renal failure.

Discuss the types of investigations performed to help diagnose acute and chronic renal failure.

Demonstrate the specific care involved with acute renal failure.

Questions

1. Define acute renal failure and explain the differences between acute and chronic renal failure.

2. Identify potential causes of acute renal failure.

3. Identify and describe the three major categories in acute renal failure

4. Identify the sign and symptoms, which would be specific to this condition.

5. Describe the specific investigations that may be carried out and why?

6. Explain the rationale for monitoring the following in patients with acute renal failure?

Cardiac monitoring Central Venous Pressure (CVP) Urine Fluid Balance

7 Explain what is meant by fluid challenge?

8. Which renal drugs might be administered to patients with ARF and why?

9 Which blood chemistry results would indicate a patient requiring haemodialysis?

10. ARF patients who receive haemodialysis require insertion of a temporary central line, why?

11. Describe the care of a temporary central line.

12. What further investigations would be carried out if a patient's renal failure did not recover?

13. What education would a patient require if they were diagnosed as having chronic renal failure?

Read the suggested material and work through the questions with your mentor.

REFERENCES

Articles are available within the ward and in the library:

STEIN, A., & WILD, J., (2000). Kidney Failure Explained. 1st edition, London: Class Publishing.

STRAUSS & WEL T, (1971). Diseases of the Kidney. 2nd Edition. Boston: Little Brown and Company.

Uldall, R., (1994). Renal Nursing. 3rd Edition. Oxford: Blackwell Scientific Publications.

Caring for a patient within the haemodialysis setting

Aim

The aim of this section of the package is for student nurses to gain sufficient knowledge in order to effectively nurse patients with chronic and acute renal failure, in haemodialysis.

Objectives

For the student to:

Identify the principles involved in haemodialysis.

Describe how to care for a patient with chronic renal failure on haemodialysis.

Discuss the different types of vascular access and implications of using each.

Discover common drug therapies utilised for patients with chronic renal failure.

Define the terms haemofiltration and haemodiafiltration.

Haemodialysis

Haemodialysis works by utilising a combination of the following:

Diffusion Ultrafiltration Convection

Diffusion is where solutes move from a higher concentration in the blood to a lower concentration in the dialysate fluid. Therefore, diffusion is the process used to remove the waste products such as urea, creatinine and salts from the blood. Ultrafiltration is used to remove fluid from a patient whist on haemodialysis. A set amount of fluid is set on the machine to be removed over dialysis and the machine works out how much needs to be removed each hour and sets a pressure gradient, pulling off the fluid at a steady rate over the dialysis time. As this fluid is removed some solutes are dragged across the dialyser membrane at the same time, this process is called 'solute drag' or convection.

1 What substances are we trying to remove during haemodialysis?

2. What are the two main types of dialysis access?

3. How and where can an arterio-venous fistula be created?

4. How do you check a fistula to ensure it is functioning?

5. Describe the immediate post operative and long term care of a fistula?

6. Can you describe one other type of access used commonly in haemodialysis?

7. What education should patients be given on care of their fistula?

Haemodialysis is the main treatment for patients with chronic renal failure. Two other methods that you may come across during your time in the haemodialysis unit are Haemofiltration and Haemodiafiltration.

Haemofiltration is mainly used for patients who are unstable and are unable to tolerate haemodialysis, such as acutely ill patients. Haemodiafiltration -used for patients who are cardiovascularly unstable on haemodialysis and to improve the quality of dialysis.

8. The assessment of patients before going on dialysis consists of:

Blood Pressure. Weight. Temperature. Checking for oedema or breathlessness. Observation of fistula/centralline exit site

Explain the reason for each of the above and what you would do if any abnormalities were noted.

9. Patients are monitored hourly on dialysis. Discuss with your mentor what patient and machine observations are being monitored and why.

10. Post dialysis patients: blood pressure, temperature and weight are recorded again, why?

11. The following are all emergencies that can occur on dialysis:

}> Hypotension }> Cramp. }> Cardiac arrest. }> Respiratory arrest. }> Air embolus. }> Dialyser reactions. }> Clotted dialyser/lines.

Discuss with your mentor how and why these occur and preventative or reactive action required if they do.

While dialysing an acutely ill patient the same observations would be monitored although the frequency of monitoring would be increased to ~ hourly and the patient would be placed on a cardiac monitor and nursed either on a one to one basis or with a higher nurse/patient ratio.

