Nephrology PDF

BANGALORE BAPTIST HOSPITAL Page: 1 of 46
DEPARTMENT OPERATING MANUAL Version No: 03

Effective Date :
PM/DOM-03/NEPH NEPHROLOGY
01/06/18
TABLE OF CONTENT
Sl. No Description Page no
1. Scope of the Department. 2
2. Assisting in femoral catheter 3
3. Starting HD through femoral catheter 4
4. Starting HD through jugular catheter 5
5. Starting HD through A.V.Fistula 6
6. Procedure of dialysis 7
7. Blood transfusion during haemodialysis 12
8. Procedure-routine blood test 14
9. Closing HD through A.V.Fistula 18
10. Closing HD through femoral catheter 20
11. Removal of jugular catheter 22
12. Removal of femoral catheter 23
13. R.O.water maintanence and disinfection procedure 24
14. Back wash, dialyzer and blood tubings reuse 26
15. SOP for Preparation of bicarbonate solution 28
16. SOP for haemodialysis for the patient with blood borne viral
29
infection
17. SOP of care on permanent catheter 31
18. Starting plasmapherisis through dialysis catheter 32
19. SOP for renal biopsy 34
20. SOP for assisting for nephrostomy drainage 36
21. SOP for preparation for percutaneous nephrostomy (pcn)
37
drainage
22. List of associated records 38
ANNEXURE
Annexure No. I
Role of
A. Consultant
B. Charge Nurse
C. Team leader
D. Staff Nurse
E. Dialysis Technician
F. Nursing Aid
Annexure No. II Organogram
Reviewed & issued by: Division Head Approved by: Director(CEO)

Effective Date :
01/06/18
1. SCOPE OF THE DEPARTMENT

1.1. Purpose:
To ensure the procedures for effective operation of dialysis unit.
1.2. Scope of Department:
To lay down the procedures for the process pertaining to the dialysis unit.
1.3. Responsibility:
The HOD and the nursing superintendent to ensure the implementation of the
instructions and other procedures laid down.
1.4. Quality objectives:
1.4.1. To provide quality care to the patient admitted in dialysis.
1.4.2. To equip the department with proper equipment and sufficient supplies.
1.4.3. To follow hand washing to prevent infection.
1.4.4. To reduce the incidents of nosocomial infection.
1.4.5. To provide supportive health to the patient's family to relieve stress

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2. ASSISTING IN FEMORAL CATHETERIZATION

2.1. Definition
Assisting to obtain access for haemodialysis through femoral vein using femoral catheter.
2.2. Purpose
2.2.1. To initiate haemodialysis in patient with pulmonary edema.
2.3. Equipment
2.3.1. Heparinized Saline
2.3.2. Injection Xylocaine
2.3.3. Femoral Catheter pack
2.3.4. Sterile doctor’s gown
2.3.5. Scalpel blade
2.3.6. Surgical towels
2.3.7. 2CC syringe, 20CC syringe
2.3.8. Disposable needles
2.3.9. Femoral catheter, guide wire, dilator, introducer
2.3.10. Antiseptic saline
2.4. General Instructions
2.4.1. Do dressing to catheter site with antiseptic
2.4.2. Secure catheter with adhesive
2.4.3. Watch for bleeding from access site
2.4.4. Provide adequate information regarding catheter care, transfer of patient for
initiation of haemodialysis and complications.
2.5. Procedure
2.5.1. Assess condition of patient check blood pressure and record
2.5.2. Explain procedure to patient / relative
2.5.3. Give O2 if patient is having dyspnoea
2.5.4. Keep patient in supine position
2.5.5. Keep legs straight, slightly bent
2.5.6. Prepare site by shaving hair & scrub with antiseptic
2.5.7. Assist doctor in initiation of catheter access
2.5.8. Document time, procedure and patient condition
2.5.9. Replace articles used

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3. STARTING HAEMODIALYSIS THROUGH FEMORAL CATHETER

3.1. Definition
Assisting to obtain access for haemodialysis through femoral vein using femoral
catheters.
3.2. Purpose
3.2.1. To provide short term Haemodialysis in patients with renal failure before
transplantation
3.2.2. Before constructing arterio – venous fistula
3.3. Procedure
3.3.1. Check doctors order
3.3.2. Check patients pre-dialysis weight.
3.3.3. Place patient comfortably on bed and explain procedure
3.3.4. Insure that machine assistant and other items are ready for use
3.3.5. Check patients blood pressure
3.3.6. Scrub the site with antiseptic
3.3.7. Wipe hands with sterile towel and wear gloves
3.3.8. Clean catheter and catheter site with spirit
3.3.9. Check patency of catheter using a syringe
3.3.10. Collect pre-dialysis blood samples if needed
3.3.11. Administer bolus dose of heparinized saline into venous lumen
3.3.12. Connect blood tubings and catheter to extra corporeal circulation
3.3.13. Replace tubings in prespective places
3.3.14. Check blood pressure and document in haemodialysis record sheet
3.4. General Instructions
3.4.1. Do dressing to catheter site with antiseptic
3.4.2. Secure catheter with adhesive
3.4.3. Watch for bleeding from access site
3.4.4. Provide adequate information regarding catheter care, Haemodialysis and
complications.

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4. STARTING HAEMODIALYSIS THROUGH JUGULAR CATHETER

4.1. Definition
Initiation of haemodialysis through jugular catheter access for clearance of toxic
substances from blood and removal of extra fluid from bodies
4.2. Purposes
4.2.1. To provide short term Haemodialysis in patients with renal failure before
transplantation
4.2.2. Before constructing arterio – venous fistula
4.3. Equipment
Haemodialysis machine, dialysis and blood tubings, dialysis starting set, gloves,
antiseptic/spirit, saline, heparinized saline
4.4. Procedure
4.4.1. Check doctors order
4.4.2. Check patients pre-dialysis weight
4.4.3. Place patient comfortably on bed and explain procedure
4.4.4. Insure that machine assistant and other items are ready for use
4.4.6. Scrub hands with antiseptic
4.4.7. Dry hands with tissue and wear gloves
4.4.8. Clean catheter and catheter site with Betadine solution
4.4.9. Check patency of catheter using a syringe
4.4.10. Collect pre-dialysis blood samples if needed
4.4.11. Administer bolus heparinized dose in venous line
4.4.12. Connect blood tubings and catheter to extra corporeal circulation
4.4.13. Replace tubings in prespective places
4.4.14. Check blood pressure and document in haemodialysis record sheet

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5. STARTING HEMODIALYSIS THROUGH AV FISTULA

5.1. Definition
Initiation of haemodialysis through Av Fistula for removal of toxic substances from blood
and for removal of excess fluid from body
5.2. Purpose
To initiate long term dialysis for patient with CRF
5.3. Equipment
Dialysis machine, Dialyzer and blood tubings, fistula set, gloves, fistula needles, , Betadine
solution spirit, saline, Syring with heparin
5.4. Procedure
5.4.1. Check doctor’s order
5.4.2. Check patients weight before dialysis
5.4.3. Put patient comfortably on bed
5.4.4.
5.4.8. Clean fistula hand with betadine solution spirit
5.4.9. Select insertion site,
5.4.10. Insert fistula needle through same puncture site and ensure adequate blood
5.4.11. Collect pre-dialysis sample if needed
5.4.12. Administer bolus dose of heparinzed saline in to venous line
5.4.13. Connect fistula needle with blood tubings to extra corporeal circulation
5.4.14. Replace articles other use
5.4.15. Document time, procedure done, condition of patient and blood pressure

