Primer for APN Nephrology Practice or CNN-NP Certification Preparation

The ZebrasLinda 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

•Pharmacology: ▫Candida (non-nutropenic) Fluconizol▫Candida (nutropenic) Echinocandin or L-

AmB ▫Aspergillus (lungs, sinus, tracheal

bronchial tree, heart, bone, CNS) Voriconzol

Invasive Fungal Infections (IFI)

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-NPPPT 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

•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

•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:•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

• 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

Applicant Eligibility Criteria

Approved Continuing Education

▫ Organizations accredited by the American Nurses’ Credentialing Center – Commission on Accreditation (ANCC-COA) 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▫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 minutesLink to blueprintLink 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 –