HUNTER-NEW ENGLAND AREA HEALTH SERVICE

SECTION 1

HUNTER-NEW ENGLAND AREA HEALTH SERVICE

Nephrology Nurse Practitioner Guidelines for Clinical Practice

All NP clinical guidelines on this site have been developed for use in a particular Area Health Service and for specific Nurse Practitioner positions in that AHS, and therefore reflect the specific scope of practice of the position and the operation of the AHS. Therefore, prior to use by Nurse Practitioners in other positions, the Guidelines will need to be reviewed and adapted as necessary to address local scope of practice and Area Health Service needs. The adapted guidelines must also be approved in writing by the AHS CE, as required by the Nurse/Midwife Practitioner Policy Directive 2005_556 prior to use.

This guideline has been developed under section 78A of the Nurses act 1991

DRAFT VERSION 1 SEPTEMBER 2006 REVIEW DATE

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Nephrology Department John Hunter Hospital-Hunter New England Health Service Version 1 – May 2006 The Clinical Practice Guidelines contained within this document have been devised by Lesley Salem, in collaboration with the Committee for the development of Clinical Guidelines for the Nephrology Nurse Practitioner. We endorse their adoption within the Nephrology Department Lower Hunter New England Health The Director General of the Department of Health or the Chief Executives of each Area Health service are required to approve guidelines relating to the functions of nurse practitioners, including the prescription of certain substances. Prior to sign off an Area or Hospital drug Committee must approve drugs identified for use by the Nurse Practitioner. The signed agreement must include the Area Director of Clinical Operations and the Area Director of Nursing Services. ______________________________ ______________________________ Mr. Terry Clout Associate Professor Jennie West Chief Executive Officer, Hunter New England Area Health Service

Area Director of Nursing, Hunter New England Area Health Service

Date: ____________

Date: ____________

______________________________

_____________________________

Associate Professor Alastair Gillies

Director of Nephrology Services Lower Hunter New England Area Health Service

Date: ____________

Date: ____________

______________________________

______________________________

Ms Carmel Peek Service Manager/Director of Nursing Division of Medicine John Hunter Hospital

Date: ____________ Date: ____________ _____________________________

______________________________

Date: ____________ Date: ____________

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CONTENTS: SECTION 1 1. SYNOPSIS 2. INTRODUCTION 3. SCOPE OF PRACTICE WITHIN SOUTHERN SECTOR HUNTER NEW

ENGLAND HEALTH SERVICE 3.1 PRACTICE ENVIRONMENT 3.2 NNP CONSULTANCY/PRACTICE 3.3 PHILOSOPHY OF CARE OF THE NNP 3.4 PROFESSIONAL PRACTICE 3.5 PROCESS OF CARE 3.6 FORMULARY 3.7 DIAGNOSTICS 3.8 RESEARCH 3.9 EDUCATION 3.10 ADMINISTRATION 3.11 COORDINATION 3.12 QUALITY CONTROL AND SAFETY MEASURES

4. PATIENT POPULATION 4.1 CKD 4.2 ESKD COMPLICATION ASSESSMENT 4.3 VASCULAR ACCESS AND DIALYSIS ADEQUACY ASSESSMENT

5. COMMITTEE FOR THE DEVELOPMENT OF CLINICAL GUIDELINES FOR THE NEPHROLOGY NURSE PRACTITIONER

6. DIAGNOSTIC SERVICES 7. PRESCRIBING BY THE NEPHROLOGY NURSE PRACTITIONER

7.1 LEGAL GROUNDS FOR PRESCRIBING

8. REFERRAL PROCESSES 9. OUTCOME MEASURES FOR THE NEPHROLOGY NURSE PRACTITIONER 10. AMENDMENTS SECTION 2 1. CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF

CHRONIC KIDNEY DISEASE (Stages 3-5) 2. CLINICAL PRACTICE GUIDELINES FOR BIOCHEMICAL AND

HAEMATOLOGICAL TARGETS 3. CLINICAL PRACTICE GUIDELINES FOR DIALYSIS ADEQUACY 4. CLINICAL PRACTICE GUIDELINES FOR ESKD PATIENTS

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WITH A VASCULAR ACCESS 5. CLINICAL PRACTICE GUIDELINES FOR PERITONITIS TREATMENT

AND PROPHYLAXIS SECTION 3. REFERENCING – EVIDENCE FOR PRACTICE

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1.SYNOPSIS The Hunter New England Health (HNEH) Nephrology Nurse Practitioner (NNP) Guidelines for Clinical Practice is intended for use by Nurse Practitioners working in the area of Nephrology and has been developed in consultation with various stakeholders to provide a framework to assist the Nurse Practitioner with the clinical management of patients with End Stage Kidney Disease (ESKD) These clinical guidelines have been developed as per NSW Health Policy Directive 2005_556 Policy for Nurse/Midwife Practitioners in New South Wales and are supported by three major sets of documents:

1. Two authoritative and internationally recognised Bodies for Clinical Practice Recommendations for the treatment of Kidney Disease KDOQI (www.doqi.org) and CARI (www.cari.org.au)

2. Local policy and protocol for multi-disciplinary and shared care of ESKD and dialysis (Dx) issues (available in the Centre dialysis Unit and Satellite Dialysis units of the Lower HNEH service).

3. Supporting documents pertaining to the scope of practice for a Nurse Practitioner of this Hospital. (www.health.nsw.gov./nursing)

The National Australian' Body for the development of evidence based guidelines for nephrology is ‘CARI’ (Caring for Australians with Renal Impairment). This body utilizes best available evidence for their guideline recommendations. Their sources include meta-analysis from sources such as The Cochrane Collaboration as well as being made up of evidence or consensus based position statements on a variety of scientific and medical issues related to kidney disease. It is our intention to include any well-supported changes to current guidelines or additions to current guidelines as they become available. Inevitably each hospital will need to develop its own emphasis of ESKD management to best serve its community and patient population. Within the community dialysis setting (satellite and home dialysis), the predominant strategy is a multidisciplinary and ambulatory care approach that interacts closely with our general practitioners and patients. DISCLAIMER This document reflects what is currently regarded as safe practice and not intended to be construed or to serve as a standard of care. However, as in any clinical situation there may be factors that cannot be covered by a single set of guidelines. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical presentation or treatment plan must be made by the nurse practitioner in light of the clinical data presented by the client and the diagnostic and treatment options available. In making clinical decisions the nurse practitioner should remain cognizant of their level of expertise and take advantage of the expertise of all members of the treating team.

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http://www.doqi.org/

http://www.cari.org.au/

http://www.health.nsw.gov./nursing

2. INTRODUCTION In October 1998 the Nurses Amendment (Nurses Practitioners) Act was passed by both houses of the New South Wales Parliament. The Amendment allowed for the Nurse Registration Board to authorise certain registered nurses to practice as nurse practitioners. Nurse practitioners are registered nurses working at an advanced practice level who have attained appropriate accreditation with the NSW Nurses Registration Board. Nurse practitioners provide expert nursing care in collaboration with other health professionals in a variety of clinical settings (NSW Health 2003a). The nurse practitioner assists nursing and medical colleagues in clinical decision making for care and intervention. Despite their expanded role, nurse practitioners are nurses, and they approach the provision of patient care with a unique nursing perspective (Patterson and Haddad 1992). This also ensures that nurse practitioners avoid simply carrying out tasks that junior doctors are too busy to do (Walsh 1999). The nurse practitioner therefore does not attempt to replace or replicate medicine but rather complements and contributes to the specialized health care available to patients. 3. SCOPE OF PRACTICE WITHIN SOUTHERN SECTOR HUNTER NEW ENGLAND HEALTH SERVICE

3.1 PRACTICE ENVIRONMENT The goal of the Department of Nephrology is to provide the highest quality secondary and tertiary services to people with End Stage Kidney Disease (ESKD), their family and significant others. With this goal in mind, the Department provides and coordinates a comprehensive package of services including education, dialysis, transplant, clinics, assessment of complications and research. The patients are long term and require ongoing multidisciplinary care.

3.2 NNP CONSULTANCY/PRACTICE • Assessment, triage, intervention and management of clients (male and female 16

years or over at the service within primary, secondary and tertiary settings- see 4.patient population)

• As an autonomous practitioner, the NNP operates within specific practice guidelines, as approved by the relevant Area Health Service Chief Executive

• Autonomous practitioner within the multidisciplinary team • Networks locally, nationally and internationally • Provision of nephrology expertise to colleagues, health professionals and health care consumers • Liaison with general practitioners • Collaborates with other health providers to optimise client management • Client/patient advocate • Professional leadership, is a role model and resource • Describe and interpret immediate and long term health management outcomes of client group /

individuals • Authority to commence, alter and cease medications according to an agreed drug formulary • Request and monitoring of agreed investigations and referrals to other specialist services,

including but not limited to: o Biochemical, haematological and viral assays o Radiological investigations

• Case management to facilitate education, care and support to clients and their significant others through all stages of Kidney Disease

• Provision of a resource and consultancy service in nephrology and dialysis

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• Anticipation and prevention of disease progression and complications for clients • Provision of optimal dialysis prescription in accordance with clinical findings, biochemical and

haematological investigations, assessment, diagnosis, monitoring and symptom management • Within the tertiary hospital environment, the NNP has access to the expertise available for

referral, and may request consultation or initiate referral for �tilizes�ed care as appropriate. • The NNP provides direct patient care, education or nursing consultation within the hospital wards,

in the outpatient clinic, in the community satellite dialysis setting and home dialysis setting. • Routine management of patients by the NNP includes physical assessment, ordering and

evaluation of diagnostic procedures and laboratory tests, and the formulation of differential diagnoses in collaboration with Nephrologists, Surgeons and other members of the nephrology team.

