My Kidney and Pancreas Transplant Discharge Checklist
Name: _____________________________________________
Date of Surgery:_________________
Target Discharge Date:_________________
Location of Anticipated Discharge: (circle one)
Home Environment
Special Care
This checklist is to better prepare you for discharge. Use it as a guide in preparation for discharge. If you
have any questions about anything on this checklist, please do not hesitate to ask a nurse or doctor.
Once you feel you have completed any of the following, check the box on the left.
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I can breathe normally or have a care plan to address any breathing issues.
I walk in the hallway without help multiple times a day or can ambulate with some help.
I can use the toilet and shower on my own, or with one person’s help.
I can dress and groom myself.
I have passed gas, or have had a bowel movement.
My blood sugars are under control, and I will continue to monitor blood sugar at home.
I have my discharge medications or signed prescriptions.
I know the equipment needs I have.
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I have the ability to take my medications, or I have a family member or friend that will assist me.
I have discussed my medications with the Transplant Pharmacist before discharge.
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Questions or comments in this section can be best answered by the social worker..
I understand the importance of hydration, and have home health for additional IV fluids upon
discharge.
I am able to tolerate my diet, and understand any special diet I may have.
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Questions or comments in this section can be best answered by the transplant pharmacist.
I have someone to stay with me when I am discharged.
I have transportation for when I am discharged.
I have housing for when I am discharged.
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Questions or comments in this section can be best answered by the primary nurse, physical
therapist, or occupational therapist.
Questions or comments in this section can be best answered by the dietician.
I have my follow up appointments.
I know how to contact the Transplant Coordinator. I have talked with the Transplant
Coordinator prior to discharge.
I know what symptoms to watch for with regard to infection and rejection.
My Kidney and Pancreas Transplant Discharge Checklist
The following should be checked off by a member of your transplant care team when they believe it
applies to you.
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Fluid status is not greater than 20% over pre-transplant body weight or care plan established.
 Name and date: _______________________________________________________
Serum creatinine (kidney function) is stable or care plan established
 Name and date: _______________________________________________________
Serum Amylase and Lipase are stable or care plan established
 Name and date:________________________________________________________
Wound is clean and dry or care plan established
 Name and date: _______________________________________________________
Urine output is adequate and amount of time with foley catheter in place has been
communicated.
 Name and date: _______________________________________________________
No special needs or special needs resolved.
 Name and date: _______________________________________________________
Glucose readings consistently below 250 mg/dL for 8 hours, or trending toward goal and care
plan established.
 Name and date: _______________________________________________________
Has no anticoagulation issues or demonstrates understanding of anticoagulation management
 Name and date: _______________________________________________________
Please ask for any assistance in filling out this card if you have questions. Also, if you have any extra
comments you would like to leave with us regarding your discharge process, please leave them here:
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Ready for discharge: