Anatomy and physiology of renal system

Organ include in renal system

1. Kidneys – 2
2. Ureters-2
3. Urinary bladder-1
4. Urethra -1
1. kidneys-2
Structure
1. Gross anatomy
 Kidneys are bean shaped.
 Kidneys lies in retroperitoneal space land posterior abdominal wall.
 The kidneys are covered by fibrous capsule.
 The kidney located at the T12 to L3 vertebra.
 The right kidney is lower due to slight displacement by the liver.
 The male’s kidney is typically a bit larger than than the female’s.
 Weight
 125-175gm in male
 115-155gm in females
 Length 11-14cm
 Wide 6cm
 Thick 4cm
2. Internal anatomy
The kidney is divided into three main type
a. Renal cortex
 The cortex is a light outer area
 Which contains all glomerulas and approximately 85% of nephrons tubules.
b. Renal medulla
 Medulla is a darker inner area
 That contains 8-18 renal pyramids
 The pyramids consists of collecting duct, collecting tubules and long loops of henle.
c. Renall hilum
 Hilum is the entry and exit site for structure servicing the Kidneys:- vessels, nerves,
lymphatics and ureters.
Nephrons
 Nephron is a functional unit of kidney
 1-2.5 millions nephron is individual kidneys
Part of nephrons
 Bowman’s capsule
 Proximal convoluted tubules

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  Loop of henle
 Distal convoluted tubules
 Collecting tubules
Bowman’s capsule
 The renal corpuscle consists of a tuft of capillaries. The glomerulus which is
surrounded by double walled sophisticated tubules called bowman’s capsule.
Proximal convoluted tubules
 This is the longest and most convoluted segment of the nephrons.
 The most of the component of glomerular filtrate are reasorbed in this segment .
Loop of henle
 This is the hairpin loop of nephrone that extends into the meddula and consists
of thick and thin segment.
Distal convoluted tubule
 Distal convoluted tubule is a portion of nephrone between the loop of henle
and the collecting tubule .
 That reasorbe sodium and chloride from the tubular filtraIt.
Collecting tubules
 It is the part of nephrone that collects the urine from the distal convoluted tubule and
discharges it into the renal pelvis.
Blood supply
 Kidneys received 20-25% of total cardiac output
 Kidney is supplied by renal artery and it’s branches to end in the glomerulas. Where
filtration occers. It is then brought back to inferior venacava through renanl vein.
 Two arterioles are [Link] arteriole supplies glomerulas and efferent arteriole
drain glomerulas.
3. Ureters-2
 Each length is about 25-30cm
 Extending from renal pelvis to urinary bladder.
4. Urinary bladder -1
 Urinary bladder is located immediately behind symphysis pubis.
5. Urethra-1
 Length of urethra is about
 In male :- 18-20cm
 In female :- 3-4cm
Functions of kidneys
 Remove the waste product from the body through urine
 Fluid and electrolyte balance
 Acid and base balance
 Long term blood pressure maintain
 Regulations of ions (sodium, potassium calcium, magnesium
 Hormones secretions
[Link]:- it stimulates production of red blood cell in the bone marrow

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 [Link]:- that helps to regulate blood pressure
[Link]:- is the activated form of vitamin D, which promotes intestinal absorption of
calcium and bone mineralization
Physiology of kidney
1. Filtration
2. Selective realsorption
3. Selective secretion
4. Excretion
1. Filtration
 Filtration, which takes place at the bowman’s capsule.
 Is the process by which cells and large proteins are retained and smalle molecules
weights are filtered from the blood to make an ultrafiltrate than eventually becomes urine.
 The kidney generates 180 liters of filtrate a day
2. Selective reabsorption
 Reabsorption is the transport back to molecules from ultrafiltrate in the tubule into the
peritubular capillary.
 It is accomplished via selective receptors in the luminal cell membrane.
 Water is 55% reabsorbed in the proximal tubule.
 Glucose at normal plasma level is completely reabsorbed in the proximal tubule.
 99% filtrate is reabsorbed and 1% only secrete through urine.
 And daily urine output 1-2 liters per day.
3. Selective secretion
 Secretion is the reverse of reabsorption.
 Non- filtered substances move from peritubular capillary through the interstitial fluid,
then through the renal tubular cell and into the ultrafiltrate. [Link],
creatinine,medicines.
4. Excretion
 Last step of processing of the ultrafiltrate is excretion.
The waste products are urea, uric acid, creatinine, sodium, potassium and etc are excreted
through the urine.

AKI (Acute Kidney Injury)

It can range from minor loss of kidney function Acute kidney injury(AKI) is where your kidneys
suddenly stop working to complete kidney failure and bulid up of waste in the blood like waste
fluid, electrolites, creatinine and blood urea nitrogen(BUN).

The estimates prevalence rate that 13.3 million people worldwide are affected by acute kidney
injury. The overall incidence of AKI was found to be 5-9% in Nepal.

Sign and Symptoms

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  Decreased urine output  Confusion
 Swelling in legs, ankles and  Nausea/vomitting
around the eyes  Chest pain
 Fatigue and tiredness  Irregular heartbeat
 Shortness of breath  Seizures or coma in severe case
 Hypertension

Causes
Most cases of AKI are caused by reduced blood flow to the kidney, usually in someone who’s
alredy unwell with another health condition.
The most common causes of AKI are=

1. Prerenal
Substantial decrease in blood flow to the kidney.

 Hemorrhage, Vomiting and diarrhea, Burns

 Increased vascular capacity and leakiness, Sepsis , Anaphylaxis
 Heart is compromised= .Heart failure .MI
[Link]
Internal structures of the kidney itself.
 Acute Tubular Necrosis( ATN)
 Renal ischemia from prerenal cause
 Nephrotoxic exoogenous compounds
 Endogenous compounds that obstruct the tubular lumen
 Interstitial Nephritis
 Glomerulonephritis
3. Postrenal
 Obstruction after the kidney
 Obstruction of both ureter
 Obstruction of the urethra
 BPH, prostate cancer
Investigations
1. Blood test
 Blood urea nitrogen(BUN)
 Serum Creatinine
 Estimated glomerular filtration rate(eGFR)
 Serum potassium
2. Urine test
. Check urine amount in 24 hours
. Hematuria

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 . Proteinuria
3. Renal ultrasound
. Ultrasound is currently underutilized in AKI. It is not only able to diagnose
obstruction, but it can also yield important data on underlying CKD status, vascular
status, ATN and inflammatory states of the kidney.
4. Kidney biopsy
. Performing a kidney biopsy is necessary to accurately diagnose diseases such as
glomerulonephritis and tubulointerstitial Nephritis, among other such conditions. These
conditions predispose patients to chronic kidney disease, as well as acute kidney injury
(AKI).
Nursing Management
1. Monitor vitals including urine output.
2. Weight patient daily to determine fluid retention.
3. Assess heart and lung sounds.
4. Assess periorbital and dependent edema.
5. Assessing fluid status and identifying potential sources of imbalance.
6. Fluid and electrolyte replacement.
7. Give antibiotics if patients have an infection.
8. Provide emotional support to the patient and family.
Chronic kidney Disease
Chronic kidney Disease (CKD) is Irreversible loss of kidney function or Decreased GFR Rate
for long time and glomerular filtration rate ( GFR) below 60ml min per 1.73m2

Staging of CKD

CKD Stage GFR (ml/min/1.73m2) Description

Stage-1 90 or higher -mild kidney damage .
-kidneys work as well as normal.
Stage-2 60-89 -Mild kidney damage.
-kidneys still work well.
Stage-3a 45-59 -mild to moderate kidney damage.
-kidneys don’t work as well as they should.
Stage-3b 30-44 -moderate to server damage.
-kidneys don’t work as well as they should.
Stage-4 15-29 -server kidney damage.
-kidneys are close to not working at all.
Stage-5 Less than 15 -most server kidney damage.
-kidneys are very close to not working or have

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 stopped working (failed).
Cause of CKD Risk factors of CKD

 Diabetes mellitus  Diabetes

 Hyper tension  High blood pressure
 Glumerulonephritis  Heart disease
 Obesity  Obesity
 Heart problem
 Family history of kidney disease
 Congenital and inherited disease
 Abnormal kidney stricter
 Prolonged obstruction of the urinary
track  Older age
 Recurrent kidney infection  Frequent use of medication

Symptoms  Itching
 Nausea, vomiting and diarrhea
 loss of energy  Bone pain due to metabolic bone
 loss of appetite disease
 Insomnia  Peripheral or pulmonary edema
 Nocturia  Symptoms due to anemia

Examination
 Short stature (in patients who have hed CKD in childhood)
 Pallor
 Tachycardia
 Brown discoloration of the nails
 Peripheral edema,raised jugular venous pressure cardiomegaly
 Flow murmurs

Investigations
 Urinalysis  Immunology
 Urine microscopy  Radio logical investigation
 Serum biochemistry  Renal biopsy
 Hematology

Complication
 Anemia
 Heart disease
 Bone disease
 Personality change
 Decreased immune response
 Skin disease
 Gastrointestinal complication

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Management of CKD
 Counseling and reassurance
 Dietary modification
 Management of hyperglycemia
 Control sodium intake
 Control blood pressure
 Correction of anemia
 Renal replacement therapy

Renal Replacement Therapy (RRT)

Introduction
If kidneys fail to perform their functions, we have to employ the alternative method which is
called Renal Replacement Therapy (RRT). However, each and every function cannot be replaced
by RRT until and unless the modality is kidney transplantation.
Indications @AEIOU
 Acidosis
 E-Electrolyte disturbances (Hyperkalemia: Potassium>6mmol/L)
 I-Intoxication
 O-Overload of fluid (Peripheral edema, pulmonary edema
 U-Uremia
Mechanism of RRT
1. Diffusion: Diffusion is the movement of solute from higher to lower concentration across a
semi permeable membrane. In RRT, diffusion occurs when the blood flows on one side of the
filter membrane, and there is counter current flow of dialysate solution on the other side. It is
used in haemodialysis, haemodiafiltration as well as peritoneal dialysis.
2. Ultrafiltration: Ultrafiltration is the movement of plasma water across a semi permeable
membrane, driven by a pressure gradient. Ultrafiltration is used for fluid removal with the use of
hydrostatic pressure.

3. Convection: Convection is the movement of solute dissolved in plasma water across a semi
permeable membrane. As the plasma is ultrafiltered, the dissolved solute is carried along by
“solvent drag”.

Modalities of RRT

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 RRT

Intermittent Continuous Transplant

IHD

CRRT PD

SLED SCUF

CVVH

CVVHD

CVVHDF

Hemodialysis
Hemodialysis is the treatment process to filter wastes and water from the [Link] helps to
control the blood pressure and balance the important minerals, such as potassium, sodium, and
calcium, in the blood. It works on the process of diffusion through the semi permeable
membrane of the dialyzer.
Vascular Access: There are two types of vascular access used for hemodialysis:

a. Temporary and permanent vascular access.

Temporary vascular access includes the insertion of dialysis catheters in the large veins. It
includes intra jugular catheter, femoral catheter, subclavian catheter as well as permanent
catheter. Similarly, the permanent vascular access includes ateriovenous fistula and ateriovenous
graft. The most commonly used permanent access is AV fistula.

In Nepal, first hemodialysis service was started in 1987 in Bir Hospital with only two
functioning HD machines. Later on, Ministry of Health(MOH) started free dialysis service for
people since 2016.

Continuous Renal Replacement Therapy(CRRT)

CRRT is the excellent hemodynamic tolerance for the kidney failure patients who are hemo
dynamically unstable like those who are on septic shock, mechanical ventilation as well as
multiple organ failure. It helps to remove more fluids and solutes for longer duration. It uses the
principle of diffusion, convection and ultrafiltration. CRRT machine has four pumps: blood
pump, replacement pump, dialysate pump and effluent pump.

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Types of CRRT:

a. Slow Continuous ultrafiltration(SCUF): It is used to remove excess fluid in patients with

severely hypervolemic, pulmonary edema, diuretic resistant patient. It requires only blood
pump and effluent pump.
b. Continuous Veno-Venous Hemofiltration(CVVH):It is the fluid removal which requires
the replacement of the fluid to prevent hypotension. It requires blood pump, effluent pump
and replacement pump.
c. Continuous Veno-Venous Hemodialysis(CVVHD): It is similar to hemodialysis but the
blood pump and the dialysate pump is very slow in comparison to hemodialysis. It requires
blood pump, effluent pump and dialysate pump.
 A combination of hemofiltration and slower form of HD. An infusion pump drives
dialysate
 No replacement fluid used
 Removes solutes/fluid
 Safe for patient with hypotension and fluid overload
d. Continuous Veno-Venous Hemodiafiltration(CVVH): It requires all four pumps. It uses
both replacement fluid as well as dialysate fluid.
e. Slow Low Efficiency Dialysis(SLED)

- SLED is a recently developed hybrid technique of RRT that uses a hemodialysis

machine with reduced blood flow(100-200mL/min) and dialysate flow rates(100-
200mL/min),
- usually performed nocturnally for an extended period(6-10hours). It is an effective

method of hemodialysis for the patient who are unable to tolerate the high flow and
ultrafiltration of hemodialysis.
Nursing Interventions
 Hemodynamic monitoring of the patient should be continuous in order to detect
hypovolemia, hypotension and arrhythmias.
 Position the circuit tubing so as to prevent kinking and obstruction of blood flow, and
thus avoid setting off machine alarms and increasing the risk of filter or circuit clotting.
 A constant and reassuring nursing presence should be provided to the patient and their
family to reduce the anxiety related to the disease as well as the treatment process.
 Proper counseling to the patient and the family members should be done regarding the
different treatment modalities of RRT.
 Health education regarding the care of AV fistula should be given to the patient.
 Encouragement regarding renal transplantation should be done in order to minimize the
morbidity and mortality of CKD.
Nursing interventions
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CKRT occurs only in the ICU because of (1) the need for frequent monitoring and specialized
skill set of the nurse to maintain safety during extracorporeal circulation (blood flow outside the
body), and (2) the need for ongoing monitoring and replacement of fluid and electrolytes.
Monitoring
 Hemodynamic monitoring should be continuous in order to detect hypovolaemia,
hypotension, and arrhythmias.
 Monitor plasma potassium levels at least 4-hourly.
 Monitor core temperature and maintain at > 36°C. Heat loss from blood in the
extracorporeal circuit and infusion of large volumes of room-temperature replacement
fluid can reduce body temperature.
 Monitor circuit pressures and blood coagulation laboratory profiles
Rest and sleep
 Ensure that the patient is allowed adequate rest and sleep. Position the circuit tubing
so as to prevent kinking and obstruction of blood flow, and thus avoid setting off
machine alarms and increasing the risk of filter or circuit clotting.
Psychological care
 The sight of large volumes of blood in the extracorporeal circuit can be frightening
for the patient and their relatives. To reduce anxiety, discussion about renal
replacement therapy as a treatment should be introduced before its commencement. A
constant and reassuring nursing presence will also support the patient and their
family.
Anticoagulation
 The aim is to prevent platelet and coagulation activation in response to contact of
blood with a foreign surface (i.e. the filter or circuit).
 Too little anticoagulation can cause clotting in the filter. This is time-consuming to
replace, expensive, and decreases efficiency as well as risking blood loss (a circuit
contains 150–200 mL of blood).
 Too much anticoagulation can cause bleeding from cannula sites or spontaneous
bleeds in the brain, bowel, or lung.
 Heparin is the most commonly used anticoagulant.
 Usually 5–20 IU/kg/h heparin is infused proximal to the filter.

