Chronic Kidney Disease: Understanding the Causes, Stages, and Management, Exams of Advanced Education

Download Chronic Kidney Disease: Understanding the Causes, Stages, and Management and more Exams Advanced Education in PDF only on Docsity! Bonent Exam Questions With 100% Correct Answers | Verified | Latest Update. In center hemo must be done - Correct Answer-3x a week for about 4 hours Cons of in center HD - Correct Answer-Most limitation on Diet, fluid than other modalities Requires the most medication Most symptoms Patients who run 4 hour tx - Correct Answer-Are 30% less likely to die than pts who run shorter times Each 30 mins extra of tx increase life by 7% Patients are 50% more likely to die after - Correct Answer-2 day no treatment weekend, the last 12 hours of the 2 days the risk of death triples diastolic blood pressure - Correct Answer-When the heart is at rest. Benefits of nocturnal in center - Correct Answer-You get 2x as many txs as standard because it is longer and more gentle with fluid removal Rarely cramp Easy on heart Fewer limitations on food and drink Free days 72% better survival rate than standard in center You check blood pressure with - Correct Answer-Stethoscope and sphygmomanometer Nocturnal in center hemo must be done - Correct Answer-3x a weeks about 8 hours per tx If BP site is below the heart.... - Correct Answer-The reading will be to high Benefits of nocturnal home hemo - Correct Answer-Better protein level Don't need binders No fluid limits Fewer symptoms Less heart damage Live as long as people who get a deceased kidney transplant If BP site is above the heart.... - Correct Answer-The reading will be to low Home hemo must be done - Correct Answer-3x a week 4-6 hours per tx Benefits of PD - Correct Answer-Can do alone at home or work Only need 1-2weeks of training Allows for a more normal diet Allows pt to feel more normal peritonitis - Correct Answer-inflammation of the peritoneum, this can scar the peritoneum and make PD no longer possible, can be avoided by doing a sterile exchange 2 types of PD - Correct Answer-Continuous ambulatory peritoneal dialysis (CAPD) Automated peritoneal dialysis (APD)- uses cycled at night done 8-10 hours during sleep During in center HD how much blood is outside of body at a time - Correct Answer-1/2 cup Short Daily Home Hemodialysis must be done - Correct Answer-5-6days a week for the 2.5-4 hour per tx a bp cuff that is too small or to loose will cause a - Correct Answer-Higher reading Nocturnal home hemomust be done - Correct Answer-At home 3-7 nights a week 8 hours per tx A no cuff that is to big for a patients arm ... - Correct Answer-Lower reading Why would someone want to do more HD than standard? - Correct Answer-Longer or more frequent HD is gentle and cause fewer symptoms and may help Pt live longer, home puts pt in charge peritoneal dialysis - Correct Answer-the lining of the peritoneal cavity acts as the filter to remove waste from the blood through tiny blood vessels. Placed in abdomen and sometimes chest wall Dialysate sits in catheter for a few hours and excess water and waste flows from BV to the dialysate. The dialysate is then drained and replaced. (Exchange) Pt can use a cycle mahjne while they sleep Can also be done by hand 4xa day and can be done anywhere. In dialysis patients the reason BP drops during or close to the end of tx is because - Correct Answer-The total blood volume drops, from the water removal regular respiration rate - Correct Answer-12-16 breaths per minute What happens in the tubules of the nephron - Correct Answer-Chemicals and water that the body needs pad back into the blood. Waste and extra water empties into the calyces and become urine Jobs of the Kidney - Correct Answer-Homeostasis, removal of waste, fluid and electrolyte balance, blood pressure control and horomones Removal of waste in kidneys - Correct Answer-Excess water becomes urine, urine has high levels of waste from metabolized food, break down of muscles, drugs, toxins and acid fluid and electrolyte balance in kidney - Correct Answer-1% of glomerular filtrate become urine the rest goes back into the bloodstream, most substance that go through kidney go back into blood or are metabolized, this helps keep the right balances in the blood Blood pressure control in kidney - Correct Answer-Kidney controls water and electrolytes, electrolytes form ions which conducts electricity that dissolve in water. Balance of these electrolytes help control bP Horomones of the kidney - Correct Answer-Erythropoietin and calcitriol Erythropoietin - Correct Answer-Tells bone marrow to make RBCs Calcitriol - Correct Answer-(Vitamin d) let's the gut absorb calcium from food acute kidney failure - Correct Answer-sudden loss of kidney function due to illness/injury/toxin. Could last a few day/weeks/months More than half of pts with AK die chronic kidney failure - Correct Answer-A long-standing disease resulting in scarring in the kidney, permanently altering function. Nephron function is lost uremia - Correct Answer-Toxins in the blood Symptoms of uremia - Correct Answer-Edema Trouble breathing Making more or less urine or nocturia Foamy/bubbly urine Severe itching from calcium phosphate Ammonia breath, metal taste, nausea Avoidance of protein food Jaundice Pain around kidneys In center HD replaces what percent of kidney function - Correct Answer-10-15% People can stay healthy with fewer than ______ nephrons working - Correct Answer- Half Good screening tools for CKD include - Correct Answer-Urine tests and blood pressure checks Creatine - Correct Answer-waste product of muscle metabolism healthy kidneys remove Creatine test - Correct Answer-Done to determine how well the kidney is working Most people with CKD also have - Correct Answer-Heart problems People with CKD can slow the process by - Correct Answer-Keeping blood sugar in range, blood pressure within target, avoid nsaids, quit smoking Stages of CKD - Correct Answer-1 GFR >90 2 GFR 60-89 3 GFR 30-59 4 GFR 15-29 5 GFR <15 Causes of kidney failure - Correct Answer-Diabetes, hypertension, glomerular disease Type 1 diabetes - Correct Answer-Immune system kills cells in the pancreas that creates insulin type 2 diabetes - Correct Answer-the pancreas doesn't produce enough insulin, cells are resistant to insulin, or both. #1 cause of kidney failure Leading cause of blindness and limb loss Native Americans, African Americans and Hispanics are at higher risk. How to prevent diabetes type 2 - Correct Answer-Losing 5% of body weight, exercising 30 mins a days 5 days a week can decrease risk by 34% Why does high BP cause CKD - Correct Answer-It can damage the blood vessels and the tiny glomeruli that lead to the kidneys Primary (essential) hypertension - Correct Answer-No identifiable cause, develops over years secondary hypertension - Correct Answer-high blood pressure caused by the effects of another disease glomerular disease - Correct Answer-Make up 9% of people with kidney failure glomerulonephritis - Correct Answer-inflammation of the glomeruli of the kidney glomerulosclerosis - Correct Answer-hardening of the glomeruli polysystic kidney disease (PKD) - Correct Answer-multiple fluid-filled sacs (cysts) within and on the kidney Other cause of CKD - Correct Answer-Birth defect, large kidney stones, lupus, use of street drugs, kidney infections, cancer, HIV/AIDS, sickle cell disease, some are unknown Anemia - Correct Answer-a deficiency of red blood cells, fewer RBCs mean not enough oxygen reaches tissues and causes fatigue, weakness, mental confusion, cold all the time, pale skin/gum/nail beds Anemia is linked to - Correct Answer-Left ventricular hypertrophy left ventricular hypertrophy - Correct Answer-increase in thickness of myocardial wall that occurs when the heart pumps against chronic outflow obstruction, causes heart to fail Technician role in anemia - Correct Answer-Rinse back as much blood as possible Tell nurse about insulation bleedings Tell nurse of infection Try using smaller blood tubes for labs Urge pts to come to tx and stay full time If reuse tell nurse of dialyzer doesn't pass test Secondary hyperparathyroidism - Correct Answer-When parathyroid makes to much parathyroid horomone Why would the parathyroid make to much parathyroid horomone - Correct Answer- Healthy kidneys make calcitrol Calcitrol let's gut absorb calcium Failing kidney makes less calcitriol Gut absorbs less calcium, lower Ca in blood Drop in Ca tells parathyroid to release PTH PTH steals Ca from bones to keep blood in balance Since no calcitriol, glands continue to make PTH Gland eventually grows so large it's unable to shut off Symptoms of Secondary hyperparathyroidism - Correct Answer-Joint and bone pain Muscle pain Phosphorus - Correct Answer-Plays role in bodies use of energy, mainly found in bones and teeth Food with Phosphorus - Correct Answer-Dairy, pop, beans, whole grains, nuts. Food with a lot of preservatives and flavor enhancers Patient should limit