• Actively promotes kidney health awareness and primary prevention • Demonstrates a high standard of professional practice and clinical leadership that incorporates

education and research • Maintains involvement in organizational and professional matters such as providing input

on working parties and into training programs • Facilitates research and quality improvement in CKD

3.3 PHILOSOPHY OF CARE OF THE NNP • The NNP provides person centered holistic care. • The NNP is a patient advocate who ensures that the patient and their families

understand their treatment and ongoing management, therefore encouraging rehabilitation and independence.

• All assessment and intervention follows the principles of safe clinical practice. • The NNP uses culturally acceptable language and assessment techniques.

3.4 PROFESSIONAL PRACTICE • The NNP is an autonomous and accountable practitioner, who demonstrates an

awareness of the nursing code of ethics and professional conduct. • The NNP demonstrates a role model of advanced practice nursing. • The NNP makes decisions based on optimum knowledge and current standards of

practice to ensure the best outcome for the adult patient. • The professional practice critical thinking and reflective practice of the NNP will

demonstrate advanced assessment, treatment skills and clinical management skills consistent with evidence-based practice.

• The NNP maintains a contemporary knowledge base, achieved by (and not limited to) regular review of professional literature, clinical research, regular attendance at conferences and participation in continuing education

3.5 PROCESS OF CARE

The NNP �tilizes advanced practice knowledge and skills to manage a caseload of patients, and to make a thorough health assessment of individual renal patients by: 1. Obtaining a comprehensive history of recent health status 2. Physical assessment 3. Differentiating between normal and abnormal findings 4. Initiating and evaluating diagnostic procedures and laboratory tests 5. Analysing information in order to formulate a differential diagnosis in collaboration

with the Nephrologists and Surgeons

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6. Utilising problem-solving skills and established evidence based guidelines to manage and often complex specific patient needs

7. Prescribing medication from a NNP formulary as defined by guidelines and approved by the Area Health Service Chief Executive

8. Regularly evaluating the health and well-being of patients to ensure optimal outcomes are maintained

• The NNP conducts an assessment of the physical and emotional needs of adults

undergoing renal replacement therapy • The NNP makes independent and/or collaborative decisions in partnership with

individuals/families. • The NNP acts as an advocate for adults on home dialysis and assists families to

access services that will keep them at home safely within their family or cultural environment.

• The NNP prescribes monitors and evaluates renal replacement therapies • The NNP �tilizes psychosocial assessment and counseling skills to provide holistic

care and ensure emotionally and physically optimal environment • The NNP collaborates and refers patients to other health professionals when

necessary.

3.6 FORMULARY The NP may prescribe and monitor medication within the scope of practice. When prescribing medication, the Nephrology NP will refer to formularies developed within approved guidelines for the nurse practitioner in accordance with section 78A of the Nurses and Midwives Act 1991. The current online Australian Medicines Handbook will be the primary reference.

3.7 DIAGNOSTICS

The Nephrology NP may request and report on certain diagnostic tests in order to monitor some physiologic parameters. These diagnostic investigations will be listed in the clinical practice guidelines.

3.8 RESEARCH

The Department of Nephrology as part of the Division of Medicine John Hunter Hospital is committed to ongoing research and to maintaining a standard of excellence in clinical care. The NNP will: • Undertake, initiate and participate in relevant renal research projects, especially those

aimed at supporting evidence based care in CKD patients

3.12 EDUCATION • Assessment of individual learning needs for health professionals, clients and their

significant others • Education and counseling clients in self-care, disease management and prevention • Promotion of a safe environment • Maintains own contemporary knowledge base, achieved by (and not limited to) regular

review of professional literature, clinical research, regular attendance at conferences and participation in continuing education

3.12 ADMINISTRATION

• Uses the managerial process to create an environment conducive to optimal public health and professional nursing practice

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• Each service provided by the Nephrology Nurse Practitioner is documented and recorded in the patients’ progress notes

3.12 COORDINATION • Collaboration expert within the multidisciplinary team to determine and achieve

realistic health care goals • Liaison with, coordination and support for other health professionals involved with

clients

3.12 QUALITY CONTROL AND SAFETY MEASURES • Regular meetings are conducted with the dialysis physician where the clinical care of

each patient is discussed • The Nurse Practitioner has direct access to the dialysis physician at all times to

discuss urgent or difficult case findings. This ongoing mentorship provides a unique opportunity for ongoing education as well as ensuring that patient care is optimized which also serves as a ‘safety net’ to review medical decisions

4. PATIENT POPULATION The NNP shall deliver care to patients (16 years onwards) with chronic kidney disease (CKD), end stage kidney disease (ESKD) and ESKD patients receiving renal replacement (RRP) Description of these patient populations:

4.1 CKD

Patients who have been identified with impaired kidney function requiring lifelong management to achieve remission and/or regression of their kidney disease. This shall be done in conjunction with the GP’s, Nephrologist and Nephrology Nurse Practitioner. These patients also require specialist and multidisciplinary care in their preparation for renal replacement therapy or palliative care once they progress to ESKD including education about dialysis or palliative care choices as well as vascular access preparation.

4.2 ESKD COMPLICATION ASSESSMENT The manifestations of chronic kidney disease affect every organ system. Care for ESKD patients requires prevention or early detection and management of ESKD manifestations though regular review.

4.3 VASCULAR ACCESS AND DIALYSIS ADEQUACY ASSESSMENT Patients with ESKD who receive renal replacement therapy are dialysed in either:

The Centre dialysis unit of the major tertiary referral hospital (John Hunter Hospital)

In the community either at home or in a Satellite Dialysis Unit (remote from the tertiary referral hospital and unsupported by full time medical officer support).

Nursing staff, the Nephrology Nurse Practitioner, Medical staff and other health professionals manage the dialysis and vascular access care. This care is through regular outpatient review as well as assessment while undertaking dialysis. Dialysis patients require ongoing management of their dialysis prescription, as well as vascular access management and education.

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5. COMMITTEE FOR THE DEVELOPMENT OF CLINICAL GUIDELINES FOR THE NEPHROLOGY NURSE PRACTITIONERCommittee for the Development of Clinical Guidelines for the Nephrology Nurse Practitioner These Clinical Practice Guidelines have been devised by Mrs. Lesley Salem RN, Neph/TCert, N.Sc/Apheresis Cert, NP, Grad Dip N.Sc and Mrs. Barbara Harvie RN, MN (Advanced Practice), MN (Nurse Practitioner), Grad Dip Nsg (Nephrology), incorporating current and relevant nursing and medical literature, and in collaboration with contributions from the following department representatives who have formed the guideline committee:

Mrs. Lesley Salem Mrs. Barbara Harvie Associate Professor Alastair Gillies Mrs. Carmel Peek Mrs. Susan Brazil

6. DIAGNOSTIC SERVICES

The NNP may request and monitor certain investigations relating to specific clinical practice guidelines. Diagnostic request forms may be signed by the Nurse Practitioner for appropriate investigations within diagnostic radiology and laboratory services

• Criteria and indications for diagnostic testing are identified within the specific treatment plans as ratified by the Medical Director of the Nephrology Department JHH in consultation with appropriate delegates of other departments

• Lines of communication are established to report adverse results to the Medical Director of the Nephrology Department JHH, or his/her delegate and health care team

• Appropriate investigations may include but are not limited to: o Blood tests, Urine tests o Wound culture o More advanced studies following consultation with the medical officer

• Referrals for radiology must be written and assigned by the Nurse Practitioner as described in the Medicare Benefits Schedule 2004 and State Records Act.

• The NNP can only request plain radiographic examinations consistent with their professional discipline. This may include, but is not limited to:

o Chest X-ray and abdominal X-ray o Duplex and ultrasound o Fistulogram and loopagram o Doppler o Bone density and skeletal surveys

• Nurse Practitioners requiring other than plain radiographic examinations must refer the patient to a Medical Officer

• If the performing Radiographer has any doubt in the validity of the request from a clinical or radiation protection perspective, he/she has the right to discuss the request with the referring Nurse Practitioner, or insist on confirmation from a Medical Officer.

o Nurse Practitioners cannot request plain examinations that involve multiple regions and or areas on the one patient. A Medical officer must make these requests.

7. PRESCRIBING BY THE NEPHROLOGY NURSE PRACTITIONER

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Reduced waiting times for patients, and increased cost efficiency in a variety of clinical settings has been demonstrated by utilising a Nurse Practitioner who can legally administer drugs from a pre-agreed hospital formulary within a multidisciplinary setting (NSW College of Nursing 2003).

• The NNP may prescribe and monitor medication within the scope of practice • When prescribing medication, the NNP will refer to formularies developed for the

nurse practitioner in accordance with section 78A (2) of the Nurses Act 1991. • The current online Australian Medicines Handbook (AMH) will be the primary

reference. • The drugs contained within this guideline are based on the Australian Medical

Handbook. • It is the responsibility of the Nurse Practitioner to ensure correct dosage using the

most recent AMH. • Medications may include agents prescribed to; manage regression and remission

of CKD, the manifestations of ESKD, achieve effective dialysis and treat adverse events of dialysis and dialysis access. The prescription of medications should be carried out with appropriate client and family education about medications and their side effects.

• Will document, maintain and update medical records for all medication changes • May authorise the continuation of existing medications (as per Formulary list)

7.1 LEGAL GROUNDS FOR PRESCRIBING

This following formulary (in SECTION 2) provides for the poisons and restricted substances that may be possessed, used, supplied or prescribed by Nurse Practitioners under section 17A of the Poisons and Therapeutic Goods Act (1966) and forms part of approved nurse practitioner guidelines, in accordance with section 78A(2)(a) of the Nurses Act (1991). 8. REFERRAL PROCESSESFollowing assessment and intervention, the NNP may make and arrange appropriate referral to departments or teams within the facilities of HNEH and other services within the health care system of New South Wales. As part of the referral process consumers are given advice and specific information about follow-up arrangements and referral details that are made for them. Referrals may be made, but not limited to the following services and organisations:

Dietitian Social Worker General Practitioner Psychologist Renal Physician Radiologist Occupational therapy Diabetic Service Podiatry Non-government Organisations e.g. Kidney Australia, HANKA

Aged Care Assessment Teams

Palliative Care Pain Management 9. OUTCOME MEASURES FOR THE NEPHROLOGY NURSE PRACTITIONER Outcome indicators: The NNP performance will be assessed against relevant outcome indicators, including but not limited to:

• The NNP participates in evaluation of the CKD/Dialysis program’s clinical indicators in order to provide cost effective, high quality renal replacement therapy for all adults across NSW

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• The NNP participates in departmental quality improvement programs • The NNP contributes to the development and ongoing review of protocols

specific to nephrology practice. 10. AMENDMENTS

Review of the Guideline This guideline was developed in May 2006. It should be viewed as an initial guide and a dynamic document that should be reviewed and revised by those who use it as the basis of their local guideline.

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SECTION 2

CLINICAL PRACTICE GUIDELINES CONTENTS INTRODUCTION 2.1 CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT

OF CHRONIC KIDNEY DISEASE (Stages 3-5) 2.2 CLINICAL PRACTICE GUIDELINES FOR BIOCHEMICAL AND

HAEMATOLOGICAL TARGETS 2.3 CLINICAL PRACTICE GUIDELINES FOR DIALYSIS ADEQUACY 2.4 CLINICAL PRACTICE GUIDELINES FOR ESKD PATIENTS WITH A VASCULAR ACCESS 2.5 CLINICAL PRACTICE GUIDELINES FOR PERITONITIS

TREATMENT AND PROPHYLAXIS

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INTRODUCTION The manifestations of chronic kidney disease affect every organ system, arising because the kidneys fail to perform normal excretory, regulatory, metabolic and biosynthetic functions. Organ system involvement includes cardiovascular, bone, neuromuscular, blood, skin, reproductive, gastrointestinal and serosal. Table 1: Primary consequences of chronic kidney disease MECHANISM EXAMPLE CONSEQUENCE Decreased excretion Uraemic toxins, including

nitrogenous wastes Uraemic syndrome

Salt & water Volume overload, hypertension Phosphate Hyperparathyroidism, metastatic

calcification Acid Metabolic acidosis Potassium Hyperkalaemia Decreased biosynthesis

Erythropoietin Anaemia

Activation of vitamin D Osteomalacia, hyperparathyroidism Altered metabolism Dyslipidaemia Atherogenesis Sex hormones Abnormal reproductive function Nephrological care of patients with CKD or ESKD can be divided into 5 major categories. CARI Guidelines have used these categories for their recommendations. These are;

1. CKD 2. Biological and Haematological targets 3. Dialysis adequacy 4. Vascular Access 5. Peritonitis treatment and prophylaxis

Each of the following guidelines outline the NNP agreed assessment, investigative, management and formulary for patients with CKD and ESKD. The guideline content has been arranged in the following format under each category. Each Guideline Category Explanation Section 1 Components of management

This section contains best available evidence for treatment aims. For Nephrology this section contains CARI, DOQI and local recommendations

Section 2 Diagnosis, Therapy and Formulary

-Tables containing assessment, investigations, non-pharmacological management, pharmacological investigations, health promotion and follow-up. -Tables of drugs (set out as per NSW Department of Health recommendations) that the NNP is permitted to prescribe or adjust

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SECTION 2.1

CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF

CHRONIC KIDNEY DISEASE (Stages 3-5)

Note that each guideline contains assessment, investigation, aims of treatment as represented in the relevant CARI Guideline, management, health promotion and prevention, follow up and formulary all relevant to the Nephrology Nurse Practitioners scope of practice

DIAGNOSIS, MANAGEMENT and FORMULARY

Guideline developed according to section 78(A)(2), Nurses Act 1991 These guidelines represent a general guide to appropriate clinical practice, and are inclusive, not prescriptive. The information aims to provide the Nurse practitioner with information on which decisions can be made.

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2.1 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT OF CHRONIC KIDNEY DISEASE (Stages 3-5) The NNP will monitor

• Patients response to treatment plan • Results of diagnostic studies • Adherence to treatment plan • Progression of CKD • For development of cardiovascular disease (CVD) or CVD risk factors

DIAGNOSIS Natural history

• Ascertain the presence and type of CKD • Ascertain the presence of CVD or CVD risk factors

Physical examination • BP, weight, respiratory rate and quality, heart sounds, breath sounds, dependent and

peripheral oedema, neck vein distension, jugular venous pressure • Calculate BMI • Assess for signs and symptoms of other end-organ damage

Identify barriers to self management

INVESTIGATIONS Biochemistry GFR estimation

Fasting lipids Presence and level of proteinuria ECG Examination of urine sediment Fasting and postprandial serum glucose Routine urinalysis Biochemical analysis Haematological analysis Radiological investigations Urine examination

Blood, urine, cultures, sediment Microbiology Urine Cardiovascular ECG Imaging Renal ultrasound

NON-PHARMACOLOGICAL MANAGEMENT

Health promotion and prevention o Referral o Weight loss o Order laboratory and diagnostic studies as appropriate o Initiate work-up for secondary HTN if indicated o Collaborate with and provide support and education for primary care providers and other health

care professionals to enhance patient screening for CKD and early referral

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PHARMACOLOGICAL MANAGEMENT

Prescribe pharmacological therapy (preferred agent) based on type of kidney disease, level of proteinuria, and hypertension according to CARI guidelines, including but not limited to: a) Diabetic kidney disease

o ACE inhibitors (ACE-I) or Angiotensin receptor antagonists (ARA), o Diuretics, beta-blocker or calcium channel blocker

b) Non-diabetic kidney disease (spot urine protein/creatinine ratio >200mg/g o Diuretics, ACE-I or ARA o Diuretic, then beta-blocker, calcium channel blocker

c) Nondiabetic kidney disease (spot urine protein/creatinine ratio <200mg/g o Diuretic, then ACE-I, ARA, beta-blocker or calcium channel blocker

See attached formulary of approved medications to meet: o Biochemical targets; o Haematological targets

HEALTH PROMOTION AND PREVENTION

o Lifestyle education for patient o Collaborate with and provide support and education including but not limited to, primary care

providers and other health care professionals to enhance patient screening, early referral and management of CKD

REFERRAL o GP o Nephrologist o Access surgeon o Renal dietitian for nutritional assessment and advice

Specialist-Nephrologist, surgeon -As per Clinical Guidelines for specific symptoms

FOLLOW UP o Monitor for complications and side effects of pharmacological therapy o Order laboratory and diagnostic investigations as appropriate o To assess response to antihypertensive therapy o Monitor adherence to treatment plan o Adjust medication regimen based on patient response - As per the clinical guideline

FORMULARY

VITAMINS AND MINERALS Australian Drug (generic name)

Route Dosage Therapeutic Class

Clinical presentation

Poisons Schedule

Ascorbic acid,vitamins B group (Multi B forte)

Oral 1-3 tablets daily Vitamins Vit. B and C deficiency

Unscheduled

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BETA BLOCKERS

Australian Drug (generic name)



Poisons Schedule

Atenolol (Hexal, Noten, Tenormin, Tensig)

Oral 100mg twice weekly to 50mg daily

Cardiovascular Beta-adrenergic blocker

Hypertension,all grades incl renal origin

S4

Carvedilol (Dilatrend)

Oral Initially - 12.5mg daily for 2 days; Maintenance 25mg daily, increased in 2 week intervals to a maximum of 50mg daily or 2 divided doses

Cardiovascular Beta-adrenergic

blocker

Hypertension;adjunctive treatment in symptomatic mild to severe congestive heart failure

S4

Labetalol (Presolol) Oral Initially 100mg bd, increased each week; maintenance 200-400mg bd

Cardiovascular Antihypeertensive Alpha blocker

and non selective beta-

blocker

All grades of hypertension

S4

Metoprolol (Minax, Betaloc, Lopresor, Metoprolol)

Oral Initially, 50-100mg daily for 1 week. Maintenance 50-100mg once or twice daily


blocker

Hypertension; angina pectoris; suspected or definite MI

S4

Oxprenolol (Corbeton)

Initially 40-80mg bd, increased each week. Maintenance, 80-160mg bd


blocker

Angina pectoris; cardiac arrhythmias; hypertension

S4

Pindalol (Barbloc, Visken)

Oral Initially, 5mg twice daily, increased by 10 mg daily every 3–4 weeks. Maintenance: 10-30mg daily in 2-3 divided doses


blocker

Hypertension; angina pectoris (prophylaxis), cardiac arrhythmias

S4

Propranolol Hydrochloride (Deralin, Inderal)

Oral Initially 20-40mg bd; increased by the same amount each week. Maintenance, 120-320mg daily in 2-3 divided doses


blocker

Hypertension; angina pectoris; some cardiac dysrhythmias

S4

Sotalol Hydrochloride (Solavert, Sotacor, Sotahexal)

