Chronic Kidney Disease and Acute Kidney Injury: Causes, Symptoms, and Management, Exams of Nursing

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Davita RISE PCT

2024 2025 Study

Guide

List the four transport mechanisms that play a role in hemodialysis - answer ✅✅Ultrafiltration Convection Diffusion Osmosis Explain ultrafiltration in hemodialysis - answer ✅✅Fluid is pushed through the semipermeable membrane (SPM). Think: wringing out a wet rag.

Explain convection in hemodialysis - answer ✅✅Solutes DRAG across the semipermeable membrane with fluid Explain diffusion in hemodialysis - answer ✅✅PARTICLES move from HIGH concentration to LOW concentration Explain osmosis in hemodialysis - answer ✅✅FLUID moves LOW concentration to HIGH concentration What are the kidneys' excretory functions? - answer ✅✅To normalize electrolytes, remove wastes, provide fluid and nutrient balance How do we replace normal excretory kidney functions? - answer ✅✅By using acid concentrate to help normalize electrolytes and ultrafiltration to provide fluid balance What is the function of acid concentrate - answer ✅✅Provides the concentration gradient for diffusion and helps normalize electrolytes

What is the function of bicarbonate in the dialysate solution? - answer ✅✅It buffers the acid concentrate What is the function of bicarbonate when it diffuses into the patient's blood? - answer ✅✅It normalizes body pH What are some S/Sx of hyperkalemia? - answer ✅✅K+ > 6.5 mEq extreme muscle weakness, dysrhythmias, and possible cardiac arrest What are some S/Sx of hypokalemia? - answer ✅✅K+ < 3.5 mEq fatigue, muscle weakness, paralysis, resp. failure, cardiac instability, arrhythmias, cardiac arrest What is the normal blood pH range? - answer ✅✅7.35 - 7. What are the kidneys' endocrine functions? - answer ✅✅Renin secretion

Erythropoietin secretion Vitamin d activation How do we replace normal endocrine kidney functions? - answer ✅✅By providing medications How much of normal kidney function is replaced by HD? - answer ✅✅15% What is uremia? - answer ✅✅Uremia is a buildup of wastes in the blood due to kidney failure What does uremia affect? - answer ✅✅Uremia affects all body systems What are the most common causes of CKD in the US? - answer ✅✅diabetes, HTN and polycystic kidney disease List the treatment goals for a pt. w/ CKD - answer ✅✅-slowing the progression of CKD -managing comorbidities and complications -controlling symptoms

-minimizing the effects if CKD on pt. lifestyles -kidney replacement therapy modality education -encouraging patients to actively participate in their healthcare Why is it so important to know what caused your pt.'s CKD? - answer ✅✅So the RN and PCT can ask about possible problems during data collection and assessment List some S/Sx of fluid imbalance - answer ✅✅HTN, edema, and SOB Why is sodium balance important? - answer ✅✅Leads to volume expansion, increased cardiac output, increased peripheral vascular resistance and increased BP List some systemic effects of CKD - answer ✅✅-Dry, itchy skin -Peripheral neuropathy in the extremities -GI problems (N/V)

-Psychological problems (anxiety, depression) What would you advise for a pt. with dry, itchy skin? - answer ✅✅-use hyper-fatted soaps and lotions -assess for safety at home -provide emotional support -control diabetes and phosphorus What would you advise for a pt. with peripheral neuropathy? - answer ✅✅-Monitor pt. for changes in motor function, decreased strength in legs, C/O restless legs, and burning feet. -Advise not to walk barefoot -Practice good foot care What would you advise for a pt. with GI problems? - answer ✅✅-inform RN and MD of any bleeding problems, constipation, diarrhea

• inform RN and MD of ER visits -Take meds as ordered (stool softeners, immodium, etc.)

