Download Primer for APN Nephrology Practice or CNN

Primer for APN Nephrology Practice
or CNN-NP Certification Preparation
The Zebras
Linda Shenton, MN, RN, ACNP,
CNN-NP
Objectives
• Identify less common patient presentations that
may be seen in CKD and the transplant setting
Zebras in CKD
Did you know……
Zebras have
white stripes
there skin is
black!
Amyloidosis
• Beta-2 microglobulin deposits found in many
organs including kidney
• Etiology is idiopathic, associated with multiple
myeloma
• Primary: amyloid fibrils produced by
immunoglobulin light chains deposit in
glomeruli blood vessel tubules
• Secondary: amyloid fibrils produced by liver as
acute phase reactant serum protein deposit in
glomeruli blood vessel tubules
Amyloidosis
• Proteinuria may progress to nephrotic syndrome
• Renal tubular acidosis and nephrogenic diabetes
insipidus may occur
• Onset of CKD approximately 1-4 years from the
onset of proteinuria
• Diagnosis: positive Congo red test, proteinuria,
hypoalbuminemia, peripheral edema, signs and
symptoms of decrease of kidney function
• Treatment: primary (no specific treatment),
secondary (decrease underlying inflammatory
process)
HIV Associated Nephropathy (HIVAN)
• Most common cause of CKD in HIV-seropositive
individuals
• Highest incidence: African American 20-64 years
old, drug use, males
• Progresses rapidly to CKD stage 5 within weeks
to months without HIV treatment
• HIV genome present in kidney tissue
• Tubular interstitium infiltrated with leukocytes
• May involve replication of virus within mesangial
cells
HIVAN cont.
• Diagnosis: nephritic syndrome symptoms,
rapidly progressive loss of kidney function, large
echogenic kidneys on US, CD4 count <200mm2,
HIV viral load >500 copies/ml
• Treatment: ACE Inhibitors (decrease
proteinuria, edema), antiretroviral drugs
(HAART), steroids are controversial but may
slow progression to HIVAN
Renal TB
• Most frequent site for TB outside the lungs
• Results from hematogenous spread of
mycobacterium tuberculosis from the lungs to
the kidneys
Renal TB cont.
• Signs & Symptoms
▫ Dysuria, urinary frequency, flank, or abdominal
pain
▫ Hematuria, pyuria, tubercle bacilli in urine
▫ Suspect with a sterile hematuria and/or pyuria
▫ Epididymitis in men
Renal TB cont.
• Early detection of renal TB is enhanced by
examining urine for tubercle bacilli in all people
with pulmonary TB
• Decrease function is present before signs and
symptoms develop and can result in irreversible
kidney damage
• Kidney failure is rare, with 2 months to 6
months of effective antituberculosis drug
therapy
Scleroderma
• Accumulation of collagen and connective tissue and
proliferative lesions in capillaries and small arteries;
more common in females 20-50 and African
Americans
• Pathophysiology: autoimmune mechanisms,
abnormal production of collagen, connective tissue
thickening
• Localized form affects skin and viscera (major cause
ischemia), characteristic skin changes Raynaud
phenomenon (feeling that skin is turning to stone)
Scleroderma
• Vascular changes lead to structural and
functional organ changes, 50% of patients
develop renal ischemia and tubular changes, 15%
of these patients develop renal crisis, oliguric
kidney failure, malignant hypertension and
renin blood levels 12x normal
Scleroderma
• Major preventive measure for renal crisis is to
control hypertension
• Treatment: control collagen accumulation and
vascular destruction, control HTN, alleviate
general signs and symptoms, maintain nutrition
and physical mobility, plasmapheresis may be
helpful
Alport Syndrome
• Three genetic types: X-linked accounts for 80%,
autosomal recessive type 15%, autosomal
dominate 5%
• Primarily affects the glomeruli, causes changes
in genes that affect type 4 collagen
• Earliest signs & symptoms: microscopic
hematuria, proteinuria , HTN, progressive
hearing loss in 80% of boys, anterior lenticonus
in 15% of men, cataract development
Alport Syndrome
• Diagnosis: clinical features, family history,
results of tissue biopsy (changes in walls of
blood vessels of the glomeruli detected by
electron microscopy of kidney biopsy tissue)
• Treatment: no specific treatment. Treat high
blood pressure and other symptoms of kidney
disease, transplantation is usually very
successful
Zebras in transplant
Did you know……
Zebra stripes are
like human
fingerprints, they
are each
individual.