Oral Initially 40–80 mg bd; increase according to response to 160 mg bd

Antiarrhythmic Cardiovascular

Class III antiarrhythmic action for prevention and treatment of supraventricular and ventricular arrhythmias

S4

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ACE INHIBITORS Australian Drug (generic name)



Poisons Schedule

Captopril (Capoten) Oral Initially 6.25mg bd Anti-hypertensive agent Cardiovascular ACE inhibitor

Hypertension (alone or with other antihypertensives); heart failure (with a diuretic)

S4

Enalapril (Renitec) Oral Initially 2.5mg daily Anti-hypertensive agent Cardiovascular ACE inhibitor

Essential and renovascular hypertension; CHF (with a diuretic); LV dysfunction where LVEF < 35%

S4

Fosinopril (Monopril, Monoplus)

Oral Initially 2.5mg daily Anti-hypertensive agent Cardiovascular ACE inhibitor+diuretic

Mild to moderate hypertension; CHF in conjunction with a diuretic

S4

Perindopril (Coversyl)

Oral Initial dose according to creatinine clearance: 30-60 mL/min 2mg daily; 15-30 mL/min, 2mg alternate days;

Anti-hypertensive agent Cardiovascular ACE inhibitor

Hypertension; CHF

S4

Quinapril (Accupril) Initially 2.5–5 mg daily. Anti-hypertensive agent Cardiovascular ACE inhibitor

Hypertension and CHF

S4

Ramipril (Tritace, Ramace)

Oral Initially 1.25mg daily; double at intervals of 2–3 weeks, depending on tolerance; up to 5mg daily

Anti-hypertensive agent Cardiovascular ACE inhibitor

Hypertension (exc renovascular); heart failure (post MI); prevent renal failure progression in persistent proteinuria (> 1 g/day); reduce cardiovascular, cerebrovascular risk

S4

Trandolapril (Gopten)

Oral Initally 1.5mg daily Anti-hypertensive agent Cardiovascular ACE inhibitor

Hypertension; left ventricular dysfunction post-MI

S4

ANGIOTENSIN II ANTAGONISTS




Poison Schedule

Candesartan cilexetil (Atacand)

Oral Usually 8mg daily; start at 4mg daily in severe renal

Anti-hypertensive agent

Hypertension S4

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Comb: Candesartan/ Hydrochlorothiazide

impairment; increase to max 16mg daily. Lower maximal dose in severe renal impairment

Cardiovascular Angiotensin II receptor antagonist (Comb + diuretic)

Eprosartan Mesylate (Teveten) Comb: Eprosartan/ Hydrochlorothiazide

Oral Initial: 600mg daily; start at 400mg daily in people taking diuretics, hepatic or renal impairment, or elderly; may be increased if necessary to 800mg daily.

Anti-hypertensive agent Cardiovascular Angiotensin II antagonist

Hypertension S4

Irbesartan (Karvea) Comb: Irbesartan/ Hydrochlorothiazide AvaproCT, Karvezide

Oral Usually 150mg daily; start at 75 mg daily in haemodialysed and/or elderly (>75 years) patients; can be increased to 300mg daily. Prevention of renal disease progression: Maintain 300mg daily


Hypertension; delay renal disease progression in hypertensive type II diabetes with persistent microalbuminuria, proteinuria

S4

Losartan Poassium (Cozaar)

50mg, , 100mg tablets

Oral Usually 50mg daily; start at 25mg daily in people taking diuretics; increase after 3–6 weeks if necessary to 100mg daily.

Anti-hypertensive agent Cardiovascular Angiotensin II

antagonist

Hypertension (alone or with other antihypertensives); renal protection in NIDDM patients with proteinuria

S4

Telmisartan (Micardis) Comb: Telmisartan Hydrochlorothiazide

40mg, 80mg 40mg/12.5mg, 80mg/12.5mg tablets

Oral Usually 20–40mg daily; can be increased to 80mg daily


Hypertension S4

CALCIUM CHANNEL BLOCKERS




Poisons Schedule

Nifedipine, (Nifecard, Adefin, Nypine, Adalat Nyefax, Nifehexal)

Oral Initially: 30 mg daily; titrate over 7-14 days to max 120 mg daily according to response

Anti-hypertensive agent Cardiovascular Calcium channel blocker

Hypertension; angina

S4

Amlodipine Besylate (Norvasc)

Oral Initially 2.5-5mg daily, increased over 1-2 weeks to max 10mg daily


Hypertension; angina (chronic stable)

S4

Felodipine (Felodur ER)

Oral Initially 5mg daily, increased over 1–2 weeks to max 10 mg daily


Hypertension S4

Lercanidipine Oral Initially 10 mg daily; if Anti-hypertensive Hypertension S4

20

Hydrochloride (Zanidip)

necessary, increase after at least 2 weeks up to a maximum of 20 mg daily

agent Cardiovascular Dihydropyridine Calcium antagonist

Diltiazem Hydrochloride (Cardizem, Cardizem,CD Vasocardol Coras Diltahexal, Dilzem)

Oral Initial: 30mg 3–4 times daily, increase up to 180–240mg daily. Controlled release: Initial 180mg daily; increase up to 360mg daily.

Anti-hypertensive (some antianginal) agent Cardiovascular Calcium channel blocker

Hypertension; chronic stable angina

S4

Verapamil Hydrochloride

(Anpec, Isoptin)

Oral Initial: oral 80mg 2–3 times daily; maintenance: 160mg 2–3 times daily.


Hypertension, angina, tachyarrhythmias, atrial fibrillation, flutter with rapid ventricular response

S4

21

DIURETICS




Poisons Schedule

Frusemide (Lasix, Urex)

Oral Hypertension: 80mg in 2 divided doses; Oedema: 80mg single dose; increase if needed by 20-40mg greater than or equal to 6-8 hours after previous dose; max 400mg/day

Diuretic Cardiovascular system Loop diuretic

Oedema; hypertension

S4

Bumetanide (Burinex)

0.5-4mg once or twice daily, adjusted for clinical response

Diuretic Cardiovascular system

Loop diuretic

Oedema S4

Ethacrynic Acid (Ethacryn)

50–200 mg once or twice daily.

Diuretic Cardiovascular system

Loop diuretic

Pulmonary, renal oedema; CHF; nephrotic syndrome in children > 2 yrs

S4

Chlorthalidone (Hygroten)

Hypertension, diabetes insipidus: 12.5–25mg daily; Oedema: 12.5-50mg daily; alt day dosing possible.

Diuretic Cardiovascular system Thiazide analogue diuretic

Essential hypertension; stable chronic heart failure (mild to mod.)

S4

Hydrochlorothiazide (Dithiazide)

Oral Hypertension: Initial 12.5-50mg (usu 25-50 mg) daily in 1-2 doses; adjust up to max 100mg/day as needed; Oedema: 25-100 mg once or twice daily, can be intermittent (alt. days or 3-5 days/week);

Diuretic Cardiovascular system Thiazide diuretic

Hypertension, oedema

S4

Indapamide (Natrilix, Dapa-Tabs, Insig Napamide,Indapamide Indahexal 2.5mg tablets (combinations differ)

1.25–2.5 mg once daily. Antihypertensive agent

Cardiovascular system

Hypertension S4

Spironolactone (Aldactone, Spiractin)

Oral Essential hypertension: 50-100mg/day. CCF: initial 100mg/day; adjust gradually Maint:enance: 25-200mg/day. Hypokalaemia: lowest effective dose; increase gradually to 100 mg/day

Diuretic Cardiovascular system Aldosterone antagonist (Potassium – sparing)

Essential hypertension; oedematous disorders incl CCF, nephrotic syndrome; malignant hypertension (adjunct); hypokalaemia (prophylaxis);

S4

Hydrochlorothiazide (Moduretic)

Oral 1-2 tablets daily Diuretic Cardiovascular system Potassium

Oedema; hypertension

S4

22

sparing Thiazide diuretic

DETOXIFYING AGENTS




Poisons Schedule

Calcium polystyrene sulfonate (Calcium Resonium)

Oral 15-30gm daily, as ordered

Detoxifying agent Hyperkalaemia S4

Sodium polystyrene sulfonate (Resonium A)

Oral 15-30gm daily, as ordered

Detoxifying agent Hyperkalaemia S4

Table 6-4 Coexisting conditions and antihypertensive choice (Australian Medicines Handbook, accessed 25.11.05)

Coexisting condition Drugs with favourable effect

Diabetes with microalbuminuria ACE inhibitors, angiotensin II antagonists

Heart failure ACE inhibitors, beta-blockers (carvedilol, slow-release metoprolol,

bisoprolol), thiazide diuretics, angiotensin II antagonists

Post MI beta-blockers (except oxprenolol, pindolol), ACE inhibitors (left ventricular

dysfunction)

Angina beta-blockers (except oxprenolol, pindolol), calcium channel blockers

Coexisting condition Drugs with unfavourable effect

asthma, COPD beta-blockers1

bradycardia, second or third degree

atrioventricular block

beta-blockers, calcium channel blockers (except dihydropyridines)

heart failure verapamil, diltiazem, selective alpha-blockers

gout diuretics

renovascular disease, pregnancy ACE inhibitors, angiotensin II antagonists

severe peripheral vascular disease beta-blockers

1cardioselective beta-blockers (eg atenolol, metoprolol) may be used cautiously in mild-to-moderate reactive airways diseases

