Hachiro Assessment Name * First Name Last Name Today's Weight (kg) dry * Any shortness of breath? * Yes No If so, when does it occur? At rest On increased physical movement On general/daily physical movement Daily UF in litres, total extra fluid from all CAPD bags? * Oral Daily intake (L) * Daily Urine output (L) * Blood pressure * Heart rate * Any Oedema (fluid build up in the lower legs, ankles, hands, under the eyes?) * Location of oedema * CAPD Regime Bags Bag No. / Volume (L) / Strength (%) / Fluid Type: Bag 1 / 1.5 / 1.5 / Balance Bag 2 / 1.5 / 2.3 / Balance Bag 3 / 1.5 / 1.5 / Balance Bag 4 / 1.5 / 2.3 / Balance Calculated Totals Total daily volume: 6 L Total weekly volume: 42 L CAPD Regime Bags * Copy & Paste above text into box below CAPD Regime, is this still correct? Exit Site, please describe appearance * Any crusty bits? Any redness? Pus? Infection recently? If so, was it treated with antibiotics? Do you wear a dressing (change daily after shower) and anchor tape each day? * Appetite * Select option Poor Fair Good Bowels Regular? * Yes No Do you use laxatives to open bowels daily? * Yes No Recent Peritonitis – are the bag exchanges fluid clear? * Yes No Any upcoming Pending procedures / surgeries ? * Any changes in Medications? * Yes No If so, please list: Are we doing the monthly blood test for dialysis? * Yes No Did you receive via email the upcoming pathology forms from Fresenius? * Yes No Are you applying Mupiricin each week to your nose? * Yes No Which day? Monday Tuesday Wednesday Thursday Friday Saturday Sunday When is your next kidney doctor appointment? assessment completed!
