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Hemodialysis Flow Sheet -AVF

Policy 
To ensure the safety and well-being of residents undergoing hemodialysis with an arteriovenous fistula (AVF) by providing structured monitoring and documentation of the AVF site and related health indicators. 

Hemodialysis Flow Sheet – AVF Resident Name:  _________________________________________________________ 

 

Access Site AVF Location: ______________________________________________________________    Dialysis Schedule:  _______________________________________________ 

 

   

Date: 

 

 

 

 

 

 

 

Assess Site for the Following: 

 

Shift 

Sunday 

Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

Vitals              BP             TPR 

 

 

11-7 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7-3 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3-11 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bruit 

 

11-7 

 

 

 

 

 

 

 

          ( + ) Positive ( - ) Negative   

 

7-3 

 

 

 

 

 

 

 

           If negative notify MD 

 

3-11 

 

 

 

 

 

 

 

 

Thrill 

 

11-7 

 

 

 

 

 

 

 

          ( + ) Positive ( - ) Negative   

 

7-3 

 

 

 

 

 

 

 

           If negative notify MD 

 

3-11 

 

 

 

 

 

 

 

 

Scab Formation 

 

11-7 

 

 

 

 

 

 

 

          ( + ) Positive ( - ) Negative   

 

7-3 

 

 

 

 

 

 

 

           If negative notify MD 

 

3-11 

 

 

 

 

 

 

 

 

Pain at site or Moving  Arm 

 

 

 

 

 

 

 

 

 

          ( + ) Positive   ( - ) Negative 

 

 

 

 

 

 

 

 

 

          If positive, notify MD 

 

 

 

 

 

 

 

 

 

 

Signs & Symptoms of Infection (Pain, Redness, Swelling, Drainage, Fever) 

 

 

11-7 

 

 

 

 

 

 

 

          ( + ) Positive   ( - ) Negative 

 

7-3 

 

 

 

 

 

 

 

          If positive, notify MD 

 

3-11 

 

 

 

 

 

 

 

 

Signs & Symptoms of Fluid Deficit (Dizziness, Decrease BP, Increase P) or Fluid Overload (Shortness of Breath, Abnormal Lung Sounds, Increase in Edema) 

 

 

 

 

11-7 

 

 

 

 

 

 

 

          ( + ) Positive   ( - ) Negative 

 

7-3 

 

 

 

 

 

 

 

          If positive, notify MD 

 

3-11 

 

 

 

 

 

 

 

 

Initials of Nurse 

 

11-7 

 

 

 

 

 

 

 

Initials of Nurse 

 

7-3 

 

 

 

 

 

 

 

Initials of Nurse 

 

3-11 

 

 

 

 

 

 

 

Abnormal Findings Require Documentation in the Nurse’s Notes & MD Notification                                                         New 9/07 

 

 

References: 

  • Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

  • Requirements of Participation for Nursing Homes, CMS 

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