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SECTION 1

                HUNTER-NEW ENGLAND AREA HEALTH SERVICE


                         Nephrology Nurse Practitioner...
Nephrology Department John Hunter Hospital-Hunter New England Health Service
Version 1 – May 2006

The Clinical Practice G...
CONTENTS:
SECTION 1

1.    SYNOPSIS

2.    INTRODUCTION

3.    SCOPE OF PRACTICE WITHIN SOUTHERN SECTOR HUNTER NEW
      E...
WITH A VASCULAR ACCESS

5.   CLINICAL PRACTICE GUIDELINES FOR PERITONITIS TREATMENT
     AND PROPHYLAXIS

SECTION 3.

REFE...
1.SYNOPSIS

The Hunter New England Health (HNEH) Nephrology Nurse Practitioner (NNP) Guidelines
for Clinical Practice is i...
2. INTRODUCTION

In October 1998 the Nurses Amendment (Nurses Practitioners) Act was passed by both
houses of the New Sout...
•   Anticipation and prevention of disease progression and complications for clients
•   Provision of optimal dialysis pre...
6. Utilising problem-solving skills and established evidence based guidelines to
       manage and often complex specific ...
•   Each service provided by the Nephrology Nurse Practitioner is documented and
    recorded in the patients’ progress no...
5. COMMITTEE FOR THE DEVELOPMENT OF CLINICAL GUIDELINES FOR THE
   NEPHROLOGY NURSE PRACTITIONER
   Committee for the Deve...
Reduced waiting times for patients, and increased cost efficiency in a variety of
       clinical settings has been demons...
•   The NNP participates in departmental quality improvement programs
       •   The NNP contributes to the development an...
SECTION 2
              CLINICAL PRACTICE GUIDELINES

CONTENTS

INTRODUCTION

2.1   CLINICAL PRACTICE GUIDELINES FOR THE M...
INTRODUCTION

The manifestations of chronic kidney disease affect every organ system, arising because
the kidneys fail to ...
SECTION 2.1

 CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF
               CHRONIC KIDNEY DISEASE
                   ...
2.1 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT OF
CHRONIC KIDNEY DISEASE (Stages 3-5)
The NNP will monitor
   • Pa...
PHARMACOLOGICAL MANAGEMENT
Prescribe pharmacological therapy (preferred agent) based on type of kidney disease, level of
p...
BETA BLOCKERS
  Australian Drug      Route           Dosage           Therapeutic                    Clinical     Poisons
...
ACE INHIBITORS
 Australian Drug        Route               Dosage          Therapeutic             Clinical         Poison...
impairment; increase to max         Cardiovascular
Comb:                         16mg daily. Lower maximal           Angio...
Hydrochloride                necessary, increase       agent
(Zanidip)                    after at least 2 weeks    Cardio...
DIURETICS
  Australian Drug        Route            Dosage                 Therapeutic         Clinical         Poisons
  ...
sparing Thiazide
                                                                                 diuretic


             ...
SECTION 2.2

  CLINICAL PRACTICE GUIDELINES FOR BIOCHEMICAL
       AND HAEMATOLOGICAL TARGETS



Note that each guideline ...
2.2.1 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT
OF BONE DISEASE, CALCIUM, PHOSPHATE AND PARATHYROID HORMONE

The ...
NON-PHARMACOLOGICAL MANAGEMENT
        o Diet/phosphate restriction
        o Dialysis adequacy
        o Dialysate adequa...
REFERRAL
    o   Dietitian
    o Nephrologist
    o Referral to social worker to ensure home environment is assessed for s...
VITAMIN D ANALOGS
   Australian Drug       Route           Dosage               Therapeutic          Clinical       Poison...
2.2.2 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MAGNESIUM
MANAGEMENT

The NP will monitor
   • Patients response to treatmen...
FORMULARY

                                     MAGNESIUM SALTS
 Australian Drug   Route         Dosage             Therap...
2.2.3. DIAGNOSIS, MANAGEMENT AND FORMULARY FOR ACIDOSIS
MANAGEMENT
The NP will monitor
   • Patients response to treatment...
FORMULARY

                                       SODIUM BICARBONATE
 Australian Drug   Rout            Dosage            ...
2.2.4 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR LIPID MANAGEMENT
The NP will monitor
   • Coronary heart disease risk equiva...
HEALTH PROMOTION
         o    Lifestyle education –modifiable risk factors
                  o Diet with <10% calories fr...
2.2.5 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR ANAEMIA
MANAGMENT
The NP will monitor
     • Results of diagnostic studies
 ...
PHARMACOLOGICAL MANAGEMENT
•   Collaborate with the nephrologist to develop and use an anaemia management plan
    for the...
FORMULARY

                                     HAEMOGLOBIN AND IRON AGENTS
Australian Drug         Route                D...
supervision.   Ferrum H in NaCl 0.9% to 5
                   100mg in       ml over last hour of dialysis
                ...
SECTION 2.3

     CLINICAL PRACTICE GUIDELINES FOR DIALYSIS
                    ADEQUACY




Note that each guideline cont...
2.3 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT
OF DIALYSIS ADEQUACY

The NNP will monitor
•    Prescribed vs. deli...
INVESTIGATIONS
Biochemistry                                       URR
                                                   U...
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
HUNTER-NEW ENGLAND AREA HEALTH SERVICE
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HUNTER-NEW ENGLAND AREA HEALTH SERVICE

  1. 1. SECTION 1 HUNTER-NEW ENGLAND AREA HEALTH SERVICE Nephrology Nurse Practitioner Guidelines for Clinical Practice All NP clinical guidelines on this site have been developed for use in a particular Area Health Service and for specific Nurse Practitioner positions in that AHS, and therefore reflect the specific scope of practice of the position and the operation of the AHS. Therefore, prior to use by Nurse Practitioners in other positions, the Guidelines will need to be reviewed and adapted as necessary to address local scope of practice and Area Health Service needs. The adapted guidelines must also be approved in writing by the AHS CE, as required by the Nurse/Midwife Practitioner Policy Directive 2005_556 prior to use. This guideline has been developed under section 78A of the Nurses act 1991 DRAFT VERSION 1 SEPTEMBER 2006 REVIEW DATE 1
  2. 2. Nephrology Department John Hunter Hospital-Hunter New England Health Service Version 1 – May 2006 The Clinical Practice Guidelines contained within this document have been devised by Lesley Salem, in collaboration with the Committee for the development of Clinical Guidelines for the Nephrology Nurse Practitioner. We endorse their adoption within the Nephrology Department Lower Hunter New England Health The Director General of the Department of Health or the Chief Executives of each Area Health service are required to approve guidelines relating to the functions of nurse practitioners, including the prescription of certain substances. Prior to sign off an Area or Hospital drug Committee must approve drugs identified for use by the Nurse Practitioner. The signed agreement must include the Area Director of Clinical Operations and the Area Director of Nursing Services. ______________________________ ______________________________ Mr. Terry Clout Associate Professor Jennie West Chief Executive Officer, Hunter New Area Director of Nursing, Hunter New England Area Health Service England Area Health Service Date: ____________ Date: ____________ ______________________________ _____________________________ Associate Professor Alastair Gillies Director of Nephrology Services Lower Hunter New England Area Health Service Date: ____________ Date: ____________ ______________________________ ______________________________ Ms Carmel Peek Service Manager/Director of Nursing Division of Medicine John Hunter Hospital Date: ____________ Date: ____________ _____________________________ ______________________________ Date: ____________ Date: ____________ 2
  3. 3. CONTENTS: SECTION 1 1. SYNOPSIS 2. INTRODUCTION 3. SCOPE OF PRACTICE WITHIN SOUTHERN SECTOR HUNTER NEW ENGLAND HEALTH SERVICE 3.1 PRACTICE ENVIRONMENT 3.2 NNP CONSULTANCY/PRACTICE 3.3 PHILOSOPHY OF CARE OF THE NNP 3.4 PROFESSIONAL PRACTICE 3.5 PROCESS OF CARE 3.6 FORMULARY 3.7 DIAGNOSTICS 3.8 RESEARCH 3.9 EDUCATION 3.10 ADMINISTRATION 3.11 COORDINATION 3.12 QUALITY CONTROL AND SAFETY MEASURES 4. PATIENT POPULATION 4.1 CKD 4.2 ESKD COMPLICATION ASSESSMENT 4.3 VASCULAR ACCESS AND DIALYSIS ADEQUACY ASSESSMENT 5. COMMITTEE FOR THE DEVELOPMENT OF CLINICAL GUIDELINES FOR THE NEPHROLOGY NURSE PRACTITIONER 6. DIAGNOSTIC SERVICES 7. PRESCRIBING BY THE NEPHROLOGY NURSE PRACTITIONER 7.1 LEGAL GROUNDS FOR PRESCRIBING 8. REFERRAL PROCESSES 9. OUTCOME MEASURES FOR THE NEPHROLOGY NURSE PRACTITIONER 10. AMENDMENTS SECTION 2 1. CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CHRONIC KIDNEY DISEASE (Stages 3-5) 2. CLINICAL PRACTICE GUIDELINES FOR BIOCHEMICAL AND HAEMATOLOGICAL TARGETS 3. CLINICAL PRACTICE GUIDELINES FOR DIALYSIS ADEQUACY 4. CLINICAL PRACTICE GUIDELINES FOR ESKD PATIENTS 3
  4. 4. WITH A VASCULAR ACCESS 5. CLINICAL PRACTICE GUIDELINES FOR PERITONITIS TREATMENT AND PROPHYLAXIS SECTION 3. REFERENCING – EVIDENCE FOR PRACTICE 4
  5. 5. 1.SYNOPSIS The Hunter New England Health (HNEH) Nephrology Nurse Practitioner (NNP) Guidelines for Clinical Practice is intended for use by Nurse Practitioners working in the area of Nephrology and has been developed in consultation with various stakeholders to provide a framework to assist the Nurse Practitioner with the clinical management of patients with End Stage Kidney Disease (ESKD) These clinical guidelines have been developed as per NSW Health Policy Directive 2005_556 Policy for Nurse/Midwife Practitioners in New South Wales and are supported by three major sets of documents: 1. Two authoritative and internationally recognised Bodies for Clinical Practice Recommendations for the treatment of Kidney Disease KDOQI (www.doqi.org) and CARI (www.cari.org.au) 2. Local policy and protocol for multi-disciplinary and shared care of ESKD and dialysis (Dx) issues (available in the Centre dialysis Unit and Satellite Dialysis units of the Lower HNEH service). 3. Supporting documents pertaining to the scope of practice for a Nurse Practitioner of this Hospital. (www.health.nsw.gov./nursing) The National Australian' Body for the development of evidence based guidelines for nephrology is ‘CARI’ (Caring for Australians with Renal Impairment). This body utilizes best available evidence for their guideline recommendations. Their sources include meta- analysis from sources such as The Cochrane Collaboration as well as being made up of evidence or consensus based position statements on a variety of scientific and medical issues related to kidney disease. It is our intention to include any well-supported changes to current guidelines or additions to current guidelines as they become available. Inevitably each hospital will need to develop its own emphasis of ESKD management to best serve its community and patient population. Within the community dialysis setting (satellite and home dialysis), the predominant strategy is a multidisciplinary and ambulatory care approach that interacts closely with our general practitioners and patients. DISCLAIMER This document reflects what is currently regarded as safe practice and not intended to be construed or to serve as a standard of care. However, as in any clinical situation there may be factors that cannot be covered by a single set of guidelines. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical presentation or treatment plan must be made by the nurse practitioner in light of the clinical data presented by the client and the diagnostic and treatment options available. In making clinical decisions the nurse practitioner should remain cognizant of their level of expertise and take advantage of the expertise of all members of the treating team. 5
  6. 6. 2. INTRODUCTION In October 1998 the Nurses Amendment (Nurses Practitioners) Act was passed by both houses of the New South Wales Parliament. The Amendment allowed for the Nurse Registration Board to authorise certain registered nurses to practice as nurse practitioners. Nurse practitioners are registered nurses working at an advanced practice level who have attained appropriate accreditation with the NSW Nurses Registration Board. Nurse practitioners provide expert nursing care in collaboration with other health professionals in a variety of clinical settings (NSW Health 2003a). The nurse practitioner assists nursing and medical colleagues in clinical decision making for care and intervention. Despite their expanded role, nurse practitioners are nurses, and they approach the provision of patient care with a unique nursing perspective (Patterson and Haddad 1992). This also ensures that nurse practitioners avoid simply carrying out tasks that junior doctors are too busy to do (Walsh 1999). The nurse practitioner therefore does not attempt to replace or replicate medicine but rather complements and contributes to the specialized health care available to patients. 3. SCOPE OF PRACTICE WITHIN SOUTHERN SECTOR HUNTER NEW ENGLAND HEALTH SERVICE 3.1 PRACTICE ENVIRONMENT The goal of the Department of Nephrology is to provide the highest quality secondary and tertiary services to people with End Stage Kidney Disease (ESKD), their family and significant others. With this goal in mind, the Department provides and coordinates a comprehensive package of services including education, dialysis, transplant, clinics, assessment of complications and research. The patients are long term and require ongoing multidisciplinary care. 3.2 NNP CONSULTANCY/PRACTICE • Assessment, triage, intervention and management of clients (male and female 16 years or over at the service within primary, secondary and tertiary settings- see 4.patient population) • As an autonomous practitioner, the NNP operates within specific practice guidelines, as approved by the relevant Area Health Service Chief Executive • Autonomous practitioner within the multidisciplinary team • Networks locally, nationally and internationally • Provision of nephrology expertise to colleagues, health professionals and health care consumers • Liaison with general practitioners • Collaborates with other health providers to optimise client management • Client/patient advocate • Professional leadership, is a role model and resource • Describe and interpret immediate and long term health management outcomes of client group / individuals • Authority to commence, alter and cease medications according to an agreed drug formulary • Request and monitoring of agreed investigations and referrals to other specialist services, including but not limited to: o Biochemical, haematological and viral assays o Radiological investigations • Case management to facilitate education, care and support to clients and their significant others through all stages of Kidney Disease • Provision of a resource and consultancy service in nephrology and dialysis 6
  7. 7. • Anticipation and prevention of disease progression and complications for clients • Provision of optimal dialysis prescription in accordance with clinical findings, biochemical and haematological investigations, assessment, diagnosis, monitoring and symptom management • Within the tertiary hospital environment, the NNP has access to the expertise available for referral, and may request consultation or initiate referral for tilizes ed care as appropriate. • The NNP provides direct patient care, education or nursing consultation within the hospital wards, in the outpatient clinic, in the community satellite dialysis setting and home dialysis setting. • Routine management of patients by the NNP includes physical assessment, ordering and evaluation of diagnostic procedures and laboratory tests, and the formulation of differential diagnoses in collaboration with Nephrologists, Surgeons and other members of the nephrology team. • Actively promotes kidney health awareness and primary prevention • Demonstrates a high standard of professional practice and clinical leadership that incorporates education and research • Maintains involvement in organizational and professional matters such as providing input on working parties and into training programs • Facilitates research and quality improvement in CKD 3.3 PHILOSOPHY OF CARE OF THE NNP • The NNP provides person centered holistic care. • The NNP is a patient advocate who ensures that the patient and their families understand their treatment and ongoing management, therefore encouraging rehabilitation and independence. • All assessment and intervention follows the principles of safe clinical practice. • The NNP uses culturally acceptable language and assessment techniques. 3.4 PROFESSIONAL PRACTICE • The NNP is an autonomous and accountable practitioner, who demonstrates an awareness of the nursing code of ethics and professional conduct. • The NNP demonstrates a role model of advanced practice nursing. • The NNP makes decisions based on optimum knowledge and current standards of practice to ensure the best outcome for the adult patient. • The professional practice critical thinking and reflective practice of the NNP will demonstrate advanced assessment, treatment skills and clinical management skills consistent with evidence-based practice. • The NNP maintains a contemporary knowledge base, achieved by (and not limited to) regular review of professional literature, clinical research, regular attendance at conferences and participation in continuing education 3.5 PROCESS OF CARE The NNP tilizes advanced practice knowledge and skills to manage a caseload of patients, and to make a thorough health assessment of individual renal patients by: 1. Obtaining a comprehensive history of recent health status 2. Physical assessment 3. Differentiating between normal and abnormal findings 4. Initiating and evaluating diagnostic procedures and laboratory tests 5. Analysing information in order to formulate a differential diagnosis in collaboration with the Nephrologists and Surgeons 7
  8. 8. 6. Utilising problem-solving skills and established evidence based guidelines to manage and often complex specific patient needs 7. Prescribing medication from a NNP formulary as defined by guidelines and approved by the Area Health Service Chief Executive 8. Regularly evaluating the health and well-being of patients to ensure optimal outcomes are maintained • The NNP conducts an assessment of the physical and emotional needs of adults undergoing renal replacement therapy • The NNP makes independent and/or collaborative decisions in partnership with individuals/families. • The NNP acts as an advocate for adults on home dialysis and assists families to access services that will keep them at home safely within their family or cultural environment. • The NNP prescribes monitors and evaluates renal replacement therapies • The NNP tilizes psychosocial assessment and counseling skills to provide holistic care and ensure emotionally and physically optimal environment • The NNP collaborates and refers patients to other health professionals when necessary. 3.6 FORMULARY The NP may prescribe and monitor medication within the scope of practice. When prescribing medication, the Nephrology NP will refer to formularies developed within approved guidelines for the nurse practitioner in accordance with section 78A of the Nurses and Midwives Act 1991. The current online Australian Medicines Handbook will be the primary reference. 3.7 DIAGNOSTICS The Nephrology NP may request and report on certain diagnostic tests in order to monitor some physiologic parameters. These diagnostic investigations will be listed in the clinical practice guidelines. 3.8 RESEARCH The Department of Nephrology as part of the Division of Medicine John Hunter Hospital is committed to ongoing research and to maintaining a standard of excellence in clinical care. The NNP will: • Undertake, initiate and participate in relevant renal research projects, especially those aimed at supporting evidence based care in CKD patients 3.12 EDUCATION • Assessment of individual learning needs for health professionals, clients and their significant others • Education and counseling clients in self-care, disease management and prevention • Promotion of a safe environment • Maintains own contemporary knowledge base, achieved by (and not limited to) regular review of professional literature, clinical research, regular attendance at conferences and participation in continuing education 3.12 ADMINISTRATION • Uses the managerial process to create an environment conducive to optimal public health and professional nursing practice 8
  9. 9. • Each service provided by the Nephrology Nurse Practitioner is documented and recorded in the patients’ progress notes 3.12 COORDINATION • Collaboration expert within the multidisciplinary team to determine and achieve realistic health care goals • Liaison with, coordination and support for other health professionals involved with clients 3.12 QUALITY CONTROL AND SAFETY MEASURES • Regular meetings are conducted with the dialysis physician where the clinical care of each patient is discussed • The Nurse Practitioner has direct access to the dialysis physician at all times to discuss urgent or difficult case findings. This ongoing mentorship provides a unique opportunity for ongoing education as well as ensuring that patient care is optimized which also serves as a ‘safety net’ to review medical decisions 4. PATIENT POPULATION The NNP shall deliver care to patients (16 years onwards) with chronic kidney disease (CKD), end stage kidney disease (ESKD) and ESKD patients receiving renal replacement (RRP) Description of these patient populations: 4.1 CKD Patients who have been identified with impaired kidney function requiring lifelong management to achieve remission and/or regression of their kidney disease. This shall be done in conjunction with the GP’s, Nephrologist and Nephrology Nurse Practitioner. These patients also require specialist and multidisciplinary care in their preparation for renal replacement therapy or palliative care once they progress to ESKD including education about dialysis or palliative care choices as well as vascular access preparation. 4.2 ESKD COMPLICATION ASSESSMENT The manifestations of chronic kidney disease affect every organ system. Care for ESKD patients requires prevention or early detection and management of ESKD manifestations though regular review. 4.3 VASCULAR ACCESS AND DIALYSIS ADEQUACY ASSESSMENT Patients with ESKD who receive renal replacement therapy are dialysed in either: The Centre dialysis unit of the major tertiary referral hospital (John Hunter Hospital) In the community either at home or in a Satellite Dialysis Unit (remote from the tertiary referral hospital and unsupported by full time medical officer support). Nursing staff, the Nephrology Nurse Practitioner, Medical staff and other health professionals manage the dialysis and vascular access care. This care is through regular outpatient review as well as assessment while undertaking dialysis. Dialysis patients require ongoing management of their dialysis prescription, as well as vascular access management and education. 9
