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: _______________________________________________
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Assess Site for the Following: |
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Shift |
Sunday |
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
Saturday |
Vitals BP TPR |
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11-7 |
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7-3 |
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3-11 |
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Bruit |
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11-7 |
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( + ) Positive ( - ) Negative |
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7-3 |
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If negative notify MD |
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3-11 |
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Thrill |
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11-7 |
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( + ) Positive ( - ) Negative |
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7-3 |
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If negative notify MD |
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3-11 |
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Scab Formation |
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11-7 |
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( + ) Positive ( - ) Negative |
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7-3 |
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If negative notify MD |
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3-11 |
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Pain at site or Moving Arm |
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( + ) Positive ( - ) Negative |
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If positive, notify MD |
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Signs & Symptoms of Infection (Pain, Redness, Swelling, Drainage, Fever) |
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11-7 |
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( + ) Positive ( - ) Negative |
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7-3 |
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If positive, notify MD |
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3-11 |
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Signs & Symptoms of Fluid Deficit (Dizziness, Decrease BP, Increase P) or Fluid Overload (Shortness of Breath, Abnormal Lung Sounds, Increase in Edema) |
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11-7 |
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( + ) Positive ( - ) Negative |
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7-3 |
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If positive, notify MD |
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3-11 |
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Initials of Nurse |
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11-7 |
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Initials of Nurse |
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7-3 |
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Initials of Nurse |
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3-11 |
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Abnormal Findings Require Documentation in the Nurse’s Notes & MD Notification New 9/07
References:
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Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM)
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Requirements of Participation for Nursing Homes, CMS