1. Patient’s SignaturePrint NameDate Patient’s SignaturePrint NameDate In my opinion, a safe level of practice has been achieved in this section: Qualified Nurse’s signaturePrint NameDate I have been advised how much fluid is safe to remove as recommended in the current Renal Association Guidelines and by my individualised fluid loss regime as indicated in my medical notes. I am aware of the risks to my health if I do not follow this advice. I now feel safe and confident to do all of the above without direct supervision. I understand that by signing this, I take responsibility for following the procedure definitions. 20

2. Procedure definitions: Hand & Arm hygiene: Prepare 'putting on' pack: Prime needles: Check fistula/graft: Cleans hands & arm according to Unit/hospital policy. Understands the importance of this in reducing infection risks. Collects items and sets out pack, correctly using 'Aseptic Technique' Understands and practises the principles of 'Aseptic Technique'. Where appropriate, primes needles with agreed flushing solution according to unit procedure. Checks fistula/graft for bruit and signs of infection. Understands the importance of doing this daily as well as pre dialysis. Assess needle sites: Clean needle sites: Remove scabs & clean: Apply local anaesthetic: Insert needles: Understands how to assess most appropriate sites for insertion of needles. Cleans fistula/graft according to unit procedure. Understands importance of this in reducing infection risks. Removes scabs using correct technique, according to buttonhole procedure. Understands importance of correct technique & additional cleaning. Applies local anaesthetic, if required, according to unit procedure. Inserts arterial and venous needles safely according to unit procedure. Agreed technique: Tape needles securely: Explains rationale for using a specific method i.e. buttonhole or ladder technique. Applies tapes to needles safely and securely according to unit procedure. 6 Preparing my fistula/graft for dialysis 21

3. Hand & arm hygiene Prepare ‘putting on’ pack Prime needles (if required) Check fistula/graft Assess needle sites Clean needle sites Remove scabs if buttonholing & clean site Apply local anaesthetic Insert needles using agreed technique Tape needles securely KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse 6 Preparing my fistula/graft for dialysis ProcedureDate: 22

4. Hand & arm hygiene Prepare ‘putting on’ pack Prime needles (if required) Check fistula/graft Assess needle sites Clean needle sites Remove scabs if buttonholing & clean site Apply local anaesthetic Insert needles using agreed technique Tape needles securely KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse 6 Preparing my fistula/graft for dialysis (…continued) ProcedureDate: 23

5. I now feel safe and confident to do all of the above without direct supervision. I understand that by signing this, I take responsibility for following the procedure definitions. Patient’s SignaturePrint NameDate In my opinion, a safe level of practice has been achieved in this section: Qualified Nurse’s signaturePrint NameDate 24

6. Procedure definitions: Hand hygiene: Prepare 'putting on' pack: Assess exit site: Washes hands in accordance with Unit/Hospital Policy, at each appropriate stage Understands the importance of This in reducing infection risk. Collects items and sets out pack, correctly using 'Aseptic Technique' Understands and practises the principles of 'Aseptic Technique' Checks tunnelled line and decides if dressing needs changing. Remove & redress tunnelled line: Clean luer-lock connections: Remove luer-lock caps & aspirate locking solution If required, removes and disposes of old dressing according to unit procedure. Is aware of signs & symptoms of infection & action to take. Understands the importance of this in reducing risk of infection. Cleans connections using aseptic technique according to Unit procedure. Is aware of the importance of removing locking solution According to Unit procedure. Assess patency: Fully assesses the patency of the tunnelled line & is aware of the Unit protocol for a non- functioning tunnelled line. Preparing my tunnelled line for dialysis 7 Adhere to local standard operating procedure. 25

7. Hand hygiene Collect & prepare ‘putting on’ pack Assess exit site Remove old dressing & redress exit site if required Clean luer-lock connections Remove luer-lock caps & aspirate locking solution Assess patency of tunnelled line KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse Preparing my tunnelled line for dialysis 7 ProcedureDate: 26

8. Hand hygiene Collect & prepare ‘putting on’ pack Assess exit site Remove old dressing & redress exit site if required Clean luer-lock connections Remove luer-lock caps & aspirate locking solution Assess patency of tunnelled line Preparing my tunnelled line for dialysis (…continued) 7 KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse 27 ProcedureDate:

9. I now feel safe and confident to do all of the above without direct supervision. I understand that by signing this, I take responsibility for following the procedure definitions. Patient’s SignaturePrint NameDate In my opinion, a safe level of practice has been achieved in this section: Qualified Nurse’s signaturePrint NameDate 28

10. Commencing my dialysis 8 Stop re-circulation: Clamp off sodium chloride (Saline): Attach arterial line to take out needle/port & prime out blood: Takes dialysis lines out of re-circulation. Understands the importance of switching off the sodium chloride (saline) before connecting bloodlines. Connects arterial line safely using correct technique in relation to access. Understands when to start blood pump & at what speed. Attach venous line to put Back needle/port & start Blood pump: Check arterial & venous pressures: Give anticoagulant: Connects venous line safely using correct technique in Relation to access. Understands when to start blood pump & at what speed. Carries out these checks correctly and understands importance of carrying out these checks at this time i.e. poor needle position, bumping/blowing etc. Gives anticoagulant using correct technique according to unit policy. Understands timing & need to check correct dose. Record all pressures at baseline pump speed: Increase blood pump to required speed: Machine in 'Dialyse' mode Re check prescription Understands the significance of measuring all pressures at baseline pump speed. Identifies required pump speed and understands the importance of checking arterial and venous pressures & needle/connection sites. Selects 'dialyse' mode correctly & understands the consequences of failing to do so. Rechecks heparin dose & stop time, anticoagulant regime, dialysate concentrates and understands the importance of carrying checks out at this time. Procedure definitions: 29