phosphorous levels to - Correct Answer-800-1000mg a day Lab values for phosphurous - Correct Answer-3.5-5.5 Hyperphosphatemia - Correct Answer-excessive phosphate in the blood, failed kidneys can't remove and neither can tx. Can cause servers itching and bone disease. Tell patients to take binders with meals Binders - Correct Answer-Bind with the gut so it absorbs less phosphorus. Extraskeletal calicification - Correct Answer-If calcium and phosphorous are both high at the same time they bond together creating sharp crystals which can form in eyes, lungs, heart, joints and can block BV. Patients can lose limbs if this occurs Hypophatemia - Correct Answer-Low phosphorous in blood, rare in HD due to poor diet or eating to many binders. Weakness paralysis and RBC function problems Dialysis blood test include - Correct Answer-Kt/v Hematocrit Albumin Calcium Phosphorus PTH HD pts are 89% more likely to live if they - Correct Answer-Hit targets for all blood tests at the same time 91.7% of HD patients are doing - Correct Answer-In center HD transplant - Correct Answer-Get 1 healthy kidney from a donor Go through a large number of test to make sure you are healthy enough Transplant doesn't cure kidney failure Rejection is possible Types of transplants - Correct Answer-Blood relative Non blood relative Deceased kidney donor You can shorten the transplant wait by - Correct Answer-Receiving incompatible blood type kidney( ABO) transplant Receive from older pts (expanded criteria donor) Donor exchange- family member or friend gives kidney to someone else compatible while you receive a compatible kidney palliative care - Correct Answer-Hospice care advance directives - Correct Answer-a living will; a document, written in advance, that states the patient's wishes regarding end-of-life care. Protein - Correct Answer-Need both plant and animal protein Helps maintain body muscle and tissue Dialysis pts need 50% more protein Protein leaves a waste like urea or BUN or creatine Protein lab values - Correct Answer-High bun-poor dialysis or to much protein Low bun-good dialysis or poor muscle mass High creatinine- poor dialysis Low creatinine- good dialysis or low muscle mass Pts who ate uremic often - Correct Answer-Lose appetites, food taste strange or metallic, or may feel sick and vomit s Signs patient is having real weight loss - Correct Answer-Sob, not able to lay flat , edema, malnutrition - Correct Answer-Black and Mexicans live longer on HD than white due to better nutrition 3x more likely to die if malnourished If albumin and cholesterol are low it suggest malnutrition Finding and treating malnutrition fast can help save pts life If supplements don't work for people with malnutrition - Correct Answer-Feeding tube, IDPN, TPN IDPN - Correct Answer-Intradialytic parenteral nutrition which is administered directly into the bloodstream during dialysis Includes carbs, protein, fats, sugars and amino acids TPN - Correct Answer-total parenteral nutrition, provide all of most of patients nutrition myocardial stunning - Correct Answer-heart failure can be due to to much water intake Patients should restrict sodium to - Correct Answer-1500mg a day or less. Avoid slay, process food, pickles and preserved meats. Pts can use no salt spices and herbs instead Vitamins - Correct Answer-Dialysis removed water soluble vitamins so patients need to take 60-100mg vitamin c 1-5mg folate 2mg vitamin b6 3mg vitamin b12 All OTC vitamins must be approved by doctor Vitamins dialysis remove - Correct Answer-Biotin Folacin Niacin Panthenic acid Riboflavin (B2) Thiamin Vitamins b6,b12,c Transient Patient - Correct Answer-Traveling patient Patients can lose hair due to - Correct Answer-Lack of protein during CKD Starting of dialysis Babies born to women on dialysis have - Correct Answer-50% survival rate Patient education steps include - Correct Answer-Readiness, need, language, repeat, belief Solution - Correct Answer-mixture of solvent and solute Solvent - Correct Answer-Fluid Solute - Correct Answer-A substance that is dissolved in a solution. What is the solution, solvent, and solute in dialysis? - Correct Answer-Solution-dialysate Solvent-treated water Solute-electrolytes and glucose Why do we match the electrolytes in dialsyate closely to patients blood? - Correct Answer-To avoid loss of electrolytes during tx Solubility - Correct Answer-How well a solute fully dissolved in a solvent concentraion - Correct Answer-Only so much solute can be dissolved before a