Upon graduating, most nurses recite the “Nightingale Pledge,” promising to practice their profession faithfully and always promote patient wellness.
Although the pledge has served well for many years, some nurses are in favor of adding a new line: ‘Preventing kidney disease progression is every nurses’ responsibility.’
“Chronic kidney disease affects every cell of the body. However, it is just more pronounced in certain organs than others. Even if you are tending to an acute illness, the patient’s kidney disease is going to be a big factor in how you deliver that care,” said Lesley Dinwiddie, MSN, RN, FNP, CNN.
Dinwiddie serves as the senior vice-president of the Institute for Clinical Excellence, Education, and Research. She also has an independent nephrology nursing consulting practice. Through her consulting, Dinwiddie seeks to help patients by educating nurses.
“The best way to help chronic kidney disease patients is to educate non-nephrology nurses in the basics of nephrology,” she said. “Know the symptoms of early chronic kidney disease, have a general knowledge of its stages, and what to look for in labs.”
Unique Nursing Position
When it comes to caring for patients with kidney disease, med/surg nurses are in a very unique situation. Though they have an acute illness vying for their attention, med/surg nurses also need to be mindful of the patient’s dialysis needs (present or future).
“When I began working in med/surg, kidney disease patients were pretty far and few between. Our primary focus was dealing with the patient’s acute illness. That is simply not the case anymore,” said Kathy Lattavo, MSN, RN, who is clinical nurse specialist in med/surg at St. David’s Medical Center in Austin, TX.
With over half a million patients being afflicted with kidney failure, med/surg nurses are increasingly being called upon to manage dialysis-related therapies, symptoms, and testing while treating acute illnesses.
“On our unit, we get so many kidney patients that it has become second nature for us. As the general population ages and we see more and more comorbities, dialysis patients are only going to become more prevalent,” said Lattavo.
Nephrology for Med/Surg Nurses
Med/surg nurses must be proficient in many different areas of medicine. This requires knowing enough about nephrology to function efficiently, while also knowing what requires a specialist.
“Med/surg nurses have to know enough to do their jobs while still knowing when to get additional help; there is a fine line between being cautious and being overly cautious,” said Lattavo.
Certain aspects of a patient’s medical history should be proverbial ‘red-flags’ for med/surg nurses; all nurses, not just nephrologists, must be able to recognize these kidney disease indicators.
“There are some red flags to look out for in a patient’s history,” Dinwiddie said.
For example, “there is a huge connection between cardiovascular disease and kidney disease,” she said. “Look out for patients with long-standing diabetes and hypertension, – these are the leading causes of kidney disease”
Along with these medical history indicators, medication currently being taken by the patient can go a long way in alerting a med/surg nurse.
“Think holistically with each patient, looking at his or her medications for red flags such as calcium carbonate routinely taken with meals. If you see a patient on that prescription, there could be progression of chronic kidney disease going on,” said Dinwiddie.
Once it has become evident that the patient is receiving dialysis, the nurse must know what assessment questions to ask in order to guide the patient’s care.
“Nurses need to keep in mind that, although they are caring for an acute illness, there are also underlying issues pertaining to the patient’s renal failure,” Lattavo said.
“Always keep in mind what sort dialysis access the patient has, how often the patient is receiving hemodialysis, and what medications the patient takes for kidney functioning.
“These are questions that every nurse needs to ask himself.”
Alerting hospital personnel with warning signage to protect the vascular access extremity from blood pressure measurements and venepuncture is a basic but important responsibility of the med/surg nurse.
When Med/Surg Nurses Need Help
When caring for patients on dialysis, med/surg nurses inevitably run into situations in which an expert’s knowledge is required.
However, referring to the dialysis department is a balancing act; refer too often and the nurse is seen as an annoyance, refuse to refer and the nurse may appear negligent.
“Nurses working with dialysis patients in the med/surg setting must have a basic general knowledge of chronic kidney disease along with knowing when to get specialized assistance. In other words, nurses need to know what it is that they don’t know,” said Dinwiddie.
The key to knowing when to refer to someone more knowledgeable, is knowing what changes to look for in the patient’s condition. Being mindful of these indicators can save a patient’s life.
“There are some instances in which a med/surg nurse might want to get a second opinion,” Lattavo said.
“For instance, if lab values come back and the patient’s potassium levels are way out of range or if the patient experiences rapid weight gain because of fluid overload,” she continued.
“Another time to consult is if the patient had previously been alert and later becomes disoriented and confused.”
When a kidney disease question arises, the dialysis department is not necessarily the first place to go; many hospitals have myriads of knowledgeable resources.
“When a nurse receives a patient with chronic kidney disease, she does not have time to go do a literature search on the subject,” Diniwiddie said.
“That’s why references need to be available or at the very least have a knowledgeable nurse manager on the unit. If need be, bring your questions to the nurses in the dialysis center.”
Lattavo and other nurses at St. David’s have created a similar sequence of resources for dialysis-related questions.
“If a nurse runs into a question, the first resource should be the charge nurse or the unit’s clinical nurse specialist. If it is a question we cannot handle then we can utilize the ICU charge nurse, Lattavo said.
“Although it is tempting to have one of the nephrology nurses come to our unit, we have to realize they have their own work to do.”
Safety Awareness Essential
Safely treating patients with CKD comes down to awareness: being aware of the responsibilities of med/surg nurses; awareness of resources if a question arises; and awareness of red-flags for CKD.
“You never want to take the chronic kidney disease patient for granted. Every system in the body is affected,” Lattavo said.
For example, “when a kidney disease patient comes in with the flu, treating the flu is not necessarily our first concern,” she said. “If we run into any trouble it is probably because we’ve overlooked something with the underlying kidney disease.”
Without a doubt, med/surg nurses have a difficult task-care for an acute illness while maintaining treatment for the patient’s various comorbidities.
“It’s not that med/surg nurses do not know about nephrology; they are just dealing with more urgent matters at the moment. Still, the nurse needs to stop and be aware of the patient’s kidney disease issues,” said Dinwiddie.
When med/surg nurses provide holistic and collaborative care for the kidney disease patient, it is the patient who ultimately wins.
“Collaboration is hugely important,” Lavatto said. “We have to recognize that nephrology nurses are the experts in their area of specialization and we are the experts in our area of specialty. If we fail in our interdisciplinary care, ultimately it is the patient who loses.”
A. Trevor Sutton is a frequent contributor to ADVANCE.