  10. 10. 5. COMMITTEE FOR THE DEVELOPMENT OF CLINICAL GUIDELINES FOR THE NEPHROLOGY NURSE PRACTITIONER Committee for the Development of Clinical Guidelines for the Nephrology Nurse Practitioner These Clinical Practice Guidelines have been devised by Mrs. Lesley Salem RN, Neph/TCert, N.Sc/Apheresis Cert, NP, Grad Dip N.Sc and Mrs. Barbara Harvie RN, MN (Advanced Practice), MN (Nurse Practitioner), Grad Dip Nsg (Nephrology), incorporating current and relevant nursing and medical literature, and in collaboration with contributions from the following department representatives who have formed the guideline committee: Mrs. Lesley Salem Mrs. Barbara Harvie Associate Professor Alastair Gillies Mrs. Carmel Peek Mrs. Susan Brazil 6. DIAGNOSTIC SERVICES The NNP may request and monitor certain investigations relating to specific clinical practice guidelines. Diagnostic request forms may be signed by the Nurse Practitioner for appropriate investigations within diagnostic radiology and laboratory services • Criteria and indications for diagnostic testing are identified within the specific treatment plans as ratified by the Medical Director of the Nephrology Department JHH in consultation with appropriate delegates of other departments • Lines of communication are established to report adverse results to the Medical Director of the Nephrology Department JHH, or his/her delegate and health care team • Appropriate investigations may include but are not limited to: o Blood tests, Urine tests o Wound culture o More advanced studies following consultation with the medical officer • Referrals for radiology must be written and assigned by the Nurse Practitioner as described in the Medicare Benefits Schedule 2004 and State Records Act. • The NNP can only request plain radiographic examinations consistent with their professional discipline. This may include, but is not limited to: o Chest X-ray and abdominal X-ray o Duplex and ultrasound o Fistulogram and loopagram o Doppler o Bone density and skeletal surveys • Nurse Practitioners requiring other than plain radiographic examinations must refer the patient to a Medical Officer • If the performing Radiographer has any doubt in the validity of the request from a clinical or radiation protection perspective, he/she has the right to discuss the request with the referring Nurse Practitioner, or insist on confirmation from a Medical Officer. o Nurse Practitioners cannot request plain examinations that involve multiple regions and or areas on the one patient. A Medical officer must make these requests. 7. PRESCRIBING BY THE NEPHROLOGY NURSE PRACTITIONER 10
  11. 11. Reduced waiting times for patients, and increased cost efficiency in a variety of clinical settings has been demonstrated by utilising a Nurse Practitioner who can legally administer drugs from a pre-agreed hospital formulary within a multidisciplinary setting (NSW College of Nursing 2003). • The NNP may prescribe and monitor medication within the scope of practice • When prescribing medication, the NNP will refer to formularies developed for the nurse practitioner in accordance with section 78A (2) of the Nurses Act 1991. • The current online Australian Medicines Handbook (AMH) will be the primary reference. • The drugs contained within this guideline are based on the Australian Medical Handbook. • It is the responsibility of the Nurse Practitioner to ensure correct dosage using the most recent AMH. • Medications may include agents prescribed to; manage regression and remission of CKD, the manifestations of ESKD, achieve effective dialysis and treat adverse events of dialysis and dialysis access. The prescription of medications should be carried out with appropriate client and family education about medications and their side effects. • Will document, maintain and update medical records for all medication changes • May authorise the continuation of existing medications (as per Formulary list) 7.1 LEGAL GROUNDS FOR PRESCRIBING This following formulary (in SECTION 2) provides for the poisons and restricted substances that may be possessed, used, supplied or prescribed by Nurse Practitioners under section 17A of the Poisons and Therapeutic Goods Act (1966) and forms part of approved nurse practitioner guidelines, in accordance with section 78A(2)(a) of the Nurses Act (1991). 8. REFERRAL PROCESSES Following assessment and intervention, the NNP may make and arrange appropriate referral to departments or teams within the facilities of HNEH and other services within the health care system of New South Wales. As part of the referral process consumers are given advice and specific information about follow-up arrangements and referral details that are made for them. Referrals may be made, but not limited to the following services and organisations: Dietitian Social Worker General Practitioner Psychologist Renal Physician Radiologist Occupational therapy Diabetic Service Podiatry Non-government Organisations e.g. Aged Care Assessment Teams Kidney Australia, HANKA Palliative Care Pain Management 9. OUTCOME MEASURES FOR THE NEPHROLOGY NURSE PRACTITIONER Outcome indicators: The NNP performance will be assessed against relevant outcome indicators, including but not limited to: • The NNP participates in evaluation of the CKD/Dialysis program’s clinical indicators in order to provide cost effective, high quality renal replacement therapy for all adults across NSW 11
  12. 12. • The NNP participates in departmental quality improvement programs • The NNP contributes to the development and ongoing review of protocols specific to nephrology practice. 10. AMENDMENTS Review of the Guideline This guideline was developed in May 2006. It should be viewed as an initial guide and a dynamic document that should be reviewed and revised by those who use it as the basis of their local guideline. 12
  13. 13. SECTION 2 CLINICAL PRACTICE GUIDELINES CONTENTS INTRODUCTION 2.1 CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CHRONIC KIDNEY DISEASE (Stages 3-5) 2.2 CLINICAL PRACTICE GUIDELINES FOR BIOCHEMICAL AND HAEMATOLOGICAL TARGETS 2.3 CLINICAL PRACTICE GUIDELINES FOR DIALYSIS ADEQUACY 2.4 CLINICAL PRACTICE GUIDELINES FOR ESKD PATIENTS WITH A VASCULAR ACCESS 2.5 CLINICAL PRACTICE GUIDELINES FOR PERITONITIS TREATMENT AND PROPHYLAXIS 13
  14. 14. INTRODUCTION The manifestations of chronic kidney disease affect every organ system, arising because the kidneys fail to perform normal excretory, regulatory, metabolic and biosynthetic functions. Organ system involvement includes cardiovascular, bone, neuromuscular, blood, skin, reproductive, gastrointestinal and serosal. Table 1: Primary consequences of chronic kidney disease MECHANISM EXAMPLE CONSEQUENCE Decreased excretion Uraemic toxins, including Uraemic syndrome nitrogenous wastes Salt & water Volume overload, hypertension Phosphate Hyperparathyroidism, metastatic calcification Acid Metabolic acidosis Potassium Hyperkalaemia Decreased Erythropoietin Anaemia biosynthesis Activation of vitamin D Osteomalacia, hyperparathyroidism Altered metabolism Dyslipidaemia Atherogenesis Sex hormones Abnormal reproductive function Nephrological care of patients with CKD or ESKD can be divided into 5 major categories. CARI Guidelines have used these categories for their recommendations. These are; 1. CKD 2. Biological and Haematological targets 3. Dialysis adequacy 4. Vascular Access 5. Peritonitis treatment and prophylaxis Each of the following guidelines outline the NNP agreed assessment, investigative, management and formulary for patients with CKD and ESKD. The guideline content has been arranged in the following format under each category. Each Guideline Category Explanation Section 1 This section contains best available evidence for Components of management treatment aims. For Nephrology this section contains CARI, DOQI and local recommendations Section 2 -Tables containing assessment, investigations, non- Diagnosis, Therapy and pharmacological management, pharmacological Formulary investigations, health promotion and follow-up. -Tables of drugs (set out as per NSW Department of Health recommendations) that the NNP is permitted to prescribe or adjust 14
  15. 15. SECTION 2.1 CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CHRONIC KIDNEY DISEASE (Stages 3-5) Note that each guideline contains assessment, investigation, aims of treatment as represented in the relevant CARI Guideline, management, health promotion and prevention, follow up and formulary all relevant to the Nephrology Nurse Practitioners scope of practice DIAGNOSIS, MANAGEMENT and FORMULARY Guideline developed according to section 78(A)(2), Nurses Act 1991 These guidelines represent a general guide to appropriate clinical practice, and are inclusive, not prescriptive. The information aims to provide the Nurse practitioner with information on which decisions can be made. 15
  16. 16. 2.1 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT OF CHRONIC KIDNEY DISEASE (Stages 3-5) The NNP will monitor • Patients response to treatment plan • Results of diagnostic studies • Adherence to treatment plan • Progression of CKD • For development of cardiovascular disease (CVD) or CVD risk factors DIAGNOSIS Natural history • Ascertain the presence and type of CKD • Ascertain the presence of CVD or CVD risk factors Physical examination • BP, weight, respiratory rate and quality, heart sounds, breath sounds, dependent and peripheral oedema, neck vein distension, jugular venous pressure • Calculate BMI • Assess for signs and symptoms of other end-organ damage Identify barriers to self management INVESTIGATIONS Biochemistry GFR estimation Fasting lipids Presence and level of proteinuria ECG Examination of urine sediment Fasting and postprandial serum glucose Routine urinalysis Biochemical analysis Haematological analysis Radiological investigations Urine examination Blood, urine, cultures, sediment Microbiology Urine Cardiovascular ECG Imaging Renal ultrasound NON-PHARMACOLOGICAL MANAGEMENT Health promotion and prevention o Referral o Weight loss o Order laboratory and diagnostic studies as appropriate o Initiate work-up for secondary HTN if indicated o Collaborate with and provide support and education for primary care providers and other health care professionals to enhance patient screening for CKD and early referral 16
  17. 17. PHARMACOLOGICAL MANAGEMENT Prescribe pharmacological therapy (preferred agent) based on type of kidney disease, level of proteinuria, and hypertension according to CARI guidelines, including but not limited to: a) Diabetic kidney disease o ACE inhibitors (ACE-I) or Angiotensin receptor antagonists (ARA), o Diuretics, beta-blocker or calcium channel blocker b) Non-diabetic kidney disease (spot urine protein/creatinine ratio >200mg/g o Diuretics, ACE-I or ARA o Diuretic, then beta-blocker, calcium channel blocker c) Nondiabetic kidney disease (spot urine protein/creatinine ratio <200mg/g o Diuretic, then ACE-I, ARA, beta-blocker or calcium channel blocker See attached formulary of approved medications to meet: o Biochemical targets; o Haematological targets HEALTH PROMOTION AND PREVENTION o Lifestyle education for patient o Collaborate with and provide support and education including but not limited to, primary care providers and other health care professionals to enhance patient screening, early referral and management of CKD REFERRAL o GP o Nephrologist o Access surgeon o Renal dietitian for nutritional assessment and advice Specialist-Nephrologist, surgeon -As per Clinical Guidelines for specific symptoms FOLLOW UP o Monitor for complications and side effects of pharmacological therapy o Order laboratory and diagnostic investigations as appropriate o To assess response to antihypertensive therapy o Monitor adherence to treatment plan o Adjust medication regimen based on patient response - As per the clinical guideline FORMULARY VITAMINS AND MINERALS Australian Drug Route Dosage Therapeutic Clinical Poisons (generic name) Class presentation Schedule Ascorbic Oral 1-3 tablets daily Vitamins Vit. B and C Unscheduled acid,vitamins B deficiency group (Multi B forte) 17
  18. 18. BETA BLOCKERS Australian Drug Route Dosage Therapeutic Clinical Poisons (generic name) Class presentation Schedule Atenolol (Hexal, Oral 100mg twice weekly to Cardiovascular Hypertension S4 Noten, Tenormin, 50mg daily Beta-adrenergic ,all grades Tensig) blocker incl renal origin Carvedilol Oral Initially - 12.5mg daily for Cardiovascular Hypertension S4 (Dilatrend) 2 days; Maintenance 25mg Beta-adrenergic ;adjunctive daily, increased in 2 week blocker treatment in intervals to a maximum of symptomatic 50mg daily or 2 divided mild to doses severe congestive heart failure Labetalol (Presolol) Oral Initially 100mg bd, Cardiovascular All grades of S4 increased each week; Antihypeertensive hypertension maintenance 200-400mg Alpha blocker and non bd selective beta- blocker Metoprolol (Minax, Oral Initially, 50-100mg daily for Cardiovascular Hypertension S4 Betaloc, Lopresor, 1 week. Maintenance 50- Beta-adrenergic ; angina Metoprolol) 100mg once or twice daily blocker pectoris; suspected or definite MI Oxprenolol Initially 40-80mg bd, Cardiovascular Angina S4 (Corbeton) increased each week. Beta-adrenergic pectoris; Maintenance, 80-160mg blocker cardiac bd arrhythmias; hypertension Pindalol Oral Initially, 5mg twice daily, Cardiovascular Hypertension S4 (Barbloc, Visken) increased by 10 mg daily Beta-adrenergic ; angina every 3–4 weeks. blocker pectoris Maintenance: 10-30mg (prophylaxis), daily in 2-3 divided doses cardiac arrhythmias Propranolol Oral Initially 20-40mg bd; Cardiovascular Hypertension S4 Hydrochloride increased by the same Beta-adrenergic ; angina (Deralin, Inderal) amount each week. blocker pectoris; Maintenance, 120-320mg some cardiac daily in 2-3 divided doses dysrhythmias Sotalol Oral Initially 40–80 mg bd; Antiarrhythmic Class III S4 Hydrochloride increase according to Cardiovascular antiarrhythmic (Solavert, Sotacor, response to 160 mg bd action for Sotahexal) prevention and treatment of supraventricul ar and ventricular arrhythmias 18
  19. 19. ACE INHIBITORS Australian Drug Route Dosage Therapeutic Clinical Poisons (generic name) Class presentation Schedule Captopril (Capoten) Oral Initially 6.25mg bd Anti-hypertensive Hypertension S4 agent (alone or with Cardiovascular other ACE inhibitor antihypertensi ves); heart failure (with a diuretic) Enalapril (Renitec) Oral Initially 2.5mg daily Anti-hypertensive Essential and S4 agent renovascular Cardiovascular hypertension; ACE inhibitor CHF (with a diuretic); LV dysfunction where LVEF < 35% Fosinopril (Monopril, Oral Initially 2.5mg daily Anti-hypertensive Mild to S4 Monoplus) agent moderate Cardiovascular hypertension; ACE CHF in inhibitor+diuretic conjunction with a diuretic Perindopril Oral Initial dose according to Anti-hypertensive Hypertension S4 (Coversyl) creatinine clearance: 30- agent ; CHF Cardiovascular 60 mL/min 2mg daily; 15- ACE inhibitor 30 mL/min, 2mg alternate days; Quinapril (Accupril) Initially 2.5–5 mg daily. Anti-hypertensive Hypertension S4 agent and CHF Cardiovascular ACE inhibitor Ramipril (Tritace, Oral Initially 1.25mg daily; Anti-hypertensive Hypertension S4 Ramace) double at intervals of 2– agent (exc Cardiovascular renovascular); 3 weeks, depending on ACE inhibitor heart failure tolerance; up to 5mg (post MI); daily prevent renal failure progression in persistent proteinuria (> 1 g/day); reduce cardiovascular, cerebrovascular risk Trandolapril Oral Initally 1.5mg daily Anti-hypertensive Hypertension; S4 (Gopten) agent left ventricular Cardiovascular dysfunction ACE inhibitor post-MI ANGIOTENSIN II ANTAGONISTS Australian Drug Route Dosage Therapeutic Clinical Poison Class Schedule (generic name) presentation Candesartan Oral Usually 8mg daily; start at 4mg Anti- Hypertension S4 cilexetil (Atacand) daily in severe renal hypertensive agent 19
  20. 20. impairment; increase to max Cardiovascular Comb: 16mg daily. Lower maximal Angiotensin II receptor Candesartan/ dose in severe renal impairment antagonist Hydrochlorothiazide (Comb + diuretic) Eprosartan Oral Initial: 600mg daily; start at Anti- Hypertension S4 Mesylate (Teveten) 400mg daily in people taking hypertensive agent diuretics, hepatic or renal Cardiovascular impairment, or elderly; may be Angiotensin II Comb: Eprosartan/ increased if necessary to antagonist Hydrochlorothiazide 800mg daily. Irbesartan (Karvea) Oral Usually 150mg daily; start at Anti- Hypertension; S4 75 mg daily in haemodialysed hypertensive delay renal agent disease and/or elderly (>75 years) Cardiovascular Comb: Irbesartan/ patients; can be increased to progression in Angiotensin II hypertensive Hydrochlorothiazide 300mg daily. antagonist type II AvaproCT, Prevention of renal disease diabetes with Karvezide progression: Maintain 300mg persistent daily microalbuminu ria, proteinuria Losartan Poassium Oral Usually 50mg daily; start at Anti- Hypertension S4 (Cozaar) 25mg daily in people taking hypertensive (alone or with agent other 50mg, , 100mg diuretics; increase after 3– Cardiovascular tablets 6 weeks if necessary to 100mg antihypertensi Angiotensin II ves); renal daily. antagonist protection in NIDDM patients with proteinuria Telmisartan Oral Usually 20–40mg daily; can be Anti- Hypertension S4 (Micardis) increased to 80mg daily hypertensive agent Comb: Telmisartan Cardiovascular Hydrochlorothiazide Angiotensin II 40mg, 80mg antagonist 40mg/12.5mg, 80mg/12.5mg tablets CALCIUM CHANNEL BLOCKERS Australian Drug Route Dosage Therapeutic Clinical Poisons (generic name) Class presentation Schedule Nifedipine, Oral Initially: 30 mg daily; Anti-hypertensive Hypertension S4 (Nifecard, Adefin, titrate over 7-14 days agent Cardiovascular ; angina Calcium channel Nypine, Adalat to max 120 mg daily blocker Nyefax, Nifehexal) according to response Amlodipine Besylate Oral Initially 2.5-5mg daily, Anti-hypertensive Hypertension S4 (Norvasc) increased over 1- agent Cardiovascular ; angina Calcium channel 2 weeks to max 10mg blocker (chronic daily stable) Felodipine (Felodur Oral Initially 5mg daily, Anti-hypertensive Hypertension S4 ER) increased over 1– agent Cardiovascular Calcium channel 2 weeks to max 10 mg blocker daily Lercanidipine Oral Initially 10 mg daily; if Anti-hypertensive Hypertension S4 20