solvent become saturated (full) Why do we use 2 concentrates to make dialysate - Correct Answer-To avoid the formation of solids Chloride Glucose Actetate Citrate Osmolarity (total solute level) must closely match - Correct Answer-Blood to keep to much water from diffusing across membrane. What does potassium in dialysate do - Correct Answer-Helps bring patient to normal plasma levels What does magnesium do in dialysate - Correct Answer-Triggers enzymes that are key to carb use What does glucose do in dialysate - Correct Answer-Prevent loss of blood glucose Can help diabetic and malnourished pts Normal sodium range in the blood - Correct Answer-135-147 Dialysate is kept between 139and 144 Sodium Modeling - Correct Answer-Sodium level is changed during tx Starts out high and is lower throughout tx When sodium level of dialysate is high more water is removed from blood Can cause thirst, weight gain and high BP Capillary refill rate - Correct Answer-Time taken for water to move back into blood stream In sodium modeling if the UFR is higher than the cap refill rate what can happen? - Correct Answer-Drop blood pressure Bicarbonate - Correct Answer-Nuetalizes acid that forms when cells use protein for fuel It's considered a buffer ( helps keep a constant ph) Pts can't get rid of enough acid in their urine so they are at a constant metabolic acidosis Bicarb is added to maintain pts PH Ranges from 33-38 Helps with cramping,low bP, nausea and fatigue after tx Actetate - Correct Answer-Forms when acetic acid reacts with bicarb Some will diffuse into bloodstream and turn back into bicarb Citrate - Correct Answer-Can help reduce clotting of dialyzer and reduce heparin use Allows for more reuse of a dialyzer Slowly lowers pts plasma ionized calcium levels What does checking the conductivity do? - Correct Answer-Checks all the electrolytes The proportioning system - Correct Answer-system where dialysate is made by mixing fresh concentrate with fixed amounts of treated water Fixed ratio pump - Correct Answer-machine take dry bicarb and mixed with RO water inside the machine Servo-controlled - Correct Answer-Conductivity Sensors check the total ion levelnof the mixture When we mix dialysate in the giant tanks in the back that is part of the - Correct Answer-Proportioning system The monitoring system - Correct Answer- Conductivity test - Correct Answer-Machine tests by pair of electrodes places in dialysate. Machine applies a charge and delivers current Temperature test - Correct Answer-Should be between 35-38 When dialysate is to hot hemolysis can happen , protein can also be broken down When dialysate is to cold the patient can feel cold and less diffusion will occur Flow rate - Correct Answer-Can range from 0-1000 Higher dialysate flow improves dialyzer efficiency Flow rate alarms can be caused by - Correct Answer-Low water pressure Dialysate pump failure A blockage in dialysate path A flow rate that was not requested Blood leak - Correct Answer-Dialyzer membranes can tear letting blood and dialysate mix Or could have major blood loss Blood could be contaminated by non sterile dialysate Detect by a light shining though dialysate that can detect color change When alarm occurs blood pump stops and venous line clamps to prevent further blood loss If blood leak occurs do not return blood because dialysate isn't sterile and can cause infection Ph - Correct Answer-Dialsyate ph must be close to blood ph so it doesn't change ph of blood (7.0-7.4) Normal blood ph is 7.35-7.45 (weak base) Bleach PH is 11 White vinegar PH is 2.9 bypass mode - Correct Answer-Can be triggered by low/high conductivity alarms, ph, and temp also by blood leak alarms Pyrogen filter - Correct Answer-After the proportioning system dialysate flows through this filter to remove and "bad" bacteria and endotoxins Neuropathy in HD patients may be caused by - Correct Answer-Waste that is not removed during tx. normal pulse ox reading - Correct Answer-Is higher than 90% A low pulse ox in a dialysis patient could mean - Correct Answer-The patient has steal syndrome pericariditis - Correct Answer-Inflammation of a heart sac (pericardium) Normal temp for dialysis patients is - Correct Answer-96.8 Hypertension - Correct Answer-high blood pressure hypotension - Correct Answer-Low blood pressure orthostatic hypotension - Correct Answer-temporary low BP and dizziness when suddenly rising from a sitting or reclining position, 15mmhg or more normal pulse - Correct Answer-60-100 Tachycardia - Correct Answer-fast heart rate, above 100 bpm Bradycardia - Correct Answer-slow heart rate (less than 60 bpm) pulse - Correct Answer-The wave of blood in an artery caused by each heart beat Arrthymia - Correct Answer-irregular heartbeat Dyspnea - Correct Answer-shortness of breath apnea - Correct Answer-absence of breathing Afebrile - Correct Answer-without fever febrile - Correct Answer-fever Air embolism - Correct Answer-Air bubbles in the blood vessels. Sign/symptoms of air embolism are - Correct Answer-Chest pain, coughing, blue lips finger toes, trouble seeing, confusion, coma, death What to do in an air embolism - Correct Answer-Immediately clamp all lines, call for help, place pt in left trendelenburg to trap air in right ventricle of heart Causes of air embolism - Correct Answer-Air detector is broken, leak or loose connection, empty IV bag How to prevent air embolism - Correct Answer-arm the air detector; tighten all connections in the extracorporeal circuit; check the normal saline level in the IV bag; return the patient's blood with saline with the air detector on Anaphylaxis - Correct Answer-Severe allergic reaction Sign/symptoms of anaphylaxis - Correct Answer-Happens within the first 5-10 minutes, trouble breathing, hypotension, hives and itching, anxious or restlessness, swelling around eyes, numbness or tingling around mouth, low back pain, tachycardia, cardiac arrest, and burning pain at venous needle site ) could be from disinfectant infusion) What to do when pt is experiencing anaphylaxis - Correct Answer-Call for help, stop tx, clamp all lines, do not return blood, monitor vitals Causes of anaphylaxis - Correct Answer-- Ethylene oxide (a new dialyzer germicide) allergy - Reaction to germicide left in the bloodlines - Drug allergy (e.g., to iron dextran, heparin) How to prevent anaphylaxis - Correct Answer-rinse dialyzers and bloodlines well during equipment preparation; avoid drugs the patients has a known allergy to Angina - Correct Answer-Chest pain Signs/symptoms of angina - Correct Answer-Pain or tightness in chest/ arm/jaw, pt may be cold/ sweating/ trouble breathing, hypotension What to do if pt is experiencing angina - Correct Answer-Lower BFR to 150 to decrease stress on heart, lower UFR to prevent further fluid loss and stress in heart, monitor vitals, give saline if hypotensive, call for help. Causes of angina - Correct Answer-- Coronary artery disease (blocked heart arteries) - Anemia (shortage of red blood cells) - Hypotension - Anxiety How to prevent Angina - Correct Answer-- Monitor blood pressure closely to avoid hypotension. - Calculate the fluid goal correctly. Arrhythmias - Correct Answer-irregular heartbeats Sign/symptoms of arrhythmia s - Correct Answer-Skipped or extra heartbeats, slow or fast pulse, palpitations, anxiety What to do if pt is experiencing arrhythmia - Correct Answer-Check vitals, manually check pulse, lower UFR is pt is hypotensive, call for help. What causes arrhythmias? - Correct Answer-Changes is ph or electrolyte levels especially potassium, hypotension, heart disease How to prevent Arrhythmias - Correct Answer-- Use the right dialysate concentrate. - Manually check the pt's pulse during tx. - Monitor blood pressure. And UFR to prevent hypotension cardiac arrest - Correct Answer-complete stopping of heart activity Sign/symptoms of cardiac arrest - Correct Answer-No pulse, no breathing, loss of consciousness What to do in cardiac arrest - Correct Answer-Call for help, stop dialysis, flush access sites, start CPR if pt is not a DNR What cause cardiac arrests - Correct Answer-Extremes hypotension, electrolyte imbalance like high potassium, arrhythmia, heart attack, air embolism, severe blood loss How to prevent cardiac arrest - Correct Answer-check vital signs during treatment; tell the nurse right away about major vital sign changes and/or if the patient complains of chest pain or sweating; verify UF goal is not too high; check vascular access and bloodline connections Dialysis Disequilibrium Syndrome - Correct Answer-Brain swelling most often in patients with high BUN levels Sign/symptoms of dialysis disequilibrium syndrome - Correct Answer- Headache,nausea,hypertension, restlessness, irregular pulse, confusion, burred vision, seizures What to do if pt is experiencing dialysis disequilibrium - Correct Answer-Notify the nurse What cause dialysis disequilibrium syndrome - Correct Answer-If BuN is removed much faster from the blood than the brain (fluid moved into