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6. PROCEDURE OF DIALYSIS
6.1. Definition:
Hemodialysis is a process of cleansing the blood of accumulated waste product like urea,
creatinine, uric acid etc by using arterial dialysis. It is used for patient with end stage
renal failure or critically ill patients who require dialysis.
6.2. Purpose
6.2.1. To extract toxic nitrogenous substances from the blood
6.2.2. To remove excess of water
6.2.3. To maintain fluid & electrolyte balance in the body
6.3. Scope
All patients undergoing haemodialysis
6.4. Responsibility & Authority
Consultant / Dialysis nurse
6.5. Methods
6.5.1. Central venous catheter
Immediate access to the patient’s circulation for acute hemodialysis is achieved
by inserting a double-lumen or multi -lumen catheter in to the subclavian internal
jugular, or femoral vein. It can be removed if patient’s condition has improved or
another type of access has been established.
6.5.2. Arteriovenous fistula
A fistula is created surgically by joining an artery to a vein. Either side to side or
end to side usually radial artery and cephalic vein or tibial artery to big cephalic
vein. Fistula takes 4-6 weeks to mature. The patient is encouraged to perform
exercises to increase the size of these vessels (i.e.: squeezing a rubber ball) and
there by to accommodate a large bore needle used for hemodialysis.
6.5.3. Arterio venous graft
It can be created by subcutaneously interposing a biologic, semi biologic or
synthetic graft placed between a artery and vein. Most commonly used synthetic
graft material is expanded polytetrafluroethylene. This created in case of patient
vessels are not suitable for fistula (common sites are fore arm, upper thigh).

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6.6. Principal of Hemodialysis

6.6.1. Diffusion
The toxins and waste in the blood are removed by dilution i.e they move from an
area of higher concentration in the blood to an area of lower concentration is the
dialysate(the dailysate is a solution made up of the important electrolytes in their
ideal extra cellular concentration)
6.6.2. Osmosis:
Excess water is removed from the blood by osmosis in which water moves from
an area of higher solute concentration (the blood) to an area of lower solute
concentration (dialysate bath)
6.6.3. Ultra filtration :
Is done as water moving under high pressure to an area of lower pressure
6.7. Indications:
6.7.1. Acute hemodialysis
a. To treat the patient with edema that does not respond to treatment
b. Hepatic coma
c. Hyperkalemia
d. Hypercalaemia
e. Hypertension
f. Uremia
g. Impending pulmonary edema
h. Increasing acidosis
i. Jaundice
j. Snake bites
k. Perecarditis
6.7.2. Equipments
a. Masks
b. Sterile gloves
c. Syringes,10cc,5cc

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d. Sterile NS
e. Dressing material
f. Betadine solution
g. Heparin
h. Non sterile glove
i. Fistulae needle
j. Dialysis machine, tubing
k. Dialyser
l. Dialysate solution
m. Tourniquet
6.7.3 Patient assessment & preparation
Steps Rational
Renal failure patient often have altered

Baseline- vital signs, weight
baseline assessment
neurological status, physical
i This is helpful so that interventions
assessment, fluid and electrolyte
including the dialysate can be
status
individualized
Graft, fistula, catheter insertion site Because these sites are used frequently.
ii
for signs on symptoms of infection Infection is always a potential risk
6.8. Pre-Dialysis Procedure:

6.8.1. New Visit:
a. Dialysis patients are received directly on OPD basis to the unit.
b. Patients are advised to undergo blood investigation after due payments are made,
then haemodialysis is initiated.
6.8.2. Revisit
a. Prior appointments are given to patients for regular haemodialysis.
b. The dialysis machines are kept ready for dialysis before the patient arrives at the
unit.

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c. Patients weight is checked and general assessment of the patient is done. Based on
the patient’s weight gain, ultra filtration rate is set for 4 hours and dialysis is
started.
d. Patient shall be identified before starting dialysis
e. Patient shall be identified with the name & hospital number in the registration
card or the friend of Baptist card
f. Incase of reuse of dialyzer the hospital number which is labeled on the dialyzer
shall be cross checked with the registration card or friend of baptist card.
g. Then the formalin which is filled in the dialyzer shall be drained in the washing
area,flushed with RO Water then shall be brought to the patient side and it shall be
primed with 1 ltr of normal saline.
h. Written consent shall be taken once in a month and verbal consent shall be taken
before every dialysis procedure.
i. After ensuring that the tubes are clamped, ‘no leaking’ stickers will be affixed
before initiating haemodialysis. On the ‘no leaking’ stickers details regarding the
name of the person verifying the clamps as well as the time & date is mentioned.
6.9. Monitoring patient during Dialysis:
6.9.1.Immediately after starting the procedure close monitoring shall be done for ten
minutes. Every half an hour once blood pressure, transmembranal pressure and
venous pressure of the patient is checked and recorded. Bedside documentation is
carried out after starting dialysis.
6.9.2. Should collect and send the routine blood samples for monthly tests which
includes electrolytes, Hb , etc. , Patient with perm catheter 10 days once PT to be
checked and virology for once in 6 months.
6.9.3. Monitoring the complications during Dialysis such as hypotension, fever, chills,
muscle cramps, hypertension, cardiac related problems, etc. and other complications
if there is any.
6.9.4. As per the Hb level we are assesing whether to transfer blood or to give
erythropoietin supplements, based on the patient’s financial need.
6.9.5. Standing order for giving injection during haemodialysis

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a. For fever and chills

i. Inj. Avil 1 amp IV
ii. Inj. Emeset 1 amp IV
iii. Inj. Hydrocort 100 mg IV
iv. Inj. Perfalgan 1gm (100ml)
b. For low hemoglobin less than 10 gm
i. Inj. Erythropoetin 4,000 units or 10,000 units IV once a week or twice a week
after each dialysis
ii. Inj. Iron Sucrose 100 mg intravenous
c. For Gastric pain
i. Inj. Omez 40mg intravenous
6.10. Post-Dialysis Procedure:
6.10.1. After terminating Dialysis immediately dialysis and tubing has taken to the re-use
area and water rinse has to be given.
6.10.2. Machine is put for normal rinse, after each dialysis procedure.
6.10.3. Patients post BP and post weight is checked and recorded.
6.10.4. All the documents of the patients undergoing dialysis are maintained in a file in
the department. These documents include the consent form as well all the
documents pertaining to dialysis

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7. BLOOD TRANSFUSION DURING DIALYSIS