Common drug therapies utilised in patients with chronic renal failure.

Patients with chronic renal failure can be on a large number of drugs the most common being:

);> Vitamins e.g. Renavit &Vitamin D. );> Phosphate binders e.g. Calcichew & Renagel. );> Blood pressure medication e.g. Atenolol & Doxazosin. );> Anticoagulants -during dialysis and at home e.g. Heparin & Warfarin. );> Antibiotics -I.V. & oral. );> Hormones e.g. Epo. );> Iron e.g. Venofer.

Briefly describe why patients would require this medication.

What special instructions or precautions would require to be taken in relation to initiating dialysis and administration of these drugs whilst patients are undergoing dialysis?

References

Royal, J., & Walsh, M., (1992). Watson's Medical-Suraical Nursing and Related PhvsioloQy. 4th Edition, Bailliere Tindall, London.

Weller, B., & Wells, R., (1990). Bailliere's Nurses DictionarY. 21st Edition, Bailliere Tindall, Edinburgh.

Stein, A., Wild, J., (2000). Kidney Failure ExDlained. 1st edition, London: Class Publishing.

Uldall,R., 1998). Renal Nursing. 3rd Edition, Oxford: Blackwell Science.

British National Formulary

Care of a patient within the peritoneal dialysis setting

Peritoneal dialysis is a dialysis option that utilises the peritoneum as the filter to excrete waste products from patients.

Aim

The aim of this section is for the student nurse to have a basic knowledge of peritoneal dialysis, how it works and what is involved in the treatment.

Objectives

For the student to:

Identify the principles of peritoneal dialysis.

Describe the care of a patient with chronic renal failure on peritoneal dialysis.

Discuss how access is achieved to the peritoneum and how dialysis is initiated.

Identify the complications of peritoneal dialysis.

Identify the different forms of peritoneal dialysis.

Questions

1. Where is the peritoneum?

2. Peritoneal dialysis works by

~ Osmosis. ~ Diffusion. ~ Convection.

Discuss these three transport principals in relation to peritoneal dialysis.

Access for peritoneal dialysis is obtained via a tenckhoff catheter, which is inserted by the surgeons, into the peritoneal cavity. Post operatively the catheter is completely covered and immobilised against the skin to promote healing and help prevent infection. The catheter is left for 7-10 days or until the exit site is completely healed, e.g. no discharge I signs of infection before dialysis is commenced. The patient is then trained to perform their dialysis and once they are competent are discharged home and reviewed at regular intervals by multidisciplinary renal team.

3. What is the care of the Tenckhoff catheter exit site?

4. What can happen if the exit site becomes infected and is not treated?

5. Describe the difference between Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal Dialysis (APD).

6. Why would patients need different strengths of peritoneal dialysis fluid?

The most common complication of peritoneal dialysis is peritonitis this is an infection of the peritoneal membrane. Presenting signs and symptoms of peritonitis can differ from patient to patient with the most common symptoms being:

~ Cloudy PD fluid ~ Nausea I vomiting ~ Crampy stomach pains I back pain ~ Flu like symptoms

Early diagnosis and treatment of peritonitis it is important to minimise the risk of developing septicaemia and damaging the peritoneal membrane.

7. What are the common causes of peritonitis and how can they be prevented?

8. What happens to the peritoneum long term with peritonitis?

9. What happens if peritonitis does not clear or the patient has recurrent episodes?

10. What are the other common problems associated with peritoneal dialysis?

REFERENCES

Adkins, R. (1994) D.I.Y. Joe's Guide to C.A.P.D. Nottinghamshire: Fresenuis Medical Care (UK).

Baxters Health Care. Understanding Treatment Options.

Coles, G. (1988) Manual of Peritoneal Dialysis. London: Kluwer Academic Publishers.

Khanna, R. et al. (1993) The Essentials of Peritoneal Dialysis. The Netherlands: Kluwer Academic Publishers.

Stein, A., Wild, J. (1999) Kidney Failure Explained. London: Class Publishing.

Smith, T. (1997) Renal Nursing. London: Bailliere Tindall.

Tucke, V. (1993) Microbiology for Nurses. (7th Ed. and Company Limited.

London: Harcourt Brace

Additional resource information may be obtained from: Protocol folder - PO department.

Trouble shooting guide folder - PO department.

www.kidneypatientguide.org.uk