Sink or swim....

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I'am a new graduate ARNP and have recently starting working as a Nephrology ARNP. I round on patients who are getting dialysis and I also see patients in clinic. During my interview I told the providers that I didn't have Nephrology experience and they agreed to train me for one month. However, when I started I got one day of orientation at the dialysis center and no orientation at the clinic before I was seeing patients alone. It was kinda like a sink or swim...The other providers are there to answer questions when i need to but it just doesn't seem right to throw a new graduate in such a situation...Over the last month I've just been teacing myself about dialysis and the care of patients with CKD...So its going ok it would just be nice to be in a more supportive environment. Any other Nephrology ARNPs out there who can offer advice on how to make the most out of this horrible situation....Any specific text books that you would recommend. I am specifically looking for a dialysis handbook that is simple and a quick read.

Thanks,

Miserable ARNP

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Specializes in Nephrology, Cardiology, ER, ICU.

Hi there - sorry you are going thru this. I too am an APN in a large nephrology practice. I started in July 06 as a new grad and had 4 months orientation - it took that long to get accreditation - lol! I round on 180 chronic hemo pts in two different units. I also take call every fifth weekend at two hospitals 55 miles from my home.

My nursing background is ER and ICU and though I had done CRRT in the early 90's but had never even seen dialysis being done before I took this job. I was very scared too. Let me look at the books I have at work and I'll get you some titles.

Other resources include ePocrates Pro, a renal dosing PDA program and a couple of books.

What type of unit do you work in? I work in two Fresenius units and can help you with the computerized charting there if you want. Just let me know.

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Thanks for responding so quickly. 4 months orientation sounds great!!! I would've appreciated 4 days of orientation compared to what I've received...LOL...I've been using Epocrates, however, I dont have a renal dosing PDA program (where did you get that program from?). The books I've been using are the Handbook of Dialysis by Daugardis and The Current Diagnosis and Treatment of Nephrology and HTN which is one of the Lange medical books and the main author is Edgar Lerma.

The dialysis book I have is 600 pages and I just need something that is simple and gets right to the point. Because there are still some parts that are unclear to me or that I would like to understand more.

About my job...I round on 60 hemodialysis patients Mon-Wednesday (4 centers total), see patients thursday and friday in clinic. No weekend call or hospital call. We dont use Fresenius units (not familiar with this). Having received an improper orientation and working with providers that are so busy and unwilling to explain reasons for doing certain things I just feel like I am missing something all the time....My experience is as an ICU nurse as well....

What did your orientation consists of? Do you have any material left over from your orienation that could be sent to me electronically?

Thanks

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Specializes in Nephrology, Cardiology, ER, ICU.

Those are the books I would recommend too. Nephrology and specifically,dialysis is far different from any other type of nursing. I'm sorry I didn't keep any orientation info. As to PDA programs:

Here is the renal dosing program I use (in addition to ePocrates Pro)

http://www.skyscape.com/estore/ProductDetail.aspx?ProductId=2296

Here are a couple more resources:

http://www.pdamd.com/products?oec-specialty=10;oec-match=nephrology;oec-sort=retailer;oec-category=;

Hope this helps. I still find nephrology to be very confusing on some points - lol.

For my orientation, I spent some time with several of the MDs (we have 15 nephrologists and 2 surgeons - they do access and transplants), then spent time with some of the other mid-levels: we have 2 PAs, 3 FNPs and me (adult health CNS).

What part of the country do you live in? I live in central IL and our practice covers the central part of the state.

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Thank you for for the resources, I will be sure to look them over.

I live on the Westcoast. I'am going to give it one more month before I start looking for another job. Either way, I will let you now how it turns out because I really do love working with patients that have renal disease. I just want to know that I am providing the best care possible and right now, it doesn't feel like that because the team work is so poor... :(

Thanks for all your help...hopefully the outcome will be good ;)

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Specializes in telemetry, dialysis, research.