7.1. Definition:
Assisting in transfusing of blood or blood product into vein, using aseptic technique
7.2. Purpose:
7.2.1. To raise blood pressure
7.2.2. To supply constituents of blood in physiologic proportion when patient has lost
whole blood due to haemorrage or when certain constituent of blood are
decreased due to diseases.
7.2.3. To treat anaemia.
7.3. Equipment:
IV stand, injection tray, blood, blood transfusion set
7.4. General instruction:
7.4.1. Rate of flow of the blood transfused should be slow during the first 15 minutes.
Around 30ml of blood should be transfused and then the next 50 ml over the
next15 minutes. This can be increased to 100ml for every half an hour.
7.4.2. Rate of flow must be slower for elderly patient and those who have heart disease
7.4.3. If there are signs of complications, stop transfusion immediately. Keep IV line
open by connecting normal saline and notify doctor.
7.4.4. Change transfusion set if another unit of blood/ blood components is to be given
7.4.5. Do not add medication to blood / blood components avoid 5% dextrose or ringer’s
solution through IV line
7.4.6. Do not store blood/ blood component in ward
7.4.7. Keep emergency drug (eg. Antihistamines, Lasix, Hydrocortisone adrenaline etc)
ready at hand.
7.5. Procedure
7.5.1. Confirm that blood has been typed and cross matched check ABO group and RH
type on label of container
7.5.2. Keep blood / blood component at room temperature for 30 minutes.
7.5.3. Inspect blood for gas bubbles, abnormal colour or for any cots
7.5.4. Explain to patient and relatives purpose of transfusion

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7.5.5. Check labels, identifying donor and recipient blood (number and type). Confirm identity
of patient by asking name, checking hospital number and blood group/ type
7.5.6. Check patient’s TPR and BP
7.5.7. Assemble equipment at bed side.
7.5.8. Keep transfusion set ready and connect to normal saline(100ml)
7.5.9. Adjust rate of flow as prescribed, replace equipment
7.5.10. Document time started, blood/component (amount, group RH, type) vital signs,
any reaction name of doctor time discontinued.
7.5.11. Monitor vital signs every 30mts and watch closely for any under reaction
7.5.12. Maintain patient’s comfort during and after procedure

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8. PROCEDURE-ROUTINE BLOOD TEST

8.1. Procedure 1
Routine test
Before starting dialysis Monthly 6months Patient with
Permanent catheter
Haemoglobin BUN PTH PT every 10 days
once
Platelets Creatinine BBV
PT Calcium
APTT Phosphorus
BUN Albumin
Creatinine Haemoglobin
Electrolytes Potassium
Calcium
Phosphorus
Uric acid
Liver function tests
Parathyroid hormone
ECG
ECHO
Chest Xray
Blood borne virus screen
8.2. Procedure 2
Handling of the infected patients
8.2.1. It is recommended that universal precautions be followed in every case. This is
economically not feasible and hence certain isolation procedures have to be
followed.

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8.2.2. The dialysis patients with respiration, urinary tract infections or septicemia can be
dialyzed along with other patients. Care should be taken to see that staff do not
handle non infected patients after attending on an infected case without proper
hand washing. The pore size of the dialyzer is such that bacteria cannot pass from
the blood compartment to any other compartment.
8.2.3. Hepatitis B This is a highly infectious virus, hence patients who are carrying the
antigen in their blood should be dialyzed in an area which is physically isolated
from the area where hepatitis B antigen negative patients are being dialyzed. The
staff from the positive area should not cross over and attend on patients who are
virus negative. Similarly those from the negative side should not go to the positive
side and then return to the negative side. In addition it is mandatory that all the
staffs in the dialysis area are immunized against hepatitis B. Patient are also
encouraged to get immunized.
8.2.4. Re-use of consumables is permitted provided that is done in a physically separate
area from where reuse of negative patient’s material is being done. Whatever can
be disposed off should be done in containers which are marked for disposal of
infected waste. Linen should be disposed off in a red bag and double autoclaved.
8.2.5. Hepatitis C Through the recommendation for isolating these patients is not
mandated, for practical purpose it is advisable to handle these patients and their
material in the same manner as the hepatitis B positive patient.
8.2.6. HIV if a HIV infected patients needs to be dialyzed, the staff should be informed
that the patient constitutes a bio hazard. The staff should wear protective gear,
goggles, double gloves and a disposable gown. None of the material used for the
dialysis should be reused. All material to be disposed off should be first treated in
bleach solution
8.3. Procedure 3
There are several emergencies that occur in the dialysis area, the common ones
are

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8.3.1. Hypotension this can occur due to many reasons, the patient may have taken his
antihypertensive medication before reporting for dialysis. Too much fluid removal
by ultra filtration and low hemoglobin are some of the common causes.
8.3.2. The emergency treatment is to lower the head end, stop the blood pump and
infuse 100 to 200 ml of normal saline, inform the medical staff. Generally the
blood pressure will come up and if stable for 30 minutes dialysis can be resumed.
8.3.3. Air embolism this is a potentially life threatening complication, it should not
occur with the air leak detector in place in the machine. If it does occur the patient
will experience sudden shortness of breath. On listening to the chest movement of
air through the heart chambers may be heard. Dialysis must be stopped, patient
propped up in the right lateral position and administered oxygen through the nose
at 12 to 15 L per minute.
8.3.4. Haemolysis this can occur when the dialysate is contaminated with chloramines
or if the temperature of the dialysate goes to 40 degrees. Dialysis must be
stopped; if significant amount of haemolysis has occurred then blood transfusion
may be required. To control hyperkalemia peritoneal dialysis may need to be
started.
8.3.5. Blood leak this if it occurs should be picked up by the blood leak detector in the
machine. The blood pump will stop and further dialysis will not take place.
8.3.6. First use syndrome this is usually manifested by acute onset of breathlessness and
a drop in blood pressure. Treatment is to slow the blood flow rate and give a dose
of antihistamine sometimes hydrocortisone also may be required to control
symptoms.
8.4. Procedure 4
Care of the vascular access at home
8.4.1. Permanent access
a. Permanent access these are usually an arteriovenous fistula or an
arteriovenous graft. Care must be taken to ensure that tight clothing or
jewellery is not placed over the vascular access since it may get blocked. The
patient and or family must also to teach to check the patency of access. If the

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flow stops they must report immediately to the hospital. If there is bleeding
from the access the patient and family must be shown where to apply pressure
proximally to prevent further bleeding. They must come to the hospital as soon
as possible.
8.4.2. Temporary vascular access
a. Femoral vein catheter it is not advisable to send patients home with a femoral
catheter. If they do insist on going home then the patient and family member must
be shown where to apply pressure should the catheter slip out. They should also be
told to come quickly to the hospital. If there is swelling or pain on the limb with
the catheter is should also be reported immediately since there is a risk of
developing deep vein thrombosis.
b. Internal jugular and subclavian vein catheter patient with these can be permitted to
go home. They must be told to keep the site dry. If the catheter slips out they need
to be shown where to apply pressure and instructed to report to the hospital as soon
as possible.
All this information needs to be reinforced from time to time.