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  A pre-filtration heparin bolus of 2000–5000 IU may also be given if there are
problems with filter clotting.
 If the patient has an adverse reaction to heparin (e.g. heparin-induced
thrombocytopenia) or is at risk of bleeding (e.g. post-surgery),
prostacyclin/epoprostenol (PG12) or alprostadil (PGE1) can be given at 2.5–10
ng/kg/min. Observe the patient for hypotension.
 Alternatively, citrate can be given in order to anticoagulate the circuit and filter
without anticoagulating the patient. Citrate is both an anticoagulant and a buffer. It
chelates ionized calcium, and the associated regional hypocalcaemia in the filter
inhibits the generation of thrombin.
 The citrate is partially removed by filtration, and the remaining citrate is rapidly
metabolized to bicarbonate in the liver, muscle, and renal cortex. Calcium infusion is
required.
Caring for the Patient Undergoing Hemodialysis
 Weigh the patient before and after dialysis.
 Know the patient's dry weight.
 Discuss with the nephrology health care provider or pharmacist whether any of the
patient's drugs should be withheld until after dialysis.
 Be aware of events that occurred during previous dialysis treatments.
 Measure blood pressure, pulse, respirations, and temperature.
 Assess for indications of orthostatic hypotension.
 Assess the vascular access site when taking vital signs and follow agency policy for
central line care and dressing changes.
 Observe for bleeding at the vascular access site and other sites where skin integrity is
disrupted because anticoagulants given during dialysis and the presence of uremia
increase bleeding risk.
 Assess the patient's level of consciousness.
 Assess for headache, nausea, and vomiting.
 Assess serum laboratory tests to evaluate effectiveness of treatment in removing
wastes and achieving desired outcomes.

Vascular Access
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Vascular access is a way to reach for haemodialysis which allows blood to travel through soft
tubes to the dialysis machine where it is cleaned as it passes through a special filter called
dialyzer. An access is placed by a minor surgery. A well functioning vascular access is a
mainstay to perform an efficient haemodialysis.
Types of vascular access

Temporary Vascular Access Permanent Vascular Access

Central Venous Catheter  Arteriovenous fistula
 Femoral Catheter  Arteriovenous graft
 Jugular Catheter
 Sub-clavian Catheter
 Permanent Catheter
Classification of Vascular Access
A. Temporary
1. Central venous catheter
i. Jugular
ii. Sub-clavian
iii. Femoral
2. Permanent catheter
B. Permanent
1. Arteriovenous fistula
2. Arteriovenous graft
A. Temporary vascular access: Temporary vascular access refers to those access which are
used for short time period. They are more easy to create and can be inserted in short time too.
These are mainly created in emergency condition for immediate use. As compared to permanent
access these access have higher infection rate. Depending upon the sites of catheter to be
inserted, it can be classified into three different types which are given below:
1. Central venous catheter
i. Jugular
 Most preferred catheter among three.
 It can be kept for 3 weeks.
ii. Sub-clavian
 It is usually not preferred because of high risk of thrombosis.
iii. Femoral
 It can be placed for <5days as it has increased risk of infection.
2. Perma Catheter

 It can be placed for 6 months to a year.

 It is expensive and require cardiac surgery too.
A tunnelled CVC (also called external catheter or central line) is a long, flexible tube.
One end of the catheter is placed in or near the right atrium of the heart and the other end is
outside the skin of the chest.

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Advantages:

 Less infection.
 -Duration longer than 6 months.
 -kinking, flow problem and chances of accidental removal is less.

Disadvantages:

 Expensive
 Cardio thoracic surgeon is required for placement and removal.
 Foreign body reaction.
 Vein thrombosis and stenosis.
 Insertion related complications is very high.

Disadvantages of temporary vascular access

 They are associated with higher mortality risk than fistula.
 Higher risk of thrombosis, infection, and discomfort.
 They have shorter expected using time.
B. Permanent vascular access
1. Arteriovenous fistula: Arteriovenous fistula is a connection between artery and vein made by
a vascular surgeon
 Advantages of arteriovenous fistula
 It provides good flow for dialysis i.e 600-1000ml/min.
 It lasts longer than other access.
 It has lower risk of infection and thrombosis.

 Pre-requisite for fistula preparation

 History taking and physical examination
-Careful consideration of patient’s dominant extremity.
- Tourniquet for visibility of cephalic and basilic vein.
- Thorough pulse examination including allen’s test.
 Laboratory investigations: complete blood count, serology, coagulation profile
 Hold medications like anticoagulation, NSAIDS etc.
 Doppler ultrasound: To assess how quickly blood flow through arteries and veins.
Vessels with diameter 2-2.5cm are only acceptable.

 Types of anastomosis
1. Side to side
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  Blood flow in both direction so thrill is felt below anastomosis too.
 More advantageous as it has less complications.

2. End to end
 More dangerous mainly in diabetic and elderly patients.
3. End to side
4. Side to end
 Most commonest among all.

 Sites of anastomosis
1. Radiocephalic (commonest)
2. Brachiocephalic
3. Brachiobasilic
 Signs of fistula maturation (Rule of 6’s)
1. 6mm in diameter
2. Less than 6mm deep from the skin
3. At least 6cm of vein for canulation
4. Blood flow of >600ml/min
5. Maturation at 4-6 weeks
 Examination of fistula

A. Look
 Vascular access scar site.
 Hematoma or signs of infection (redness, warmth, pain, pus etc.)
 Ischemic signs: Steal syndrome; blue or cold hand up to gangrene, pain at rest
 Aneurysm: Arm elevation test; normally collapse if not outflow stenosis in
venous side
B. Feel
1. Arteriovenous fistula pulse character
 Normal: soft compressible
 Abnormal: i. Hyperpulsatile in outflow stenosis ii. Hypopulsatile in inflow
stenosis
2. Arteriovenous fistula thrill: Normally continuous thrill is present
 Outflow stenosis: discontinuous and strong thrill
 Inflow stenosis :discontinuous and weak thrill
3. Augmentation test: Normally pulse augmentation and absence of thrill
 Inflow stenosis: absence of pulse augmentation and thrill

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  Accessory vein: absence of pulse augmentation and still thrill

C. Listen
 Bruit: normal continuous thrill
 Outflow stenosis: loud, discontinuous thrill
 Inflow stenosis: soft, discontinuous thrill
 Steps for preparing access for canulation
1. Identify the type of access and direction of blood flow
o Inspection
 Alteration in access: compare to the other arm and leg (skin colour,
circulation, integrity)
 Signs and symptoms of steal syndrome
 Size and areas of canulation vein, signs of infection, presence of aneurysm
o Palpation: temperature, pulse and thrill
o Auscultation: presence of bruit throughout the access

2. Needle site selection

o The arteriolized vein, the segment must be as straight as possible.
o Segment should have at minimal the sized of needle
o Arterial canulation should be > 3.5 cm from the site of anastomosis
o Distance between the needles should be ≥2.5cm or 6cm between the tip of needles
o Arterial canulation may be in any direction but when possible antegrade direction
is recommended.
o Venous canulation always towards the blood flow of access.
o Avoid aneurysms and doubtful trajectories.
3. Skin preparation
o Ensure hand hygiene and PPE.
o Ensure appropriate supplies on hand.
o Clean with antibacterial agent (betadine, 70% alcohol, 2% chlorohexidine)
o Do not go over already cleaned area with the same cleaning wipe.
o Allow adequate contact time of at least 15sec and leave for air dry.
4. Local anaesthesia
o It should be given half an hour before pricking.
5. Needle selection
o Choose right needle size as per required blood flow rate.

Needle gauze Blood flow rate (ml/min)

17 300
16 300-350
15 350-450
14 >450

6. Canulation technique: There are mainly three types of canulation techniques which are
given below:

15
 1. Rope ladder technique: Needling sites move progressively up the vessel in a
systematic manner with each needle site approximately 0.5- 1cm above the previous
site. It should utilize as much length of the vessel as possible. Once the highest needle
site is reached, needling should start at the bottom of the vessel.
 Advantages
- Expand lifespan of fistula as it has decrease risk of infection and stenosis.
- Provides previous needle site time to heal and decrease chance of
formation of aneurysms.
 Disadvantage
- More painful.

2. Button hole technique: It involves needling each site in the same manner during each
needle insertion. Made track/tunnel by frequent pricking on same site so, pain is also
less experienced as compared to others. Button hole tenchnique can be performed using
sharp and blunt needles. Button hole with blunt needles has low complications.
 Advantages
- Prolong fistula lifespan
- Reduce needling attempts, pain, bleeding, hematoma, infiltration and aneurysms.
- Effective for those who self canulate .
 Disadvantages
- High infection rate ;“one side itis”
- Difficult with fistula covered by heavily scarred skin and large amount of subcutaneous
fat.
- Nor applicable for graft.

3. Area technique: It refers to puncturing same general area session after session.
 Advantage
- Easy canulation
 Disadvantage
- More complications especially aneurysms.

Procedure
 Stabilize patient’s hand using L-technique and three points technique.

16
  Hold and slightly secure the skin.
 Choose appropriate angle of canulation i.e 20-35° in fistula and 45°in graft.
 Canulate preferably with bevel up.
 Verify if there is blood flow to the needle as soon as vessel is penetrated.
 Always aspirate the blood first and progress the needle in the same angle of canulation.
 Verify if blood flow is adequate.

7. Securing the needle : Safe taping should be done.

o Place first tape stripe over needle insertion site and wings.
o And then 2nd tape from stripe by making V shape in both direction.
o Third tape stripe around needle tubing.

8. Canulation problem solving

9. Removal of needles
o Wear PPE.
o Do not apply pressure as needle is withdrawn.
o Press immediately upon needle removal.
o Remove needle using the same angle performed in canulation.
o Compression should be done over skin using two fingers at 90°angle.
o Involve patient too.

10. Discharge dressing and assessment

o Apply dressing that is adequate to cover site and protect.
o Avoid excessive pressure that may resist blood flow.
 Care of fistula
o Check for the signs of infection like redness, tenderness and pus drainage.
o Keep access clean all the time.
o Use access site only for dialysis
o Protect from bumping or cutting of access.
o Check for thrill in access everyday.
o Avoid measuring blood pressure and collecting blood sample from the access arm.
o Avoid tight clothing and jewellery over the access site.
o Avoid sleeping with access arm under the head or body.
o Avoid lifting heavy objects or putting pressure on access arm.

[Link] graft (AVG):

Arteriovenous graft is a surgically created anastomosis between an artery and vein via prosthetic
conduit. The conduit can be straight or looped and placed superficially under skin for easy
cannulation.
The graft becomes an artificial vein that can be used repeatedly for needle placement and blood
access during haemodialysis.
 Sites: Can be placed in arm or leg and mostly placed in forearm.

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 Indications
-Small, weak or hypoplastic peripheral vein
-Obesity
-Severe arterial occlusive disease
 Advantages
-Implanted during minor outpatient surgery.
-Can be used within 3-4 weeks.
-Initial high blood flow rates.
-Less primary failure than fistula.
 Disadvantages
-Usually only lasts 3-5 years.
-High risk of bleeding, infection and thrombosis than fistula.
Complications
o Infection o Infiltration
o Thrombosis o Hematoma
o Bleeding o Stenosis
Complication during hemodialysis and its management

Common Complication:

 Hypotension ( intradialytic) 25-55%  Dialysis Disequilibrium syndrome

 Muscle Cramp 5-20%  Headache 5%
 Nausea and Vomiting 5-15%  Air Embolism
 Chest pain and back pain 2-5%  Seizure
 Hypertension 5-15%  Itching

 Fever and chills 1%

1. Intradialytic Hypotension:
 Define as Low blood pressure
 Decrease Systolic BP by >20-30 mm of hg from predialytic blood pressure

Causes of IDH( Intradialytic Hypotension)

 Removing too much weight(Fluid)

 Inaccurate target weight
 Inaccurate pre weight
 Taking antihypertensive drugs before dialysis
 Heart disease( MI or arrhythmias)
Less Common Causes:
 Anaemia ( Mostly Haemorrhagic)
 Dehydration
 Eating/Drinking during dialysis

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  Dialyser Reaction
Sign and symtoms:
 Blood pressure Low  Restless and anxious
 Weakness  Muscle cramp
 Dissiness  Pale diaphoretic and or cold
 Nausea and vomiting clammy skin
 Yawing/sighing

If Hypotension is not addressed further symptoms my include:

 Chest pain
 Loss of consciousness

Nursing management and prevention of IDH:

 Place patient in supine position or Trendelenburg position

 Place in minimum ultrafiltrtion at 0
 Administer oxygen @ 2 lit/min via nasal prong as needed
 A bous of 0.9% saline 100ml or more as necessary should be rapidly administer through
venous blood line
 25 to 50% Dextrose
 If not subside contact the doctors

Prevention of Hypotension during dialysis:

 Avoid excessive ultrafiltraton below the Patients dry weight

 Avoid large intradialytic weight gain(ideally < 1 kg/day)
 Using a dialysis solution with a sodium level that is equal to or greater than the
plasma volume.
 Avoid intradialytic food ingestion in hypotensive patients.
 Correct anaemia for cardiac stability
 Give a daiy dose of antihypertensive after dialysis
 dialysis in hypotension prone patient.
2. Muscle Cramp:

Causes:

 Removal of large volume of fluid.

 The patient being below the dry weight.
 use of loe sodium dialysis solution.
 Electrolyte imbalance(Hyponatramia, hypocalcaemia,hypokalemia)

Sign and symptoms:

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  Involuntary contraction of muscle with relaxation lasting from second to minute.
 Pain discomfort, hard legs ,feet
 Restlessness , anxiety
 Muscular firmness , tenderness, bulging.

Management:

 Reduce UFR to minimum and decrease total UF target.

 Massage and stretch the cramp muscles s appropriate.
 Apply hot application to the thigh muscle eg . warm towel.
 Suggest low intensity exercise (eg Stationary bike) during [Link] impact workout
that assess smooth movement to strengthen bones and joints without putting much
pressure on them.
 Calcium gluconate injection for hypocalcemia.
 Carnitine drugs used for supplement(Quartinary ammonium compound).
3. Nausea and vomiting: is caused by
 excessive fluid removal(hypotension),
 Dialyser reaction,
 Exposure to watery contaminants ,
 contaminated or incorrectly formulated dialysis solution( high sodium, calcium),
 Eating during dialysis(hypotension),
 Uremia.

Nursing management of Nausea and vomiting:

 Ruled out possible dialysis related and patient related causes and treat as suggestive
causes.
 Administer anti emitics.
 Elevate head of bed.
 Assess patients haemodialysis adequacy (clearance).
 If history of nausea /vomiting > 3 days contact MD/Nephrologist.
4. Headache:

Causes:

 Disequibrilium syndrome
 Hypotension
 Hyperthermia
 Change in electrolytes during dialysis,
 Mental health of the patient among may other.
 Coffine withdrawl
 Hard water syndrome, High calcium and magnesium dialysate
 contaminated dialysate.

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Prevention and management:

 Oral analgesics(Acstaminophen)
 Coffee ingestion during dialysis.
 Ultrafiltration profile.
 Use of reprocessed dialyser.
 Slow dialysis with reduced blood flow rates.

5. Dialysis disequilibrium Syndrome:

Characterized by a range of neurologic symptoms that affect patient on haemodialysis

particularly when they are first started. However it is also seen among patient who have missed
multiple consecutive dialysis treatment .

Symptoms are range from mild to moderate symptoms such as headache, Nausea or blurred
vision , Restlessness or confusion and severity became coma and seizure in rare cases.

Causes: Rapid removal of urea during haemodialysis.

Management of DDS:

 Mild DDS:
 Symptomatic treatment
 In acutely uremic patient during dialysis the flow rate of blood should be reduced
to decrease the efficiency of solute removal and pH change and consideration
should be given to terminating the dialysis session earlier than planned.
 Severe DDS:
 If seizure or Coma occur during dialysis session should be stopped.
 Maintain airway and patient ventilated if necessary.
 If Seizure occurs blood should be sampled immediately and serum glucose,
Calcium and other electrolyte values determined.
 IV Glucose should be administer if hypoglycemia suspected .
 If seizure persist then 5-10 mg of diazepam can be infused slowly IV than can be
repeated at 5 min interval to a max dosage of 30 mg .
 The management of coma is supportive.
 If the coma is due disequilibrium than the patient should improve with In 24 hour.
6. Air Embolism:

Obstruction of peripheral pulmonary vessels by gas bubbles. Air lock from gas in large
pulmonary vessels or the heart .

