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Hemodialysis Flow Sheet- Catheter

Hemodialysis Flow Sheet – Catheter Resident Name

Goal 

To ensure the safety and well-being of residents undergoing hemodialysis with a permanent catheter by providing structured monitoring and documentation of the catheter site and related health indicators. 

Policy 

To ensure continuous and effective monitoring of residents with permanent catheters undergoing hemodialysis, ensuring timely identification and management of any complications or issues. 

 

Hemodialysis Flow Sheet – Catheter Resident Name:  __________________________________ 

 

Access Site Permanent Catheter 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 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dressing Intact/Catheter Cuff Intact (Cuff Protrudes if dislodged) 

 

11-7 

 

 

 

 

 

 

 

          ( + ) Positive ( - ) Negative   

 

7-3 

 

 

 

 

 

 

 

           If negative notify MD 

 

3-11 

 

 

 

 

 

 

 

 

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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