I graduated last May from an FNP program and have been looking for a position in my area as a Nephrology NP (or any position for that matter). There was one in my area (St. Louis) that was filled right before I graduated. Your situation does sound difficult. It would be difficult for me and I have been working in dialysis since 1995 (hemo and PD). Go to ANNA's website http://www.annanurse.org and maybe order "Core Curriculum for Nephrology Nursing © 2008 (5th edition)". The Nurse manager at the clinics you work at might have this in the office for you to borrow. I know we used to have older copies at my clinic. Good Luck.

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I was a nephrology NP for 8 years and a dialysis RN for 8 years before an NP. I am now a hospitalist NP. I had a lot of experience going into the nephrology NP role but the docs I started out with had me read and learn the "Primer on Kidney Diseases" put out by the National Kidney Foundation (NKF). It really helped me learn the renal diseases and causes of prerenal, postrenal and the different glomerular diseases. I did function in the dialysis units and also rounded in the hospital and had a CKD clinic. Remember with CKD to just address the main issues of 1) Stage of CKD, etiology of renal disease 2) Hypertension 3) anemia due to CKD 4) secondary hyperparathyroidism from CKD 5) nutrition as low albumins are usually a problem esp with nephrotic syndrome disease states and late CKD. Always remember to tell the patient to avoid NSAIDS, huge factor in preservation of remaining kidney function in these patients and to let any doc who wants to do a dye study on them know of their renal disease in consideration of contrast nephropathy prevention. Prevention of further renal decline and preparation for ESRD are big goals in the CKD patient. Hope this is helpful. Good luck.

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Specializes in Nephrology, Cardiology, ER, ICU.

Excellent thoughts!

And...I just wanted to add that as an APN coming to nephrology who knew nothing about it, it did take me about a year to even feel a little confident!

Also - as a nephrology APN, it is very important to ensure you (and anyone else that prescribes for renal pts) knows the renal dosing. I learned this the hard way and its a lesson I will never forget.

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on that note, i have wondered. Does someone have to be dx with renal disease for me to consider using renal dosage? Or what about someone with chronic uncontrolled BP?

I did a rotation with nephro clinic and transplant clinic, and it was my understanding after transplant dosages were all normal not renal dosages, but i think they would still want to avoid nsaids right? even though they have a good kidney, they wouldn't want to risk harming it, or is that wrong?

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Specializes in Nephrology, Cardiology, ER, ICU.

Yes, even after transplant, they must still avoid NSAIDs and dye. As to renal dosing after transplant - not so much unless they do not have a normal creatinine. Still very important to control their BP and DM since those are the two main reasons people fry their own kidneys.

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As far as transplants ,since the kidney transplant is not "cure" but a treatment for ESRD which will eventually chronically reject hopefully not until years later. I would always document as "ESRD status post living related(LRT) or Cadaveric(CRT) and then document the GFR. Many transplant patients do not have a normal GFR and will need renal dosing especially with antibiotics and other drugs than can affect their immunosuppression. I use Epocrates the most complete version. It had all the renal dosing adjustments on it and it went on my Palm. Any patient who has ever had any type of renal problem should permanently avoid NSAIDS.

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on that note, i have wondered. Does someone have to be dx with renal disease for me to consider using renal dosage? Or what about someone with chronic uncontrolled BP?

I did a rotation with nephro clinic and transplant clinic, and it was my understanding after transplant dosages were all normal not renal dosages, but i think they would still want to avoid nsaids right? even though they have a good kidney, they wouldn't want to risk harming it, or is that wrong?

Anyone who writes a scrip should be aware of renal dosing. There are a lot of people walking around that have poor kidney function and should be renal dosed.

As far as transplant meds most of the time there is good renal function after transplant and you don't need to renal dose. Depending on the immunosuppressive regime used and how much rejection the patient has (for kidneys). Prograf is nephrotoxic and will result in reduced renal clearance the longer its used. I work in Liver transplant and a lot of our patients have significant kidney disease. Its one reason that transplant programs are required to have a pharmacist as part of their transplant team.

David Carpenter, PA-C

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