  21. 21. Hydrochloride necessary, increase agent (Zanidip) after at least 2 weeks Cardiovascular up to a maximum of Dihydropyridine 20 mg daily Calcium antagonist Diltiazem Oral Initial: 30mg 3–4 times Anti-hypertensive Hypertension S4 Hydrochloride daily, increase up to (some antianginal) ; chronic (Cardizem, 180–240mg daily. agent stable angina Cardizem,CD Controlled release: Cardiovascular Calcium channel Vasocardol Coras Initial 180mg daily; blocker Diltahexal, Dilzem) increase up to 360mg daily. Verapamil Oral Initial: oral 80mg 2– Anti-hypertensive Hypertension S4 Hydrochloride 3 times daily; agent Cardiovascular , angina, Calcium channel (Anpec, Isoptin) maintenance: 160mg blocker tachyarrhythmias, 2–3 times daily. atrial fibrillation, flutter with rapid ventricular response 21
  22. 22. DIURETICS Australian Drug Route Dosage Therapeutic Clinical Poisons (generic name) Class presentation Schedule Frusemide (Lasix, Oral Hypertension: 80mg in 2 Diuretic Oedema; S4 Urex) divided doses; Oedema: Cardiovascular hypertension 80mg single dose; system increase if needed by 20- Loop diuretic 40mg greater than or equal to 6-8 hours after previous dose; max 400mg/day Bumetanide (Burinex) 0.5-4mg once or twice Diuretic Oedema S4 daily, adjusted for clinical Cardiovascular response system Loop diuretic Ethacrynic Acid 50–200 mg once or twice Diuretic Pulmonary, S4 (Ethacryn) daily. Cardiovascular renal oedema; system CHF; nephrotic Loop diuretic syndrome in children > 2 yrs Chlorthalidone Hypertension, diabetes Diuretic Essential S4 (Hygroten) insipidus: Cardiovascular hypertension; 12.5–25mg daily; system stable Oedema: 12.5-50mg Thiazide chronic heart daily; alt day dosing analogue failure (mild possible. diuretic to mod.) Hydrochlorothiazide Oral Hypertension: Initial 12.5- Diuretic Hypertension S4 (Dithiazide) 50mg (usu 25-50 mg) Cardiovascular , oedema daily in 1-2 doses; adjust system up to max 100mg/day as Thiazide needed; Oedema: 25- diuretic 100 mg once or twice daily, can be intermittent (alt. days or 3-5 days/week); Indapamide (Natrilix, 1.25–2.5 mg once daily. Antihypertensive Hypertension S4 Dapa-Tabs, Insig agent Napamide,Indapamide Cardiovascular Indahexal 2.5mg system tablets (combinations differ) Spironolactone Oral Essential hypertension: Diuretic Essential S4 (Aldactone, Spiractin) 50-100mg/day. CCF: Cardiovascular hypertension; oedematous initial 100mg/day; adjust system disorders incl gradually Maint:enance: Aldosterone CCF, nephrotic 25-200mg/day. antagonist syndrome; Hypokalaemia: lowest (Potassium – malignant hypertension effective dose; increase sparing) (adjunct); gradually to 100 mg/day hypokalaemia (prophylaxis); Hydrochlorothiazide Oral 1-2 tablets daily Diuretic Oedema; S4 (Moduretic) Cardiovascular hypertension system Potassium 22
  23. 23. sparing Thiazide diuretic DETOXIFYING AGENTS Australian Drug Route Dosage Therapeutic Clinical Poisons (generic name) Class presentation Schedule Calcium polystyrene Oral 15-30gm daily, as Detoxifying agent Hyperkalaemia S4 sulfonate ordered (Calcium Resonium) Sodium polystyrene Oral 15-30gm daily, as Detoxifying agent Hyperkalaemia S4 sulfonate (Resonium ordered A) Table 6-4 Coexisting conditions and antihypertensive choice (Australian Medicines Handbook, accessed 25.11.05) Coexisting condition Drugs with favourable effect Diabetes with microalbuminuria ACE inhibitors, angiotensin II antagonists Heart failure ACE inhibitors, beta-blockers (carvedilol, slow-release metoprolol, bisoprolol), thiazide diuretics, angiotensin II antagonists Post MI beta-blockers (except oxprenolol, pindolol), ACE inhibitors (left ventricular dysfunction) Angina beta-blockers (except oxprenolol, pindolol), calcium channel blockers Coexisting condition Drugs with unfavourable effect asthma, COPD beta-blockers1 bradycardia, second or third degree beta-blockers, calcium channel blockers (except dihydropyridines) atrioventricular block heart failure verapamil, diltiazem, selective alpha-blockers gout diuretics renovascular disease, pregnancy ACE inhibitors, angiotensin II antagonists severe peripheral vascular disease beta-blockers 1 cardioselective beta-blockers (eg atenolol, metoprolol) may be used cautiously in mild-to-moderate reactive airways diseases 23
  24. 24. SECTION 2.2 CLINICAL PRACTICE GUIDELINES FOR BIOCHEMICAL AND HAEMATOLOGICAL TARGETS Note that each guideline contains assessment, investigation, aims of treatment as represented in the relevant CARI Guideline, management, health promotion and prevention, follow up and formulary all relevant to the Nephrology Nurse Practitioners scope of practice DIAGNOSIS, MANAGEMENT and FORMULARY 2.2.1 BONE DISEASE, CALCIUM, PHOSPHATE AND PARATHYROID HORMONE 2.2.2 MAGNESIUM 2.2.3 ACIDOSIS 2.2.4 LIPIDS 2.2.5 ANAEMIA Guideline developed according to section 78(A)(2), Nurses Act 1991 These guidelines represent a general guide to appropriate clinical practice, and are inclusive, not prescriptive. The information aims to provide the Nurse practitioner with information on which decisions can be made 24
  25. 25. 2.2.1 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT OF BONE DISEASE, CALCIUM, PHOSPHATE AND PARATHYROID HORMONE The NP will monitor • Patients response to treatment plan (Diet, medications, exercise) • Results of diagnostic studies • Adherence to treatment plan • For development of bone disease and signs of extra-skeletal calcification DIAGNOSIS Natural history o Assess for risk factors for osteoporosis (older age, post menopausal status, race, vitamin D deficiency, medications, malignancy, prolonged immobilization) o History of injuries o Adherence to diet, medication and treatment regimens (include -Current medications and supplements, GI history) o Financial constraints in meeting dietary and medication regimens Physical examination o Muscle strength, gait, and range of motion (limitations) o Joints for enlargements, swelling, stiffness and tenderness o Bone pain o Skin for local tissue injury, maculae, papules or purities o Eyes for visible injury local inflammation o Extremities (vascular insufficiency) o BP and pulse Dialysis prescription (hours, dialysate) INVESTIGATIONS Biochemistry Predialysis blood sample should be used. (Level B evidence) Calcium, phosphate, ionized calcium, albumin, PTH Estimation of the calcium x phosphate product, alkaline phosphatase, vitamin D, PTH, Aluminum Radiological Plain x-ray (determination of metastatic calcification) examination Bone x-ray (for patient with fractures or known risk of osteoporosis) Cardiovascular ECG Exclude -Hypomagnesaemia -Vitamin D deficiency -Primary Hyperparathyroidism -Aluminium exposure Differentiate -Decreased renal excretion & increased phosphate load -Diabetic management/insulin -Reduced dietary intake (with hypophosphataemia) 25
  26. 26. NON-PHARMACOLOGICAL MANAGEMENT o Diet/phosphate restriction o Dialysis adequacy o Dialysate adequacy-correct calcium concentrate PHARMACOLOGICAL MANAGEMENT o Phosphate binder o Calcium supplement o Vitamin D analogue (Dose adjustment) Practice tips phosphate management o Calcium carbonate and acetate, Magnesium carbonate, Aluminium hydroxide and Sevelamer (RenaGel) are effective phosphate binders. o Dissociation of phosphate binders may differ between manufacturers and formulations. It may be useful to try a different formulation if phosphate control is poor despite patient compliance. o Ranitidine may reduce phosphate binding by calcium carbonate. Other drugs that increase gastric pH may have a similar effect. o Solubility and efficacy differences between calcium acetate and carbonate may not be present if calcium carbonate is taken on an empty stomach shortly before meals. o Although intestinal calcium uptake has been reported to be lower with calcium acetate than with calcium carbonate, both may induce hypercalcaemia. o Adequate phosphate control may necessitate the use of aluminium-containing phosphate binders although this should be minimised. o Calcium-containing phosphate binders should be used with caution in patients o With Vitamin D administration -Monitor for hypercalcaemia and over suppression of PTH HEALTH PROMOTION AND PREVENTION o Assess patients understanding of and educate patient on; Kidney function and calcium and phosphate homeostasis Dialysis prescription and its relationship to disorders of bone metabolism (Dialysis compliance) Consequences of alterations in bone metabolism • Bone disease • Extra-skeletal calcification • Development of cardiovascular disease Signs and symptoms of • Disorders of bone metabolism • Extra-skeletal calcification • Hypo-and hyperphosphphataemia • Hypo-and hypercalcaemia Reducing mobility hazards in the home and work environment Exercise to maintain strength and mobility Prevention and management of bone disease and extraskeletal calcification (Medication compliance/education) Dietary education & information 26