23

SECTION 2.2

CLINICAL PRACTICE GUIDELINES FOR BIOCHEMICAL

AND HAEMATOLOGICAL TARGETS


DIAGNOSIS, MANAGEMENT and FORMULARY

2.2.1 BONE DISEASE, CALCIUM, PHOSPHATE AND PARATHYROID

HORMONE 2.2.2 MAGNESIUM 2.2.3 ACIDOSIS

2.2.4 LIPIDS

2.2.5 ANAEMIA

Guideline developed according to section 78(A)(2), Nurses Act 1991 These guidelines represent a general guide to appropriate clinical practice, and are inclusive, not prescriptive. The information aims to provide the Nurse practitioner with information on which decisions can be made

24

2.2.1 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT OF BONE DISEASE, CALCIUM, PHOSPHATE AND PARATHYROID HORMONE The NP will monitor

• Patients response to treatment plan (Diet, medications, exercise) • Results of diagnostic studies • Adherence to treatment plan • For development of bone disease and signs of extra-skeletal calcification


o Assess for risk factors for osteoporosis (older age, post menopausal status, race, vitamin D deficiency, medications, malignancy, prolonged immobilization)

o History of injuries o Adherence to diet, medication and treatment regimens (include -Current

medications and supplements, GI history) o Financial constraints in meeting dietary and medication regimens

Physical examination o Muscle strength, gait, and range of motion (limitations) o Joints for enlargements, swelling, stiffness and tenderness o Bone pain o Skin for local tissue injury, maculae, papules or purities o Eyes for visible injury local inflammation o Extremities (vascular insufficiency) o BP and pulse

Dialysis prescription (hours, dialysate) INVESTIGATIONS

Biochemistry Predialysis blood sample should be used. (Level B evidence) Calcium, phosphate, ionized calcium, albumin, PTH Estimation of the calcium x phosphate product, alkaline phosphatase, vitamin D, PTH, Aluminum

Radiological examination

Plain x-ray (determination of metastatic calcification) Bone x-ray (for patient with fractures or known risk of osteoporosis)

Cardiovascular ECG Exclude -Hypomagnesaemia

-Vitamin D deficiency -Primary Hyperparathyroidism -Aluminium exposure Differentiate -Decreased renal excretion & increased phosphate load -Diabetic management/insulin -Reduced dietary intake (with hypophosphataemia)

25

NON-PHARMACOLOGICAL MANAGEMENT o Diet/phosphate restriction o Dialysis adequacy o Dialysate adequacy-correct calcium concentrate

PHARMACOLOGICAL MANAGEMENT o Phosphate binder o Calcium supplement o Vitamin D analogue (Dose adjustment)

Practice tips phosphate management o Calcium carbonate and acetate, Magnesium carbonate, Aluminium hydroxide and Sevelamer

(RenaGel) are effective phosphate binders. o Dissociation of phosphate binders may differ between manufacturers and formulations. It may

be useful to try a different formulation if phosphate control is poor despite patient compliance. o Ranitidine may reduce phosphate binding by calcium carbonate. Other drugs that increase

gastric pH may have a similar effect. o Solubility and efficacy differences between calcium acetate and carbonate may not be present if

calcium carbonate is taken on an empty stomach shortly before meals. o Although intestinal calcium uptake has been reported to be lower with calcium acetate than with

calcium carbonate, both may induce hypercalcaemia. o Adequate phosphate control may necessitate the use of aluminium-containing phosphate

binders although this should be minimised. o Calcium-containing phosphate binders should be used with caution in patients o With Vitamin D administration -Monitor for hypercalcaemia and over suppression of PTH

HEALTH PROMOTION AND PREVENTION o Assess patients understanding of and educate patient on;

Kidney function and calcium and phosphate homeostasis Dialysis prescription and its relationship to disorders of bone metabolism

(Dialysis compliance) Consequences of alterations in bone metabolism

• Bone disease • Extra-skeletal calcification • Development of cardiovascular disease

Signs and symptoms of • Disorders of bone metabolism • Extra-skeletal calcification • Hypo-and hyperphosphphataemia • Hypo-and hypercalcaemia

Reducing mobility hazards in the home and work environment Exercise to maintain strength and mobility Prevention and management of bone disease and extraskeletal

calcification (Medication compliance/education) Dietary education & information

26

REFERRAL o Dietitian o Nephrologist o Referral to social worker to ensure home environment is assessed for safety and financial

difficulties are addressed o Referral to physiotherapy and Occupational Therapists for mobility assessment and assistance

FOLLOW UP

o 4-8 weeks following commencement of or manipulation of phosphate binders o PTH every 3 months o Bone density as required

FORMULARY

PHOSPHATE BINDERS

Australian Drug (Generic name)



Poisons Schedule

Calcium Carbonate (Caltrate)

Oral 1-2 tablets with food as directed and titrated to predialysis serum phosphate level

Phosphate binder

Hyperphosphataemia in chronic renal failure Calcium supplementation

Unscheduled

Calcium Carbonate (Titralac)

Oral 1-2 tablets as needed (titrated to phosphate/ calcium levels)

Phosphate binder


Unscheduled

Calcium carbonate; magnesium carbonate (Rennie)

Oral Adults- 1-2 tablets with food as directed. Tablets, calcium carbonate 680mg, magnesium carbonate (heavy) 80mg; sucrose, saccharin

Phosphate binder


Unscheduled

Aluminum Hydroxide

Oral As prescribed and titrated to serum phosphate and serumaluminium levels

Phosphate binder

Phosphate binder in chronic renal failure

Unscheduled

Magnesium Salts (Magnesium carbonate, magnesium hydroxide and magnesium trisilicate)

Oral As instructed-titrated to magnesium/ aluminium serum levels and phosphate binding requirements Tablets, liquid

Phosphate binder

Phosphate binder in chronic renal failure

Unscheduled

27

VITAMIN D ANALOGS




Poisons Schedule

Calcitriol (Rocaltrol, Citrihexal, Kosteo, Sitriol)

Oral 0.25mcg daily; increase by 0.25mcg daily at 2-4 week intervals according to response; Decrease by 0.25mcg daily when normocalcaemic. NB Titrate only in consultation.

Vitamin D substance

Hyperparathyroidism Hypocalcaemia in hypophosphataemic rickets, Hypoparathyroidism, renal osteodystrophy, chronic renal dialysis

S100

28

2.2.2 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MAGNESIUM MANAGEMENT The NP will monitor

• Patients response to treatment plan • Results of diagnostic studies • Adherence to treatment plan

DIAGNOSIS

o Natural history o Physical examination o Dialysis prescription (hours, dialysate)

INVESTIGATIONS Biochemistry Measure serum magnesium monthly in patients who are taking

magnesium salts or using dialysate with a magnesium concentration out of the range 0.25- 0.50 mmol/L. Measure magnesium in other dialysis patients 3-6-monthly

Cardio examination

ECG

Exclude Gut losses – diarrhoea Excessive ingestion (supplements/phosphate binder use) Poor diet


o Diet o Dialysis adequacy o Dialysate adequacy


o Magnesium/aluminium oral phosphate binders o Magnesium supplementation with magnesium salts

HEALTH PROMOTION

o Dietary education o Medication compliance and education o Dialysis compliance

REFERRAL

o GP o Nephrologist

FOLLOW UP

o Regular magnesium check 3 monthly after commencing supplementation

29

FORMULARY

MAGNESIUM SALTS

Australian Drug (Generic name)



Poisons Schedule

Magnesium Salts (Magnesium Aspartate,

Oral As instructed-titrated to magnesium/ aluminium serum levels

Vitamins and minerals

Magnesium supplementation

Unscheduled

30

2.2.3. DIAGNOSIS, MANAGEMENT AND FORMULARY FOR ACIDOSIS MANAGEMENT The NP will monitor

• Patients response to treatment plan • Results of diagnostic studies • Adherence to treatment plan

DIAGNOSIS Natural history Physical examination Dialysis prescription (modality, hours, Dialysate)

INVESTIGATIONS

Biochemistry Pre dialysis estimation of serum bicarbonate Exclude Respiratory conditions leading to/or exacerbating metabolic acidosis


o Diet/protein restriction o Dialysis adequacy o Dialysate adequacy o Decrease intradialytic weight gain due to fluid retention o Avoid interdialytic hypo tension


o Oral alkali (exogenous alkali administration)

HEALTH PROMOTION AND PREVENTION o Dietary education o Medication compliance and education o Dialysis compliance o Compliance with fluid restrictions

REFERRAL

o GP o Nephrologist

FOLLOW UP

o Review serum bicarbonate level when; o When starting oral alkali-one month then three monthly o Commencing dialysis then with regular follow up three monthly

31

FORMULARY

SODIUM BICARBONATE


Route

Dosage Therapeutic Class

Clinical presentation Poisons Schedule

Sodium Bicarbonate (SodiBic)

Oral Commence cautiously with 1 capsule daily, increasing dosage steadily if repeated bicarbonate levels indicate the need. Capsules, 840 mg:

Metabolic acidosis

Renal failure associated with renal tubular acidosis in which bicarbonate replacement becomes necessary.