Management :
 Clamp venous blood line.

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  Stop blood pump
 Place patient in the recumbent position on the left side with the chest and head tilted
dowm ward .
 Further treatment includes administration 100% oxygen with mask or ET Tube
Prevention :
 Aspirate blood and flush with saline before connection.
 Perform good priming of extra corporeal circuit including dialyzer .
 Avoid the use of arterial line during dialysis or other infusion.
7. Hypertension:
Diastolic BP more than 90mm of hg
Causes:
 Fluid overload
 Anxitey
 Renin over production
 Newly diagnosis

Management of hypertension:

 Low salt intake ( 2gm/ day sodium intake)

 increased ultrafiltration(lowering of dry weight).
 More than three dialysis treatment per week( lowering of dry weight).
 Give antihypertensive as ordered.
 Medicine such as nefidipine ,Clonidine or short acting ACE inhibitor such as captropril
can be used.
 Special attention to dry weight and fluid removal.
 Limiting the use of high calcium dialysate.
 Achieving adequate sodium solute removal during dialysis.

8. Seizure:

Sudden uncontrolled electrical disturbance in the brain can cause changes in behaviour,
movement ,Level of consciousness causes DDS, Hpoglycemia, hypokalcemia.
Management:
 Stop dialysis- Ask for help
 Maintain patency of airway
 Send Sample immediately for serum calcium and glucose.
 IV Glucose should be administer if hypoglycemia suspected .
 Diazepam 5 -10 mg can be infused slowly IV.
9. Fever & Chills:

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A Febrile phenomena caused by infusion of contaminated solution commonly characterized by
cold ,chills and fever ( oral temperature >10 degree centigrade form baseline).
Causes:
 Patient Related
 Access site or non access related
 Break in aseptic practice
Differential diagnosis:
Blood Transfusion reaction
Management:
 Assess for sign and source of infection such as vascular access , Pressure ulcer , UTI .
 Take Vital signs including pre dialysis temperature.
 Administer antipyretics ( Tab .Paracetamol orally stat).
 Send blood culture from patient .
 Discontinue haemodilysis without returning blood if pyogens and endotoxins suspected .
 Obtain water system inlet outlet samples of dialysate to culture.
 Best practice such as good hand hygiene and aseptic technique for the vascular access .
10. Itching:
Causes:
 Dry skin
 Secondary hyperparathyroidism
 Uremia
Management:
 Apply coconut oil on dry skin
 inj Avil given to itching following BT.

11. Chest pain:

Cardiac Causes:
 Underlying coronary artery disease with demand ischemia from low BP, high
ultrafiltration rate , anaemia .
 Myocardial infraction.
 Angina
 Arrythemia
Other : Gastric Reflex
Sign and symptoms:
Pain and tightness in the chest , back , arm and jaw which may accomplained by nausea, dyspnea
and diaphoresis.
Management:
 Place machine in he minimum ultrfiltration rate.
 Decrease pump speed .
 Assess vital signs.
 Assess nature of chest pain including location .
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 Drugs used in chronic kidney disease
 Anti- hypertensive
 Anti- Diabetic
 Phosphate Binders
 Anti Coagulants
 E. S A (Erythropoitine stimulating Agents)
 Vitamin Supplements (vit B. (4 D)
 Cinacalet it PTH Level increase
 statin for maintain s. Cholesterol level
 Steroids.
DURING DIALYSIS
 Iron therapy  Inj avil
 Blood Transfusion  PPI’s
 Inj 50% Dextrose  Paracetamol
 Inj ondem Perinorm  Inj calcium glucanate
 Inj hydrocortisone

1. Antihypertensive (Target bp 140/90 mm of Hg)

 ACE inhibitors: Angiotensin-converting-enzyme inhibitors are a class of medication
used primarily for the treatment of high blood pressure and heart failure. They work by
causing relaxation of blood vessels as well as a decrease in blood volume, which leads to
lower blood pressure and decreased oxygen demand from the heart. Eg: enalapril,
benazepril (most common)
 Beta blockers: Beta-blockers are drugs that can lower stress on the heart and blood
vessels by blocking the action of adrenaline. They can also help manage migraine,
anxiety, tremor, and other conditions. Other names for beta-blockers include beta-
antagonists, beta-adrenergic blocking agents, and beta-adrenergic antagonists. Eg:
atenolol, bisoprolol
 Calcium channel blockers: Calcium channel antagonists or calcium antagonists are a
group of medications that disrupt the movement of calcium through calcium channels.
Calcium channel blockers are used as antihypertensive drugs, i.e., as medications to
decrease blood pressure in patients with hypertension. Use: hypertension, arrhythmia,
cluster headache Eg: nifidipile, amlodipine (most common)
 Diuretics: Low salt diets and diuretics constitute the center piece for blood pressure
control in CKD. In patients with CKD stage 4, loop diuretics are generally preferred to
thiazides. Furthermore, thiazide diuretics have long been held as being of limited efficacy
in this population.
Indication- hypertension, oedema, heart failure, renal failure.

Nursing consideration

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  Strictly apical heart rate monitoring(beta blocker)
 Daily weight monitoring(diuretic receiving patient)
 Watch for drugs hypersensitivity
 Bp monitoring regularly if systolic blood pressure less then 90 mm of Hg hold medicine
and consult with doctor.
 Assess peripheral oedema

2. Anti diabetics: Diabetic mellitus is the leading cause of chronic kidney disease
approximately 20-30% of t2 diabetic mellitus cases have renal impairment. Glipizide is the
SU of choice in patients with CKD. Glibenclamide and glyburide are each metabolized by
the liver and are eliminated equally in the bile and urine. Hypoglycemic episodes may be
severe in patients with renal failure, and the drugs are contraindicated from stage 3 of CKD
(eGFR <60 mL/min).

Nursing consideration:

 Watch for hyper sensitivity

 Take 15-30 min prior to meal.
 Monitor blood glucose level.
 Kept diabetic identification card and candy on bag.
 Check feature of hypoglycemia.
 Provide teaching about diabetic diet, follow up visit and eye and cardiologic
consultation.
3. Phosphate binders: These agents work by binding to phosphate in the GI tract, thereby
making it unavailable to the body for absorption. Hence, these drugs are usually taken with
meals to bind any phosphate that may be present in the ingested food. Phosphate binders may
be simple molecular entities (such as magnesium, aluminium, calcium, or lanthanum salts)
that react with phosphate and form an insoluble compound. Phosphate binders such as
sevelamer may also be polymeric structures which bind to phosphate and are then excreted
Normal phosphorus level in blood: 2.5-4.5 mg/dl

Nursing consideration:

 Check hyper sensitivity.

 Contraindication in bowl obstruction.
4. Anti-coagulant: Oral anticoagulants are commonly used drugs in patients with CKD and
patients with ESKD to treat atrial fibrillation to reduce stroke and systemic embolism. Some
of these drugs are used to treat or prevent deep venous thrombosis and pulmonary embolism
in patients with CKD who undergo knee and hip replacement surgeries.
Uses:
 To prevent thromboembolism
 To prevent deep vein thrombosis, pulmonary embolism and arterial fibrilation

Routine heparin, constant-infusion method

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 Initial bolus dose Infusion dose

2000 iu 1,200 IU/hr

Intermittent HD
50 IU/kg 800-1500 IU/hr

500-1000 IU/hr
CRRT 2000-5000 IU (5-10 IU/kg/hr)
(30 IU/kg) Target : aPPT
45 to 60 sec or 1.5 to 2.0 times normal

Patients on oral anticoagulants:

 Patients on Warfarin with
 IN of <2.5 - require anticoagulation
 INR of >3.0 - do not require heparin
 Patients on aspirin and other antiplatelet agents also require standard heparin dosages
 Heparin doses should be reduced or withheld in patients with thrombocytopenia ( <50,000 ×
10 6 /L)
Termination of heparin infusion:
 The heparin half-life in dialysis patients -> 30 minutes - 2 hours
 Stopping heparin infusion approx. 1 hour prior to the end of dialysis
 ACT value of baseline plus 40% at termination of the session
 With venous catheters, heparin infusions are commonly continued right up to the end of
dialysis.

NOTE: INDICATIONS FOR HEPARIN-FREE DIALYSIS

 Pericarditis
 Recent surgery, with bleeding complications or risk, especially:
 Vascular and cardiac surgery
o Eye surgery (retinal and cataract)
o Renal transplant
o Brain surgery
o Parathyroid surgery
 Coagulopathy
 Thrombocytopenia
 Intracerebral hemorrhage
 Active bleeding
 Routine use for dialysis of acutely ill patients by many centers

5. Erythropoitin stimulating agent

Types :
Short acting – epoetin alpha and beta
Long acting – darbepopetin
Continues epo receptor activator(CERA)

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6. Vitamin supplement
a. Vitamin B12 and Folate and vitamin B12 deficiency are uncommon but important causes
of treatable anemia, typically associated with macrocytic red blood cell (RBC) indices.
Nonetheless, since these deficiencies are easily correctable, and in the case of vitamin B12
may indicate other underlying disease processes, assessment of folate and vitamin B12
levels are generally considered standard components of anemia evaluation, especially in the
presence of macrocytosis. Folate deficiency is best detected in most patients with serum
folate level testing; RBC folate levels can be measured when serum folate levels are
equivocal or when there is concern that recent dietary intake may obscure underlying folate
deficiency using serum levels alone.
b. Vitamin D: The principal biological function of vitamin D is the maintenance of normal
levels of serum calcium and phosphorus in the bloodstream by enhancing the efficacy of
the small intestine to absorb these minerals from the diet. normal range of vit D level 20-40
ng/dl. Target vitamin d level 25-30 ng/dl . Monitor vitamin D level every 12 weeks.
c. Cinacalcet: Cinacalcet is used to treat hyperparathyroidism in patients with chronic kidney
disease who are on dialysis. Hyperparathyroidism is a condition that is caused when the
parathyroid glands located in the neck make too much parathyroid hormone (PTH).

Precaution: allergic reaction, monitor calcium, phosphorus and parathyroid hormone level before
administered.

d. Statin : Statins work by competitively blocking the active site of the first and key rate-
limiting enzyme in the mevalonate pathway, HMG-CoA reductase. Inhibition of this site
prevents substrate access, thereby blocking the conversion of HMG-CoA to mevalonic
acid. Eg : atorvastation, lovastation, fluvastation(must common)

Uses for hyperlipidemia and hypercholesterolemia

Precaution: hyper sensitivity.

e. Steroids: The mineralocorticoid, aldosterone, and the glucocorticoids, cortisol and

corticosterone, are produced uniquely in the adrenal cortex. These steroids act by binding
to intracellular receptors which then act to modulate gene transcription in target tissues. In
chronic kidney diseases most common use steroid is prednisolone. It is
immunosuppressive drugs. It helps to minimize the chance of kidney transplantation
rejection.
f. Inj 50 % dextrose: When administered intravenously this solution restores blood glucose
levels in hypoglycemia and provides a source of carbohydrate calories. Carbohydrate in the
form of dextrose may aid in minimizing liver glycogen depletion and exerts a protein-
sparing action.

Uses : dialysis related muscles cramp, prevent and treatment of hyperglycemia.

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 g. Antie metics: to block serotonin from interacting with the 5-HT3 receptor. Of these,
ondansetron and granisetron are the most frequently encountered. Intravenous (IV) and oral
(PO) preparations are available. Side effects include headache, dizziness, and constipation.
Eg: ondem,perinorm
h. Hydrocortisone: Hydrocortisone binds to the glucocorticoid receptor leading to
downstream effects such as inhibition of phospholipase A2, NF-kappa B, other
inflammatory transcription factors, and the promotion of anti-inflammatory genes.
Hydrocortisone has a wide therapeutic index 8 and a moderate duration of action.
Indication: inflammation, severe allergic reaction, kidney diseases, adrenal problem, eye or
vision problem etc.
i. Inj avil: it helps to block the histamine action.

Indication: insect bite sting, rashes, swelling, allergic reaction.

j. Proton pump inhibitors: Proton pump inhibitors (PPIs) block the gastric H,K-ATPase,
inhibiting gastric acid secretion. This effect enables healing of peptic ulcers,
gastroesophageal reflux disease (GERD), Barrett's esophagus, and Zollinger-Ellison
syndrome, as well as the eradication of Helicobacter pylori as part of combination
regimens. Eg: omeprazole, pantoprazole.

Nursing consideration : give drugs 30 min prior to meal.

k. Paracetamol: Analgesic, antipyretic & anti inflammatory action

Indication: fever, pain, chills, rigors,

Precaution: 10gm pcm (toxicity)

7. INVESTIGATION IN CKD

Urine Analysis (urine R/E, M/E, urine Culture, 24 hours urine collection)

Blood Analysis (urea, creatinine, calcium, phosphorus, CBC, RFT, LFT, iron profile,serology,
vitamin D)
Radiological Examinations
 X-ray KUB
 CT/ MRI
 cystoscopy
 Renal Biopsy
Key points
The recommended interval for investigation include :
• CBC and serum albumin every month
• Serum calcium and phosphate ,every 1-3 months;
• iPTH every 3-6 months

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 • Alkaline phosphate activity,every 12 months,or more frequently in the presence of
eleveted PTH
• Calcidiol Levels might be measured, And repeated testing Determined by baseline
Values and therapeutic investigation;vitamin D deficiency
• HIV,HBsAG and anti HCV serology every 3 months it is preferable to test for HCV
with nucluic acid test (PCR)
• Cardiovascular assessment need to be done Clinically and with echocardiogram as
clinically indicated and at least annually
• Serum vitamin B12 and folate levels
• The other investigations for hemodialysis patients need to be decide as case by case
basis.

