Manual Review of emergency procedures and equipment: Fire drill procedure, fire extinguisher, emergency disconnect, er equipment and evacuation, bomb threat, disaster plan, er transfer of patients




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1Nephrology Nurse Internship Program Template for Hemodialysis Units
WEEK 1

Classroom Module: Facility Orientation

Introduction to dialysis organization

Introduction to patient and staff shifts

Introduction to team members

Orientation to physical plant: Locker room, kitchen, supply room, offices, medication room, laboratory, bathroom, crash cart, oxygen supplies, employee bulletin boards, location of MSDS book, fire alarm locations, fire extinguisher locations, emergency exits, location of PPE, location of policy and procedure manuals

Review employee handbook/manual

Review of emergency procedures and equipment: Fire drill procedure, fire extinguisher, emergency disconnect, ER equipment and evacuation, bomb threat, disaster plan, ER transfer of patients

Review of job description

CPR certification

Infection control: Preventing the spread of infections in dialysis units (OSHA and CDC guidelines), exposure to blood borne pathogens and post exposure plan

Worker's compensation

Orientation to computer system and documentation

HIPPA policies

Review company specific compliance policies

Review reporting of adverse occurrences
General Safety: Emergency preparedness, general safety; fire safety, standard precautions, preventing slips, trips, and falls; working safely and your back; lifting and transporting patients; latex allergies; transmission precautions
Clinical Experience with Nurse Preceptor

Observation in clinical area

Demonstrate crash cart check and complete appropriate documentation

Discuss and demonstrate performing hand crank during electrical failure

Observe implementation of hemodialysis infection control practices in the clinical area

Discuss the fire drill procedure

Discuss and/or demonstrate performing the emergency termination of dialysis

Discuss and exhibit the contents of the emergency evacuation kit

Discuss response to a bomb threat

Demonstrate or verbalize disaster and emergency readiness

Discuss patient evacuation procedure

Demonstrate proper use of the fire extinguisher

Discuss a facility fire

Discuss emergency transfer of patients to the hospital from the clinic
WEEK 2

Classroom Module: Principles of Hemodialysis

Hemodialysis principles

Concepts related to solute removal

Concepts related to water removal

Components of the system

Anticoagulation

Sodium variation

Sequential ultrafiltration

Water treatment

Monitoring systems of hemodialysis machines

Dialysis procedure

Dialysis adequacy

Kidney Dialysis Outcome Indicators (KDOQI) Adequacy Guidelines

Patient initiation, monitoring, and termination of dialysis treatment

Hand washing/PPE
Clinical Experience with Nurse Preceptor

Read unit practices/policies related to predialysis nursing assessment; equipment assessment, initiation of treatment, intradialytic monitoring, termination of treatment
Predialysis nursing assessment (Observe first clinical day; perform second clinical day)

Patient history since last treatment

State of well-being

Degree and level of activity/exercise since last treatment

Vital signs

Volume status (weight, respiratory rate (RR), auscultation of lungs, assessment of neck vein distention, presence/absence of edema)

Bruising/bleeding

Vascular access assessment

Compare data to previous findings

Notify MD of any significant changes or findings

Adjust treatment plan based on assessment data

Implement appropriate nursing interventions based on assessment data
Predialysis equipment assessment, the nurse will assess

Equipment suitability for prescribed therapy, disinfected per facility protocol, and free of residual disinfectant

Integrity of dialyzer membrane and blood tubing

Prescribed dialyzer

Follow manufacturer's instructions

Follow AAMI standards

Follow unit policies and procedures

Prescribed dialysate fluid composition

Conductivity and pH of dialysate

Temperature of dialysate
Absence of residual reprocessing agents in dialysate delivery system and/or the extracorporeal blood circuit

Proper occlusion of the blood pump

Proper function of equipment alarms

Water treatment system quality checks

Intervention

Implement modifications to the treatment plan based on assessment findings

Assure correction of problems related to delivery system prior to initiation of treatment
Initiation of treatment