Unscheduled

32

2.2.4 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR LIPID MANAGEMENT The NP will monitor

• Coronary heart disease risk equivalent conditions (coronary artery disease, peripheral arterial disease, abdominal aortic aneurysm)

• For modifiable risk factors for cardiovascular disease • Results of laboratory tests • Response to treatment plans (CVD risk factor reduction, lifestyle changes, diet,

medication regimen) • Adherence to treatment plan

DIAGNOSIS

Natural history • Lifestyle habits (smoking, alcohol consumption and exercise frequency • Adherence to dietary and medication regimens

Physical examination • Weight and BMI, BP and heart rate, apical and peripheral pulses, respiratory rate and

quality, peripheral oedema Assess for;

• CVD risk-equivalent conditions -Clinical coronary heart disease, Peripheral arterial disease, abdominal aortic aneurysm, diabetes mellitus

• Modifiable risk factors for CVD (Smoking, hypertension, low HDL, family history of CVD, age, risk factors of CKD-anaemia, hyperhomocysteinaemia, disorders of calcium and phosphate homeostasis, volume overload)

INVESTIGATIONS

Biochemistry UEC Calcium, phosphate, PTH Lipid profile-Cholesterol/ Triglycerides/ LDL (low density lipoprotein, HDL (high density lipoprotein) Hepatic function LFT’s

Homocystein Haematology Hb and HCT Exclude Liver disorders


• Health promotion o Education, lifestyle changes, fluid restriction

• Referral dietitian • Order diagnostic studies and frequency of laboratory testing


• Treat dyslipidaemias o Statins o Fish oil (hypertriglyceraemia)

• Refer for HRT consideration

33

HEALTH PROMOTION

o Lifestyle education –modifiable risk factors o Diet with <10% calories from saturated fats-referral to dietician and weight

management o Exercise o No smoking o Alcohol consumption

o Education on CKD and its relationship to lipoprotein levels

REFERRAL o GP o Nephrologist o Dietitian o CNC Diabetes

FOLLOW UP

o Lipid profile, haematology and hepatic function o 4 weeks following initiation and alteration of medication

FORMULARY

LIPIDS

Australian Drug

(generic name)


Clinical presentation Poisons Schedule

Atorvastatin Calcium Simvastatin

Oral Hypercholesterolaemia or mixed hyperlipidaemia Initially 10mg in evening. Adjust at 4-week intervals prn. Max 80mg daily. Existing coronary artery disease:Initially 20mg in evening; adjust as above

Hypolipidaemic agents - Cardiovascular System HMG-CoA reductase inhibitor (Statin)

Hypercholesterolaemia and adjunct to the diet in the treatment of HypercholesterolaemiaMixed hyperlipidaemia and adjunct to the diet in the treatment of hyperlipidaemia

S4

34

2.2.5 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR ANAEMIA MANAGMENT The NP will monitor

• Results of diagnostic studies • Adherence to treatment plan • Response to treatment plan • For potential causes of hyporesponse to anaemia management

DIAGNOSIS o Natural history o Physical examination

o Weight, BP and heart rate, respiratory rate and quality, skin and mucous membranes

o Signs and symptoms of anaemia Angina, hypotension, tachycardia, dyspnoea Decreased energy and activity levels Diminished appetite and weight loss Lessened sense of well-being Diminished sexual interest and function

o Assess patient for potential causes of anaemia Blood loss, iron deficiency, vitamin deficiencies, inflammation and infection,

secondary hyperparathyroidism, malnutrition o Dialysis prescription (modality, hours, dialysate) o Evaluate for comorbid conditions such as angina, pulmonary disease, hypotension, congestive heart failure or cerebrovascular disease

INVESTIGATIONS

Biochemistry Haemoglobin HCT Iron studies-(Ferritin, Iron, TIBC(total iron binding capacity), Transferrin Saturation) Serum B12 Folate levels C-reactive protein Coagulation studies

Radiological examination Exclude Exclude blood loss - determine that intrinsic renal

disease, is the primary cause of the anaemia’ (decreased production of red blood cells) Exclude infective or inflammatory states


• Diet

35


• Collaborate with the nephrologist to develop and use an anaemia management plan for the patient

• Iron supplementation – as per treatment aims • Erythropoietin administration • Adequate anticoagulation for blood loss due to clotting on dialysis

HEALTH PROMOTION

• Kidney function and its relationship to anaemia • Signs and symptoms of anaemia • Consequences of anaemia • Diagnostic tests used to evaluate anaemia • Signs of bleeding • Medication compliance • Diet

REFERRAL

• Nephrologist • Gastroenterologist

FOLLOW UP

• Monitoring o BP particularly during initiation of erythropoietin

• Haemoglobin should rise 1–2 g/L daily, or 20 g/L over 3–4 weeks • Monitor haemoglobin for therapeutic response; If no improvement after 4 weeks,

review. • Avoid unnecessary long term use of iron supplements • Note-any changes in prescribed treatment. Takes from 7-28 days to see effect

36

FORMULARY

HAEMOGLOBIN AND IRON AGENTS




Poisons Schedule

Darbopoetin alfa (Aranesp) Substitution of Darbopoetin alfa for epoetin alfa: Initial SC dose is total weekly SC dose of epoetin alfa (iu) divided by 200; initial IV dose is total weekly IV dose of epoetin alfa (iu) divided by 240. (Aranesp Manufacturer’s instructions).

SC or IV Presentation pre-filled syringes.

CRF: Initial: authorised medical officer only (0.45mcg/kg) Nurse practitioner titration. Increase dose if rise is <10 g/L in 4 weeks. Decrease dose by 25%–50% if rise is >25 g/L in 4 weeks. Withhold dose if Hb >140 g/L until reduced to <130 g/L. Recommence at dose 25% < previous dose. Maintenance: Hb level of 110-140 g/L, titrated fortnightly as required. NB. CARI guidelines recommend withhold treatment if Hb above 130mmol/L (CARI, 2003). Maintain Hb at >120g/L. IV and SC doses are similar. Adjust dose to nearest syringe size.

Haemopoietic agents - Endocrine and Metabolic Disorders

‘Treatment of anaemia requiring transfusion, defined as a haemoglobin level of less than 100 g/L, where intrinsic renal disease, as assessed by a Nephrologist, is the primary cause of the anaemia’. (NSW Health Information Bulletin, accessed 3.7.2004).

Restriction: S100 Authority Script

Epoetin alfa (Eprex)

Subcutaneous or IV

CRF Initial: Authorised medical officer only (50 IU/kg) three times weekly. Titrated by nurse practitioner. Increments 25 IU/kg. Increase dose if rise is <10 g/L in 4 weeks. Decrease dose by 25%–50% if rise is >25 g/L in 4 weeks. Withhold dose if Hb >140 g/L until reduced to <130 g/L. Recommence at dose 25% < previous dose. Maintain Hb at >110 g/L. Change dose fortnightly if needed. IV and SC doses are similar. Adjust dose to nearestsyringe size. Hb>150g/L *see local safe work practice


‘Treatment of anaemia requiring transfusion, defined as a haemoglobin level of less than 100 g/L, where intrinsic renal disease, as assessed by a Nephrologist, is the primary cause of theanaemia’. (NSW Health Information Bulletin, accessed 3.7.2004).

Restriction: S100 Authority Script

Iron polymaltose (Ferrum H)

Intravenous infusion (options) First dose under medical

Initial: First dose 100mg IVI in hospital with medical support Maintenance: According to orders. Haemodialysis: 100mg


Iron deficiency anaemia where oral treatment not appropriate or enteric absorption defective

S4

37

supervision. 100mg in 2ml ampoules

Ferrum H in NaCl 0.9% to 5 ml over last hour of dialysis Management range: 100mg each dialysis to 100mg monthly dependent on Hb, Aranesp/EPO dosage and iron studies. CAPD/APD: IV 1Gm in 300ml NaCl 0.9% over 4 hrs in hospital with medical support

Ferrous sulphate Oral One tablet daily Iron - Vitamins and Minerals Fe deficiency

Therapeutic, prophylactic. Iron deficiency treatment or iron deficiency anaemia, esp. for those not tolerant to oral iron.

S2

Folic acid (Mega-fol)

Oral 5mg daily Vitamins (single agents) - Vitamins and Minerals Megaloblastic anaemia due to folic acid deficiency

Folic acid deficiency S2

Vitamin B12 (Cyanocobalamin, Cytamen)

IM Initial (for vitamin B12 deficiency): IM 250-1000mcg alternate days for 1-2 weeks. Maintenance: IM 250-1000mcg monthly.

Parenteral vitamins, minerals and nutrition – Nutrition Vit B12 deficiency, esp pernicious anaemia

Vitamin B12 deficiency

Unscheduled

38

SECTION 2.3

CLINICAL PRACTICE GUIDELINES FOR DIALYSIS

ADEQUACY


DIAGNOSIS, THERAPY AND FORMULARY


39

2.3 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT OF DIALYSIS ADEQUACY The NNP will monitor • Prescribed vs. delivered dose of dialysis • Response to dialysis prescription • Signs of inadequate dialysis • Adherence to dialysis prescription • Vascular access function (see section 4) • Response to medications • Response to diet and fluid prescription • Adherence to treatment plans (including any treatment and equipment

related complications) • Cardiovascular status


• Ask re current complaints (headaches, dizziness, blurred vision, nausea, change in bowel habits, fever, chills, dyspnoea, chest pains, palpitations, pain, bleeding, sleeping habits, weakness, fatigue, change in level of activity, change in appetite)

• Medication o History for pharmacologic agents that effect anticoagulation, cardiovascular

stability (include prescribed, over the counter and non-traditional medicines) Physical examination for;

• Manifestations of ESKD o Anaemia status o Cardiovascular status o Calcium and phosphate complications

• Ideal ‘Dry’ weight • Response to current dialysis prescription

o Monitor prescribed vs. delivered dose of dialysis o Dialysis modality –current prescription

• Signs of inadequate dialysis o Abnormal electrolytes, hypovolaemia, symptoms of uraemia, worsening nutritional

status, anaemia, bone disease, neuropathies, abnormal sleep patterns, insomnia, neurological symptoms (restless legs, poor concentration), poor quality of life