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9. CLOSING HEMODIALYSIS THROUGH ATRIOVENOUS FISTULA ACCESS

9.1. Definition:
Assisting to cease hemodialysis through arteriovenous fistula access, once dialysis is
over.
9.2. Purposes:
9.2.1. To reduce problems in access like inadequate blood flow
9.2.2. To prevent complications like irreversible hypotension.
9.3. Equipment :
Haemodialysis closing set, gloves, antiseptic, spirit, gauze pieces adhesive, arterio
venous fistula belt.
9.4. Procedure:
9.4.1. Explain procedure to patient
9.4.2. Check patients BP and record
9.4.3. Record blood pump speed at 100ml/mt and negative pressure to 0-10mm of Hg
9.4.4. If any blood sample is required keep specimen bottle ready with label
9.4.5. Keep articles ready and scrub with antiseptic
9.4.6. Wipe hands with sterile towel and clear gloves
9.4.7. Clean posterior part of forearm with spirit and make patient rest arm on sterile
towel
9.4.8. Ask assistant to switch off blood pump and clamp arterial blood line.
9.4.9. Clamp arterial line with artery clamp and disconnect blood line from fistula and
give it to assistant
9.4.10. Connect saline to arterial blood line connector
9.4.11. Ensure that blood is returned through venous lines at pump speed of 75-100 ml/mt
9.4.12. Collect blood samples if indicated from arterial line
9.4.13. When venous blood line is almost clear. Clamp venous line and put of blood
pump.
9.4.14. Disconnect venous blood line from venous line carefully after clampling venous
line with artery clamp.
9.4.15. Remove artery clamp first and then venous clamp.

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9.4.16. Cover fistula site with sterile gauze bandage

9.4.17. Explain to patient about fistula access care
9.4.18. Remove gloves and replace articles
9.4.19. Check patients weight and record in haemodialysis document and in dialysis
record and in dialysis hand book.
9.4.20. If post dialysis weight is more or less than patients original weight it should be
informed to duty doctor.
9.4.21. Patient’s next appointment time to be informed and entered in dialysis hand book
as well as in posting file.

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10. CLOSING HEMODIALYSIS THROUGH FEMORAL
10.1. Definition:
Assisting to close haemodialysis through femoral catheter access once dialysis is over
10.2. Indication:
10.2.1. To reduce problem with the access like inadequate blood flow.
10.2.2. To prevent complications like irreversible hypotension.
10.3. Equipment
Haemodialysis closing set, sterile gloves, antiseptic, normal saline, heparinezed saline,
tegaderm 2cc syringe, adhesive, rubber connector
10.4. Procedure:
10.4.2. Checked blood pressure and document
10.4.3. Reduce blood pump speed to 100ml/mt and negative pressure to 0-10 mm of Hg
10.4.4. Keep blood investigation bottles ready after labeling if indicated
10.4.5. Wash hands and remove old dressing
10.4.6. Observe site for infection and check whether check whether suture are intact
10.4.7. Scrub hands with Soap and water
10.4.9. Ask assistant to switch off blood pump
10.4.10. Disconnect arterial blood tubing carefully from arterial lumen and give to assistant
connect saline to arterial line connection
10.4.11. Clamp arterial lumen and arterial blood tubing simultaneously
10.4.12. Ensure blood which is in the tubing and dialysis is to be returned through venous
line after switching on blood pump.
10.4.13. Collect post dialysis blood samples if needed
10.4.14. Flush arterial line with saline
10.4.15. When venous blood line is almost clean clamp venous line, put off blood pump and
lamp venous lumen simultaneously.
10.4.16. Disconnect venous lumen with saline

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10.4.17. Both lumens to be filled with heparinized saline (Arterial 1.16cc and venous 1.2cc
to keep lumen patent.
10.4.18. Recap adapters and secure them with gauze and adhesive
10.4.19. Put antiseptic dressing our catheter site and apply tegaderm
10.4.20. Secure both lumans our tegaderm with adhesive
10.4.21. Remove gloves and replace articles
10.4.22. Check blood pressure (Lying and sitting or standing )
10.4.23. Check post dialysis weight and record in haemodialysis record and dialysis hand
book.
10.4.24. If post dialysis weight is more or less than patient original weight, to be informed to
duty doctor
10.4.25. Make sure that next appointment time is informed to patient entered in dialysis hand
book and in posting file
10.4.26. Transfer patient to ward

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11. REMOVAL OF JUGULAR CATHETER

11.1. Definition:
Removing jugular catheter access used for haemodialysis
11.2. Purpose
11.2.1. To cease haemodialysis
11.2.2. To prevent infection at catheter site
11.2.3. To prevent inadequate blood flow (or) any block
11.2.4. To cannulate other blood vessels for haemodialysis
11.3. Equipment:
Dressing pack, glove, antiseptic, suture, cutting scissors, dynoplaster
11.4. Procedure:
11.4.1. Collect equipment
11.4.2. Check doctor’s order for jugular catheter removal
11.4.4. Make patient comfortable on bed
11.4.5. Remove jugular dressing
11.4.8. Clean catheter site with antiseptic
11.4.9. Remove sutures
11.4.10. Remove jugular catheter by applying pressure over catheter site
11.4.11. Apply pressure till bleeding stops.
11.4.12. Apply sterile antiseptic dressing & apply dynoplaster
11.4.13. Replace articles
11.4.14. Document procedure time & patients response during procedure
11.4.15. Transfer patients to bed

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12. REMOVAL OF FEMORAL CATHETER

12.1. Definition:
Assisting to remove femoral catheter used for dialysis
12.2. Purposes:
12.2.1. To cease haemodialysis
12.2.2. To Prevent infection at catheter site
12.2.3. To rectify inadequate blood flow or any block in catheter
12.3. Equipment:
Dressing pack, gloves, antiseptic, sutures, scissors, dynoplaster
12.4. Procedure:
12.4.1. Check doctor’s order for catheter removal
12.4.3. Place patient comfortably on bed
12.4.4. Wash hands and keep equipment ready for use
12.4.5. Remove dressing over femoral site
12.4.8. Clean catheter site with antiseptic
12.4.9. Remove sutures
12.4.10. Remove catheter by applying pressure on catheter site
12.4.11. Apply pressure till bleeding stops
12.4.12. Replace articles
12.4.13. Apply sterile dressing with antiseptic and secure with dynoplast.
12.4.14. Record time and type of catheter removed

Effective Date :
01/06/18
13. R.O WATER MAINTENANCE AND DISINFECTION PROCEDURE

The key to any monitoring programme is the consistency and frequency of testing. In
addition, the actual collection and periodic review of the data, problematic trends can be
identified and corrective action can be taken
13.1. Disinfection protocols:-
13.1.1. The objective of a disinfection procedure for a dialysis system is to inactivate
bacteria that are in the fluid pathways associated with the dialysis system is to
inactivate bacteria that are in the fluid pathways associated with the dialysis system
and to prevent these organisms from growing to significant levels once the system is
in operation.
13.1.2. The frequency of disinfection must assure that bacterial contamination needs
AAMI standards.
a. The system must be monitored with bacterial cultures.
b. Appropriate culture techniques must be used. The disinfection procedure should
assure that all aspect of the RO and distribution system are disinfected.
c. The incoming water line to the dialysis machine is a site that is often overlooked.
d. Monthly tank washing has to be done and RO water has to be tested for culture
and sensitivity regularly
13.1.3. Tank washing Procedure :
a. RO water tank 1 & 2 has to be emptied
b. Both the tanks has to be cleaned thoroughly with RO water and wiped with
sterile cloth
c. The internal and external surface area of both the tanks has to be cleaned
thoroughly with raw water.
13.2. RO water chemical analysis
13.2.1. Once in three months the RO sample shall be collected from the RO water tap in a
1 liter container (can).
13.2.2. The sample shall be collected by the maintenance staff
13.2.3. The Sample shall be sent outside for chemical analysis testing in an authorized
lab.