What would you advise for a pt. with psychological problems? - answer ✅✅Verbalize struggles to IDT (core team), especially the social worker A common cause of HTN in dialysis patients is: - answer ✅✅Fluid overload What does HTN lead to? - answer ✅✅Left ventricular hypertrophy Left ventricular hypertrophy leads to: - answer ✅✅Ischemic heart disease, arrhythmia, myocardial infarction, and sudden death. Define pericarditis - answer ✅✅An inflammation of the membrane (pericardial sac) that surrounds the heart due to fluid an waste build up What is the Tx for pericarditis? - answer ✅✅Decrease or stop heparin and give more frequent dialysis

Why are dialysis patients anemic? - answer ✅✅The lifespan of their red blood cell is 60 days, 1/2 of the normal 120 days. What is the primary cause of anemia in dialysis patients? - answer ✅✅Lack of the hormone erythropoietin (EPO) What are secondary causes of anemia in dialysis patients? - answer ✅✅-Inadequate iron stores, -inadequate dialysis, -malnutrition, -blood loss during Tx How can you prevent contributing to lower hemoglobin and blood loss in dialysis patients? - answer ✅✅-Verify epogen dose is correct and administered -Rinse back until venous line is pink tinged -Avoid repeat lab draws What are the four key elements contributing to CKD-Mineral Bone Disorder (MBD) - answer ✅✅- Calcium

-Phosphorus -PTH -Vitamin D (calcitriol) can all lead to CKD-MBD when abnormal What are the S/Sx of CKD-MBD in addition to bone disease? - answer ✅✅-Soft tissue calcification -Itching -Muscle weakness -Pathological fractures -Tendon ruptures -Compression of vertebrae -Atherosclerosis -Heart disease What is your role in CKD-MBD management? - answer ✅✅-report symptoms, -urge patients to take meds (home & treatment) -report noncompliance problems related to nonadherence

Define AKI - answer ✅✅-Wide spectrum of kidney issues -Includes acute renal failure & renal function changes -May dialyze in an out-patient facility until kidney function recovers Give 3 examples of prerenal causes of AKI - answer ✅✅Obstruction, volume depletion and impaired cardiac function Give 3 examples of intrarenal causes of AKI - answer ✅✅Ischemic ATN, sepsis, SIRS, septic shock, anaphylaxis drugs, goodpasture syndrome, acute glomerulonephritis, trauma, open heart surgery Give 3 examples of postrenal causes of AKI - answer ✅✅Obstruction, oliguria, bladder rupture and pregnancy Explain the difference between AKI and CKD - answer ✅✅Eliminating the cause of the AKI can often lead to the return of kidney function. You cannot eliminate the cause of CKD which is HTN, Diabetes, genetic disorders (PKD)

In the outpatient facility, how do you help in restoring kidney function? - answer ✅✅Find the cause of the AKI In the outpatient facility, what do you need to consider in regards to pt. vasc. access? - answer ✅✅Patients will typically have a dialysis catheter- be careful to avoid catheter related infections How do you protect kidneys from further injury? - answer ✅✅Avoid substances to the kidney which may be toxic (radiographic contrast, amphotericin B, low dose aspirin, NSAIDS) What is important when monitoring weight and BP?

• answer ✅✅Keep a little extra fluid on them so it is available to the kidneys when they start filtering/ultra-filtrating on their own AKI patients are at increased risk for which complications? - answer ✅✅Hypovolemia and hypotension

What makes dialysis patients more susceptible to HAIs? - answer ✅✅They are immunosuppressed and more vulnerable to infection, which leads to the 2nd most common cause of death in this population Why are dialysis patients at increased risk for acquiring a HAI at the facility? - answer ✅✅The dialysis procedure itself requires prolonged access to the patient's blood, especially those involving CVC vascular accesses, making them more at risk What is the most common transmission route for HAIs - answer ✅✅Contact What is the most important intervention you can do to to prevent HAIs - answer ✅✅Hand hygiene What is the most common infectious complication in hemodialysis patients? - answer ✅✅Vascular access infection What is the most common cause of bacterial infections in dialysis patients? - answer ✅✅• The use of catheters for hemodialysis treatments

What germ causes the most common infections in hemodialysis patients? - answer ✅✅Methicillin- resistant Staphylococcus aureus (MRSA) - Must pay attention to infection control! Proper hand hygiene, cleaning & disinfecting procedures to prevent spread of infection (viable on surfaces for days) Why is wearing gloves so important? - answer ✅✅It reduces the risk of hand contamination and prevents the transfer of organisms already on hands Why do you need to perform hand hygiene before and after wearing gloves? - answer ✅✅Gloves are not impervious and have microscopic pores Explain the acceptable hand hygiene technique when caring for a patient with active C-diff - answer ✅✅Handwashing with soap and water per policy is the only acceptable hand hygiene What is the difference between OSHA and CMS infection control requirements? - answer ✅✅OSHA:

Requires employers to provide workers with a safe workplace CMS: Concerned with patient care and patient safety What are V-tags and why are they important? - answer ✅✅They state specific regulations to be met within a condition such as infection control, providing interpretive guidance for each regulation and citing deficiencies by tag # Is a cleaned dialysis machine considered a'clean' area? - answer ✅✅No When should sharps containers be removed from the treatment floor? - answer ✅✅When they are ¾ full State the 3 strategies recommended by KDOQI to decrease the risk of infection when working with a CVC - answer ✅✅• Using facemasks when lumens or exit site is exposed

• Wearing clean gloves and avoid touching exposed surfaces

• Minimizing catheter lumen or exit sites from being exposed Who can use clean sinks for hand washing? - answer ✅✅Teammates and patients What is the correct procedure in regards to your hands when you have casual contact with a patient? - answer ✅✅No gloves but hand hygiene is required How can you tell when an area or sink is clean or dirty in your facility? - answer ✅✅It is clearly labeled with a 'clean' or 'dirty' sign What do surveyors use to verify infection control training and education has been completed for teammates? - answer ✅✅Documentation of infection control training in the teammate's file or transcript Explain the HBV classification and state which test is performed monthly on HBV susceptible patients - answer ✅✅• HBsAg: Hepatitis B surface Antigen -

tested monthly for susceptible pts and non- responders

• Anti-HBs: Hepatitis B Surface Antibody
• Anti-HBcIgM: Hepatitis B Core AB-IGM Which patient care assignments are appropriate when caring for Hepatitis B patients? - answer ✅✅• Caring for HBsAg positive and Hepatitis B immune patients at the same time
• Caring for Hepatitis B susceptible patients and those in the process of receiving the vaccination at the same time
• Caring for Hepatitis B immune and susceptible patients at the same time How often are machine alarm tests performed? - answer ✅✅Before the initiation of each patient treatment How long can a dialyzer be set up for once recirculation is complete? - answer ✅✅2 hours Why can't a dialyzer remain set up longer than the allotted time? - answer ✅✅It can grow bacteria

Manual Conductivity must match _____________________ on the Fresenius (FMC) 2008K and K2 dialysis delivery system displayed conductivity - answer ✅✅+/- 0.4 mS True or False: Checking independent conductivity is NOT required when using the Fresenius 2008T or T BlueStar models or B Braun hemodialysis machines. - answer ✅✅True What is the safe dialysate pH range? - answer ✅✅Between 6.9 and 7. What is "strikethrough" of an external pressure transducer and why is it of concern? - answer ✅✅It is when fluid could have entered the machine and contaminated the internal pressure transducer protector providing a reservoir for microorganisms and causing subsequent patient blood infections Why is it important for patient care teammates to know when the water treatment system disinfection was performed? - answer ✅✅Because the end-to-end disinfection process will also

introduce the disinfectant solution to the dialysis delivery systems through their water inlet lines What are the key concepts related to "Reasonable & Prudent" Care? - answer ✅✅• The Standard of Care is care which a reasonable and prudent nephrology nurse would give under the same or similar circumstances.

• Actions a reasonable and prudent nephrology nurse would do, as well as actions the nurse would avoid doing
• The skills and knowledge expected of a nephrology nurse is key to the specialty of nephrology nursing Who established the Standards of Care for Nephrology Nursing and for what purpose? - answer ✅✅• American Nephrology Nurses Association (ANNA) establish the standards of care and scope of practice for Nephrology nursing
• Standards of Care can serve as a basis for many areas including policy and procedures, protocols, educational offerings, regulatory systems, and more.