the brain cells causing swelling), may be seen in pts who skip treatments How to prevent dialysis disequilibrium syndrome - Correct Answer-- Monitor the pt during tx. - Tell the nurse right away about major vital sign changes. - In pt's with high BUN (>150mg/ml) a smaller dialyzer and/or a slower blood and dialysate flows are preferred. Short, slow dialyses may be prescribed daily for a few tx's. pyrogenic reaction - Correct Answer-Sudden onset of fever, chills, backache, headache, nausea, and vomiting as a result of being exposed to foreign proteins, such as those found in bacteria or fungi. Sign/symptoms of pyrogenic reaction - Correct Answer-Afebrile at start of treatment and started to develop fever and chills 45-75 mins into treatment What to do in a pyrogenic reaction - Correct Answer-Tell nurse, stop tx, you may or may not return blood depending on policy, check vitals Cause of a pyrogenic reaction - Correct Answer-Infection, contamination (endocrine exposure) How to prevent pyrogenic reactions - Correct Answer-Evaluate patients for infections, check vitals, tell nurse of major vital changes, using aseptic technique during machine set up, checking temp before tx, using right process to disinfect machines and water; checking reprocessed dialyzer . first use syndrome - Correct Answer-Sensitivity to a dialyzer Signs/symptoms of first use syndrome - Correct Answer-Severe reactions happen within the first 5-10 mins, mild reactions first 20-40 mins. Itchings, chest/back pain, sob, hypotension, nausea and general discomfort What to do in first use syndrome - Correct Answer-Notify the nurse How to prevent first use syndrome - Correct Answer-rinse the dialyzer well before treatment, per your clinic's procedure; use the right dialyzer pruritis - Correct Answer-itching What causes pruritus? - Correct Answer-Uremia, dry skin, high phosphorus, calcium phosphate crystal deposition under the skin, secondary hyperparathyroidism. How to prevent Pruritus - Correct Answer-- Keep skin clean and dry - Deliver dialysis tx correctly Precleaning for reuse - Correct Answer-Removes some blood from dialyzer, May use reverse ultrafiltration, this is done by placing a cap on one of dialyzer ports and sending water through the dialyzer and out the other port Clean disinfect and header for reuse - Correct Answer-You may have to remove header to get out blood clots if so use only free flow water, once clean dip in disinfectant before you put the cap back on. When to reject a reuse dialyzer - Correct Answer-It has reached the max number of uses Fails test Cracks or leaks Have been exposed to one or more germicide Having large clots or deposits in header Have more than a few discolored fibers Have labels they can't read Tcv baseline less than 80% germicide - Correct Answer-Dialyzer must only be exposed to one type of germicide during reuse Types: peracetic acid, formaldehyde;gluteraldyhe, and heat with disinfection Storing reprocessed dialyzers - Correct Answer-Never store a reprocessed dialyzer with new ones or a dirty one. Always rinse the germicide out of dialyzer... - Correct Answer-Before it used Aami standards for the total microbial count of dialysate shall not exceed - Correct Answer-200CFU/mL (colony forming units/mililiter) Endotoxins should be... - Correct Answer-Less than 2eu/ml Steps for reuse after dialysis - Correct Answer-Precleanin, tests, dialyzer rejection and disinfection Contact time - Correct Answer-The exposure time for a disinfectant to accomplish the desired antimicrobial effect, as defined by the disinfectant manufacturer. Ground water - Correct Answer-Come from wells and springs, high in ions (ex: CA,Mg, Fe) but lower in microbes Surface water - Correct Answer-Come from lakes ponds, rivers and reservoirs. Higher in pesticides, waste, sewage and microbes Ultrafiltration (UF) - Correct Answer-In hemodialysis, UF is filtration caused by a pressure gradient between two sides of a filter. When the UF is set the machine calculate the TMP so the pressure is higher on the blood side than the dialysate side so the water is pushed out of the blood Transmembrane pressure (tmp) - Correct Answer-Difference in pressure across the membrane exhaustion - Correct Answer-Running out of site to place a dialysis access 1 in 4 hospitalization in HD pt are due to - Correct Answer-Access problems Poorly working access leads to - Correct Answer-Poor dialysis and can lead to uremia Poor needle placement can - Correct Answer-Cause an access to fail