Effective Date :
01/06/18
13.2.4. The report will be received with in one week same shall be filed in dialysis
department.
13.3. RO water endotoxin analysis
13.3.1. Once in a month the R.O sample shall be collected from the R.O water tap in a
500ml of glass bottle container.
13.3.2. The sample shall be collected by the maintenance staff.
13.3.3. The sample shall be sent outside for endotoxin analysis testing in an authorized
lab.
13.3.4. The report will be received with in one week same shall be filled in dialysis
department.

Effective Date :
01/06/18
14. BACK WASH, DIALYZER AND BLOOD TUBINGS RE-USE

14.1. Purpose:
Back wash is done for the proper clearance of sand filters and carbon filter
14.2. Procedure:
14.2.1. Switch off the raw water motor
14.2.2. Keep 2nd and 3rd filter on filter mode
14.2.3. Keep the 1st filter on back wash mode for 15mins and an rinse mode for the next
15mins. Finally keep the 1st filter back on filter mode.
14.2.4. Keep the 1st filter and 3rd filter in filter mode.
14.2.5. Keep the 2nd filler on back wash mode for 15mins and on rinse mode for the next
15min keep the 2nd filter back on filter mode.
14.2.6. Keep the 1st filter and 3rd filter on filter mode.
14.2.7. Keep the 3rd filter on back wash mode for 15mins and on rise mode for the next
15mins
14.2.8. Finally after the back wash, keep all the 3 filter on filter mode and check the RO
water conductivity.
14.3. Diailzer Reprocessing Procedure
14.3.1. After a dialyzer has been used, the rinsing process is initiated for 5-6 minutes
when the patient’s blood is returned with a saline rinse back.
14.3.2. It is continued by flushing both the blood & dialysate compartment of the dialyzer
with water.
14.3.3. Chemical cleaning agents are used to remove remaining blood & dissolve
absorbed deposits.
14.3.4. Dialyzer is filled with 3-4% of H2O2 (as recommended) for ½ an hour to remove
the blood clots.
14.3.5. After ½ an hour dialyzer is rinsed with water & a visual inspection of dialyzer for
blood clots is cracks & defects should be performed.
14.3.6. Finally formal dehyde 4% is filled as disinfection with a minimum contact time of
24 hours.

Effective Date :
01/06/18
14.4. Dialysis blood tubes reprocessing procedure

DILUTION RATIO
CHEMICAL COMMERCIALLY USING% DILUTION
AVAILABLE
H2O2 10% 3-4% Dilute 350 to
400ml of 10%
H2O2 in 5 lit
of RO water
FORMALIN 36-38% 4% Dilute 500ml of
36% formalin in
5 lit of RO water

Effective Date :
01/06/18
15. SOP FOR PREPARATION OF BICARBONATE SOLUTION

15.1. Preparation of bicarbonate solution
15.2. Instruction Of Dilution & Use: 1 volume of part 1st to be diluted with 34 volumes of
purified water & mixed with 1.83 volumes of reconstituted part. 2.
15.3. Bicarbonate solution should be freshly prepared for each dialysis.

Effective Date :
01/06/18
16. SOP FOR HAEMODIALYSIS FOR THE PATIENT WITH BLOOD BORNE VIRAL
INFECTION
16.1. Purpose: To provide for surveillance, prevention and control of hospital associated
infection among the patient including outpatient, and inpatient, staff and visitors.
16.2. Scope: Hospital wide.
16.3. Responsibility: Nurse and doctors.
16.4. Procedure:
16.4.1. All patients are to be screened for hepatitis B, Hepatitis C and HIV infection prior
to be being taken up for dialysis at BBH and periodically thereafter as per
protocol.
16.4.2. In view of the limited floor space in the dialysis unit at BBH isolation of the
patient is not feasible, therefore as a matter of policy patients with these infections
are not being offered regular dialysis at BBH at present.
16.4.3. In case of an emergency, patients with any of these infections can be taken up for
dialysis as a life saving measure. The CDC recommends isolation only for
Hepatitis B infection and not for HCV or HIV, however this is provided by the
universal precautions that are being implemented for all dialysis procedure, and
this would become very expensive.
16.4.4. In the event that the dialysis unit at BBH has to treat any patient with any of these
infections the following MUST be observed.
16.4.5. STAFF-The same staff should be assigned to care for the infected patient through
the entire procedure, this person should not care for any other patients during this
time. Staff will wear protective mask, gown, eye shield and gloves when handling
the patient or their blood.
16.4.6. MATERIAL-All material used for the dialysis procedure, AV Fistula needles,
blood linens, transducer protector to be discarded after single use, dialyzer shall
be reused for 15 times for the same patient after disinfection..
16.4.7. Reusable material instruments and other reusable materials double bagged and
double autoclaved.

Effective Date :
01/06/18
16.4.8. Surface cleaning of the Hemodialysis machine with disinfectant solution and
double hot disinfection of machine to be done prior to being used for any other
patient.
16.4.9. Needles stick injury, blood splash to be handled as per protocol

Effective Date :
01/06/18
17. SOP OF CARE ON PERMANENT CATHETER

17.1. Purpose: To ensure that standard procedure are followed for the patient on permanent catheter
17.2. Scope: All patients undergoing dialysis on permanent catheter
17.3. Responsibility: Consultant/Dialysis nurse/Dialysis technician
17.4. Procedure:
17.4.1. In case the patient are on permanent catheter ,Kindly use sterile gloves and mask
to handle the catheterized area
17.4.2. The permanent catheter area should be thoroughly cleaned with betadine 5% using
cotton swab do not use surgical spirit for cleaning the permanent catheter
17.4.3. The permanent catheter should be covered by sterile towel in order to prevent
contamination of the site
17.4.4. The Artery and the Venous port may be interconnected if necessary
17.4.5. The pump speed should set at 300ml/min or greater if there is no alarm
17.4.6. CLOSING: Take 5cc syringe, add 1ml of Inj.Heparin 5000IU/+1.2ml of
Inj.Cefotaxime (125mg) + 2.8ml of Normal saline Mix well inject 2.5cc to the
artery port 2.5cc to the venous port to ensure patency of the port
17.4.7. Tegaderm plaster to be used for dressing
17.4.8. The patient INR should be monitored every 10 days or earlier as required (if there
is bleeding tendency) measures should be taken to maintain PT with INR between
1.5-2

