DATE: _____________________

DRY WT: ________

DIALYSIS NO.: _________

PRE DIALYSIS
Pre Wt.: _______
Loss: _____
BP
: _______
RR: _____

POST DIALYSIS

Gain
HR: _____

UF Goal: ___________ Treatment

Time ______
Program Used:
__________________________
Sequential: _______ Hr.: ______ Min.:
_____
UF Profile:
_________

BLOOD TYPE: ________

Na Profile

SLEDD: Time: _________ DFR:

__________

Post Wt.: _______

Loss: _____
BP
: _______
RR: _____

REMINDERS

Gain
HR: _____

Pre
___________________________

HD

Post
___________________________

HD

HEPATITIS STATUS

Machine No.: _______

Dialyzer Size:
F6
F7
F8
NEW
Number of Re-Uses : _________
HI-FLUX: ________
NEW
Number of Re-Uses : _________
Dialysate Bath: Bicarbonate

HbsAg:
Non-Reactive
Reactive
Date Taken: _______________________
HCV:
Non-Reactive
Reactive
Date Taken: _______________________

PRE HD NURSING ASSESSMENT

[ ] Ambulatory
[ ] Wheelchair [ ] Stretcher
[ ]
Pale Appearance
[ ] Dyspneic
[ ] Rales
[ ] Wheezing [ ]
Dry Cough
[ ] Productive Cough
[ ] Distended
Abdomen
[
]
Pain
(0-10):
[ ___ ]
Location:
_______________________________
[
] Edema:
1
2
3
Location:__________________________
[
]
Signs
of
Bleeding:
__________________________________________
[
]
Others:
__________________________________________________

POST HD NURSING ASSESSMENT

[ ] Pale Appearance
[ ] Dyspneic
[ ] Rales
[ ] Wheezing
[ ] Dry Cough
[ ] Productive Cough [ ]
Distended Abdomen
[ ] Pain (0-10): [ ___ ]
Location:_______________________________
[ ] Edema:
1
2
3
Location:__________________________
[ ] Signs of
Bleeding: ________________________________________
[ ] Left facility in stable / Improved condition
[ ] Others:
________________________________________________

VASCULAR ACCESS LOCATION

AV Fistula
____
Femoral ____
____
Perm-Cath ____
AV Shunt ____
____
Subclavian ____
Others:
__________________________

VASCULAR ACCESS ASSESSMENT

Graft

Strong Thrill / Bruit

with Bruit
Weak Thrill / Bruit
Bruit

IJ Cath

Absent Thrill,
Absent Thrill /

Redness

CANNULATION

Hematoma

CENTRAL CATHETER ASSESSMENT

With Ease
Poor Backflow
No Backflow
Infiltrate

Both Patent

Arterial Clotted

Venous Clotted

Both Clotted

Redness

Pus

INSTILLATION POST HD:

Dura-lock w/ Heparin

Heparin

Dose

Number of Punctures

Arterial ________ ml

Venous ________ ml

Dressing Done By: ______________________________________

Needle Gauge Used:
Xylocaine 2 %

[ A ] _____
Yes

[ V ] _____
No

Cannulation Done By:

______________________________________

A N T I C O A G U L A T I O N
LOW MOLECULAR WEIGHT HEPARIN (LMWH)
Enoxaparin Na ______
Nadroparin ______

UNFRACTIONATED HEPARIN (UFH)

LOADING:

1000 IU

UNITS PER HOUR:

500 IU

2000 IU
1000 IU

mg
PNSS Flushing
__________________________________________

H E M O D I A L Y S I S
TIM
E

BP

HR

BFR

AP

VP

TMP

M O N I T O R I N G

UFV

C O M M E N T S

Dr.

Nurse/s
On Duty

Attending

Physician

Patient Name: _______________________________________________________________

Age: _________
F
M
Last Name
Given Name
Middle Name
MODE OF DISCHARGED:
Hospital No.:

Ambulatory

Wheelchair

Gender:

Stretcher

M E D I C A T I O N S
TIME

SIGN & SYMPTOMS

PRE / INTRA / POST

MEDICATIONS GIVEN

B L O O D
TIME

VOL.

SERIAL NO.

ROUTE

ADMINISTERED
BY

T R A N S F U S I O N
BLOOD PRODUCT

P H Y S I C I A N S
PROGRESS NOTES

DOSAG
E

VERIFIED BY

ADMINISTERED
BY

O R D E R S

TIME

Date & Time

NOD Signature

AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT WITHIN DIALYSIS UNIT

I, the undersigned, a patient of Adventist Medical Center Iligan Dialysis Unit, hereby authorized

Dr.

Dr., with the Staff of AMC-Iligan Dialysis Unit to administer such treatment as necessary, and to perform the
following procedures:
Routine Hemodialysis
Blood transfusion

Others: ______________________________________

And such additional procedures that will be considered therapeutic and necessary upon the findings during the
course of treatment. I hereby confirmed through my signature below, that I have fully understood the above name
procedure/surgery its considerations, advantages and whatever complications. I fully understood that no guarantee or
assurance has been discussed as to whatever results may obtain during or after the procedure.
In case of LEGAL ACTIONS that may arise in the future out of this condition/s, I agree to submit myself to the
jurisdictions to the COURTS OF LAW of ILIGAN CITY and not on other places.
____________________________________________
______________________________
Patients Signature over Printed Name

Date:
Or

_______________
____________________________________________
___________________________________
Signature over Printed Name of the Relative
Relation to Patient
Witnessed by:
_____________________________________________
Signature over Printed Name of NOD

Time: