Primer for APN Nephrology Practice or CNN-NP Certification Preparation

1. Primer for APN Nephrology Practice or CNN-NP Certification Preparation The Zebras Linda Shenton, MN, RN, ACNP, CNN-NP

2. Objectives • Identify less common patient presentations that may be seen in CKD and the transplant setting

3. Zebras in CKD Did you know…… Zebras have white stripes there skin is black!

4. 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

5. 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)

6. 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

7. 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

8. Renal TB • Most frequent site for TB outside the lungs • Results from hematogenous spread of mycobacterium tuberculosis from the lungs to the kidneys

9. 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

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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

16. Zebras in transplant Did you know…… Zebra stripes are like human fingerprints, they are each individual.

17. 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

18. PTLD • EBV-negative transplant recipients may have risks up to 25% • Treatment with Rituximab shows promise and low toxicity profile

19. 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

20. 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

21. Invasive Fungal Infections (IFI) • High mortality, incidence higher in first 6 months post transplant • Clinical symptoms sparse and lack specificitymaking 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

22. 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

23. 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

24. 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

25. 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

26. The WHY….

27. 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?

28. 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

29. Barriers to taking the CNN-NP exam • Cost • Lack of support or rewards • Lack of time • Lack of relevance • Fear of failure

30. Benefits for taking CNN-NP examCited 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

31. 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

32. Benefits Cited by Nurses “Most nurses who sat for certification exams did so for personal fulfillment and commitment to excellence in practice” AACN

33. 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

34. CERTIFICATION  EMPOWERMENT EMPOWERMENT INCREASED ACCESS TO: JOB RELATED POWER OPPORTUNITIES IN ORGANIZATION OPPORTUNITIES IN HEALTH CARE FIELD

35. The What…

36. 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

37. Applicant EligibilityCriteria • 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

38. 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)

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. The HOW..

46. The Test • Paper and pencil test • Monitored • Pick a seat where you won’t be distracted

47. 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

48. 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

49. 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

50. 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