Effective Date :
01/06/18
18. STARTING PLASMAPHERISIS THROUGH DIALYSIS CATHETER

18.1. Definition: Plasmapheresis or therapeutic plasma exchange refers to an extracorporeal
procedure in which blood separator technology is used to remove large quantities of
plasma from a patient and replaced with fresh frozen plasma,albumin and or saline.
18.2. Purpose:
18.2.1. Removal of abnormal circulatory factor.
18.2.2. Replinshment of plasmafactor
18.2.3. Improvement in function of immune system.
18.3. Scope: All patients undergoing plasmapheresis.
18.4. Responsibility: Dialysis nurse/ technician.
18.5. Indications: In auto immune disorder to remove abnormal in the body.
18.6. Equipment and Articles:
18.6.1. Dialysis machine
18.6.2. Plasmapheresis filter 0.5m2 BSA
18.6.3. Dressing Set
18.6.4. Sterile gloves
18.6.5. Any dialysis access(IJC,FC,Fistula)
18.6.6. Disposable syringe 5cc,10cc one each
18.6.7. Diluted heparin (1ml=1000 units)
18.6.8. IV set
18.6.9. Urosac
18.6.10. Normal saline 3500ml
18.6.11. Human albumin 20%as prescribed
18.6.12. Injection calcium gluconate 10ml 10%as prescribed
18.6.13. Inj. Hydrocort 100mg,Inj. Emeset 4mg,Inj. Avil 1 amp
18.6.14. FFP as prescribed
18.7. Procedure:
18.7.1. Check the doctors order,ensure that the consent is obtained.
18.7.2. Explain the procedure.
18.7.3. Ensure the blood products are ready

Effective Date :
01/06/18
18.7.4. Monitar vital signs prior to initiating the exchange and then every half an hour
18.7.5. Position the patient comfortably on the bed.
18.7.6. Monitor vital sings prior to initiating exchange and then every half an hour.
18.7.7. Send blood for investigation(PT,APTT)as per doctor’s order.
18.7.8. Inj.Albumin is administered as prescribed.
18.7.9. Pre[pare the vascular access of the patient.
18.7.10. Check post plasmapheresis BP,weight record it.
18.7.11. Patient is monitored for 15-30 min.
18.7.12. FFP is transfused.
18.7.13. Document all the procedures.

Effective Date :
01/06/18
19. SOP FOR RENAL BIOPSY

19.1. Definition: Is a medical procedure in which a small piece of kidney is removed from
the body for examination, usually under a microscope. Microscopic examination of the
tissue can provide information needed to diagnose, monitor or treat problems of the
kidney.
19.2. Purpose: To define the procedure for doing renal biopsy so as to identify what is
causing abnormal kidney function or urine abnormalities.
19.3. Scope : All patients undergoing Renal Biopsy
19.4. Responsibility : Doctors, Staff Nurses
19.5. Equipments and Articles :
1) Sterile Foleys Catheterization set Or LP set- 1
2) Disposable gloves no 7 – 2 or as requested.
3) 5 CC disposable syringe -2
4) Inj. 2% Xylocaine – 1
5) Betadine Solution – 1
6) LP needle no 26 or 27 – 1
7) Surgical Blade no 11 – 1
8) 4% Formaline bottle for specimen – 1
9) Normal saline bottle for specimen – 1
10) Normal saline 500ml – 1
11) Sterile Throat Swab Stick – 1
12) Arrange for Ultrasound Scan Machine at specified time.
19.6. Procedure :
19.6.1. PRE RENAL BIOPSY MONITORING
a. Check the Doctors order, ensure that the consent for renal biopsy is obtained.
b. Explain the procedure.
c. No fasting is necessary,the patient can have light food.
d. Secure IV line.
e. Xylocaine test dose
f. Arrange the drugs / syringes

Effective Date :
01/06/18
g. Shift the patient on the stretcher only.

h. Monitor vital signs prior to initiating the procedure.
i. Position the patient comfortably on the bed.
j. Document all the procedure.
19.6.2. POST RENAL BIOPSY MONITORING

a. Absolute bed rest for 24hrs.
b. BP monitoring every 15 min for 1 hour followed by every 30 min for3hours
followed by every hour for 20 hours.
c. Preserve first 3 sample of voided urine.
d. Inform if there is hematuria (Blood in the urine), or if systolic BP is less than
100mm/HG or 20mm/HG below the base line or if diastolic BP is greater than
110mm/HG.
19.6.3. Patient needs to be given discharge instructions by the Doctors after the procedure
19.6.4. Bed rest for 1 day.
19.6.5. Limited activity for 3 days.
19.6.6. Avoid lifting heavy weight for 7 days.
19.6.7. To come to Hospital immediately if there is blood in the urine or if there is
giddiness or any symptoms that you feel requires urgent medical attention.
19.6.8. Cap. Augmentin 625mg 1-0-1 for 5 days.
19.6.9. Cap. Ultracet 1-0-1 for 3 days for pain.
19.6.10. Tab. Ondem MD 4mg 1-0-1 for 3 days.()
19.6.11. To review with renal biopsy report after one week.
19.6.12. Kindly take other medications and instructions as suggested by your treating
Doctor.

Effective Date :
01/06/18
20. SOP FOR ASSISTING FOR NEPHROSTOMY DRAINAGE

20.1. Definition: Maintaining of skin hygiene at Nephrostomy site and maintain short
output through Nephrostomy drainage tube
20.2. Purposes
20.2.1. Prevent leakage
20.2.2. Prevent infection
20.2.3. Prevent skin excoriation around the Nephrostomy site
20.3. Equipment ~ A tray containing
20.3.1. Sterile glove
20.3.2. Small dressing pack
20.3.3. Betadine
20.3.4. Adhesive scissors
20.4. Procedure
20.4.1. Explain procedure to the patient
20.4.2. Collect article and bring to the bed side
20.4.3. close curtains around bed
20.4.4. Position Patient on side lying (or) prone, drape, patient so that only the area
around the Nephrostomy is exposed.
20.4.5. wear sterile glove
20.4.6. Clean around the Nephrostomy side with betadine and applying dressing
20.4.7. Remove gloves. Secure drainage tubing to the patient
20.4.8. Assist the patient to a comfortable position, cover the patient with bed linen and
place the bed in the lowest position
20.4.9. Secure drainage bag below the lever of the bladder check the drainage tubing is
not kinked and the movement of side rails does not interfere with the drainage bag
20.4.10. Replace the articles and perform hand hygiene
20.4.11. Watch for bleeding and patient’s complaints on urgency, frequency and
hesitancy
20.4.12. Document the time, cleaning done and amount of urine output through
Nephrostomy drainage by proper labeling in Intake and Output chart

Effective Date :
01/06/18
21. SOP FORPREPARATION FOR PERCUTANEOUS NEPHROSTOMY (PCN)

DRAINAGE
21.1. Definition: Establishing drainage from kidney by making an incision on the right or
left flank region of the patient through a pigtail catheter
21.2. Purpose
21.2.1. Provide urinary diversion
21.2.2. Maintain patency of urine drainage form upper urinary tract, when urethra is
blocked.
21.3. Nursing Action
21.3.1. Keep the patient nil orally for 6 hours prior to procedure.
21.3.2. Get written consent for procedure
21.3.3. Remove all metals or jewelry
21.3.4. Confirm if patient is on anticoagulant
21.3.5. Check PT, APTT reports, before procedure.
21.3.6. Care on the day of procedure
21.3.7. Explain procedure and reassure the patient
21.3.8. Provide hospital gown.
21.3.9. Review the medical order for PCN, antibiotics and premedication
21.3.10. Ensure that the patient removes all jewelry
21.3.11. Check the patient’s vital signs.
21.3.12. Move patient to get him/her on to stretcher.
21.3.13. Administer premedication and antibiotics as per order.
21.3.14. Secure the patient with belt and side rails in the stretcher.
21.3.15. Send the patient to Digital subtraction Angiography (DSA) room with IP
chart and OP chart after documenting.
21.3.16. Post-procedure care
21.3.17. Check vital signs Q1 hour for 6hrs.
21.3.18. Check urine output Q 1 hour.
21.3.19. Check PCN site.
21.3.20. Document the date, time, site of PCN and amount of urine in the Intake and
Output chart.
21.3.21. Report any abnormal findings