ALARM MANAGEMENT
Parts of hemodialysis machine
 Monitor  Blood pump
 Module  Heparin pump
 Hydraulic  Air detector
1. Monitor 3. Hydraulic
 Arterial pressure  part A : sodium, potassium ,
 Venous pressure magnesium
 Blood leak  Part B : sodium chloride , sodium
 Trans membrane pressure bicarbonate
2. Module
Color coding of hemodialysis machine
1. Green : normal working
2. Yellow : preparation , disinfection , warning
3. Red : problem for machine and blood
Types of alarm
1. Blood alarm
 Arterial pressure alarm
 Venous pressure alarm
 Trans membrane pressure alarm
 Blood leak alarm
 Air leak detector alarm
 Ultra filtration alarm
2. Dialysate alarm
 Conductivity alarm
 Temperature alarm
3. Other alarm
 Flow pump alarm
 Heparin alarm
 Water deficiency alarm
 Power failure alarm

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1. Blood alarm

A. Arterial pressure management

 normal range - 30 to - 150 mmHg
 Maximum tolerate pressure range – 250 mmHg
 Arterial pressure is measured in one of two place one is between patient blood access and
blood pump and other is between blood pump and dialyzer
a. High arterial pressure alarm
 Leak between the patient and monitoring site
 Clotted dialyzer
 Arise in the blood flow rate
 Kink in the blood tubing from the dialyzer
 drop in the blood pump
 Poor placement of the venous needle or catheter
b. Low arterial pressure
 Kinked vascular access or clamped line
 Wrong position of access
 Clotted line
 Blockage of arterial blood flow from patient access
 Poorly working central and femoral catheter
 Hypotension
 Hypovolemia
Management of low and high arterial pressure alarm
 Correct the position
 Check the needle position and access clots
 Remove kink and clamp
 De-clot line , aspirate both lumen
 Stop UF , decrease blood flow rate
 Press RESET alarm if it is unable send machine to technician

2. Venous pressure alarm

 positive pressure normal range 100 to 150 mmHg
 maximum range 150 to 300 mmHg

a. High venous pressure alarm

 kinked or clotting in the access
 poor working central femoral catheter
 obstruction from patient side
 malposition of vascular access
 blood tubing is blocked between monitor and venous needle
b. Low venous pressure alarm
 low blood pump speed
 venous and arterial line disconnection

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  suction in vascular access
 badly clotted dialyzer
 drop in the blood flow rate
 blood tubing separation from venous needle or catheter
Management
 Increase blood flow rate
 check the venous and arterial line
 correct the position of access
 check venous tubing for loose connection clamp , kink and clotting
 Press RESET alarm if it is unable send machine to technician

3. Trans membrane alarm

 Trans membrane pressure is different pressure between blood and dialysate compartment
 The maximum range tolerated 450 mmHg
Causes
 clamp the line kinked dialysate line
 high ultra filtration rate
 clotted line measured error
 rupture membrane or leakage filter
 clogged dialysate filter poor vascular
Management
 check the dialysate line for kink
 check the shun connection with dialyzer
 check transducer protector whether it is dry or wet
 if TMP is lower then increase UF rate or increase blood flow
 check access point for clotting and needle position
4. Blood leak alarm
 sensitivity of monitor is 0.25 to 0.35 ml of blood per liter of dialysate
 the blood leaks monitor allows detection of blood leaks and prevention of dialysate
contamination by blood downstream of the dialyzer

Causes
 leak in the dialyzer membrane cause RBC leak into the dialysate
 interrupting the light transmission
 blood detector is dirty
 clamp the line
Management
 clamp the venous line
 stop the blood pump
 stop treatment without returning blood into the patient
5. Air leak detector alarm

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  the usual volume of air needed to active alarm is 60 ml to 124 ml

Causes
 Empty saline bottle
 Inadequate priming
 Line disconnection at arterial access
 The blood level in the bubble trap is too low
 The air detector is detached from the return line
Management
 Stop blood pump
 Remove venous chamber to remove air bubble then place as it is
 Make sure the air detector is properly attached
 Correct the blood level look for actual bubbles aspirate the bubbles
 Air bubbles are not remove then draw it help the syringe
 Now circulate blood pump

6. Ultra filtration pump alarm

 UF removes water from the close loop through the dialyzer membrane
 It creates negative pressure in the dialysate side of the dialyzer versus the blood side
Causes
 UF is not connected or is not pulsing properly
Management
 UF is on
 Take machine out of service and send to technician

7. Dialysate alarm
 Dialysate machine range 13 to 15 ms/cm
a. Conductivity alarm
 The conductivity normal range is 13.5 to 14. 5 ms/cm
Causes
 Dialysate container is empty
 Abnormal water inlet pressure
 Change in electrolyte concentration of dialysate
 Water leaks or puddles beneath the mixing chamber
 Concentration line connector unplugged
Management
 Replace the dialysate container
 Check the dialysate flow
 Concentrate has been mixed properly i.e sodium bicarbonate mixed well with RO water
 check the connector are sucking concentrate if not :
 turn of dialysate flow and disconnect concentrate suction connector from their wands
 reconnect connecter to the wand turn on dialysate flow and recheck connector for suction

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  if suction is present allow 5 min for conductivity to reach normal level
 if conductivity alarm is still ongoing discontinue treatment and remove patient from
machine
 send machine to the technician

b. Temperature alarm
 the dialyzer usual recommended temperature range is 35 degree to 38 degree C
Causes
 low water supply
Management
 Check machine is in dialysis status and dialysate flow is on
 Make sure heater is in switch on position on the back panel
 Check that dialysate flow at drain line is 500 ml per min
 If temperature alarm is still ongoing then discontinue treatment and send machine to
technician

3. Other alarm
a. Flow pump alarm
 A dialysate flow rate range from 0 to 1000 ml per min adjust dialysate flow up to 500
ml/min
Causes
 Low water pressure supply
 Dialysate pump failure
 A blockage in dialysate flow

b. Heparin alarm
Causes
 Heparin line not connected correctly or kinked
 Arterial line not inserted into occlusion clamp
 heparin syringe not correctly held in place
Management
 Check the heparin needle position
 Check the arterial tubing in kink clamp and Clotting
 Check needle position and access clots
 Ensure that transducer protector is dry

c. Water deficiency alarm

 Patient are expose to large volume of water during is hemodialysis the purify of the
water is essential to avoid exposure to aluminum , endotoxin and bacteria

Causes

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  The machine is not receiving enough water
 A water inlet valve alarm has occurred
Management
 Inspect the treated water sources supplying the machine
 Correct as required
 If water deficiency alarm still send machine to the technician

d. Power failure alarm

 The battery sets off an alarm on the machine
 All system and monitors are now off
Causes
 Machine is unplugged
 Machine failure
 Dead battery
 No longer battery backup
Management
 Do not pump blood from the patient into the system
 Recirculate blood manually for a maximum 15 to 30 min
 Disconnect the venous clam to return blood with heparin manually
 Return the blood into the patient body as soon as possible
 If power failure alarm still send machine to the technician
RENAL DIET

Kidneys are vital organ in our body. These bean shaped organs are responsible for filtering waste and
extra fluids from our body, and maintain a healthy balance of salts, minerals and water. Having kidney
disease affects general health conditions of the body. Thus, it is important to take extra care of body, if
one is experiencing kidney diseases. The top factor in maintaining overall health is determined by dietary
intake.

Kidneys perform functions like filtration of blood, removal of waste through urine and maintenance in
level of fluids in the body.

Essential functions of kidneys can be summarized as below:

B – B.P. regulation

E – Erythropoitin hormone production

A – Acid Base balance

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N – Excretion of Nitrogenous wastes

Kidneys cannot filter blood in a usual way when it is infected. This allows accumulation of sodium,
potassium, phosphorus, and protein byproducts in the blood. Thus, the kidney health gets worsen and
cause body to hold on to too much fluid.

A renal diet aims at keeping levels of fluids, electrolytes, and minerals balanced in the body in individuals
with chronic kidney disease or who are on dialysis. Dietary changes may include the restriction of fluid
intake, protein, and electrolytes including sodium, phosphorus, and potassium. A renal diet supports
healthy functioning of the kidneys for those with kidney disease. A renal diet is low in protein, sodium,
potassium, and phosphorus.

Diet must be,

 More energy giving.

 Reducing risks of infections and disease progression.
 Maintaining healthier body weight.
The specific intake amounts of protein, sodium, potassium, and phosphorus depend on the extent of
kidney disease.

DOs on a Renal Diet

Fresh, whole foods rather than packaged, frozen, or canned foods are best recommended renal diet.
Whole foods are naturally lower in sodium and more nutritious, so they’re healthier for kidneys and to the
rest of the body as well. With some planning, it’s easier to prepare meals with a variety of lean protein
foods and low potassium fruits, vegetables, and whole grains.

Choices of Protein

Though protein is essential is for healthy kidneys, excess consumption of protein should be limited if
kidneys are unable to remove excess waste. It is acceptable to take small serving of protein at each meal
after consultation with dietitian.
Some good protein options include:
 Skinless chicken or turkey.
 Fish or seafood.
 Eggs.
 Tofu and beans, like kidney beans or lentils. These are higher in potassium and phosphorus, so it
is needed to limit the portion size.

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Fruit and vegetable choices
Most fruits and vegetables are high in potassium contents so it is best to work with renal dietitian for
estimation of appropriate intake amount. Besides, some lower potassium fruits and vegetable options
include:

 Apples  Pineapple  Cucumbers

 Blackberries  Strawberries  Eggplant
 Blueberries  Tangerines  Kale
 Cherries  Green beans  Lettuce
 Grapes  Cabbage  Sweet peppers
Grain and starch choices
Though high in potassium input, Whole grains contribute fiber, vitamins and minerals so it is urged to
limit the portion sizes and how often to eat.
Some healthy, lower potassium options include:
 Barley
 Buckwheat
 Bulgur wheat
 Wild rice
 Unsalted popcorn
White bread, pasta, or rice is lower in potassium than their whole-grain counterparts.
Foods to Avoid on a Renal Diet
Most snack foods and packaged or convenient canned foods are very high in sodium and the same is with
processed or seasoned meats and pickled vegetables.

Avoid or limit these high sodium-containing foods:

 Chips, crackers, and salted popcorn.

 Canned soups or stews.
 Pickles, olives, and pickled vegetables or relishes.
 Deli meats and cheeses (unless they say “low sodium”), hot dogs, sausages, and bacon.
 Packaged meals like frozen dinners and cheese.
 Packaged, seasoned rice or noodles.
 Frozen, seasoned meats or fish like chicken strips or fish sticks.
Also, limit these high potassium-contributing foods:
 Apricots.  Bananas.

36
  Dried fruits.  Tomatoes (and tomato sauce or juice).
 Honeydew.  Winter squash.
 Kiwi.  Nuts and nut butters.
 Nectarines.  Seeds like sunflower or pumpkin seeds.
 Oranges.  Chocolate.
 Broccoli.  Molasses.
 Carrots.  Granola and bran cereals.
 Potatoes (white and sweet).  Salt substitutes that contain potassium.
 Spinach.
Eventually, avoid or limit portions of this high phosphorus containing food on a renal diet:
 Dairy foods like milk, yogurt, cheese, or ice cream.
 Dried beans like kidney, black, or pinto beans.
 Mushrooms.
 Cocoa.
 Beer.
 Dark soft drinks like colas or root beers.
Renal Diet Cooking Tips
Preparation and cooking of renal diet is a bit of practice. Once habituated, it becomes a second nature.
Follow and try some tips below to reduce sodium and potassium contents in food while cooking:
 Avoid salt or potassium chloride salt substitute for seasoning while cooking. Instead, use fresh or
dried herbs or salt free herb blends for flavor. Onions, garlic, mustard, flavored vinegar, and
citrus zest are also great flavor enhancers.
 When choosing canned foods like beans, vegetables, or tuna, choose low sodium or no added salt
versions. Drain and rinse them to reduce salt even more.
 To reduce potassium in foods like potatoes or winter squash, cut and soak them in a large amount
of water. When ready to cook, drain the water and replace it with fresh water before boiling.
 Choose canned fruits packed in water instead of fresh fruit. Make sure to drain off the water
before eating the fruit.
Fluids

Fluids include water, milk, juice, tea, coffee, soup and others. The amount of fluid intake will be based on
the amount of urine production by kidneys.

Recommended fluids intake for,

37
  Oliguria is determined as, Volume of urine output per day + 500ml fluids.
 Anuria is amount of 1000ml fluids in total of liquid sources.
Eating foods during dialysis should be prohibited because

 Occurrence of redistribution of blood in the circulatory blood vessels leads to alteration in cardiac
output resulting in lowering of blood pressure. So cramping, muscle twisting, nausea, vomiting
may be encountered due to shifting of blood to the stomach.
 Difficulty in maintaining personal hygiene
 Can cause chocking, aspirations
ANEMIA IN CHRONIC KIDNEY DISEASE

INTRODUCTION
Anemia refers to the condition of absolute reduction in the number of red blood cells. Anemia is
considered when one or more of the following are reduce (haemoglobin , haematocrit or red
blood cells). Normocytic normochromic & hypoproliferative type of anemia is found in CKD.
PREVALENCE OF ANEMIA IN CKD
The overall prevalence of CKD in all stages is 53.5%. In CKD, risk of developing anemia is 30%
higher in males than in females. Prevalence of anemia is lower in current smokers, which has
been attributed to secondary erythocytosis. Prevalence of anemia is increased with stages of
CKD as per review of National Health and Nutrition Examination Survey)
 Stage 1 : 8.4%
 Stage 5: 53.4%
 Prevalence is also greater in people older than 60 years ,as compared to those with 46-60
years

ETIOLOGY
 Low Erythropoeitin
 Decreased RBC Production
 Increased RBC Production
 Decreased RBC Life
 Inflammation & Infection
 Vitamin B12/Folate Deficiency
 Bone marrow fibrosis secondary to hyperparathyroidism
 ACE Inhibitors
 Hepcidin

38
  Blood Loss ( Dialyzer Loss, Uremia induced platelet dysfunction, GI Loss, Frequent
Sampling).
CLINICAL FEATURES

 Generalized weakness/ Malaise  Inability to Concentrate

 Body ache  Loss of appetite
 Orthostatic symptoms ( light  Other findings include:
headacheness, dizziness )  Skin : Pallor
 Syncope or near syncope  Eyes : Pale Conjunctivae
 Decreased exercise tolerance  CV : Orthostatic hypotension,
 Chest Discomfort tachyarrhythmia
 Palpitation  Pulmonary : Tachypnoea
 Cold Intolerance  Abdomen : Ascites,
 Sleep Disturbances Hepatospleenomegaly
DIAGNOSTIC EVALUATION
 RBC indices ( MCV, MCH, MCHC)
 Peripheral Blood Smear
 Reticulocyte Count
Other lab tests that may help eliminate other common causes of anemia include the
following :
 Iron Panels –Serum Iron, Ferritin, TIBC ,Transferrin Saturation
 Serum Vitamin B12 & Folic Acid
 Serum Bilirubin, AST , ALT
 TSH
TREATMENT CONSIDERATION
 Treatment of underlying causes
 Concomitant factors that needs to be addressed are concomitant blood loss, iron
deficiency or vitamin B12 or folate deficiency.
 ESAs and blood transfusion for severe cases are the preferred initial therapy of CKD.

ERYTHROPOEITIN STIMULATING AGENTS

TYPES

39
  Short acting : Epoetin alpha & beta
 Long acting : Darbepoetin
 Continuous EPO receptor activator ( CERA)
Available in different doses ( 2000 IU, 3000 IU, 4000 IU , 5000 IU, 10000 IU , 30000 IU
ROUTE OF ADMINISTRATION
 Subcutaneous : Half Life – 24 hours
 Peak Levels : 12-18 hours after the dose
 Intravenous : Half Life ( Normal Subjects- 4 hours )
 Renal Failure ( 7-8 hours )
INDICATIONS
 Anemia
 Chemotherapy induced anemia in Cancer
 Treatment of anemia in HIV infected patient on Zidovudine
PRIOR TO START OF THERAPY
TSAT level should be checked and maintained at least 20 % & ferritin should be at least
100ng/ml
Blood Pressure should be controlled
CONTRAINDICATION
Uncontrolled hypertension, hypersensitivity to the products, patient with severe coronary,
peripheral arterial ,carotid or CVA disease.
ADVERSE REACTIONS
Hypertension, nausea and vomiting ,headache, flu like symptoms ,skin related skin
reaction ,urticaria etc.
WARNING AND SPECIAL PRECAUTIONS
 Platelets count should be monitored during initial 8 weeks of initiation of therapy.
 Haemoglobin should be checked every 3 months during maintainence therapy and 1 months
during initiation of therapy
 ESAs are associated with thrombotic events & increased mortality
 ESAs increases RBC produced ,raising the possibility of tumor growth potential.

40
  As per US Food & Drug Administration (FDA) consider starting of ESA treatment for
patient with CKD when the Hb is less than 10gram/dl.
 Target Hb ( in relation to ESA ) 10-12 g/dl
 Greater than 12 g/dl increases risk of CVD ( Stroke, heart attack, heart failure ,death)
 As per KDIGO Guideline : Hb in patient with CKD should not be maintained above
11.5g/dl.
ADVERSE EFFECTS OF ESAs

Increased systemic BP and occurrence of seizures. Hypertension is the most side effect of IV use
of ESAs.

ESAs RESISTANCE

Required for greater than 150 U/kg of ESA at least 3 times per week or sudden response
refractoriness to previous stable maintainence dose. Most common cause of ESA resistance is
iron deficiency. Iron stores should be adequate during ESAs treatment. Second cause is chronic
infection/ inflammatory states and such resistance is attributed to inflammatory cytokines.

2. ROLE OF IRON THERAPY

Most common identifiable cause of ESA resistance is iron deficiency. Two important tests to
assess iron deficiency are :

Transferrin saturation & serum ferritin

As per KDIGO Guidelines: Iron repletion if serum ferritin less than equals to 500 ng/ml in CKD
patient with TSAT less than equals to 30%.Current guidelines recommend against use of iron
products when ferritin is 500 ng/ml or greater. Measure iron stores (1-3 ) monthly .No earlier
than 1 wk after IV iron administration. Can be given by both oral and intravenous route.

