Attachment A

UPMC Shadyside

Hemodialysis Patient Care Rubric

PATIENT / ACCESS / MACHINE
BEFORE / Data Gathering
Assessment of Patient
Safe Patient Set-Up
Review of Orders
Determining Fluid Removal
Plan the Treatment / Assessment of Access Site
Assessment of Access / Water Safety Checks
Water Room
RO Machine
Machine Set-Up
Safety Checks
DURING / Assess Patient
Monitor Tolerance to Treatment
Documentation / Assess for Infiltration
Assess for Flow
Keep Access Visible at All Times / Machine Alarms
Assessment for Clotted
END / Assess Patient / Collect Blood Samples
De-access Catheter, AVF or AVG
Replace Dressing if Indicated / Rinse Back
AFTER / Assess Patient
Final Documentation
Call Report
Communicate Safe Hand Off
Discharge Patient / Monitor Access Site for Bleeding / Post Machine Cleaning and Maintenance
Documentation of Ready to Use.

Attachment B

UPMC Shadyside

Hemodialysis Patient Report/Chart Review

This form should be used as a template for report from the floor nurse.

It is intended to give more Dialysis specific information to enhance patient safety.

Best used in conjunction with the Nurse Hand off Report and Chart (written & electronic).

This form is not part of the medical record.

Diagnosis/Active Problems:______

Current Condition:______

Allergies:______

Testing / Procedures for Today:______

Isolation:______Patient transported via: BedCarrier Wheelchair Ambulatory

Contact Physician for Non-Renal Issues/Concerns:Pager:

Renal Team Contact:Pager:

Neuro / LOC
Orientation
Demeanor
Seizure Risk / Psych/
Social
Cardiac / Cardiac history
Rhythm & Rate
Monitor for transport
BP Issues
Medications / Y / N
Y / N
Y / N
Y / N / HR:
BP: / Trends:
Resp / Lung sounds
Oxygen requirements
Respiratory effort
Respiratory treatment
Aspiration Risk / Y / N
Y / N
Y / N
Y / N / NC L/min ______FM %___
Chest X-Ray: / Pulse Ox:
RR: / Trends:
GI / NPO/Diet
Last meal
Diabetic:
Insulin Treatment
N/V/diarrhea / Y / N
Y / N
Y / N
Y / N
Y / N / Tube feeds/rate
Last CBS/time
Insulin:
Coverage dose needed
GU / Foley / Y / N / I& O Past 48 Hours:
Mobility / Restraints
Fall Risk
Wander Risk / Y / N
Y / N / Independent / Partial / full assist
Activity Level: BR/ OOB/UP ad lib
Skin / Bruising, wounds, breakdown / Y / N / Lines, tubes & drains
Dialysis & Access / AVF/G or Catheter / Lab work needed:
Drips & drugs & IVs / IVF/ PCA to last through treatment?
Did pt receive any antihypertensives?
Verify if pt received Midodrine
Did pt receive topical anesthetics
Heparin infusion
Blood products to be administered / Y / N
Y / N / NA
Y / N / NA
Y / N / NA
Y / N / NA / IV Access:
Last medicated for pain
Fluids: Type: Rate:
Midodrine - admin 30 min before tx
Meds &
Pain Rx / Given: / Labs /
Due:

Attachment C

UPMC Shadyside

Hemodialysis Planning the Treatment Worksheet

Pre / During / End / Post
Medications / Insulin
Pain
Anxiety
BP
Antibiotics
Other
Blood / T & C
Transfuse / Product
Labs / CBS
BMP
CBC
Cultures
Other
Check Results
Meals
HD Rx / UF
K+
Mannitol
SPA
Flushes
Transonic
BP Threshold
Critline
Calls / MD
Report
Lab
Radiology
Transport
Dietary
Other
Post Rx Plan