• For compromised urea clearances o Inadequate access blood flow, access recirculation, inappropriate dialyser size,

excessive dialyser clotting, inadequate extracorporeal blood flow rate, inadequate dialysate flow rate, inadequate needle placement

• For reduction in treatment times o Uncompensated interruptions in actual treatment times (clinical complications,

hypotension), equipment alarms, manipulation of needles, dialysis catheter, dialysate bypass situations (i.e. temperature or conductivity alarms)

• For shortened treatment time Patient demand, Dialysis Unit issues, clinical complications, Missed treatments

• Psychological assessment re adjustment to dialysis • Nutritional status

40

INVESTIGATIONS Biochemistry URR

Urea, electrolytes, creatinine, calcium, phosphate PTH Coagulopathy screen LFT Residual renal function PET test

Microbiology Blood cultures Wound and access swabs Access device culture

Cardiovascular ECG Oximetry

Imaging Chest x-ray Abdominal x-ray Ultrasound (hand held) Access duplex

Exclude Decrease adequacy due to Access failure Decreased or increase peritoneal membrane permeability


o Modify and -adjust dialysis prescription (Blood flow, dialysate choice, dialysate flow, dialyser, hours on dialysis, dialysis modality, eating strategies)

• Based on URR results • Based on patient response to treatment and occurrence of complications • To prevent intradialytic symptoms without compromising delivered dialysis dose –

(sodium modeling, ultrafiltration profiling, haematocrit monitoring) • For ultrafiltration strategies that allow for cardiovascular stability (see appendix)

o Increase venous return, TED stockings, exercise o Order additional laboratory tests or diagnostic studies

• As appropriate • As follow up to complications

o Initiate consults or referrals o Adjust diet and fluid prescription based on patient response


o Adjust medication regimen based on patient response o Initiate treatment of dialysis access complications (see section 4 and 5)

• Dialysate selection as titrated to biochemistry (See Table 1 below) • Peritonal dialysis fluid selection as titrated to biochemistry and fluid removal

requirements (See Table 1 and Table 2 below) • Treat constipation

41

HEALTH PROMOTION AND PREVENTION

o Patient education • Dialysis principles and procedure • Signs and symptoms of dialysis complications • Anticoagulation regimen • Vascular access • Routine tests and how therapy is monitored • Diet • Dialysis compliance • Medication compliance • Education re early manifestations of ESKD and dialysis complications to ensure

timely management and prevention of adverse events • Sodium restriction and thirst management • Reporting of problems or complications

o Establish good communication with staff and patients

REFERRAL

o GP o Nephrologist o Access surgeon

FOLLOW UP

o As required following; • Abnormal URR findings • Dialysis prescription changes

Table 1. Components of dialysate and dianeal

Dialysate Glucose Potassium Calcium A331 10 1.0 1.3 A333 10 2.0 1.3 A365 Nil 2.0 1.75 A400 10 1.0 0.9 A357 10 2.0 1.5 Peritoneal dialysate (each 1000ml)

1.5% 1.5% dextrose - 1.25 (1.0 available) 2.5% 2.5% dextrose - 1.25 (1.0 available) 4.25% 4.25% dextrose - 1.25 (1.0 available) Extraneal Icodextrin 75g - 1.75mmol

42

Table 2 Selection of dianeal strength

Patient weight Dianeal Selected At ideal body weight or up to 0.4kg over ideal body weight

1.5% dianeal

Patients body weight 0.5 to 1.4kg over ideal body weight

2.5% dianeal

1.5kg plus above ideal body weight 4.25%

FORMULARY

HAEMODIALYSIS Australian Drug (generic name)



Poisons Schedule

0.9% Sodium Chloride

IV 200ml increment Oral and parenteral

electrolytes – Nutrition

Electrolyte and fluid volume replacement

For prevention or treatment of symptomatic hypotension

during haemodialysis

S4

0.9% Sodium Chloride

IV 10ml Vehicle for compatible

parenteral drugs

For drug dilution

S4

HAEMODIALYSIS ADJUSTMENTS

Parameter Route Adjustment range Adjustment mode Mg++ additive Haemodialysis-dialysate Limited by standard

dialysate composition 5L container

K+ additive Haemodialysis-dialysate 1mmol/litre to 4 mmol/litre per 1litre dialysate

Additive to dialysate Available 13gm/50ml (this increases K+ concentration by 1mmol/litre when dialysate dilution occurs at a ratio of 1:34)

Na++ Haemodialysis-dialysate dilution

140mmol/l to 150mmol/l Haemodialysis machine options (as available

with individual brands) Bicarbonate Haemodialysis-dialysate

dilution Increase from standard settings monitoring either serum bicarbonate or base excess through blood gas monitoring (not exceeding minus 1.5)

Haemodialysis machine options (as available

with individual brands)

43

SECTION 2.4

CLINICAL PRACTICE GUIDELINES FOR ESKD PATIENTS WITH A VASCULAR ACCESS




44

2.4 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT OF VASCULAR ACCESS NP will monitor

• The vascular access function • Dialysis adequacy laboratory results • The vascular access for complications including haemodynamic

compromise • The patents peripheral vascular system for future access sites


• Patients subjective response to the vascular access (body image, self concept, fears) Physical examination of dialysis access for

• Absence of oedema, pulsatility, changes in thrill or bruit, changes to physical appearance, limb color and temperature, assessment of arterial and venous pressures, attainability of blood flow rates, changes in delivered dose of dialysis, development of abnormal collateral circulation, prolonged bleeding times, high dynamic venous pressures, difficulty with cannulation, pain with cannulation, difficulty achieving desired blood flow rate

• Readiness for cannulation (Maturation, identify blood flow direction, palpate arterial, mid and venous sections for presence or absence of pulse or thrill, plan for rotation of cannulation sites

Physical examination of access limb for haemodynamic compromise (pulses, swelling, change in color or temperature, numbness or decreased sensation, limitations of movement, change in function, capillary refill >2 seconds, comparison to contra lateral extremity)

Physical examination of dialysis catheter for; • Exit site inflammation or infection (redness, swelling, induration, discoloration or

bruising, drainage or bleeding • Integrity of catheter (including air or foam in lines) and dressing • Facial or neck oedema • Catheter migration (i.e. visible cuff) • Respiratory distress • Cardiac arrhythmia

Monitor function • Review dialysis adequacy

Dialysis modality • Current access in use and care plan (for management or cannulation

45

INVESTIGATIONS

Biochemistry URR Microbiology Blood cultures

Skin, wound, exudates, access swab Imaging Ultrasound

Access duplex Exclude Infection

Failure to mature Vascular steal Thrombosis Aneurysm (true, false, dilatation) Ischaemia Venous outflow obstruction (clot, stenosis) Arterial inflow obstruction (clot, stenosis) Carpal tunnel syndrome


• Utilise portable ultrasound devices to assist: o Development of cannulation care plans o Identifying need for further investigation

• Order laboratory and diagnostic studies as appropriate • Initiate evaluation and treatment of Dialysis Access complications


• Antibiotic therapy as indicated by microbiology results • Use and manipulation of anticoagulants to prevent clotting or haematoma formation • Antiplatelet agents • Local anaesthetic agents

HEALTH PROMOTION

• Education Access monitoring and care Purpose and type of dialysis access Care and protection How to assess for patency Signs and symptoms of complications and information to report Information re management strategies Rotation of cannulation sites Proper compression of needle sites for haemostasis Emergency care Appropriate clothing to suit access Vein preservation of future potential sites

• Discussion Preferred dialysis access

46

REFERRAL • GP • Nephrologist • Access surgeon

FOLLOW UP

• As requested by staff, patient or carer cannulating access

FORMULARY

ANTICOAGULANTS Australian Drug (Generic name)



Poisons Schedule

Warfarin (Coumadin, Marevan)

Oral Usually 5 mg daily for 2 days then adjust according to INR. Maintenance: 1-10mg daily, taken at the same time each day; duration of treatment varies with indication.

Anticoagulants, antithrombotics Cardiovascular System

Prevention and treatment of VTE. Prevention of thromboembolism in patients with prosthetic heart valves. Primary stroke prevention in patients with AF associated with mitral valvulopathy or other risk factors

S4

Heparin Sodium IV

Load 5000 units up to a limit of 2000 units. Increase load by 500 unit increments per treatment until optimum achieved Hourly rate for haemodialysis; 500 units up to 2000 units per hour. Increase load by 500 unit increments per treatment until optimum achieved


Prevention of vascular thrombotic episodes in high risk medical patients. Prevention of extracorporeal thrombosis during haemodialysis.

S4

Enoxaparin (Clexane)

IV 1 mg/kg –stat dose-into the arterial line of the dialysis circuit at the start of session; reduce dose in patients at high risk of haemorrhage. Start with 20-40mg. Increase 10mg per dialysis session. If


Treatment of venous thrombosis To prevent clotting of extracorporeal haemodialysis circuit

S4

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prolonged bleeding at needle site reduce dose by 10mg per session

Aspirin Oral <150 mg/day is considered safe.

Anticoagulants, antithrombotics Cardiovascular System Inhibition of platelet aggregation

Inhibition of platelet aggregation

S2

Dalteharin (Fragmin)

IV Haemodialysis for >4 hours: bolus of 30–40 units/kg followed by infusion of 10-15 units/kg/hour. Haemodialysis for up to 4 hours, IV, bolus of 5000 units or dose as above.


Treatment of venous thrombosis. Prevention of extracorporeal thrombosis during haemodialysis

S4

Clopidogrel (Plavix)

Oral 75 mg daily. Anticoagulants, antithrombotics Cardiovascular System Platelet aggregation inhibitor

Prevention of thromboembolism

S4

Danaparoid (Orgaron)

IV 750 units –stat dose-into the arterial line of the dialysis circuit at the start of session; reduce dose in patients at high risk of haemorrhage.