1. ORAL IRON THERAPY: Generally of least benefit, particularly in higher CKD stages.
2. INTARVENOUS IRON SUCROSE INJECTION

Available in 100 mg dose in 5 ml ampoule. Each ml contains 20 mg .

Consitutes of Ferric Hydroxide and Sucrose.

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During intravenous infusion, iron sucrose dissociates into iron & sucrose. Iron is transported as
a complex with transferrin to target cells & in incorporated into Hb as the cells mature into
RBCs. Iron is used for Hb synthesis & to replenish iron stores in anemia.

CONTRAINDICATIONS

Hypersensitivity & anemia not caused by iron deficiency.

WARNING & PRECAUTION

Serious hypersensitivity reactions can occur .Patient may present with shock, significant
hypotension & loss of consciousness. Monitor for signs of hypersensitivity during & after iron
sucrose injection for at least 30 minutes. Clients with hypotension & iron overload should be
addressed cautiously.

ADMINISTRATION
Slow intravenous route : undiluted over 2 to 5 mins
Via intravenous infusion : diluted in 0.9% of 100 ml NS given at duration of at least 15 mins.
TARGETS FERRITIN LEVELS
 Greater than 200 mcg/L (HD)
 Greater than 100 mcg/L ( PD)
 Generally aim 200-500 mcg/L & avoid greater than 800 mcg/L
BLOOD TRANSFUSION
 Used for treatment of severe anemia
 Can temporarily relieve symptoms of anemia.
LIMITATIONS OF BLOOD TRANSFUSION
 Fluid overload
 Body may develop antibodies over time that damage or destroy the donor blood cells and
may reduce or delay the possibility of kidney transplant.
 Iron from transfused blood may build up in the body & damage organs called iron
overload or hemochromatosis.
 Can cause hyperkalemia , calcium loss. So transfusion is not so much preferred in
treating anemia by health professionals in CKD.
COMPLICATIONS

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  Higher rate of hospitalization
 Reduced quality of life ,worsen renal survival and increased mortality & morbidity
 Increased risk of cardiovascular disease.

HEALTH CARE WASTE MANAGEMENT

INTRODUCTION

Health care waste includes a large component of general waste and a smaller proportion of
hazardous waste. According to the WHO estimation, among the total amount of HCW generated,
80% is general HCW, 15% is pathological waste and infectious waste, 1% is sharp waste, 3% is
chemical or pharmaceutical waste and less than 1% special waste such as radioactive or
cytotoxic waste, pressurized container or broken thermometer and used batteries. Thus, very less
amount of HCWs is hazardous if it is properly managed.

Health care waste can be divided into:

A. Non-Hazardous General Waste; 70 to 90% of medical waste

B. Hazardous General Waste; 10 to 25% of medical waste

Solid Waste Management Act 2011 has clearly indicated that processing and management of
hazardous waste, medical waste, chemical waste or industrial waste under the prescribed
standards shall rest with the person or institution that has generated the waste.

The Stockholm Convention is related with the reduction and total elimination of unintentional
production of persistent organic pollutants and has given priority for Best Available Technique
and Best Environmental Practice. In our context, following basic steps are considered essential
for the proper waste management:
• Waste minimization
• Waste segregation
• Waste collection and storage
• Waste transportation
• Waste treatment and disposal
• Monitoring and evaluation

1. Waste Minimization

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Waste minimization is defined as the prevention of waste production and/or its reduction. Waste
minimization usually benefits the waste producer by reducing the costs for the purchase of
goods. It involves specific strategies of changes in management and behavioral change.

However, no actions should be taken that would impact on the quality and limit the access to
health care. Waste minimization can be achieved through:

 Waste reduction at source (product substitution, product change, procedural change)

 Giving preference to recyclable and reusable items
2. Waste Segregation

Waste segregation refers to the process of separation of waste at the point of generation and
keeping them apart during handling, collection, interim storage and transportation. Segregation
of the waste at source is the key principle of successful and safe waste minimization and is the
most important step for a successful management of HEALTH CARE WASTE (HCW) . In fact,
it reduces the quantity of that waste, which is hazardous and require special attention and
treatment. It is highly recommended that segregation of HCW occurs on-site at the time the
waste is generated, for example, when an injection is given, needle and syringe are placed in a
different waste container, or when packaging is removed from supplies and equipment and kept
separately. Thus, segregation must take place at the bed site, at the operation theater, at ward, at
laboratory, wherever it is generated. Non-risk waste (e.g. paper, glass, plastic, iron) can be
recycled. Non-risk biodegradable organic wastes (i.e. food waste, garden waste) can be
composted. Infectious waste must never be mixed with non-infectious waste to keep the volume
of infectious waste as low as possible.

Color code of waste segregation: the suggested colors for the containers for the different
categories of waste are shown in figure below:

Waste category, symbol and Color of container

label

Biodegradable Green

Non risk HCW Non-biodegradable Blue

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 Risk HCW Pathological waste Red

Danger pathological waste

Infectious waste
Pharmaceutical waste
Cytotoxic waste
Chemical waste yellow
Danger to be discarded by
authorized staff only

Radioactive waste Black

Danger radioactive waste

3. Waste Collection and Storage

In order to avoid accumulation of the waste, it must be collected and transported to a central
storage area within the HCF on a regular basis before being treated or removed. All the collected
HCWs should be stored in waste storage area until transported to a designated off-site treatment
facility. This area must be marked with warning sign. Storage facilities for waste should be
suitably established within the HCF; however, these areas should be located away from patient
rooms, laboratories, hospital function/operation rooms or any public access area. The storage
facility should be lockable, hygienic and appropriately sign-posted.

4. Waste Transportation

Health care waste collection and transportation practices should be designed to achieve an
efficient movement of waste from point of generation to storage or treatment. A program for
collection of HCW should be established as part of the HCWM plan. Certain recommendations
should be followed by the auxiliary worker in-charge of waste collection:

• Suggested collection frequency on room to room basis is once every shift. Time of collection
regardless of category should be at the start of every shift. In case of difficulty in the collection
of waste in every shift, waste should be collected on daily basis (or as frequently as required) and
transported to the designated central storage site of HCF.

45
  No bags should be removed unless they are labeled with their point of production
(hospital and ward or department) and contents.
 The bags or containers should be replaced immediately with new ones of the same type.
 A supply of fresh collection bags or containers should be readily available at all locations
where waste is produced.

The waste disposal plan of HCF should include procedures for on-site and off-site transport of
wastes.

5. Waste Treatment and Disposal

The methods for treatment and disposal of HCWs depend on specific factors applicable to the
HCF, relevant legislation and environmental aspects affecting the public. The bulk of HCW falls
into the category of non-risk HCW, much of which can be recycled or reused. With correct
segregation, low amount of waste can be categorized as risk HCW requiring specific attention
and are hazardous waste. The hazardous waste and infectious waste must be managed by
approved treatment methods. Once treated, the waste may be re-classified accordingly for
disposal. Currently available waste treatment options have various capabilities and limitations.
As technology changes, HCFs should evaluate treatment alternatives for their safety,
effectiveness, environmental impacts, costs and compliance Health Care Waste Management
Guideline 34 with country requirements. Any treatment option for HCWs should:

 Render sharps incapable of causing penetration injury.

 Achieve a significant volume reduction with no hazardous by-products.
 Result in residues being suitable for approved landfill disposal without harmful leaching
to the environment.
 Result in minimum levels of hazardous or toxic by-products including POPs such as
polychloro biphenyls.
 Reduce the potential for the transmission of infection.
 Have automatic controls and built-in safe mechanism.
 Have continuous automatic monitoring and recording.
 Ensure that the waste cannot bypass the treatment process.
 Have safe alternative treatment and disposal in case of emergency.

46
  In case of autoclave, be tested at least annually to ensure that optimal performance is
[Link] can be treated and disposed through the following techniques:

a. Biological procedure f. Burial

b. Autoclave g. Septic/concrete vault
c. Chemical disinfection h. Incineration
d. Encapsulation i. Inertization
e. Sanitary landfill

a. Biological Procedure:

Biological process uses an enzyme mixture to decontaminate HCW and the resulting byproduct
is put through an extruder to remove water for sewage disposal. The technology requires
regulation of temperature, pH, enzyme level and other variables. Presently, biological procedure
is getting popularity for the disposal of non-risk HCW. Composting (aerobic and anerobic
composting) of the biodegradable waste is one of the options for the disposal of HCWs.

b. Autoclave :

Autoclave is a process of steam sterilization under pressure. It is a low heat

process in which steam is brought into direct contact with the waste material for duration
sufficient to disinfect the material. Typically, autoclaves are used in hospitals for the
sterilization of medical equipments to render waste harmless. This technique has been
used for long time in HCFs for sterilization of reusable medical equipment. Autoclaves
are commonly used for the treatment of highly infectious waste, such as microbial
cultures or sharps. It has been reported that the effective inactivation of all vegetative
micro-organisms and most bacterial spores in a small amount of waste (about 5–8kg)
requires a 60 minute cycle at 121°C (minimum) and 1 bar (100kPa); this allows for full
steam penetration of the waste material (WHO, 1999); however, the effective penetration
of steam and moist heat depends on many factors including time, temperature, pressure,
load size, stacking, configuration and packing density, types and integrity of bags or
containers used, physical properties of the materials in the waste (such as bulk density,

47
 heat capacity and thermal conductivity), amount of residual air and the moisture content
in the waste.

c. Chemical disinfection :
Chemical disinfections are usually applied for the treatment of infectious and highly
infectious HCW. Aldehydes, chlorine compounds, phenolic compounds are added to HCW to
kill or inactivate pathogens. It is the preferred treatment for liquid infectious wastes, but can
also be used in treating solid waste too. This technique is most suitable in treating blood,
urine, stools and sewage. Some chemical systems use heated alkali to destroy tissues, organs,
body parts and other anatomical waste. Chemotherapy waste (including bulk cytotoxic
agents) can be treated by chemical decomposition. Examples are: reaction with 5% sodium
hypochlorite; acid hydrolysis followed by alkaline hydrolysis; reduction using zinc powder,
degradation using 30% hydrogen peroxide; and destruction using heated alkali. Micro-
organism types, degree of contamination, type of disinfectant, contact time; and other
relevant factors such as temperature, pH, mixing requirements and the biology of the micro-
organism should be considered when using chemical disinfections. Occupational health and
safety should be taken in consideration while using chemical disinfection. Ultimate disposal
of chemically treated waste should be in accordance with national and local requirements.
d. Encapsulation:
Encapsulation involves the filling of the containers with waste, adding an immobilizing
material and sealing the container. The process uses either cubic boxes made of high density
polyethylene or metallic drums. When containers are three quarters filled with sharps,
pharmaceuticals and chemical waste, an immobilizing agent such as plastic foam, bituminous
sand, cement mortar or clay is poured into it. Material is allowed to be dried and the
container is sealed and disposed safely.

Encapsulation is effective in reducing the risk of scavengers gaining access to the

hazardous waste. It is particularly suitable for sharps and pharmaceutical waste. e. Sanitary
landfill Sanitary landfill is an engineered method, designed and constructed to keep the waste
isolated from the environment. So, it shouldn’t contaminate the soil, surface, and ground water
and should limit air pollution, smells and direct contact with public. Disposing of certain types of

48
HCW (infectious waste and small quantities of pharmaceutical waste) in sanitary landfills is
acceptable. Some essential features of sanitary landfills are:

 Easy access to the site and working areas for waste delivery.
 Personnel should be available on-site for effectively controlling the daily operation.
 The site should be planned appropriately and divided into manageable phases, before
starting the landfill. Health Care Waste Management Guideline 37
 Lining of the base and sides of the sites must be adequately sealed to minimize the
movement of waste water. Landfill site should be at least 50 meter away from water
sources.
 There must be landfill gas control measures, environmental monitoring points and bore
holes (for monitoring air and ground water quality).
 There must be adequate and efficient mechanism of leachate collection and treatment.
 The site must be well organized in a small area, i.e. proper spreading, compaction, and
daily covering the waste with soil.
 The landfill site must be protected with wire bar/fence to prevent from unauthorized
persons, animals and birds.
 Final cover must be constructed to prevent/minimize rain water infiltration when each
phase of the landfill is completed.
e. Burial:
Hazardous waste can be buried in a special pit. Burial is recommended in those HCFs
that have minimal programs for HCWM, especially in remote locations, in temporary refugee
encampments, or in areas experiencing exceptional hardship and in those cases where the
safe burial of waste on hospital premises may be the only feasible option available at the
time. For the purpose, the pit should be 2-5 m deep and 1-2 m wide. The bottom of the pit
should be at least 2 m above the water table. After each waste load, it should be covered with
a 10–30 cm thik soil layer. If coverage with soil is not possible, lime may be deposited over
the waste. In case of outbreak of an especially virulent infection (such as Ebola virus), both
lime and soil cover may be added. When the level of the waste reaches 30 to 50 cm to the
surface of the ground, fill the pit with dirt, seal with concrete and dig another pit. Certain
rules need to be established for proper HCWM in burial pit, as follows:
 Access to this dedicated disposal area should be restricted to authorized person only.

49
  The use of a pit would make supervision by landfill staff and thus prevent scavenging.
The water deposition around the burial pit should be prevented.
 The burial site should be lined with a material of low permeability, such as clay, to
prevent pollution of ground water.
 Large quantities (higher than 1 kg) of chemical/pharmaceutical wastes should not be
buried.
 The burial site should be managed as a landfill, with each layer of waste covered with a
layer of earth to prevent from rodents and insects and odor as well.
 Burial site should not be located in flood prone areas.
 The burial site should be fenced with warning signs.
 The location of waste burial pit should be down-hill or down-gradient from any nearby
wells and about 50 meters away from any water body such as rivers or lakes.
 HCF should keep a record of the size and location of the existing burial pits to prevent
construction works. Health Care Waste Management Guideline 38 g. Septic/concrete
vault This method can be used for the disposal of used sharps and syringes. In this
technique, the following process is applied.
 Dig a pit (1m x 1m x 1.8m depth), enough to accommodate sharps and syringes for
certain period without reaching the ground water level. The site must be isolated and at
least 500 feet away from the ground water sources and dwelling units.
 Construct concrete walls and slabs of the pit. Provide slab with opening or manhole for
easy deposition of collected sharps and syringes. The manhole should be extended a few
centimeters above the soil surface to overcome infiltration of the surface water.
 Deposit the collected safety boxes filled with used sharps and needles inside the
septic/concrete vault.
 Install a security fence around the site.

h. Incineration:

Incineration converts combustible materials into non-combustible residue or ash.

Incinerators can be oil-fired or electrically powered or a combination of both. Broadly,
three types of incinerators are used for treatment of HCWs: multiple hearth, rotary kiln
and controlled air type. All the three types can have primary and secondary combustion

50
 chambers to ensure optimal combustion. Gases are ventilated through the incinerator
stacks, and the residue or ash is disposed in a sanitary landfill. Wastes containing
mercury or cadmium should never be burned or incinerated because of the risk of
atmospheric pollution with toxic vapors. When wastes are incinerated at low
temperatures or when plastics that contain polyvinyl chloride (PVC) are incinerated,
dioxins, furans and other toxic gases may be produced as emissions and/or in bottom or
fly ash (ash that is carried by air and exhaust gases up the incinerator stack). This
happens particularly when wastes are incinerated at temperatures lower than 800°C or
when the wastes are not completely incinerated. Even in high temperature incinerators
(>800°C), temperatures are not uniform and dioxins and furans can form in cooler
pockets or during start-up or shutdown periods. Where incineration is used, two
chambered incinerator should be used and must follow the standard operating procedure
(SOP). HCF must utilize emission limits and other requirements to ensure effective waste
treatment, minimize emissions and decrease exposure and risks to workers and the
community. This should include the use of approved incinerator designs that can achieve
appropriate combustion conditions (e.g., proper temperature, required chimney heights);
appropriate location (e.g., away from populated areas or where food is grown); adequate
training to the operator (including both class room and practical training); appropriate
waste segregation, storage and ash disposal facilities; adequate equipment maintenance;
managerial support, supervision; and sufficient budgeting. The temperature must be at
least of 850°C to ensure minimal emission of toxic gases at the primary chamber. High
chimney is also required (higher Health Care Waste Management Guideline 39 than
nearby roofs) and following wastes should never be incinerated:

 Pressurized gas containers

 Large amounts of reactive chemical waste
 Radioactive waste
 Silver salts or radiographic wastes
 Halogenated plastics (e.g. PVC)
 Mercury or cadmium
 Ampoules of heavy metals

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i. Inertization: Inertization is usually suitable disposal method for the pharmaceuticals and
incinerated ash with heavy metal content. (WHO, 1999) In this technique, the HCW is mixed
with cement and other substances in a composition of 65% waste, 15% lime, 15% cement and
5% water. The formed mixture is allowed to set into cubes or pellets and then these are
transported to suitable storage site. For proper setting of the mixtures into cubes and pellets, the
waste must be grinded.

j. Monitoring And Evaluation: Regular monitoring and evaluation of the plan in each HCF should
be performed. Regular reviews help in identifying potential loopholes and bottle necks and
enable the HFC to reveal new issues which may arise while managing HCW.