PTLD (post-transplant lymphoproliferative
disorder)
• Life threatening complication following solid
organ transplant
• PTLD incidence approximately 0.5-1% post renal
transplant
• EBV (Epstein-Barr virus) main causative factor
in PTLD ; can be detected within lymphoma cells
in up to 90% of patients with PTLD
American Journal of Transplant, 2005; 5: 2901-2906
PTLD
• EBV-negative transplant recipients may have
risks up to 25%
• Treatment with Rituximab shows promise and
low toxicity profile
Multi drug resistant UTI
• High risk groups: older age (increase 2% each
year with age), female (1.8 x male risk), delayed
graft function
• Hep C virus and PKD independently associated
with two-fold risk for recurrent UTIs
• First UTI caused by multi-drug resistant
pathogen = 5.6 fold risk for recurrent UTI
Multi drug resistant UTI
• Prevention strategies: remove urinary catheter
ASAP, discharge from hospital ASAP, dose
Cefazolin immediately prior to surgery,
Tmp/Smx three times during first six months
post transplant
• Use inhaled pentanidine for allergy to
sulfamides
Invasive Fungal Infections (IFI)
• High mortality, incidence higher in first 6
months post transplant
• Clinical symptoms sparse and lack specificity
making dx difficult
• Diagnostics: (gold standard) for invasive
candidiasis blood cultivation, microscopic tests,
culture of clinical material, Id. of biochemical
strain of pathogen, testing for drug resistance
• Management: prompt diagnosis, early initiation
of anti-fungal therapy, reduced
immunosuppression if possible
Invasive Fungal Infections (IFI)
• Pharmacology:
▫ Candida (non-nutropenic) Fluconizol
▫ Candida (nutropenic) Echinocandin or L-AmB
▫ Aspergillus (lungs, sinus, tracheal bronchial
tree, heart, bone, CNS) Voriconzol
Pregnancy Pearls
• Transplant: wait 1 year before becoming
pregnant and only after kidney function is stable
with <1gram proteinuria
• Recommend: MMF and EC-MPS be
discontinued or replaced with azathioprine
before pregnancy is attempted
• Suggest: mTORi be discontinued or replaced
before pregnancy attempted
Pregnancy Pearls
• STOP ACE inhibitors ASAP!
• CKD Stage 5 potential complications include :
40-50% infant survival, 80% deliver at 32 weeks,
requires a much more intensive dialysis regimen
Primer for APN Nephrology Practice
or CNN-NP Certification Preparation
Test Taking
Present by: Linda Shenton, MN, RN,
ACNP, CNN-NP
PPT created by: Sally Campoy, DNP,
ANP-BC, CNN-NP
The WHY….
Questions to ask yourself
• Are you a practicing nephrology NP?
• Do you have your CNN?
• Do you have your CNN-NP?
• If not, why not?
Why You Should Take The
CNN-NP EXAM
• Licensure validates entry-level
competence
• Certification reflects mastery of
knowledge and skills
• CNN of nursing knowledge and skills
• CNN-NP of advanced practice knowledge
and skills
Barriers to taking the CNN-NP exam
•
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•
Cost
Lack of support or rewards
Lack of time
Lack of relevance
Fear of failure
Benefits for taking CNN-NP exam
Cited by
Patients, Organizations and Employers:
•
•
•
•
•
Experience/knowledge beyond entry level
Commitment to continual learning
More confident decisions
Adherence to evidence based practice
Enhanced teaching/collaboration and
planning/evaluation
More benefits
•
•
•
•
•
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Less turnover and vacancies
Increased job satisfaction
Commitment to quality and profession
Hospitals distinguished from competitors
Important for magnet designation
Indicates competence to Joint
Commission
Benefits Cited by Nurses
“Most nurses who sat for certification
exams did so for personal fulfillment and
commitment to excellence in practice”
AACN
Benefits as cited by nurses:
•
•
•
•
•
•
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•
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Personal satisfaction
Increased specialty knowledge
Increased professional credibility
Increased commitment to nursing &
specialty
Increased marketability
Increased salaries
Increased recognition from peers
Valued by certified and non-certified
nurses
Sense of empowerment
CERTIFICATION 
EMPOWERMENT
EMPOWERMENT
INCREASED ACCESS TO:
- JOB RELATED POWER
- OPPORTUNITIES IN
ORGANIZATION
- OPPORTUNITIES IN HEALTH
CARE FIELD
The What…
Application Preparations
• Planning period—6 months
▫ 3 months application preparations
▫ 3- 6 months studying
• Application must be post-marked 10 weeks
in advance of testing date
• Cost
▫ ANNA Member: $325
▫ Non-Member: $350
▫ Late Fee: $50
Applicant Eligibility Criteria
• Full and unrestricted license as a registered nurse in
the United States, or its territories
• Nationally certified as a nurse practitioner.