  27. 27. REFERRAL o Dietitian o Nephrologist o Referral to social worker to ensure home environment is assessed for safety and financial difficulties are addressed o Referral to physiotherapy and Occupational Therapists for mobility assessment and assistance FOLLOW UP o 4-8 weeks following commencement of or manipulation of phosphate binders o PTH every 3 months o Bone density as required FORMULARY PHOSPHATE BINDERS Australian Drug Route Dosage Therapeutic Clinical Poisons (Generic name) Class presentation Schedule Calcium Carbonate Oral 1-2 tablets with food as Phosphate Hyperphosphatae Unscheduled (Caltrate) directed and titrated to pre- binder mia in chronic dialysis serum phosphate renal failure level Calcium supplementatio n Calcium Oral 1-2 tablets as needed Phosphate Hyperphosphatae Unscheduled Carbonate (titrated to phosphate/ binder mia in chronic (Titralac) calcium levels) renal failure Calcium supplement ation Calcium carbonate; Oral Adults- 1-2 tablets with Phosphate Hyperphosphatae Unscheduled magnesium food as directed. binder mia in chronic carbonate (Rennie) Tablets, calcium carbonate renal failure 680mg, magnesium Calcium carbonate (heavy) 80mg; supplementation sucrose, saccharin Aluminum Oral As prescribed and titrated to Phosphate Phosphate Unscheduled Hydroxide serum phosphate and serum binder binder in aluminium levels chronic renal failure Magnesium Salts Oral As instructed-titrated to Phosphate Phosphate binder Unscheduled (Magnesium magnesium/ aluminium binder in chronic renal carbonate, serum levels and failure magnesium phosphate binding hydroxide and requirements magnesium trisilicate) Tablets, liquid 27
  28. 28. VITAMIN D ANALOGS Australian Drug Route Dosage Therapeutic Clinical Poisons (generic name) Class presentation Schedule Calcitriol (Rocaltrol, Oral 0.25mcg daily; increase by Vitamin D Hyperparathyroidism S100 Citrihexal, Kosteo, 0.25mcg daily at 2-4 week substance Hypocalcaemia in Sitriol) intervals according to hypophosphataem response; Decrease by ic rickets, 0.25mcg daily when Hypoparathyroidis normocalcaemic. m, renal NB Titrate only in osteodystrophy, consultation. chronic renal dialysis 28
  29. 29. 2.2.2 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MAGNESIUM MANAGEMENT The NP will monitor • Patients response to treatment plan • Results of diagnostic studies • Adherence to treatment plan DIAGNOSIS o Natural history o Physical examination o Dialysis prescription (hours, dialysate) INVESTIGATIONS Biochemistry Measure serum magnesium monthly in patients who are taking magnesium salts or using dialysate with a magnesium concentration out of the range 0.25- 0.50 mmol/L. Measure magnesium in other dialysis patients 3-6-monthly Cardio ECG examination Exclude Gut losses – diarrhoea Excessive ingestion (supplements/phosphate binder use) Poor diet NON-PHARMACOLOGICAL MANAGEMENT o Diet o Dialysis adequacy o Dialysate adequacy PHARMACOLOGICAL MANAGEMENT o Magnesium/aluminium oral phosphate binders o Magnesium supplementation with magnesium salts HEALTH PROMOTION o Dietary education o Medication compliance and education o Dialysis compliance REFERRAL o GP o Nephrologist FOLLOW UP o Regular magnesium check 3 monthly after commencing supplementation 29
  30. 30. FORMULARY MAGNESIUM SALTS Australian Drug Route Dosage Therapeutic Clinical Poisons (Generic name) Class presentation Schedule Magnesium Salts Oral As instructed-titrated Vitamins and Magnesium Unscheduled (Magnesium to magnesium/ minerals supplementation Aspartate, aluminium serum levels 30
  31. 31. 2.2.3. DIAGNOSIS, MANAGEMENT AND FORMULARY FOR ACIDOSIS MANAGEMENT The NP will monitor • Patients response to treatment plan • Results of diagnostic studies • Adherence to treatment plan DIAGNOSIS Natural history Physical examination Dialysis prescription (modality, hours, Dialysate) INVESTIGATIONS Biochemistry Pre dialysis estimation of serum bicarbonate Exclude Respiratory conditions leading to/or exacerbating metabolic acidosis NON-PHARMACOLOGICAL MANAGEMENT o Diet/protein restriction o Dialysis adequacy o Dialysate adequacy o Decrease intradialytic weight gain due to fluid retention o Avoid interdialytic hypo tension PHARMACOLOGICAL MANAGEMENT o Oral alkali (exogenous alkali administration) HEALTH PROMOTION AND PREVENTION o Dietary education o Medication compliance and education o Dialysis compliance o Compliance with fluid restrictions REFERRAL o GP o Nephrologist FOLLOW UP o Review serum bicarbonate level when; o When starting oral alkali-one month then three monthly o Commencing dialysis then with regular follow up three monthly 31
  32. 32. FORMULARY SODIUM BICARBONATE Australian Drug Rout Dosage Therapeuti Clinical presentation Poisons (generic name) e c Class Schedule Sodium Oral Commence cautiously with Metabolic Renal failure associated Unscheduled Bicarbonate 1 capsule daily, increasing acidosis with renal tubular acidosis (SodiBic) dosage steadily if repeated in which bicarbonate bicarbonate levels indicate replacement becomes the need. necessary. Capsules, 840 mg: 32
  33. 33. 2.2.4 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR LIPID MANAGEMENT The NP will monitor • Coronary heart disease risk equivalent conditions (coronary artery disease, peripheral arterial disease, abdominal aortic aneurysm) • For modifiable risk factors for cardiovascular disease • Results of laboratory tests • Response to treatment plans (CVD risk factor reduction, lifestyle changes, diet, medication regimen) • Adherence to treatment plan DIAGNOSIS Natural history • Lifestyle habits (smoking, alcohol consumption and exercise frequency • Adherence to dietary and medication regimens Physical examination • Weight and BMI, BP and heart rate, apical and peripheral pulses, respiratory rate and quality, peripheral oedema Assess for; • CVD risk-equivalent conditions -Clinical coronary heart disease, Peripheral arterial disease, abdominal aortic aneurysm, diabetes mellitus • Modifiable risk factors for CVD (Smoking, hypertension, low HDL, family history of CVD, age, risk factors of CKD-anaemia, hyperhomocysteinaemia, disorders of calcium and phosphate homeostasis, volume overload) INVESTIGATIONS Biochemistry UEC Calcium, phosphate, PTH Lipid profile-Cholesterol/ Triglycerides/ LDL (low density lipoprotein, HDL (high density lipoprotein) Hepatic function LFT’s Homocystein Haematology Hb and HCT Exclude Liver disorders NON-PHARMACOLOGICAL MANAGEMENT • Health promotion o Education, lifestyle changes, fluid restriction • Referral dietitian • Order diagnostic studies and frequency of laboratory testing PHARMACOLOGICAL MANAGEMENT • Treat dyslipidaemias o Statins o Fish oil (hypertriglyceraemia) • Refer for HRT consideration 33
  34. 34. HEALTH PROMOTION o Lifestyle education –modifiable risk factors o Diet with <10% calories from saturated fats-referral to dietician and weight management o Exercise o No smoking o Alcohol consumption o Education on CKD and its relationship to lipoprotein levels REFERRAL o GP o Nephrologist o Dietitian o CNC Diabetes FOLLOW UP o Lipid profile, haematology and hepatic function o 4 weeks following initiation and alteration of medication FORMULARY LIPIDS Australian Route Dosage Therapeutic Clinical presentation Poisons Drug Class Schedule (generic name) Atorvastatin Oral Hypercholesterolaemia or mixed Hypolipidaemic Hypercholesterolaemia S4 Calcium hyperlipidaemia agents - and adjunct to the diet Initially 10mg in evening. Adjust Cardiovascular in the treatment of at 4-week intervals prn. Max System HMG- Hypercholesterolaemia CoA reductase Simvastatin 80mg daily. inhibitor (Statin) Mixed hyperlipidaemia Existing coronary artery disease: and adjunct to the diet Initially 20mg in evening; adjust in the treatment of as above hyperlipidaemia 34
  35. 35. 2.2.5 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR ANAEMIA MANAGMENT The NP will monitor • Results of diagnostic studies • Adherence to treatment plan • Response to treatment plan • For potential causes of hyporesponse to anaemia management DIAGNOSIS o Natural history o Physical examination o Weight, BP and heart rate, respiratory rate and quality, skin and mucous membranes o Signs and symptoms of anaemia Angina, hypotension, tachycardia, dyspnoea Decreased energy and activity levels Diminished appetite and weight loss Lessened sense of well-being Diminished sexual interest and function o Assess patient for potential causes of anaemia Blood loss, iron deficiency, vitamin deficiencies, inflammation and infection, secondary hyperparathyroidism, malnutrition o Dialysis prescription (modality, hours, dialysate) o Evaluate for comorbid conditions such as angina, pulmonary disease, hypotension, congestive heart failure or cerebrovascular disease INVESTIGATIONS Biochemistry Haemoglobin HCT Iron studies-(Ferritin, Iron, TIBC(total iron binding capacity), Transferrin Saturation) Serum B12 Folate levels C-reactive protein Coagulation studies Radiological examination Exclude Exclude blood loss - determine that intrinsic renal disease, is the primary cause of the anaemia’ (decreased production of red blood cells) Exclude infective or inflammatory states NON-PHARMACOLOGICAL MANAGEMENT • Diet 35