11. Stop re-circulation Clamp off sodium chloride (saline) Attach arterial line to take-out needle/ port & prime blood out Attach venous line to put-back needle/port Start blood pump at baseline pump speed Check arterial & venous pressures Give anticoagulant(see section 12) Record all pressures at baseline pump speed Increase blood pump to required speed Put machine into ‘dialyse’ mode Re check prescription KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse Commencing my dialysis 8 ProcedureDate: 30

12. KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse Stop re-circulation Clamp off sodium chloride (saline) Attach arterial line to take-out needle/ port & prime blood out Attach venous line to put-back needle/port Start blood pump at baseline pump speed Check arterial & venous pressures Give anticoagulant(see section 12) Record all pressures at baseline pump speed Increase blood pump to required speed Put machine into ‘dialyse’ mode Re check prescription Commencing my dialysis (…continued) 8 ProcedureDate: 31

13. I now feel safe and confident to do all of the above without direct supervision. I understand that by signing this, I take responsibility for following the procedure definitions. Patient’s SignaturePrint NameDate In my opinion, a safe level of practice has been achieved in this section: Qualified Nurse’s signaturePrint NameDate 32

14. Discontinuing dialysis with my fistula/graft 9 Procedure definitions: Aware of completion of dialysis: Hand hygiene: Connect sodium chloride (Saline) to arterial line: 'Wash back': Identifies when dialysis is complete. Understands importance of completing prescribed time dialysis. Cleans hands using hand gel according to Unit/Hospital Policy. Understands the importance of doing this after the procedure, in reducing infection risk. Safely and securely attaches sodium chloride (saline) to arterial line. Performs 'wash back' to ensure all the blood is returned. Checks for clots/streaks. Understands the importance of washing back all the blood. Disconnect blood lines From fistula needles: Remove needles, apply pressure, apply dressings: Hand hygiene: Safely disconnects arterial and venous lines from fistula needles. Safely removes needles and applies correct amount of pressure to needle sites. Disposes of fistula needles safely according to Unit/hospital sharps policy. Ensures bleeding has stopped and applies dressings. Washes hands according to Unit/Hospital Policy. Understands the importance of doing this after the procedure to reduce infection risk. 33

15. Aware of completion of dialysis Hand hygiene Connect sodium chloride (saline) to arterial line ‘Wash Back’ Disconnect blood lines from fistula needles Remove & dispose of fistula needles, apply pressure, apply dressings Hand hygiene KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse ProcedureDate: Discontinuing dialysis with my fistula/graft 9 34

16. KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse Aware of completion of dialysis Hand hygiene Connect sodium chloride (saline) to arterial line ‘Wash Back’ Disconnect blood lines from fistula needles Remove & dispose of fistula needles, apply pressure, apply dressings Hand hygiene ProcedureDate: Discontinuing dialysis with my fistula/graft (…continued) 9 35

17. I now feel safe and confident to do all of the above without direct supervision. I understand that by signing this, I take responsibility for following the procedure definitions. Patient’s SignaturePrint NameDate In my opinion, a safe level of practice has been achieved in this section: Qualified Nurse’s signaturePrint NameDate 36

18. Discontinuing dialysis with my tunnelled line 10 Procedure definitions: Aware of completion of dialysis: Hand hygiene: Collect & prepare taking off' pack: Identifies when dialysis is complete. Understands importance of completing prescribed time. Cleans hands using hand gel & applies sterile gloves according to Unit procedure. Understands the importance of doing this before touching tunnelled line. Collects items and sets out pack correctly using 'Aseptic Technique'. Understands & practises the principles of 'Aseptic Technique'. Cleans luer-lock connections: Connect sodium chloride (saline) to arterial dialysis line: 'Wash back': Cleans connections using aseptic technique according to Unit procedure. Safely and securely attach sodium chloride (saline) to arterial dialysis line using aseptic technique & according to Unit procedure. Performs 'wash back' to ensure all the blood is returned. Recognises any reasons for not performing a washback. Checks for clots/streaks. Understands the importance of washing back all the blood. Disconnect blood lines from tunnelled line: Flush & lock tunnelled line: Attach luer-lock caps: Hand hygiene: Safely disconnects arterial and venous blood lines from tunnelled line. Flushes tunnelled line to maintain patency & is fully aware of locking guidelines. Identifies correct locking solution. Attaches luer-lock caps securely & is fully aware of rationale for doing this. Washes hands in accordance with Unit/Hospital Policy. Understands the importance of doing this after locking tunnelled line. Checks drug prescription & line for correct dose. 37

19. Aware of completion of dialysis Hand hygiene Collect & prepare ‘taking off’ pack Clean luer-lock connections Connect sodium chloride (saline) to arterial line ‘Wash Back’ Disconnect blood lines from tunnelled line Flush & lock tunnelled line Attach luer-lock caps Hand hygiene (Training by a qualified nurse only.) Adhere to local standard operating procedure. KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse Discontinuing dialysis with my tunnelled line 10 ProcedureDate: 38

20. KEY X S P C = Demonstrated by qualified nurse or level 3 support worker = Supervised closely by qualified nurse or level 3 support worker = Practising to become competent under distant supervision = Agreed as competent by qualified nurse Aware of completion of dialysis Hand hygiene Collect & prepare ‘taking off’ pack Clean luer-lock connections Connect sodium chloride (saline) to arterial line ‘Wash Back’ Disconnect blood lines from tunnelled line Flush & lock tunnelled line Attach luer-lock caps Hand hygiene (Training by a qualified nurse only.) Discontinuing dialysis with my tunnelled line (…continued) 10 ProcedureDate: 39