• Minimum of 2000 hours as a nurse practitioner
practicing in nephrology within two (2) years prior to
submitting this application.
• Minimum of a master’s degree in nursing.
• Completed sixty contact hours of approved continuing
education in nephrology within two (2) years prior to
submitting this application
Approved Continuing Education
▫ Organizations accredited by the American Nurses’
Credentialing Center – Commission on Accreditation (ANCCCOA) the credentialing body of the American Nurses
Association
▫ The American Association of Critical-Care Nurses (AACN)
▫ The Council of Continuing Education
▫ The American Academy of Nurse Practitioners
▫ California, Florida, Iowa, Kansas, or Ohio State Boards of
Nursing*
▫ Organizations accredited by the Accreditation Council for
Continuing Medical Education (ACCME)
Application
• Complete all sections of the application
• Complete the employment verification portion of the
application
▫ By supervisor, employer, or collaborating physician
• Include copy of Master’s Degree in Nursing diploma, or
transcript showing nursing as major
• Include copy of license and national certification
• Include copies of continuing education/contact hour
certificates – 60 hours in nephrology
Test Preparation
• Intellectual Preparation
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▫
▫
NNCC
Read the test blueprint
Read the test specifications
Read the reference list
Focus on areas with which you are least
familiar
Intellectual Preparation
▫ Learning Strategies
 Systematically review a nephrology nursing
reference textbook
 Participate in a study group
 Spend a day with a colleague working in an
area you need to learn about
 Certification Review Course
Intellectual Preparation
▫ Take the Online Practice Exam
 Cost $50
 Consists of 50 questions with a 90 minute
time limit
 Results given with rationales for each answer
 May take again at same cost- the experience
may vary, but the questions will be the same
Emotional Preparation
▫ Moderate anxiety is normal and may be helpful
 May improve alertness and openness to learning
 Too much anxiety detrimental and will interfere with
test
▫ Study and prepare for the examination so that you feel
confident.
▫ Think positively
▫ Use anxiety-reducing strategies
 Relaxation response
 Guided imagery
 Exercise
 Prayer
Physical Preparation
▫ Get a good night's sleep
▫ Eat before the examination
▫ Gather all the materials you need to take the test the
night before the exam:
 Government-issued photo ID
 Nursing license
 Examination permit
 Sweater or jacket in case the room is cool
▫ Allow plenty of time to arrive early
The HOW..
The Test
• Paper and pencil test
• Monitored
• Pick a seat where you won’t be distracted
Test taking strategies
• Read carefully
▫ Read directions
▫ Read each question
• Never skim the question or possible
answers first
• Come up with your answer first before
looking at the possible choices
▫ Then read answer choices
Answer the question
• Determine exactly what is being asked
• Don’t make assumptions about what is
being asked
• Watch for double negatives or key words
in the question
• “ALL of the Above” ?
▫ If you know at least 2 questions are correct,
probably all is the correct answer
• “None of the Above”?
▫ If you know at least 1 choice is true, probably
none is the correct answer
Don’t know the answer?
• Try to eliminate the ones you know are
wrong
• Select the best of the remaining question
• If you can’t decide, move on
▫ Go back to it when you are done with the
rest of the test
Should you change your answer?
• If it is a strong instinct, it is probably the
correct answer
• If you are certain you have the correct
answer, do not go back
• If after another review, you reconsider
your answer. Don’t be afraid to change it
Test taking strategies
• Better to answer as many questions as
you can
• Give yourself time to go back to review
the questions you missed
• Pace yourself
▫ 175 questions
▫ Average time to answer a question
1 ¾ minutes
Link to blueprint
Link to test specifications
Unsure of a content area?
• Don’t dwell on it
• Skip that section
• Complete the other sections you are more
sure about
• Leave that section for last
SIT FOR THE CNN-NP
Demonstrate commitment to advanced
nephrology nursing by taking
responsibility for your own professional
development –
the benefits far outweigh the barriers –