Hemodialysis Waste Management

The meaning and definition of dialysis is the following: “a procedure that is the substitute for
many of the normal functions of kidneys”. Thus, dialysis allows people to live fulfilling lives
even if their kidneys aren’t working properly anymore. According to a statistical report from
2015 of the US Renal Data System, there were approximately 468 000 patients who had received
dialysis treatment in the United States that year. The overall prevalence of CKD in Nepal
was 6.0%. We estimate the incidence of end stage renal disease to be 2900 patients (100 per
million populations).
Dialysis centers use two main types of treatments to help patients in need. Hemodialysis uses a
special filter to remove waste and water from the patient’s blood, while peritoneal dialysis uses a
particular fluid (dialysate) in the patients’ abdominal cavity to remove these waste products from
the blood.
Dialysis waste disposal process won’t just be easier and cheaper, but also completely safe. Once
the treatment process is over, anything that comes out of this machine is completely sterile, and
as such, the removal of dialysis waste products can be handled just like regular municipal waste,
greatly reducing the risks that are usually associated with medical waste storage and
transportation.

Dialyzer Reuse

52
  A dialyzer is the part in the hemodialysis machine where your blood gets filtered.
 A dialyzer is often referred to as artificial kidney. Its function is to remove the excess
wastes and fluid from the blood, when the patient’s kidneys can no longer perform that
task.
 Dialyzers are made of a thin, fibrous material.
 There are different sizes of dialyzers.
Types of dialyzer

There are 3 types of dialyzer.

 Coil dialyzer
 Parallel plate dialyzer
 Hollow fiber dialyzer
In addition, dialyzers are internationally classified into three types.

 Low flux
 High flux
 Protein-leaking
Dialyzer

An ideal dialyzer should have

 High clearance of small and medium molecular weight toxins.

 Adequate ultra filtrate.
 Non toxic composition.
 Minimal blood volume.
 Reliability(the quality of being trust)
 Reusability
 Low cost
Dialyzer Reuse

 Hemodialyzer reuse is a practice of using the same dialyzer more than once for the same
patient .this practice has been prevalent in US since 1980s.
 Reuse appears to be safe and cost-effective procedure for high-flux. When dialyzers are
reused, they are cleaned and disinfected after each treatment. They must also be tested to
make sure they are still working well before they are used again.
 More than 80% facilities currently reprocess and reuse dialyzers.
 Dialyzer reuse is now rare in the United States and most resource-rich countries.
 There are variations in the practice of reuse in terms of the method of reprocessing
(manual vs automated).
There are 3 types of dialyzer based on function:
a. High flux dialyzer: Beta-2 micro globulin clearance >20ml/min
b. Low flux dialyzer: Beta-2 micro globulin clearance <15ml/min

53
 c. Plasma leaking dialyzer: Greater clearance of low molecular weight proteins &
small protein-bound solutes
Reprocessing techniques

The basic procedure for dialyzer reprocessing involves four steps;

 Rinsing
 Cleaning
 Performance testing
 Disinfection and sterilization
Why do you reuse a dialyzer?
 Dialyzer reuse can reduce or eliminate the physical reaction some patients have to certain
dialyzer membrane. In addition, dialyzer reuse allows the dialysis center to use high-flux
dialyzer, which are more costly. High-flux dialyzer are more porous and clear larger
toxins from your blood.
Requirement for Dialyser wash

 Ro water
 Hydrogen peroxide
 -This is meant for instillation only in the dialysate compartment.
 Formaldehyde 4%
- Commercially available as 40%, this can be diluted with the water used for
reprocessing to give a final strength of 4%.

 Normal saline
Dialyzer reuse procedure

1. Remove dialyzer and tubings from the machine and take to the reprocessing area in a
covered tray to avoid blood spills.
2. Disconect the dialyzer from blood line and connect dialyzer into water source. The blood
compartment is rinsed with R/O water till the effluent is clear.
3. [Link] by instilling 6%Hydrogen peroxide into the blood compartment till it is
completely filled(20-30ml) and allowed to stay for not more than 2 min .
4. 4. Rinse out the cleaning agents with R/O water.
5. [Link] the dialyzer for a large number of discolored fibers, large clots in the header,
generalized blackening, change in colour, or aesthetically unpleasing appearance. If the
clots in the headers appear small and friable the header may be removed from the
dialyzer to be cleaned separately.
6. [Link] out the cleaning agents with water.
7. [Link] one end of the blood compartment is connected to the water supply,
which is turned off, while the other end is left open. The direction of flow should be
reversed at 5 min intervals.

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 8. [Link] the header is removed special care should be taken to check the O ring and replace it
properly. Improper placement of the O ring or failure to replace it will result in a blood
leak when the dialyzer is next used.
9. 9. Filled dialyzer with the disinfectant(4% formaldehyde) from the other direction,
allowing the disinfectant to displace water. The dialysate compartment should be
completely filled with disinfectant.
10. 10. After that cap the dailyzer for chemical preservation into membrane and check for
any leakage and damage.
Labeling and storage

 After complition of dialyzer wash we should strickly put the label of patient Name Age,
Sex and Date of dialyzer wash, then store in a proper place.
 Dialyzer should be store in a manner to prevent deterioration, contamination or breakage.
Points to Remember

 Although the main objective of reprocessing dialyzers is lowering cost, this should not
compromise the quality of dialysis and safety of patients.
 The hollow fiber dialyzers may be reprocessed in order to reduce the cost of the HD
procedure.
 That the practice reuse should have an adequate protocol of reprocessing and a reliable
system of monitoring.
 The dialyzer is tested to make sure there are no broken fibers and it is still working.
When the dialyzer is ready for use, The germicide is rinsed out.

• No reuse dialyzer for sero positive patients.

• Dialyzer are never shared between patients.
• Rigors, fever, and hypotension on dialysis suggest the possibility of infection caused by
failure of the reprocessing technique, and hemolysis caused by the chemical disinfectants.
• Chemical fill dialyzer minimum storage time 11hour and maximum time 6 to 7 days.
• Dialysis facilities that reuse dialyzers must follow strict guidelines set forth by the
Association for the Advancement of medical Instrumentation(AAMI).
Advantage of Dialyzer Reuse

 Save cost
 Reduced incidence or intradylytic symptoms- 1st use syndrome
 Reduced exposure to residual industrials chemicals used in manufacture of new dialyzer.
 Its also help to reduce medical waste from health centre.
 By choosing reuse we can dramatically reduce the negative impact on the environment.
Disadvantage of dialyzer Reuse

 Risk to life – Mortality

 Risk of infection
 Pyrogenic reaction
 Toxicity from disinfection

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  Reduced dialyzer permormance
 Impaired removal of large molecules
How many times can I safely reuse my dialyzer

 There is no set number of time that is considered safe for dialyzer reuse. As long as the
total cell volume (TCV) shows that the dialyzer is working well, and the dialyzer looks
clean, it should be safe for you to reuse dialyzer.
 The sizes are related to the blood volume that will go through them, which depends on
the patient's size and weight.
ETHICS
 Ethics is the rules or principles which human actions are right or wrong.
Code of ethics
Ethical principles

Ethical principle that the nurse should consider when making decision are as follows:
• Autonomy
• Beneficence
• Non-maleficence
• Justice
• Veracity
• Fidelity
a. Autonomy : refers to a patient's right to self determination without outside control.

• e.g., the purpose of HD consent that clients must read and signed before
procedure is the assurance in writing that the healthcare team respects the client's
independence by obtaining permission to proceed.

• ( what if the patients want to do something that will cause them harm?)

b. Beneficence: states the duty to actively do good for clients. Beneficence refers to taking
positive actions to help others.

• The practice of beneficence encourages the urge to do good for others. A child's
immunization may cause discomfort during administration, but the benefits of protection
from disease outweigh the temporary benefits.

c. Nonmaleficence: states the duty to prevent or avoid doing harm whether intentional or
unintentional.

• The healthcare professional tries to balance the risk and benefits of a plan of care while
striving to do the least harm possible. e.g., accepting assignment to work in an unfamiliar
area of responsibility.

• (If the ward is understaffed, is it acceptable to refuse to work there?)

56
d. Justice: states the duty to treat all clients fairly, without regard to age, socioeconomic status
or other variables.

• " on what basis should scarce ICU beds be allocated? Individuals to be treated equally
regardless of race, sex, marital status, medical diagnosis, social standing, economic level,
religious belief, caste and language".

• ( what is fair and who decides?)

e. Veracity: states the duty to tell truth or not intentionally misleading patients.

• e.g., Do you tell the truth when you know it will cause harm to an individual?
(nonmaleficence).

• Do you tell a lie when it would make someone less anxious and afraid? (doing good).
You might see this is beneficence, but then you have abandoned the principle of veracity.

( Is lying to a patient ever justified?)

f. Fidelity: means duty to be faithful to commitments or the agreement to keep promises.

• It is the foundation of the concept of accountability. It involves keeping promises and

information confidential as well as maintaining privacy. e. g., maintaining patient's
confidentiality regarding a positive HIV test.

( To whom do we owe our fidelity? patient/ family/ physician/institution/profession?)

Ethical issues in HD patients

• medical, ethical, legal, and psychosocial challenges to care such patients who lack
decision-making capacity with a focus on variable approaches by regions and culture.

BLOOD TRANSFUSION

• A blood transfusion is a routine medical procedure in which donated blood is provided to

patient’s through a narrow tube placed within a vein in your arm. This potentially life-
saving procedure can help replace blood lost due to surgery or injury or suffer from
critical disease.

• It is well known that errors in blood transfusion practices can lead to serious
consequences for the recipient in terms of morbidity and mortality.

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 • Blood transfusion is given to treat low red blood cell count, also called anaemia. Kidney
failure is an important cause of anaemia. If the blood count is too low, despite giving you
iron replacement and the erythropoietin (EPO) hormone, you may need a transfusion.

• The guidelines provide a standardized approach to transfusion so that the potential for
errors is minimized and the administration of safe and efficacious blood products in the
health care setting is maximized.

• They also contain provide guidelines for the use of specialised blood products.

Overview of Blood transfusion:

• Transfusion of blood & blood products should be undertaken only to treat a condition that
would lead to significant morbidity or mortality & that cannot prevent or managed
effectively by other means (WHO).
• Hemoglobin 7-8 gm/dl (American association of blood bank, 2012) required blood
transfusion or below 10 gram/dl and Hematocrit below 30 % for ongoing bleeding during
surgery or trauma less than 6 gm/dl almost always indication (WHO).
Purpose:
- To replace the blood volume
- To replace needed component
- To meet the target level of blood and blood components
Indications:
 Low production blood .
 Major road traffic accident.
 Chronic blood loss with anaemia.
 Conditions such as : bleeding disorders, malignancies, coagulopathies, major surgeries,
severe burn, critical illness for e.g kidney disease cardiovascular disease.
Types:
• Whole blood: Whole blood obtains from donors& none of element has been removed
combined with anticoagulant & preservative.
• Fresh blood: Transfusion within 6 to 12 hours after donation/within the day
• RCC(PRBC): Erythrocytes are separated from whole blood/ apheresis typically used in
low hemoglobin.
• Fresh frozen plasma: Separated from unit of blood within 6-8 hours of donation which
contains water, electrolytes, coagulation factors, and protein.
• Cryoprecipitate: It is a concentrated subset of FFP prepared from plasma which contains
fibrinogen, factor VIII (refined anti hemophilic).
• Platelets: Used for blood clotting.

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59
60
Nursing Management
BEFORE PROCEDURE

 Identify the patient.

 Check the physician’s order, patient condition and past history of transfusion reaction.
 Obtain blood from blood bank according to organizational policy.
 Explain patient about the procedure, need for transfusion and approximate length of time.
 Obtain informed consent from the patient/patient party.
 Bedside curtain / close the door.
 Wash and dry hands.
 Prepare required articles.
 Identify the patient’s condition by taking vital signs and document pre-transfusion vital
signs in patients file.
 Check for type of blood and compatibility.
 Ensure the patient to empty bowel and bladder.
 Keep the patient in comfortable position.
 Inspect the blood product by 2 nurses
o Patient’s name
o Identification number
o Blood group and type
o Collection date
o Expiry date
o Compatibility

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 o Abnormal color, clots, excess air bag leakage
 Warm blood if needed using special blood warmer. Dialysis case this is not need because
dialyzer maintain temperature.
 If blood product is found to be correct, start the blood transfusion.
 Start blood product slowly at the rate of 2ml/minute.
 Remain at bedside for 15-30minutes,check the vital signs every 15 minutes according to
hospital policy
 Increase infusion rate if no adverse reactions are noticed.
 Assess the condition of the patient every 30 minutes.
 If transfusion reaction occurs (symptoms like fever, chills,flushing, urticarial ,anxiety,
vomiting, headache, back pain, edema, difficulty in breathing)
o Stop the transfusion immediately and notify to physician. Start 0.9% NS
o Remain with patient, vital signs every 5 minutes till patient becomes stable
o Administer medicines like antihistamine, antibiotic, steroids adrenaline as per
prescription or as protocol.
 Frequent monitoring of the patient’s condition and vital signs
 Documentation : date, time, volume, bag no, type of reaction, performed interventions,
patient condition
 [Link] transfusion if no adverse reaction is observes.

Point to be remember in dialysis for blood transfusion

• In dialysis case while blood transfused for patient there we have to increase the
ultrafiltration(UF) rate of patients to prevent from volume overload.
• No need to warm the blood before transfusion.
• There also no need for drop calculation .
• Near expired date blood also not use for dialysis patients.
• Blood transfusion is start after 30 mins of dialysis n complete before half hour of dialysis.
• Before 3month blood transfusion is contraindication for kidney transplant cases.
• Send haemoglobin level every weekly.
• Send serology test (HIV, HBsAG, HCV)every 3 monthly.
Nursing Management
AFTER PROCEDURE

- 23. Discard the empty blood bag and blood transfusion set in appropriate place.
- 24. Remove gloves and wash hands.
- 25. Obtain vitals in 15min after completion of transfusion than 30min, 60min and
then routinely
- 26. Replace the equipment’s properly.
- 27. Send post transfusion investigations according to physicians instruction.
- Documentation
- Product and volume transfused, identification number and blood group

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 - Time of administration started and completed
- Name and signature of nursing staff carrying out procedure and patient’s condition
- Risks & Complications
- Adverse reactions to transfusion can occur and may be -
- immunological or non-immunological in origin, and either acute (occurring during the
transfusion or within 24 hours) or delayed (occurring >24 hours after the start of the
transfusion).
- Some of the most common complications in blood transfusions are listed below.
- Allergic Reactions
- Fever/Rash

Oxygen and O2 Therapy?

▶ Oxygen is a life saving medical gas.

▶ Oxygen is a colorless, odorless, tasteless gas that is essential for the body to function properly
and to survive.

 Oxygen therapy is the administration of oxygen at concentrations greater than that in the
room air to treat or prevent hypoxia

 Primary goal of oxygen therapy is to improve arterial hypoxemia and ensure appropriate
oxygen delivery to vital end organ tissues.