  36. 36. PHARMACOLOGICAL MANAGEMENT • Collaborate with the nephrologist to develop and use an anaemia management plan for the patient • Iron supplementation – as per treatment aims • Erythropoietin administration • Adequate anticoagulation for blood loss due to clotting on dialysis HEALTH PROMOTION • Kidney function and its relationship to anaemia • Signs and symptoms of anaemia • Consequences of anaemia • Diagnostic tests used to evaluate anaemia • Signs of bleeding • Medication compliance • Diet REFERRAL • Nephrologist • Gastroenterologist FOLLOW UP • Monitoring o BP particularly during initiation of erythropoietin • Haemoglobin should rise 1–2 g/L daily, or 20 g/L over 3–4 weeks • Monitor haemoglobin for therapeutic response; If no improvement after 4 weeks, review. • Avoid unnecessary long term use of iron supplements • Note-any changes in prescribed treatment. Takes from 7-28 days to see effect 36
  37. 37. FORMULARY HAEMOGLOBIN AND IRON AGENTS Australian Drug Route Dosage Therapeutic Clinical Poisons (generic name) Class presentation Schedule Darbopoetin alfa SC or IV CRF: Haemopoietic ‘Treatment of Restriction: Presentation agents - S100 (Aranesp) Initial: authorised medical anaemia requiring pre-filled Endocrine and officer only (0.45mcg/kg) transfusion, Authority syringes. Metabolic Nurse practitioner titration. Disorders defined as a Script Increase dose if rise is haemoglobin level <10 g/L in 4 weeks. Decrease of less than 100 dose by 25%–50% if rise is g/L, where intrinsic Substitution of >25 g/L in 4 weeks. Withhold renal disease, as Darbopoetin alfa dose if Hb >140 g/L until assessed by a for epoetin alfa: reduced to <130 g/L. Nephrologist, is Initial SC dose is Recommence at dose 25% < the primary cause total weekly SC previous dose. of the anaemia’. dose of epoetin Maintenance: Hb level of (NSW Health alfa (iu) divided 110-140 g/L, titrated Information by 200; initial IV fortnightly as required. Bulletin, accessed dose is total NB. CARI guidelines 3.7.2004). weekly IV dose of recommend withhold epoetin alfa (iu) treatment if Hb above divided by 240. 130mmol/L (CARI, 2003). (Aranesp Maintain Hb at >120g/L. IV Manufacturer’s and SC doses are similar. instructions). Adjust dose to nearest syringe size. Epoetin alfa Subcutaneo CRF Haemopoietic ‘Treatment of Restriction: agents - S100 (Eprex) us or IV Initial: Authorised medical anaemia requiring Endocrine and officer only (50 IU/kg) three Metabolic transfusion, defined Authority times weekly. Titrated by Disorders as a haemoglobin Script nurse practitioner. level of less than Increments 25 IU/kg. 100 g/L, where Increase dose if rise is intrinsic renal <10 g/L in 4 weeks. disease, as Decrease dose by 25%– assessed by a 50% if rise is >25 g/L in Nephrologist, is the 4 weeks. Withhold dose if primary cause of the Hb >140 g/L until reduced to anaemia’. (NSW <130 g/L. Recommence at Health Information dose 25% < previous dose. Bulletin, accessed Maintain Hb at >110 g/L. 3.7.2004). Change dose fortnightly if needed. IV and SC doses are similar. Adjust dose to nearest syringe size. Hb>150g/L *see local safe work practice Iron polymaltose Intravenous Initial: First dose 100mg IVI Haemopoietic Iron deficiency S4 (Ferrum H) infusion in hospital with medical agents - anaemia where (options) support Endocrine and oral treatment not First dose Maintenance: According to Metabolic appropriate or under orders. Disorders enteric absorption medical Haemodialysis: 100mg defective 37
  38. 38. supervision. Ferrum H in NaCl 0.9% to 5 100mg in ml over last hour of dialysis 2ml Management range: 100mg ampoules each dialysis to 100mg monthly dependent on Hb, Aranesp/EPO dosage and iron studies. CAPD/APD: IV 1Gm in 300ml NaCl 0.9% over 4 hrs in hospital with medical support Ferrous sulphate Oral One tablet daily Iron - Vitamins Therapeutic, S2 and Minerals prophylactic. Iron Fe deficiency deficiency treatment or iron deficiency anaemia, esp. for those not tolerant to oral iron. Folic acid (Mega- Oral 5mg daily Vitamins Folic acid deficiency S2 fol) (single agents) - Vitamins and Minerals Megaloblastic anaemia due to folic acid deficiency Vitamin B12 IM Initial (for vitamin B12 Parenteral Vitamin B12 Unscheduled (Cyanocobalamin, deficiency): IM 250- vitamins, deficiency Cytamen) 1000mcg alternate minerals and days for 1-2 weeks. nutrition – Maintenance: IM 250- Nutrition 1000mcg monthly. Vit B12 deficiency, esp pernicious anaemia 38
  39. 39. SECTION 2.3 CLINICAL PRACTICE GUIDELINES FOR DIALYSIS ADEQUACY Note that each guideline contains assessment, investigation, aims of treatment as represented in the relevant CARI Guideline, management, health promotion and prevention, follow up and formulary all relevant to the Nephrology Nurse Practitioners scope of practice DIAGNOSIS, THERAPY AND FORMULARY Guideline developed according to section 78(A)(2), Nurses Act 1991 These guidelines represent a general guide to appropriate clinical practice, and are inclusive, not prescriptive. The information aims to provide the Nurse practitioner with information on which decisions can be made 39
  40. 40. 2.3 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT OF DIALYSIS ADEQUACY The NNP will monitor • Prescribed vs. delivered dose of dialysis • Response to dialysis prescription • Signs of inadequate dialysis • Adherence to dialysis prescription • Vascular access function (see section 4) • Response to medications • Response to diet and fluid prescription • Adherence to treatment plans (including any treatment and equipment related complications) • Cardiovascular status DIAGNOSIS Natural history • Ask re current complaints (headaches, dizziness, blurred vision, nausea, change in bowel habits, fever, chills, dyspnoea, chest pains, palpitations, pain, bleeding, sleeping habits, weakness, fatigue, change in level of activity, change in appetite) • Medication o History for pharmacologic agents that effect anticoagulation, cardiovascular stability (include prescribed, over the counter and non-traditional medicines) Physical examination for; • Manifestations of ESKD o Anaemia status o Cardiovascular status o Calcium and phosphate complications • Ideal ‘Dry’ weight • Response to current dialysis prescription o Monitor prescribed vs. delivered dose of dialysis o Dialysis modality –current prescription • Signs of inadequate dialysis o Abnormal electrolytes, hypovolaemia, symptoms of uraemia, worsening nutritional status, anaemia, bone disease, neuropathies, abnormal sleep patterns, insomnia, neurological symptoms (restless legs, poor concentration), poor quality of life • For compromised urea clearances o Inadequate access blood flow, access recirculation, inappropriate dialyser size, excessive dialyser clotting, inadequate extracorporeal blood flow rate, inadequate dialysate flow rate, inadequate needle placement • For reduction in treatment times o Uncompensated interruptions in actual treatment times (clinical complications, hypotension), equipment alarms, manipulation of needles, dialysis catheter, dialysate bypass situations (i.e. temperature or conductivity alarms) • For shortened treatment time Patient demand, Dialysis Unit issues, clinical complications, Missed treatments • Psychological assessment re adjustment to dialysis • Nutritional status 40
  41. 41. INVESTIGATIONS Biochemistry URR Urea, electrolytes, creatinine, calcium, phosphate PTH Coagulopathy screen LFT Residual renal function PET test Microbiology Blood cultures Wound and access swabs Access device culture Cardiovascular ECG Oximetry Imaging Chest x-ray Abdominal x-ray Ultrasound (hand held) Access duplex Exclude Decrease adequacy due to Access failure Decreased or increase peritoneal membrane permeability NON-PHARMACOLOGICAL MANAGEMENT o Modify and -adjust dialysis prescription (Blood flow, dialysate choice, dialysate flow, dialyser, hours on dialysis, dialysis modality, eating strategies) • Based on URR results • Based on patient response to treatment and occurrence of complications • To prevent intradialytic symptoms without compromising delivered dialysis dose – (sodium modeling, ultrafiltration profiling, haematocrit monitoring) • For ultrafiltration strategies that allow for cardiovascular stability (see appendix) o Increase venous return, TED stockings, exercise o Order additional laboratory tests or diagnostic studies • As appropriate • As follow up to complications o Initiate consults or referrals o Adjust diet and fluid prescription based on patient response PHARMACOLOGICAL MANAGEMENT o Adjust medication regimen based on patient response o Initiate treatment of dialysis access complications (see section 4 and 5) • Dialysate selection as titrated to biochemistry (See Table 1 below) • Peritonal dialysis fluid selection as titrated to biochemistry and fluid removal requirements (See Table 1 and Table 2 below) • Treat constipation 41

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