Effective Date :
01/06/18
22. LIST OF ASSOCIATED RECORDS

22.1.1. Ward Drug Register R/NS/DIALYSIS/03
22.1.2. Ward Teaching Register R/NS/DIALYSIS/04
22.1.3. HICC Register R/NS/DIALYSIS/05
22.1.4. Emergency Trolley Register R/NS/DIALYSIS/06
22.1.5. Fumigation Register R/NS/DIALYSIS/08
22.1.6. Continuous Quality Improvement Register R/NS/DIALYSIS/09
22.1.7. CSSD register R/NS/DIALYSIS/10
22.1.8. Meeting minutes file R/NS/DIALYSIS/11
22.1.9. Inventory & Condemned Register R/NS/DIALYSIS/12
22.1.10. Linen Inventory & Mending Register R/NS/DIALYSIS/13
22.1.11. Preventive Maintenance Register R/NS/DIALYSIS/14
22.1.12. Repair Register R/NS/DIALYSIS/15
22.1.13. Dialyser and blood tubings reprocessing register R/DIALYSIS/01
22.1.14. Dialysis register R/DIALYSIS/02
22.1.15. Patient timing register R/DIALYSIS/03
22.1.16. Calls register R/DIALYSIS/04
22.1.17. Monthly consult register R/DIALYSIS/05
22.1.18. Cleaning register R/DIALYSIS/06
22.1.19. Rotary register R/DIALYSIS/07
22.1.20. Machine disinfection register R/DIALYSIS/08
Forms
22.1.21. Dialysis information folder F/NEPH/01
22.1.22. Haemodialysis record F/NEPH/02
Signature: Signature:

Effective Date :
01/06/18
ANNEXURE I
1 Role of Consultant
a) To work in accordance with the mission, vision and ethics of the Hospital and serving as
a role model in all areas of life.
b) To participate in all Hospital activities including the administrative social spiritual events
and to extent support to the administration of the Hospital.
c) To co-ordinate the activities of the Dialysis Unit.
d) To provide medical care for the patients in Dialysis. Attend to their medical needs.
e) To advise the patients and their family members about the various treatment options for
patients with Kidney failure.
f) To disseminate knowledge to the patients and family on prevention of Kidney disease
and also measures to slow progression of disease.
g) To ensure that appropriate consumable used in Dialysis are made available for care.
h) To provide in-service training in the theory and practice of Dialysis to the staffs of the
Dialysis unit.
i) To provide Nephrology advice for patients admitted to the Hospital under other services.
j) To examine and provide treatment for out patients who need Nephrology services.
k) To perform Kidney biopsies where indicated and to interpret the results of these and plan
out treatment based on the biopsy report.
l) To create temporary vascular access for Haemodialysis, Femoral, Internal Jugular or
rarely
Subclavian vein catheterization.
m) To guide the residents in creation of temporary vascular access.
n) To conduct classes theory and clinical for the under graduates students as well as the
DNB trainers.
2 Role of charge nurse
a) Upholds the standard of nursing practice for critical ill patients.
a) Maintains life saving equipments – ventilators, defibrillators.

Effective Date :
01/06/18
b) Evaluates performance of the staff under her supervision and nursing care as a whole.
Suggests modifications.
c) Upholds the standard of nursing practice in relation to safety, quality and quantity.
Inspects unit areas to verify that patient needs are met.
d) Assigns duties to professional and ancillary nursing personnel based on needs for the
efficient functioning of her department.
e) Supports, interprets and promotes the philosophy and objectives of the hospital and of the
nursing service division. Interprets needs and interests of nursing personnel to the
CNO/ACNO on specific problems and interpretations of hospital policies.
f) Responsible for the maintenance of safe and sterile environment in the unit.
g) Formulates the schedule for staffing the unit. Adjusts the weekly schedule as needed to
provide optimum coverage for the unit. Is available to the institution in emergency
situations which create excessive demands on hospital personnel.
h) Orient new staffs to the unit. Participates in guidance and educational programs.
i) Engages in investigations related to improving nursing care.
j) Assists in interviewing applicants and makes recommendations for employing or
terminating personnel.
k) Assists physicians and ensures that nursing care is carried out as directed and treatment is
administered in accordance with physician’s instructions.
l) Directs preparation and maintenance of patient’s clinical record.
m) Investigates complaints of staff, patients and relatives and refers them to supervisor.
n) Instructs patients and members of their families in techniques and methods of home care
after discharge.
o) Ensures establishes inventory standards for medicine solutions, supplies and equipments
accounts for narcotics.
p) Presides over unit personnel meetings to discuss patient care needs. Attends meetings of
the nursing service division to discuss unit operation and staff training needs and to
formulate programmes to improve nursing care.
q) Assists in the development and revision of nursing policies, regulations and procedures.
r) Rotates to evening and night duty to fill the position of evening and night supervisor.

Effective Date :
01/06/18
s) Encourage the staff to participate in regular in-service education.

t) Ensure all staff and educate them about pollution control.
u) Develops, Justify and maintains the fiscal plans (Budget) for Ward. Monitors Operating
and other expenses (salaries, capital expenses) and provides appropriate reports to CNO.
v) To perform any other duties assigned by the CNO/ACNO.
3. Role of Staff Nurse
1. To uphold the standards of nursing practice for critical ill patients.
2. To maintain life saving equipments – ventilators, defibrillators and care of patients on
ventilator and monitors
3. To check inventory of all equipment, crash cart and instruments as per the inventory
register and inform the senior nurse /head nurse in case of any discrepancies noted.
4. To check the communication book for any new instructions during every shift.
5. To check the census of the department.
6. To Enquire and know about the following:
a. New admissions.
b. Transfers.
c. Surgery and investigation list.
d. Discharges.
7. To take over of all patients as the shift changes.
8. To send patients for surgeries / investigations as per the schedule.
9. To document the initial assessment findings in the nurse’s notes.
10. To monitor vital signs routine / as per the orders and document it.
11. To ensure that water and diet is provided for all patients as per the diet orders.
12. To accompany the doctors for clinical rounds and carry out their written orders.
13. To ensure replacement of medicines, if not endorse to the next shift.
14. To complete all relevant documents.
15. To check the patient’s records for any changes, special orders etc.
16. To endorse the patients to the next shift staff.
17. To inform any special events during the shift to the CNO/ACNO.
18. To ensure that the hygienic needs of patients are met and the unit is tidy at all times.

Effective Date :
01/06/18
19. To check medicines for the entire day.