Reference ranges Arterial blood Venous blood

pH 7.35 – 7.45 7.35 – 7.43

pCO2 35 - 45 mmHg 38 – 50 mmHg
pO2 80 – 100 mmHg 30 – 50 mmHg
HCO3- 22 – 26 mM 23 – 27 mM
O2 saturation 95 – 100% 60 – 85%
Purpose
• To increase oxygen saturation in tissues where the saturation level are too low due to
illness or injury.
• To maintain the ability of cells to carry out the normal metabolic function.
• To reduce the effect of anoxemic.
• To relieve dyspnea
• To reduce or prevent hypoxemia.

Three clinical goals of O2 therapy

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 - Treat hypoxia
- Decrease work breathing
- Decrease myocardial work

Key Terms

SpO2- SpO2 stands for peripheral capillary oxygen saturation, an estimate of the amount of
oxygen in the blood.
SpO2 – oxygen saturation as measured by pulse oxymeter.
 PaO2 – partial pressure of oxygen
 measurement of oxygen pressure in arterial blood
 reflects how well oxygen is move from the lungs to the blood
 SaO2 – oxygen saturation as measured by blood analysis
• - % of available binding sites on hemoglobin bound with oxygen in arterial blood.
 FiO2 – fraction of inspired oxygen
Note : FiO2 21% means the concentration of o2in room is 21%.
Indications
• Acute Respiratory Failure
• Acute myocardial infraction
• Cardiac failure
• During CPR
- Shock
• Anemia
• Hyper-metabolic state induced by trauma, burns or sepsis
• Cyanide poisoning
• During anesthesia for surgery
Note: - Oxygen is a prescribed drug must be written by the doctor and prescription should be
dated. Physician must indicate duration, O2 concentration and flow rate of O2 therapy.
Sources of oxygen
 Oxygen plant
 Oxygen cylinder
 Oxygen wall outlets
 Oxygen concentrators
Oxygen Delivery Devices
a. Nasal cannula/Nasal Prong /Nasal probe
b. Simple mask,
c. Partial rebreathe mask,
d. Non rebreathe mask,
e. Venturi mask
FiO2 = 20% + (4 x oxygen liter flow)
f. Face tent

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g. Oxygen tent / Oxygen hood
h. Artificial manual breathing unit /Manual resuscitation / Ambu bag
i. Tracheotomy mask /Tracheostomy collar
j. Noninvasive ventilation

Noninvasive Ventilation
• an alternative to mechanical ventilation
• used to maintain positive airway pressure
• and to improve alveolar ventilation
Indications :
• Type II respiratory failure,
• cardiogenic pulmonary edema,
• congestive heart failure,
• sleep disorders
Continuous positive pressure ventilation (CPAP):
• It provides a set positive airway pressure throughout the patient’s breathing cycle.
• It is commonly used for the patients who experience sleep apnea
Bilevel positive airway pressure (BiPAP):
• It provides assistance during inspiration and keeps the airway from closing during
expiration
• i.e. it can provide different level of pressure during inspiration and expiration.
Weaning from oxygen therapy
• Discontinuing oxygen or lowering the concentration for a fixed period, e.g., 30 min.

65
 • Re-evaluate the clinical parameters and SpO2
When to stop oxygen therapy
• Patient comfortable
• Underlying disease stabilized
• Hemodynamics stable
• Skin color and SpO2: normal range
Complications of Oxygen therapy
• Oxygen induced hypoventilation
• Oxygen toxicity
• Absorption atelectasis
• Retinopathy
• Drying of mucus membrane
• Fire hazard
• Continuous assessment of patient for weaning Oxygen therapy should be considered.
• Special Precaution regarding cylinder safety , pipeline/ connector safety and fire safety
should be done
Kidney transplant
A kidney transplant is surgery to place a healthy kidney into a person with kidney [Link]
transplantation or renal transplantation is the organ transplant of a kidney into a patient with
end-stage renal disease

During a transplant, the surgeon places the new kidney in your lower abdomen and connects the
artery and vein of the new kidney to your artery and vein. Often, the new kidney will start
making urine as soon as your blood starts flowing through it. But sometimes it takes a few weeks
to start working.

History

 300 AD Christian Arab Saints Cosmas and Damian

 1950s Mathieu Jaboulay and Alexis Carrel
 1954 First successful Kidney transplantation between
identical twins – In Boston, USA by Joseph Murray and
Colleagues
 1959 Schwartz & Dameshek – 6- mercaptopurine and Calne
showed azathioprine, prevented rejection
 1963 Starzl performed first human liver transplantation
 1967 Barnard performed the first human heart transplantation
• 1968 Derom performed the first human lung transplantation

• 1974 Sutherland and Najarin performed the first human

pancreatic islet transplantation

66
 • 1981 Reitz and Shumway performed the first human heart- lung
transplantation

Kidney Donor
The donated kidney may be from:
• Living related donor -- related to the person receiving the transplant, such as a parent,
sibling, or child
• Living unrelated donor -- such as a friend or spouse
• Deceased donor -- a person who has recently died and who has no known chronic kidney
disease

Kidney Transplantation Patient Selection Criteria

Indications for Kidney Transplantation

A. End Stage Renal Disease

B. Estimated renal function < 20% of normal on two sequential determinations or dialysis
dependent.

C. Significant symptoms or signs of uremia such as nausea, loss of appetite, insomnia, or

chronic fatigue; or acid-base or electrolyte irregularities unresponsive to oral treatment.

Conditions that Increase the Risk with Kidney Transplantation

A. Significant cardiac disease

B. Significant pulmonary disease
C. Significant gastrointestinal disease
D. Severe vascular disease: coronary, cerebral or peripheral
E. Renal disease with significant potential for recurrence causing kidney graft loss
F. Potential for noncompliance
G. Psychosocial/financial issues causing an inability to achieve adequate post-transplant
care
I. Age greater than 70 years
J. HIV positive
Absolute Contraindications to Kidney Transplantation

A. Active infection
B. Active malignancy
C. Active drug use, alcoholism, or psychosis.
D. Medical noncompliance
E. Severe irreversible extrarenal diseases (e.g. inoperable cardiac disease, chronic lung
disease, severe peripheral vascular disease).

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F. High probability of peri-operative mortality

G. Anatomy that makes transplantation technically impossible

Prognosis

• Kidney transplantation is a life-extending procedure. The typical patient will live 10 to 15

years longer with a kidney transplant than if kept on [Link] increase in longevity is
greater for younger patients, but even 75-year-old recipients (the oldest group for which
there is data) gain an average four more years of life.

• An adult donor kidney transplanted to the left iliac fossa of an adult recipient.

CRITERIA FOR LIVING DONOR SELECTION

- Blood relative.
- Highly motivated.
- ABO blood group-compatible.
- HLA-identical or haploidentical with negative cross-match.
- Excellent medical condition with normal renal function.
CRITERIA FOR CADAVER DONOR SELECTION
- Irreversible brain damage.
- Normal renal function appropriate for age.
- No evidence of preexisting renal disease.
- No evidence of transmissible diseases.
- ABO blood group-compatible.
- Negative cross-match.
- Best HLA match possible, particularly at the DR and B loci.
Evaluation Of Kidney Function In Potential Kidney Donor
 Serum creatinine.
 Creatinine clearance.
 Radionuclide glomerular filtration rate.
 Urine analysis.
 Urine Culture.
 GFR > 70 ml/min.
Matching between Recepient And Donor

A- Tissue typing

 Determined by 6 antigens located on cell surface encoded for by the HLA gen located on
the short arm of chromosom 6.
 Class I antigens (HLA-A and HLA-B) are expressed on the surface of most nucleated
cells.
 Class II antigen (HLA-DR) are expressed on surface of APC and activated lymphocytes.

68
  These 6 antigens are refered to as major transplant antigens.
 The match between donor and recepient can range from 0 to six.
B- Cross matching

 A laboratory test that determines weather a potential transplant recepient has preformed
antibodies against the HLA antigens of the potential donor. (Donor Lymphocytest
+Recepient Serum)
 A Final CM is mandatory
C- Compatible ABO blood group.

Procedure
• In most cases the barely functioning existing kidneys are not removed, as this has been
shown to increase the rates of surgical morbidities. Therefore, the kidney is usually
placed in a location different from the original kidney, often in the iliac fossa, so it is
often necessary to use a different blood supply:
• The renal artery of the kidney, previously branching from the abdominal aorta in the
donor, is often connected to the external iliac artery in the recipient.
• The renal vein of the new kidney, previously draining to the inferior vena cava in the
donor, is often connected to the external iliac vein in the recipient.
Complications
Problems after a transplant may include:

 Transplant rejection (hyperacute, acute or chronic)

69
  Infections and sepsis due to the immunosuppressant drugs that are required to decrease
risk of rejection
 Post-transplant lymphoproliferative disorder (a form of lymphoma due to the immune
suppressants)
 Imbalances in electrolytes including calcium and phosphate which can lead to bone
problems among other things
 Other side effects of medications including gastrointestinal inflammation and ulceration
of the stomach and esophagus, hirsutism (excessive hair growth in a male-pattern
distribution), hair loss, obesity, acne, diabetes mellitus type 2, hypercholesterolemia, and
osteoporosis.
Pre-op. Management
Goals:
• Bringing the patient's metabolic state to a level as close as to normal as possible.
• Making sure that the patient is free of infection.
• Preparing the patient for surgery and post-op. care.
Medical management
Pre- operative management
• A complete physical examiation to detect and treat any conditions that could cause
comlications after transplantations.
• Matching between Recepient And Donor
• The patient is evaluated and treated for any infection
• Psychlogical evaluation should be performed because history of any psychiatric illness /
conditions aggravaated by the corticosteroids needed for immunosupression after
transplantation.
• Immunosuppression is initiated before transplantation to prevent immediate graft
rejection
• If the pt is in regular hemodialysis it should be performed the day before the schedule
transplantation.
Post – operative medical management
• After kidney transplant rejection and failure can occur with in 24 hours (hyper acute),
within 3-4 days (acute), or after many years.
• To overcome or minimize the body’s defense mechanisms immunosuppressive agents are
administered.
• Renal transplant pts require lifelong immunosuppression to prevent rejection.
• Current “triple” regimes include cyclosporine-microemulsion or tacrolimus,
mycophenolate mofetil or azathiopine and corticosteroids.
• A psychological evaluation to assess the pt.'s ability to adjust to the transplantation,
coping styles, social history, social support available and financial resources.
• A history of psychiatric illness is ascertained because psychiatric condition is often
aggravated by the corticosteroids needed for immunosuppressant after transplantation.

70
 • Hemodialysis the day before transplantation to optimize the pt.'s physical status, if
dialysis routine had already been established.
• However, it is preferable to avoid initiation of dialysis when donor kidney is available.
Risks associated with chronic Immunosuppression
• Malignancy • Hirsutism
• Infection • Tremors
• Nephrotoxicity • Blood dyscrasisas
• Hypertension • Cataracts
• Hyperlipidemia • Gingival hyperplasia
Nursing Interventions for Kidney Transplant
PREOPERATIVE CARE
• Provide routine preoperative care as the pt with other types of kidney surgery.
• Assess knowledge and feelings about the procedure, answering questions and clarifying
information as needed.
• Listen and address concerns about surgery, the source of the donor organ, and possible
complications.
• Addressing concerns and reducing preoperative anxiety improve postoperative recovery
• Continue dialysis as ordered. Continued renal replacement therapy is necessary to
manage fluid and electrolyte balance and prevent uremia prior to surgery.
• Administer immunosuppressive drugs as ordered before surgery.
Post operative management
1. Assessing the pt. for transplantation rejection
- Early sign of rejection include temperature greater than 100.4 F, decreased urinary
output, weight gain of 1.5 kg or more overnight, plain or tenderness over the graft site,
hypertension, increased serum creatinine.
- Monitor BUN, creatinine, leukocyte & platelet counts closely as immunosuppressant
decreases the formation of leukocyte and platelets.
- Monitor closely for infection- shaking chills, fever, tachycardia, either an increase or
decrease in WBC count.
2. Preventing infection
 Infection may be introduced through the urinary tract, the respiratory tract, the
surgical site or other sources.
 Urine cultures because high incidence of bacteriuria during early and late stage of
transplantation.
 Watch for wound drainage.
 Catheter and drainage tubes may be cultured.
 Hand washing by HCT (health care team) and visitors, use of face mask and
gowns, slippers.
3. Monitoring urinary function
 A kidney from a living donor who is related to patient usually begins to function
immediately after surgery and may produce large amount of dilute urine.
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 Cadaver donated kidney may undergo acute tubular necrosis so may not function for 2 or
3 weeks, during which time anuria, oliguria or polyuria may be present.
 During this stage significant change in the fluid and electrolyte status may be experienced
by the patient.
 Careful monitoring of output from the catheter is measured every hour. I.V. fluids are
administered on the basis of urine volume and serum electrolyte level and as prescribed
by the physician.
 Care of vascular access: hemodialysis may be required if fluid overload and
hyperkalemia occur.
4. Psychological concern
 Anxiety and uncertainty about the future and difficulty post transplantation
adjustment are often sources of stress for the patient and family.
 The rejection of transplant kidney remains a matter of great concern for the patient ,
family and HCT (health care team) for many months.
 The fear of rejection and the complications of immunosuppressive therapy( Cushing's
Syndrome, diabetes, capillary fragility, osteoporosis, glaucoma, cataract and acne)
place tremendous stress on the patient.
 Assess the patient and family's stress and coping, if requested or indicated refer for
counselling.
5. Monitoring and managing potential complications
 Careful assessment for the complications related to renal failure and major surgical
procedure.
 -Breathing exercise, early ambulation, care for surgical incision is important.
 -GI ulceration and cortico-induced bleeding may occur, fungal colonization of the GI
tract and urinary bladder may occur.
6. Promoting home and community based care

Postoperative diet

 Kidney transplant recipients are discouraged from consuming grapefruit, pomegranate

and green tea products.