Treatment of venous thrombosis To prevent clotting of extracorporeal haemodialysis circuit

S4

ANTIBIOTICS

Australian Drug

(Generic name)



Poisons Schedule

Cephalothin Sodium (Keflin)

IV IV, initially 1–2 g, then 0.5–1 g every

12 hours.

Cephalosporins - Infections and Infestations

Treatment or Staphylococcal and streptococcal infections in people with mild to moderate penicillin allergy; urinary tract infections due to susceptible Gram-negative bacteria

S4

Penicillin Oral Initially 500mg, then Penicillins - Treatment or S4

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(Augmentin, Amoxycillin, Dicloxacillin)

250–500 mg every 24 hours

Infections and Infestations

prevention of infection caused by susceptible Bacteria

Gentamicin sulfate

IV Infuse over 15–30 minutes

40 mg/ml in 2 ml amp

Aminoglycosides - Infections and

Infestations

Empirical treatment of serious Gram neg. infections. Combined treatment with vancomycin for serious systemic enterococcal infections. Surgical and non-surgical prophylaxis

S4

Vancomycin IV Trough concentration monitoring to guide dosage interval; give another dose when concentration is <15 mg/L. 1.0 g every 4–10 days. IV infusion: give over at least 60 minutes (rate not >10 mg/minute for doses >500 mg).

Infections and Infestations Potentially life threatening Gram positive (incl methicillin resistant Staph. aureus) infections

Severe infections caused by susceptible organisms in cases of penicillin resistance or intolerance, eg meningitis, endocarditis (with other agents) MRSA infections

S4

Cephalexan (Ibilex, Keflex)

Oral 250–500 mg every 8–12 hours; higher doses are often used.

Cephalosporins - Infections and Infestations

Staphylococcal and streptococcal infections in people with mild-to-moderate penicillin allergy.UTI’s due to susceptible Gram neg. bacteria

S4

Mupirocin Topical Apply 3 times daily for up to 10 days

Topical antiseptics, anti-infectives - Skin

Effective against Gram-positive aerobes and some Gram-negative aerobes

S4

Medihoney Topical Apply to dialysis catheter exit site with each dressing change

Topical antibacterial honey barrier

For moist healing environments.

Unscheduled

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Prophylaxis for dialysis catheter exit sites

Urokinase IV via dialysis catheter

100,000 units of Urokinase to 100ml bag of normal saline

Fibrinolytic agent

To remove clots/fibrin from permcath lumen and therefore improve flows for the purpose of haemodialysis

S4

ANAESTHETIC AGENTS

Australian Drug

(generic name)



Poisons Schedule

Xylocaine 1% SC or topical

2mg (0.2ml of 50mg/5ml lignocaine 1%) per SC injection site or 2g (lignocaine 25mg/gram and pilocaine 25mg/g cream) per cannulation site

Anaesthetic agent for subcutaneous tissues

Subcutaneous tissues that require cannulation for vascular access for haemodialysis

S4

EMLA Cream, 5%, 5 g

topical Skin. A thick layer should be applied to the skin and covered with an occlusive, impermeable dressing. A dose of approximately 1.5 g/10 cm2 is recommended. The occlusive dressing should be applied for at least one hour. Following the application of EMLA cream for one to two hours, the minimum duration of anaesthesia is two hours after removal of the occlusive dressing.

Local anaesthetic

Dermal anaesthesia prior to IV cannula insertion and blood sampling

S4

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SECTION 2.5

CLINICAL PRACTICE GUIDELINES FOR PERITONITIS

TREATMENT AND PROPHYLAXIS




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2.5 DIAGNOSIS, MANAGEMENT AND FORMULARY FOR MANAGEMENT OF PERITONITIS The NNP will monitor

• Patient risk factors for infection • For exit site infection • For peritonitis • Response to treatment • Response to dialysis prescription • Adherence to treatment plans (including any treatment and equipment

related complications) • Results of diagnostic studies


• break in aseptic technique, accidental contamination of the dialysis , Catheter or dialysis fluid bags, recent illnesses, current medications, allergies, trauma to exit site or catheter

• Chills • Drug allergies

Physical examination • Abdominal pain, rebound tenderness, distended abdomen, nausea and vomiting, Fever

(temperature > 37.5oC • Weight, Blood pressure, Pulse and respiratory rate • Inspection and palpation of the Tenckhoff catheter exit-site and tunnel for evidence of infection-

erythaema, induration, inflammation, pain or exudate, crusting, drainage Hydration (JVP, oedema, mucous membranes, capillary refill rate)

Dialysate • Cloudy dialysis effluent, turbidity, presence of fibrin, colour, presence of faecal material

INVESTIGATIONS

Biochemistry • UEC • LFT’s

Haematology • FBC Radiological examination

• Plain abdomen

Microbiology • Peritoneal fluid culture, gram stain and cell count • Exit-site swab (if there is discharge from the catheter exit

site) • Urine • Blood culture (fever > 38.5)

Exclude • Catheter malfunction • Catheter placement

-Constipation

NON-PHARMACOLOGICAL MANAGEMENT • Dialysis prescription for ultrafiltration strategies • Dialysis prescription for frequency of dialysis cycles to assist pain management and

ultrafiltration

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PHARMACOLOGICAL MANAGEMENT • As per identified organism and department protocol (avoid repeated courses of

gentamycin) • Remove organisms from catheter lumen • Monitor abnormal drug removal of other routine medications during inflammatory phase of

peritonitis • Manage exit site infections to prevent systemic infection (peritonitis or septicaemia) • Analgesia

HEALTH PROMOTION

• Maintain adequate nutrition • Education re recognition of signs and symptoms of peritonitis and exit site infection

REFERRAL

Nephrologist Surgeon Peritoneal Dialysis Training Unit and home visiting nurse

FOLLOW UP

• During infective stages to assess effectiveness of antibiotic choices, dry weight,, pain and nutritional status

• Post antibiotic treatment completion- resolution of symptoms • PD Training Unit - Review of technique (in-patient, out-patient, home visit) • Discharge summary/referral to General Practitioner, Nephrologist, Rural Out-Reach Renal

Nurse • Consumer Fact Sheet – Management of Peritonitis • Follow up appointment or home visit in one week

FORMULARY

Australian Drug

(Generic name)



Poisons Schedule

Gentamycin IP

Initial: 0.6mg/kg body weight to 1 dialysate exchange volume indwelling for 6 hours repeat once daily until sensitivities are available Subsequent treatment; If no growth continue treating for 14-21days. Check serum level after 3rd dose-cease if culture negative and peritonitis resolving clinically

Aminoglycosides - Infections and Infestations

Gram-negative organisms

S4

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Australian

Drug (Generic

name)



Poisons Schedule

Vancomycin IP Initial: 2 grams added to 1 dialysate exchange volume indwelling for 6 hours Subsequent treatment; If no growth continue treating for 14-21days. If appropriate repeat dose after 7 days.

Anti-infective (Glycopeptide)

Gram-positive organisms

S4

Rifampicin Oral 600mg daily in divided doses Antituberculotics and antileprotics - Infections and Infestations

Refractory staphylococcal infections MRSA Infections

S4

Heparin Sodium

IP 100units per litre Anticoagulants,antithrombotics - Cardiovascular System

Prevent fibrin formation and blockage of peritoneal dialysis catheter

S4

Mupirocin Topical Apply 3 times daily for up to 10 days

Topical antiseptics, anti-infectives - Skin

Effective against Gram-positive aerobes and some Gram-negative aerobes

S4

Metoclopramide

Oral/IV/IM

10mg every 6-8hours as needed. In renal impairment reduce dose by 50%. Use lower doses in the elderly (as they are more sensitive to adverse events)

Dopamine antagonist

For nausea and vomiting

S4

Potassium Chloride

IP 3-5 litre dialysis fluid depending on serum potassium level

Mineral and electrolyte replacement / supplement

Hypokalaemia Unscheduled

Paracetamol

Oral Adult: 500 –1000 mg every 4 hrly Maximum dose: 8 tablets/day

Simple analgesics and antipyretics - Analgesia

Pain and fever S2

Panadeine Oral Adult: 500 –1000 mg every 4 hrly Maximum dose: 8 tablets/day

Combination simple analgesics - Analgesia

Pain S2

Xylocaine 1%

IP 1ml per 1 litre of dialysis fluid. Maximum 3mg/kg/dose

Anaesthetics - local and general

Abdominal pain with peritonitis

S4

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SECTION 3

REFERENCING FOR EVIDENCE FOR PRACTICE

These clinical guidelines have been developed as per NSW Health Policy Directive 2005_556 Policy for Nurse/Midwife Practitioners in New South Wales and are supported by three major sets of documents:

5. Two authoritative and internationally recognised Bodies for Clinical Practice Recommendations for the treatment of Kidney Disease KDOQI (www.doqi.org) and CARI (www.cari.org.au)

6. Local policy and protocol for multi-disciplinary and shared care of ESKD and dialysis (Dx) issues • Available in the Centre dialysis Unit and Satellite Dialysis units of the Lower

sector HNEH service (hard copy and electronic versions) 7. Supporting documents pertaining to the scope of practice for a Nurse Practitioner

of this Hospital. (www.health.nsw.gov./nursing)

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http://www.doqi.org/

http://www.cari.org.au/

http://www.health.nsw.gov./nursing

HUNTER-NEW ENGLAND AREA HEALTH SERVICE

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