20. To ensure that all admissions, transfers and discharges are entered in the admission
discharge register.
21. To prepare the patients for surgeries / procedures.
22. To check and receive all investigation reports done during the day.
23. To send intimation to the concerned departments.
24. To administer quality care which meets the best standards for nursing practice of the
hospital.
25. To know the purpose, expected result and the safety factors involved in the nursing
care.
26. Not to divulge confidential information concerning the patient or hospital affairs
except to authorized personnel.
27. To participate in studies related to nursing practice.
28. To participate in the in-service education programs of the institution.
29. To evaluate patients care and make recommendations for the improvement of care.
30. To identify the nursing needs of the patients.
31. To determine observable spiritual, emotional and social factors which might influence
a plan of therapy.
32. To make care plan in the light of nursing needs and the program of therapy as
prescribed by the physician.
33. To maintain a professional level of conduct.
34. To accept direction, supervision, and evaluation of performance.
35. To ensure economical use of time, effort and material.
36. To keep abreast of literature in nursing.
37. To perform any other duties assigned by the charge nurse/ACNO/CNO.
4. Role of Team leader

1. To have an intricate understanding of the mechanics of dialysis.
2. To assess vital signs, discuss patient concerns and answer questions relevant to
patient care

Effective Date :
01/06/18
3. To oversee dialysis from start to finish and monitor patient reaction to treatment.
4. To verify that patients are taking all prescribed medications,
5. To inform doctors of any significant change in patients' health
6. To work closely with others on the dialysis team.
7. To ensure that all equipment is functioning properly, and that any repairs needed are
reported in a timely manner.
8. To maintain medical inventory, notify manager when supplies are needed
9. To arrange for follow up appointments, and reporting to upper management and/or
physicians as needed.
10. To be accountable for inventory.
11. To adhere to hospital policies and procedures.
12. To know the purpose, expected results, and the safety factors involved in the patient
care.
13. To utilize the knowledge and skills in giving safe nursing care.
14. To be responsible for fulfilling the activities of the job.
15. Not to divulge confidential information concerning the patient’s or hospital affairs
16. To self-direct in learning and/or improving the abilities needed for the job.
17. To participate in studies related to nursing practice.
18. To participate in the in-service education programs of the institution.
22. To keep abreast of literature in nursing.
23. To take responsibilities during Supervisor’s absence.
5. Role of Dialysis Technicians
1. To have an intricate understanding of the mechanics of dialysis.
2. To assess vital signs, discuss patient concerns and answer questions relevant to
patient care
3. To oversee dialysis from start to finish and monitor patient reaction to treatment.

Effective Date :
01/06/18
4. To verify that patients are taking all prescribed medications,

5. To inform doctors of any significant change in patients' health
6. To work closely with others on the dialysis team.
7. To ensure that all equipment is functioning properly, and that any repairs needed are
reported in a timely manner.
8. To arrange for follow up appointments, and reporting to upper management and/or
physicians as needed.
9. To be accountable for inventory.
11. To know the purpose, expected results, and the safety factors involved in the patient
care.
12. To be responsible for fulfilling the activities of the job.
13. Not to divulge confidential information concerning the patient’s or hospital affairs
14. To self-direct in learning and/or improving the abilities needed for the job.
15. To participate in the NABH programs of the institution.
19. To take care of R O plant
6. Role of Nursing Aid
1. To give the quality of service which meets the standards for practice of the hospital.
3. Not to divulge confidential information regarding patients and hospital affairs except
to authorized personnel.
4. To conduct himself in a courteous, friendly manner and treat the patient as a guest in
the hospital.
5. To assist the Staff Nurses in the care of patients as directed.
6. To report all observations concerning patients to a Staff nurse.

Effective Date :
01/06/18
7. To assist in admission procedure for patients admitted through the casualty and
outpatient department.
8. To assist patients in preparing for examination by the doctor.
9. To collect specimen as directed (urine, stool, sputum).
10. To transport patients to the various locations as needed. .
11. To obtain, clean and return equipments and supplies handled in the ward.
12. To take responsibility for seeing that the working area kept clean and equipment is
kept in its place.
13. Runs errand to other departments; pharmacy, central supply, lab, cashier, medical
record, other nursing units.
14. To be accountable for her/his assigned patients hospital linen.
15. To perform any other duties as directed by the Charge Nurse or unit supervisor

Effective Date :
01/06/18
Annexure II
Organogram
Director
Deputy Director
Consultant nephrology
Incharge Nurse
Team Staff Technician Ward

Leader Nurse Aide

Nephrology PDF

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Nephrology PDF

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BANGALORE BAPTIST HOSPITAL Page: 1 of 46

DEPARTMENT OPERATING MANUAL Version No: 03

Reviewed & issued by: Division Head Approved by: Director(CEO)

1. SCOPE OF THE DEPARTMENT

Reviewed & issued by: Division Head Approved by: Director(CEO)

2. ASSISTING IN FEMORAL CATHETERIZATION

Reviewed & issued by: Division Head Approved by: Director(CEO)

3. STARTING HAEMODIALYSIS THROUGH FEMORAL CATHETER

Reviewed & issued by: Division Head Approved by: Director(CEO)

4. STARTING HAEMODIALYSIS THROUGH JUGULAR CATHETER

Reviewed & issued by: Division Head Approved by: Director(CEO)

5. STARTING HEMODIALYSIS THROUGH AV FISTULA

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

6.6. Principal of Hemodialysis

Reviewed & issued by: Division Head Approved by: Director(CEO)

Renal failure patient often have altered

6.8. Pre-Dialysis Procedure:

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

a. For fever and chills

Reviewed & issued by: Division Head Approved by: Director(CEO)

7. BLOOD TRANSFUSION DURING DIALYSIS

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

8. PROCEDURE-ROUTINE BLOOD TEST

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

9. CLOSING HEMODIALYSIS THROUGH ATRIOVENOUS FISTULA ACCESS

Reviewed & issued by: Division Head Approved by: Director(CEO)

9.4.16. Cover fistula site with sterile gauze bandage

Reviewed & issued by: Division Head Approved by: Director(CEO)

10. CLOSING HEMODIALYSIS THROUGH FEMORAL

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

11. REMOVAL OF JUGULAR CATHETER

Reviewed & issued by: Division Head Approved by: Director(CEO)

12. REMOVAL OF FEMORAL CATHETER

Reviewed & issued by: Division Head Approved by: Director(CEO)

13. R.O WATER MAINTENANCE AND DISINFECTION PROCEDURE

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

14. BACK WASH, DIALYZER AND BLOOD TUBINGS RE-USE

Reviewed & issued by: Division Head Approved by: Director(CEO)

14.4. Dialysis blood tubes reprocessing procedure

Reviewed & issued by: Division Head Approved by: Director(CEO)

15. SOP FOR PREPARATION OF BICARBONATE SOLUTION

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

17. SOP OF CARE ON PERMANENT CATHETER

Reviewed & issued by: Division Head Approved by: Director(CEO)

18. STARTING PLASMAPHERISIS THROUGH DIALYSIS CATHETER

Reviewed & issued by: Division Head Approved by: Director(CEO)

Reviewed & issued by: Division Head Approved by: Director(CEO)

19. SOP FOR RENAL BIOPSY

Reviewed & issued by: Division Head Approved by: Director(CEO)

g. Shift the patient on the stretcher only.

19.6.2. POST RENAL BIOPSY MONITORING

Reviewed & issued by: Division Head Approved by: Director(CEO)

20. SOP FOR ASSISTING FOR NEPHROSTOMY DRAINAGE