 These food products are known to interact with the transplant medications, specially
tacrolimus, cyclosporine and sirolimus; the blood levels of these drugs may be increased,
potentially leading to an overdose

72
 विपन्न नागरिक औषधी उपचार कार्यक्रम

परिचय

नागरिक राहत, क्षतिपूर्ति तथा आर्थिक सहायता सम्बन्धि कार्यविधि, २०६८ को दफा
१३मा रहेको विपन्न नागरिक औषधी उपचारबापत आर्थिक सहायता उपलब्ध गराउन नेपाल
सरकारले स्वास्थ्य तथा जनसंख्या मन्त्रालय अन्तर्गत एक छुट्टै कोष स्थापना गरि
विपन्न नागरिक औषधी उपचार कार्यक्रम लागु गरियो ।

 मुटु, मृर्गौला, क्यान्सर, पार्किन्सस, अल्जाइमर्स, स्पाइनल ईन्जुरी, हेड ईन्जुरी तथा
सिकलसेल एनिमिया जस्ता ८ वटा कडा एवम् जटिल प्रकृतिका रोगहरुको उपचार विपन्न नागरिक
औषधि उपचार कार्यक्रम अन्तर्गत प्रदान गरिन्छ ।
 जम्मा सुचीकृत सेवा प्रदायक स्वास्थ्य संस्थाहरु ९९ वटा
 सेवा प्रदान गर्ने सेवा प्रदायक स्वास्थ्य संस्थाहरु ९२ वटा
 सुचिकृत तोकिएका अस्पतालहरुबाट मात्र सहुलियत पाउने ।
सहुलियत प्राप्त गर्ने लक्षित बर्ग
 आफ्नो खर्चले उपचार गर्न नसक्ने विपन्न नेपाली नागरिकहरु
 तर, विदेशमा गई उपचार गर्ने व्यक्ति यस अन्तर्गत पर्दैनन् ।
औषधि उपचार सहुलियत सम्बन्धी व्यवस्था

 नेपाल सरकारले विपन्न नागरिक औषधि उपचार कोष निर्देशिका जारी गरि स्थानीय
तह एवम् जिल्ला स्तरीय सिफारिस समितिको सिफारिसमा विभिन्न अस्पतालहरु
सूचिकृत गरि २०६९ साल देखी सेवा प्रदान गर्दै आइरहेको छ ।

१. मृर्गौला रोगः

क। डायलाइसिसः

• हेमोडायलाईसिस - रु २५०० प्रति सेसन, (हप्ताको २ पटक भन्दा बढी

गर्नुपर्ने भएमा चिकित्सकको प्रेसक्रिप्सन अनिबार्य हुनुपर्ने )

• सेरो पोजेटिभ डायलाईसिस- रु ४ हजार प्रति सेसन

• CAPD- रु ४०८ प्रति प्याकेट

ख। AKI- अधिकतम १ लाख सम्म

ग मृगौला प्रत्यारोपणः रु ४ लाख सम्म ।

घ. प्रत्यारोपण पश्चात औषधि सेवन: रु १ लाख

ª. प्रत्यारोपण पूर्व अंग ग्रहणकर्ता तथा अंगदाताको प्रयोगशाला परिक्षणका लागीः

रु ५० हजार सम्म ।

२. मुटु, क्यान्सर, पार्किन्सन्स, अल्जाइमर्स, हेड इन्जुरी, स्पाइनल इन्जुरी तथा

सिकलसेल एनिमियाका विरामीहरुलाई रु १ लाख सम्म सहुलियत ।

73
३. एउटै व्यक्तिलाई बढी रोग लागेमा फरक फरक रोग अनुसारको तोकिए बमोजिमको रकम
वरावरको सहुलियत व्यवस्था ।

सेवा लिने प्रकृया

(१) वडा कार्यालयमा निवेदन दिई वडा कार्यालयबाट बिपन्न नागरिक हो भनि
सिफारिस लिने।

(२) स्थानीय तहमा गठित समितिले आवश्यक जाँचबुझ गरी निजको आर्थिक अवस्थालाई
हेरेर सुचीकृत अस्पतालमा सिफारिस गर्ने।

(३) तत् पश्चात सूचिकृत अस्पतालबाट तोकिएको रकम बराबरको उपचार सहुलियत
पाउनेछन्।

स्थानीय तहको मुख्य कार्य

१. वडाको सिफारिस ग्रहण गर्ने ।

२. एउटा विरामीको एकै रोगको दोहोरो नपर्ने गरि, आवश्यक जाँचबुझ गरी निजको
आर्थिक अवस्थालाई हेरेर सुचिकृत भएका अस्पतालहरुमा उपचारका लागी सिफारिस
गर्ने ।

भुक्तानी प्रकृया

१) अस्पतालको उपचार विवरण अनलाइन अभिलेख विधिलाई अनिवार्य बनाइएको

२) सोही आधारमा प्रतिवेदन महाशाखामा प्राप्त भए पश्चात
सो को रुजु गरी भुक्तानी व्यवस्थापन समितिको बैठकमा पेश हुने
३) सो समितिको निर्णयानुसार भुक्तानी गर्ने व्यवस्था रहेको
अन्य मुख्य मुख्य व्यवस्था

(1) मृगौला रोगको डायलाइसिस हप्ताको २ पटक भन्दा बढी गर्नुपर्ने भएमा
चिकित्सकको सिफारिस अनिवार्य हुनुपर्नेछ । विरामीको माग अनुसार डायलाइसिस
दिन पाइने छैन ।

(2) पेरिटोनियल डायलाईसिसको Fluid महिनाको ९० प्याकेट सम्म हुने र सो भन्दा बढी
गर्नुपर्ने भएमा चिकित्सकको सिफारिस अनिवार्य हुनुपर्नेछ ।

३) उपचार खर्चको विलमा अनिवार्य रुपमा ड्युटीमा रहेका चिकित्सक, नर्स,

पारामेडिक्स, अन्य कर्मचारी मध्ये १ जना र विरामी वा विरामीको कुरुवाको दस्तखत
अनिवार्य गर्नु पर्नेछ

४) उपचार सम्बन्धी आम्दानी खर्चको लेखा परिक्षण गराउने जिम्मेवारी सम्बन्धित

अस्पतालको हुनेछ ।

अस्पतालको काम कर्तव्यहरु

(क) दफा ३ को उपदफा(४) बमोजिम सिफारिस भई आएका विपन्न विरामीको अभिलेख अनलाइन
विद्युतिय प्रविधिमा अनिवार्य रूपमा राखि अलग-अलग फाइल खडा गर्ने,

74
(ख) दोहोरो सिफारिस भई आएमा सेवा प्रवाह नगर्ने र सोको जानकारी **महाशाखालाई
दिने,
(ग) खण्ड क बमोजिमका बिरामीलाई सम्बन्धित चिकित्सक समक्ष प्रेषण गर्ने व्यवस्था
मिलाउने,
अस्पतालको काम कर्तव्यहरु
(क) दफा ३ को उपदफा(४) बमोजिम सिफारिस भई आएका विपन्न विरामीको अभिलेख अनलाइन
विद्युतिय प्रविधिमा अनिवार्य रूपमा राखि अलग-अलग फाइल खडा गर्ने,
(ख) दोहोरो सिफारिस भई आएमा सेवा प्रवाह नगर्ने र सोको जानकारी **महाशाखालाई
दिने,
(ग) खण्ड क बमोजिमका बिरामीलाई सम्बन्धित चिकित्सक समक्ष प्रेषण गर्ने व्यवस्था
मिलाउने,
*
(ग.१) मन्त्रालयबाट स्वीकृत स्तरीय उपचार प्रोटोकल (standard treatment protocol)
बमोजिम सेवा प्रदान गर्ने।
(घ) तोकिएको सहुलियत रकम सम्मको परिधिमा रही बिरामीलाई चिकित्सकको सल्लाह
बमोजिम आवश्यक पर्ने औषधि, औषधिजन्य सामाग्री, निदानात्मक सेवा, शल्यक्रिया, शैया
आदि समेत अस्पतालले उपलब्ध गराउनु पर्नेछ ।
(ङ) विपन्न विरामी नागरिकलाई प्राप्त हुने सुविधा बापतको रकमको सर्वाधिक सदुपयोग
हुने वातावरण अस्पताल आफैंले मिलाउनु पर्ने ।
*
(ङ१)सुचीकृत हुने अस्पतालले फार्मेसी सेवा संचालन गरेको हुनुपर्ने र
निर्देशिकामा सुचीकृत गरेका रोगहरुको लागी स्तरीय उपचार प्रोटोकल अनुसार आवश्यक
औषधीहरु अस्पताल फार्मेसीमा उपलब्ध हुनुपर्ने ।
(च) विपन्न बिरामी नागरिकलाई प्राथमिकताक्रम अनुसार उपचारको व्यवस्था
मिलाउनु पर्ने,
(छ) विपन्न विरामी नागरिकले औषधि उपचार सेवा लिइरहेको अस्पतालबाट अन्य विपन्न
सेवा उपलव्ध हुने अस्पतालमा थप उपचारको लागि प्रेषण गर्नुपर्ने भएमा विरामीले
पाउनु पर्ने बाँकी रकम बराबरको उपचार सुविधा पाउन सक्नेछन् । यसको लागि
सम्बन्धित अस्पतालबाट उपचार सुविधा पाएको रकम, प्रेषण पुर्जा र दफा ३ को उप दफा(४)
बमोजिमको समितिको सिफारिसको प्रतिलिपि समेत संलग्न गरी सम्बन्धित अस्पतालमा
पठाई सो को जानकारी **महाशाखालाई दिने,
(ज) खण्ड (छ) बमोजिमको व्यहोरा अनलाइन प्रविधिबाट अनिवार्य अभिलेख गरि प्रेषण
गर्नुपर्ने,
(झ) तोकिएको सहुलियत रकमभन्दा बढी रकम एक बिरामीको लागि खर्च नहुने गरी स्पष्ट
अभिलेखको व्यवस्था मिलाउने,
(ञ) खण्ड (घ) वमोजिम औषधि उपलब्ध गराएको अभिलेख अनुसूची ५ र अनुसूची ६ बमोजिमको
अभिलेख रजिष्टर तथा विद्युतीय प्रविधि अनलाइन रेकर्ड तथा अनलाइन रिपोर्टिङ
अनिबार्य राख्नु पर्नेछ । अनलाइन रिपोर्टिङ नगर्ने अस्पतालहरूको सम्झौता रद्द
गर्न सकिनेछ ।
(ट) अस्पतालले चौमासिक रुपमा सेवाको विवरण र खर्च भएको रकम अस्पतालको सूचना
पाटीमा सार्वजनिक गर्नुपर्ने,
(ठ) अस्पताल प्रमुखले ‘विपन्न विरामी नागरिकको उपचारको सम्बन्धमा समय समयमा
मन्त्रालय तथा महाशाखाले दिएको निर्देशन पालना गर्नु पर्ने,
(ड) अस्पतालले उपचार खर्चको सोधभर्ना माग गर्दा मासिक रुपमा अनुसूची–७,
अनुसूची–८ र अनुसूची–९ बमोजिमको प्रतिवेदन फाराममा भरी महाशाखामा प्रत्येक
महिनाको सात गतेभित्र अनिवार्य रुपमा पठाउनु पर्ने,

75
(ढ) विरामी डिस्चार्ज हुँदा तोकिएको रकम मध्ये के कति रकम वरावर उपचार सेवा
प्रदान गरिएको हो सो वारे विरामीलाई जानकारी दिई सोही अनुसार अनुसूची–५ र
अनुसूची–६ बमोजिमको अभिलेख रजिष्टर तथा विद्युतीय प्रविधिमा अनिवार्य रूपमा
अद्यावधिक गर्नु पर्ने,
(ण) विपन्न विरामी नागरिक वा निजको कुरुवा, ड्युटी चिकित्सक वा नर्सलाई
प्रत्येक विलमा दस्तखत गराई अस्पतालको बिरामी अभिलेख फाइलमा दुरुस्त
राख्नुपर्ने,
(त) विरामी अस्पतालमा भर्ना भएकै अवस्थामा सम्बन्धित स्थानीय तहको सिफारिश
माग गरेको र सिफारिस प्राप्त गर्न ढिला भएको अवस्थामा डिस्चार्ज हुने दिनसम्म
सिफारिश ल्याएमा सम्बन्धित अस्पतालले सम्बन्धित विरामीलाई तोकिएको सहुलियत रकम
वरावरको उपचार सेवा दिनु पर्ने र विरामीले सिफारिश माग गरेको जानकारी अस्पतालको
सामाजिक स्वास्थ्य सुरक्षा इकाईलाई जानकारी दिनु पर्ने, तोकिए भन्दा वढी रकमको
सोधभर्ना भुक्तानी हुने छैन ।
तर विरामीको उपचारका क्रममा मृत्यु भई दफा ३ को उपदफा
(४)बमोजिमको सिफारिस नल्याएमा अस्पतालका निर्देशक, उपचारमा सम्लग्न प्रमुख
चिकित्सक र सामाजिक स्वास्थ्य सुरक्षा इकाई प्रमुखले सिफारिस गरेमा विरामीको
खर्च भएको रकम सम्बन्धित अस्पतालले सोधभर्ना माग गर्न सक्नेछ ।
(थ) अस्पतालको सामाजिक स्वास्थ्य सुरक्षा इकाईमा आवश्यक जनशक्ति र प्रविधिको
व्यवस्था गर्ने गराउने जिम्मेवारी अस्पताल प्रमुखको हुनेछ,
(द) सामाजिक स्वास्थ्य सुरक्षा इकाइको साईन वोर्ड सवैले देख्ने गरी सम्वन्धित
अस्पतालमा अनिवार्य रुपमा राख्नु पर्नेछ ।
(ध) विभागबाट सोधभर्ना रकम प्राप्त हुन ढिला भएमा पनि सेवा अवरुध्द गर्न नपाइने,
**
(न) अस्पताल दर्ता एवम् नविकरण नेपाल सरकारको प्रचलित ऐन, नियमावली, स्वास्थ्य
संस्था स्थापना, सञ्चालन तथा स्तरोन्नती मापदण्ड सम्बन्धी निर्देशिका,२०७०,
प्रदेश र स्थानीय सरकारले जारि गरेको नियमावली /निर्देशिका ̷ मापदण्ड अनुरुप भएको
हुनु पर्नेछ ।
(प) बिरामीको उपचार गर्ने अस्पतालमा उपचार हुन नसकी थप उपचारको लागि अर्को
अस्पतालमा प्रेषण गर्नु पूर्व त्यस अस्पतालमा विरामीको उपचार हुने सम्बन्धमा
यकीन गर्नुपर्ने,
(फ) विपन्न विरामीलाई अनुसूचि-१२ को ढाँचामा विपन्न नागरिक औषधि उपचार सहुलियत
कार्ड उपलब्ध गराउनु पर्नेछ ।
(ब) एक्युट रेनल फेलियर भई छोटो अवधि डायलाइसिस गराउनुपर्ने विरामीको हकमा दफा ३
को उपदफा ४ बमोजिमको सिफारिश आवश्यक पर्ने छैन। अस्पताल प्रमुख वा निजले तोकेको
व्यक्तिको स्वीकृतीमा निःशुल्क सेवा प्रदान गर्नुपर्नेछ । यसरी उपचार गराएका
विरामीहरुको अभिलेख तथा प्रतिवेदन दुरुस्त हुनुपर्नेछ । बिरामी निको भई पुनः
सेवा लिन आउन परेमा सिफारिस अनिवार्य पेश गर्नुपर्नेछ ।
**
(भ) मृगौला प्रत्यारोपण पश्चात औषधि सेवन गर्ने विरामीहरुका लागी आवश्यक पर्ने
औषधिको व्यवस्था सम्बन्धित अस्पतालले मिलाउनु पर्नेछ ।
(म) विरामी थप उपचारका लागी अन्य सूचिकृत अस्पतालमा प्रेषण गर्नुपर्ने भएमा
सम्बन्धित अस्पतालले सोझै गर्न सक्नेछन् ।प्रेषण गरेको जानकारी शाखालाई
सम्बन्धित अस्पतालले गर्नुपर्नेछ । विशेष कारण बाहेक विद्युतीय प्रविधि(अनलाइन)
बाट अभिलेख नगरि गरिएको प्रेषण मान्य हुने छैन् ।
(य) विपन्न नागरिकलाई सुचिकृत अस्पतालबाट सेवा उपलब्ध गराइ सकेपछि सूचिकृत रोगको
तोकिएको औषधि उपचारमा तोकिएको शोधभर्ना हुने रकम सकिए पनि उसलाई थप उपचार

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गर्नुपर्ने भएमा साविककै सहुलियत दररेटमा सेवा उपलब्ध गराउनु पर्नेछ
दोस्रो संशोधनमा संशोधित व्यवस्थाहरु
१) बिपन्न नागरिक औषधी उपचार कोष निर्देशिकाको दफा ५ को उपदफा (न) मा अस्पताल दर्ता
एवम् नविकरण स्वास्थ्य संस्था स्थापना, सञ्चालन तथा स्तरोन्नती मापदण्ड
सम्बन्धी निर्देशिका,२०७०, प्रदेश र स्थानीय सरकारले जारी गरेको नियमावली
/निर्देशिका /मापदण्ड अनुरुप भएको हुनु पर्नेछ ।
२) बिपन्न नागरिक औषधी उपचार कोष निर्देशिकाको दफा ५ मा तपसिलको उपदफा (ट) र (ठ) थप
गरिएको
(ट) विपन्न नागरिक औषधी उपचार कार्यक्रमलाई आवश्यक पर्ने थप बजेटको व्यवस्था
मिलाउन मन्त्रालयलाई माग गर्ने ।
(ठ) थप अस्पताल सूचिकरण गर्दा सो क्षेत्रमा सेवाको आवश्यक्ताको सुनिश्चितता
भएपछि सूचिकरणको लागि मन्त्रालयमा सिफारिस गरिनेछ ।

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