Observe preparation of the vascular access for initiation of the treatment and according to established protocol with attention to hand washing and access site prep

Collect, label, and appropriately prepare blood specimens

Administer anticoagulant therapy according to treatment prescription

Elicit history of injuries, bleeding, bruising, menses, surgical procedures, or gastrointestinal bleeding

Review anticoagulation regimen from previous treatment

Assess for ecchymosis, hematomas, or previous injury

Review previous hemoglobin/hematocrit or bleeding studies

Review medication history noting pharmacologic agents affecting anticoagulation, including over the counter medication and non-traditional medication

Adjust anticoagulation regimen based on clotting results, if available, patient's condition, patency of extracorporeal circuit, response to previous anticoagulation, postdialysis bleeding of cannulation site, and MD order

Administer or discard prime solution as indicated and according to established protocol

Set blood flow rate, ultrafiltrate (UF) rate, and sodium modeling rate as prescribed

Activate all alarms and set limits to maximize patient safety

Monitor integrity of dialysate circuit

Monitor patient's response to initiation of treatment
Intradialytic monitoring

Read unit practices/policies related to intradialytic monitoring

Continue skills from previous weeks

Intradialytic monitoring

Assess vital signs, BP monitoring

Assess volume status

Vascular access patency and visible to staff

Needles or connections in place and secure

Site clean and dry

Venous pressure

Arterial pressure

Signs and symptoms of recirculation

Signs and symptoms of infiltration
Anticoagulation effectiveness

Well-being; level of consciousness

Delivery of dialysis prescription

Response to treatment
Delivery system

Integrity of extracorporeal circuit

Pressure monitor readings

Anticoagulation delivery

Blood flow rate

Alarm limits and/or condition

Modify treatment plan based on patient's response

Notify patient's MD of any significant change or problem

Implement strategies to minimize intradialytic hypotension such as variable sodium modeling per MD order
Termination of treatment

Read unit practices/policies related to termination of treatment

Assure prescribed treatment time has been delivered

Assemble supplies and equipment for termination of treatment

Following unit policies and procedures:

Return blood in extracorporeal circuit

Monitor vital signs

Provide post-treatment access care

Perform post-dialysis patient response to treatment assessment

Have patient wash hands prior to leaving

Dispose of supplies as appropriate

Clean and disinfect equipment and treatment area

Notify MD of significant events/findings
WEEK 3

Classroom Module: Circulatory Access for Hemodialysis

KDOQI Vascular access guidelines

Arterio-venous fistula (AVF) (indications, advantages, disadvantages, placement, nursing management)

Arterio-venous graft (AVG) (indications, advantages, disadvantages, placement, nursing management)

Central venous catheter (CVC)

Femoral catheters

Cannulation technique and practice (dummy arm)
Clinical Experience with Nurse Preceptor (Continue skills from previous week)

Proper hand washing/PPE

Predialysis nursing assessment

Patient history since last treatment

State of well-being

Degree and level of activity/exercise since last treatment

Vital signs

Volume status (weight, RR, auscultation of lungs, assessment of neck

vein distention, presence/absence of edema

Bruising/bleeding

Vascular access assessment

Compare data to previous findings

Notify physician of any significant changes or findings

Adjust treatment plan based on assessment data

UF calculation, assess need for volume replacement
Predialysis equipment assessment, the nurse will assess

Equipment suitability for prescribed therapy, disinfected per facility protocol, and free of residual disinfectant

Integrity of dialyzer membrane and blood tubing

Prescribed dialyzer

Follow manufacturer's instructions

Follow AAMI standards

Follow unit policies and procedures

Prescribed dialysate fluid composition

Conductivity and pH of dialysate

Temperature of dialysate

Absence of residual reprocessing agents in dialysate delivery system and/or the extracorporeal blood circuit

Proper occlusion of the blood pump

Proper function of equipment alarms

Water treatment system quality checks

Intervention

Implement modifications to the treatment plan based on assessment findings

Assure correction of problems related to delivery system prior to initiation of treatment
Initiation of Treatment

Prepare the vascular access for initiation of the treatment based on predialysis assessment and according to established protocol

Assess vascular access for patency and evidence of complications

Establish direction of flow for internal access

Prior to first use of CVC, verify proper position with chest X-ray/interventional radiology

Cannulate vascular access according to protocol; access CVC according to established protocol

Utilize KDOQI guidelines for vascular access as resource for vascular access care

Collect, label, and appropriately prepare blood specimens

Administer anticoagulant therapy according to treatment prescription

Administer or discard prime solution as indicated and according to established protocol

Set blood flow rate, UF rate, and sodium modeling rate as prescribed

Activate all alarms and set limits to maximize patient safety

Monitor integrity of dialysate circuit

Monitor patient's response to initiation of treatment

Keep access visible to staff
Intradialytic monitoring

Assess vital signs

Assess volume status

Assess vascular access patency:

Needles or connections in place and secure

Site clean and dry

Venous pressure

Arterial pressure

Signs and symptoms of recirculation

Signs and symptoms of infiltration

Anticoagulation effectiveness

Well-being; level of consciousness

Delivery of dialysis prescription

Response to treatment

Assess delivery system

Integrity of extracorporeal circuit

Pressure monitor readings

Anticoagulation delivery

Blood flow rate

Alarm limits and/or condition

Modify treatment plan based on patient's response

Notify patient's physician of any significant change or problem

Implement strategies to minimize intradialytic hypotension such as variable sodium modeling per physician order

Have patient wash hands prior to leaving
Termination of Treatment

Read unit practices/policies related to termination of treatment

Assure prescribed treatment time has been delivered

Assemble supplies and equipment for termination of treatment

Following unit policies and procedures:

Return blood in extracorporeal circuit

Monitor vital signs (including postural BP)

Provide post-treatment access care

Perform post-dialysis patient response to treatment assessment

Assess weight/volume status

Assess volume replacement during treatment and patient's response

Assess vascular access condition

Assess patient's sense of well-being and mental status

Assess other conditions or complications

Dispose of supplies as appropriate

Clean and disinfect equipment and treatment area

Notify MD of significant events/findings
WEEK 4

Classroom Module: Acute Complications of Dialysis

Discuss causes, signs and symptoms, prevention, and treatment for following complications:

Hypotension, disequilibrium, hypertension, fever/pyrogenic reactions, angina, muscle cramps, rising venous pressures, shortness of breath, transfusion reaction, seizures, clotted dialyzer, blood leaks, arterial pressures, changing blood lines, arterial blood flow interruption, air embolus, cardiac arrest, anaphylactic reactions, hemolysis, arrhythmias, back pain, blood loss, crenation, hypoglycemia

Power failure

Interruption of water services
Classroom Module: Oversight of the ESRD Medicare Program in the U.S.

Review ESRD conditions of coverage

Review state specific requirements or regulations for ESRD

Review role of ESRD Networks

Review survey and certification process for outpatient dialysis programs

Review dialysis compare
Classroom Module: ANNA

Discuss importance of professional association membership

Review resources available to an ANNA member

Discuss opportunities for certification in nephrology nursing specialty
Clinical Experience with Nurse Preceptor

Continue activities from previous weeks

Discuss and respond to dialysis complications
WEEK 5

Classroom Module: Dialysis and Drug Therapy

Discuss dialyzability of drugs, alterations in dosage and frequency of common drugs
Classroom Module: Anemia Management

KDOQI guidelines

Review facility specific guidelines
Classroom Module: Medication Documentation
Medication Administration Test
Clinical Experience with Nurse Preceptor

Continue preassessment, initiation of treatment, intradialytic monitoring, termination of treatment

Read unit practices/policies related to medication administration

Review appropriate lab values and compare to previous values

Notify MD as appropriate

Administer assigned patient medications according to unit policy

Document medication administration and patient response according to unit policy
WEEK 6

Classroom Module: Renal Osteodystrophy

Discuss:

Pathophysiology

Review KDOQI for bone and mineral management

Lab values and X-rays studies (calcium, phosphorus, calcium/phosphorus product, alkaline phosphatase, parathyroid hormone (PTH), aluminum, bone biopsy, hand films)

Mobility limitations

Dietary modifications

Phosphate binding agents and vitamin D supplements

Hyperparathyroidism
Clinical Experience

Administer medications as prescribed

If on vitamin D metabolite or analog therapy, monitor drug regimen and response to therapy

Assess patient's muscle strength, gait, and range of motion, noting limitations in movement

Assess joints for enlargement, swelling, stiffness, and tenderness

Review lab values and X-ray studies

Assess patient's psychological and behavioral response to current mobility limitations

Assess patient's understanding of the dietary modifications necessary for phosphorus and calcium control

Evaluate use of phosphate binding agents and calcium and vitamin D supplements

Assess patient's understanding of the effects of calcium on PTH secretion

Assess patient's dietary adherence

Administer medications or therapies as prescribed

If on vitamin D metabolite or analog therapy, monitor drug regimen and response to therapy
WEEK 7

Classroom Module: Adequacy of Hemodialysis

Review KDOQI adequacy guidelines

Review procedure for drawing BUN samples

Discuss reasons for deviation from prescribed dialysis dose
Clinical Experience with Nurse Preceptor

Assure that laboratory specimens/data used to determine delivered dose of hemodialysis are collected correctly following facility protocol

Assess the patient's understanding of the importance of the delivered dose and their role in meeting the target level

If delivered dose of dialysis is below target level, assess potential reasons for deviation:

> Dialyzer clearance

> Treatment time

> Prescription

Patient adherence to treatment time

Incorrect needle placement or reversal of lines

Incorrect blood sampling techniques

Initiate measures to decrease intradialytic complications:

Review estimated dry weight (EDW)

Reduce ultrafiltration rate

Review intradialytic weight gain (IDWG) with patient

Evaluate current dialysate sodium concentration
Clinical Experience: Care Planning

Review facility specific procedures for patient care planning

Review short-term and long-term plans for assigned patients

Participate in the care planning process of new and existing patients

Attend Care Planning Conferences
WEEK 8

Classroom Module: Delegation of Responsibility to Unlicensed Assistive Personnel

Review Nurse Practice Act (NPA) for RNs specific to state

Review regulations and role parameters for RNs that conform with state regulations

Resources: National Council of State Boards of Nursing Delegation documents (www.ncsbn.org/regulation/uap_delegation)

- Role Development: Critical components of delegation curriculum outline

- Five rights of delegation

- Delegation decision-making tree

- Delegation decision-making grid

- Selected references: delegation and unlicensed assistive personnel

Review ANA code for nurses; ANNA Nephrology Nursing Standards of Practice and Guidelines for Care, ANNA position statement on delegation

Review various roles of health care workers in facility

Review level of patient care responsibilities that can be assigned to unlicensed staff and LPN/LVNs

Evaluate skill level of unlicensed personnel before assigning tasks

Assign only those tasks that the health care worker is legally responsible to carry out

Give specific directions to health care worker regarding the client information you wish reported and how you wish to receive it (i.e., verbal and/or written)

Provide current information to health care worker in a timely manner as it impacts their care of the patient (e.g., change in dialyzer order)
Classroom Module: Standards of Nephrology Nursing Practice and Professional Performance

Definition and role of standards

Standards of Care

Assessment

Diagnosis

Outcome identification

Planning

Implementation

Evaluation

Standards of Professional Performance

Quality of Care

Performance Appraisal

Education

Collegiality

Ethics

Collaboration

Research

Resource Utilization
WEEK 9

Classroom Module: Principles of Patient Education

Assess patient's current level of knowledge related to disease, diet, medication, current treatment plan

Evaluate patient's ability and readiness to learn through assessment of the following:

Ability to communicate

Physical condition

Psychological status

Degree of motivation

Developmental stage

Literacy level

Identify potential barriers to learning that may include:

Physical condition

Psychological status

Environmental situation

Cultural beliefs/practices

Language

Evaluate effectiveness of teaching and level of learning using:

Verbal feedback

Return demonstration

Written test as appropriate

Involve patient in the development of multidisciplinary teaching plan

Use culturally sensitive and ethnically appropriate educational materials

Use teaching techniques and materials that are appropriate for the patient's developmental stage and/or disabilities

Involve support person/family in teaching process

Refer patient to other resources for assistance in the learning process

Reinforce teaching as necessary using multiple teaching approaches, return demonstration, and verbal and written feedback

Promote age-appropriate self-care
WEEKS 9-24

Additional Modules for Consideration
Classroom Module: Patient Choices

Modality information
Classroom Module: Peritoneal Dialysis

Initial evaluation

Patient education

Ongoing monitoring

Acute and chronic peritoneal dialysis

Predialysis assessment

Initiation of treatment

Intradialytic monitoring

Termination of treatment and postdialysis assessment

Peritoneal catheter placement

Preoperative care

Intraoperative care

Postoperative care

Adequacy of peritoneal dialysis

Complications

Clinical experience in peritoneal dialysis training with preceptor/PD nurse
Classroom Module: Renal Transplantation

Deceased donors

Living donors

Universal postop guidelines for care of donors and recipients

Recipient

Pretransplant evaluation

Perioperative education and discharge plan

Allograft dysfunction
Classroom Module: CKD

Review stages of CKD

Review intervention of stages of CKD

Classroom Module: Continuous Quality Improvement

Identification of aspects of care important for quality monitoring

Analysis of outcome and process data to identify opportunities for improving care

Development of policies, procedures, and practice guidelines to improve quality of care

Identification of indicators used to monitor quality and effectiveness of nursing care

Collection of data to monitor quality and effectiveness of nursing care

Formulation of recommendations to improve nursing practice or patient outcomes

Implementation of activities to enhance the quality of nursing practice

Participation on interdisciplinary teams that evaluate clinical practice or health services

Use of clinical outcome findings to initiate changes in nursing practice

Use of results of quality of care activities to initiate changes throughout the health care delivery system as appropriate
Classroom Module: Palliative Care - End of Life

Review materials available to assist patients and families to make end-of-life decisions
Classroom Module: Research Utilization Process

Use of best available evidence, preferably research data, to develop plan of care and interventions

Participation in research activities as appropriate to nurse's education and positions including:

Identifying clinical problems suitable for research

Participating in data collection

Participating in unit, organization, or community research committee or program

Critiquing research for application to practice

Using research findings in the development of policies, procedures, and practice guidelines for care
Classroom Module: Activity and Rehabilitation

Assessment:

Assess previous, actual, possible, and desired level of activity

Assess physical, psychological, and economic factors contributing to activity limitation

Discuss patient's activity preferences

Assess clinical indicators that may potentially affect patient's level of activity

Assess expected activity for age and level of development

Assess patient's perceptions of physiologic limitations

Assess family expectations for their role in patient's activity and rehabilitation

Intervention:

Collaborate with health care team in planning for appropriate interventions including employment, exercise, as well as ongoing encouragement and evaluation

Encourage patient to participate in activities of preference as appropriate

Assist patient and family to plan activities that minimize fatigue

Encourage school attendance or home-based education as appropriate

Identify sources of social, physical, and vocational support and assistance

Develop/implement a standardized activity assessment instrument

Encourage patient to report activities that increase fatigue

Encourage participative play

Provide activity/rehabilitation resources

Patient teaching:

Teach/reinforce the benefits of medication, exercise, diet therapy

Reinforce activities/sports as appropriate

Teach patient how to develop a rest/activity/treatment pattern that will maximize patient's energy level.

Copyright 2005, American Nephrology Nurses' Association (ANNA). Creating nephrology nurse externships and internships: Task force recommendations. Reprinted from Nephrology Nursing Journal, Volume 32, Number 6, pp. 633-658.

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