What are three considerations when delegating nursing care activities? - answer ✅✅• Must be within the nurses scope of practice • Must be delegable by State Board of Nursing • Personnel must be adequately trained to perform activity What role does DaVita's P&Pplay? - answer ✅✅• Provides evidenced-based guidance

• Meets CMS' Conditions for Coverage (CfC)
• Complies with state & federal laws What are the risks of performing activities your way? - answer ✅✅Not providing safe evidence- based care can lead to Civil Liability What are the four reasons why we document in the medical record? - answer ✅✅• Proof care was rendered
• Provides data continuity
• Communication tool
• Permanent legal record List six occurrences when to document - answer ✅✅• Baseline assessment

• Change from baseline assessment
• Change in patient's condition
• Procedure or treatment
• Medication given and patient response
• Patient teaching What does SMART communication stand for? - answer ✅✅S: Simple: keep message clear and simple M: Meaningful: think about what and why you are sending the message A: Actual: just report the facts R: Read: make sure you are sending the message you intend T: Teach: others about SMART communication What is the difference between data collection and assessment - who does what? - answer ✅✅• Assessment-Nurse o Determining depth of edema o Rate, rhythm, quality of heart sounds o Respiration rate, rhythm, effort being put into breathing, identifying unusual lung sounds

• Data Collection-PCT o Noting presence of edema o Heart rate and rhythm o Respiration rate, rhythm, recognizing unusual breath sounds o Machine parameters, safety checks What is the role of the licensed nurse prior to treatment initiation? - answer ✅✅Assess abnormal findings from data collection, determine appropriate interventions (based on physician orders) and contact physician if needed When is a pre-treatment assessment by the licensed nurse required? - answer ✅✅• For a CKD hemodialysis patient: Based on State law (may be before tx initiation or within an hour of tx initiation) or if data collection has abnormal findings
• For patients with AKI - a pre-treatment assessment is always required What is the role of the PCT prior to treatment initiation - answer ✅✅Complete data collection and

PCT must notify the RN if there are any abnormal findings prior to initiation of tx What are the appropriate times for documentation? PRE - answer ✅✅• Pre-treatment safety checks: o Prior to treatment initiation

• Pre-treatment patient data collection o Done pre- treatment /assessment: prior to treatment initiation if required by state law or within the first hour of dialysis treatment What are the appropriate times for documentation? DUR - answer ✅✅• Observations during treatment o Document Assessment pre-treatment, continuous monitoring during treatment, as they occur What are the appropriate times for documentation? POST - answer ✅✅Post treatment data collection/assessment o Must be done after treatment is complete - some of the things needed post tx: o Documentation of clearance of dialyzer after rinse back.

o Blood pressure o Heart rate o Temperature o Respiratory rate o Weight What are possible consequences of poor or incomplete documentation? - answer ✅✅Entries may be discarded if unable to be read, can be left open to interpretation or attack on your care What policy should you refer to to document late entries - answer ✅✅From Policy 3-02-02: Medical Record Preparation and Charting Guidance How do you document late entries - answer ✅✅If unable to chart immediately after rendering a service or at the time of an observation, the teammate is to make the appropriate entry as soon as possible How do you document late electronic entries - answer ✅✅If documenting within the electronic

medical record, the notation will automatically contain your electronic signature, date and time How do you document late paper chart entries - answer ✅✅o The late entry must be signed by the person making the late entry o The late entry must be timed and dated at the time it is entered

. How do you document charting errors? - answer ✅✅When documenting on paper draw a single line through the entry, date/ signature/ teammate credentials, chart the correct information. If documenting in an electronic health record system follow facility procedure for that system. What is the preferred location for taking an accurate blood pressure? - answer ✅✅Upper, non- vascular access arm What BP reading error can be caused by a cuff that's too small - answer ✅✅Reading may be higher than actual BP

What BP reading error can be caused by a cuff that's too big - answer ✅✅Reading may be lower than actual BP What is a normal pre-treatment blood pressure? - answer ✅✅Systolic equal to or less than 180 mm/Hg or equal to or greater than 90 mm/Hg and diastolic less than 100 mm/Hg What is the normal heart rate range? - answer ✅✅60-100 bpm What is the normal respiratory range? - answer ✅✅12-16 breaths/minute What is a normal temperature? - answer ✅✅Less than 100˚ Fahrenheit or 37.8˚ Celsius or less than 2 ˚F (1˚C) of baseline (pre-treatment temperature reading) The three words DaVita uses in order to easily recall the pre-treatment AVF/AVG access evaluation are: - answer ✅✅'Look, Listen, Feel'