Fluid Balance

Fluid Balance Guidelines

Clinical Educator Team (Acutely Ill)

Aim To facilitate good practice in fluid balance

monitoring To provide staff with the teaching tools

necessary to improve practice

Objectives By the end of this presentation staff should

be able to: Articulate why fluid balance is important State which patients should start fluid balance Critique a badly completed fluid balance chart Demonstrate how to approximate input and

output if exact amounts are not known State that they have read and understood the

fluid balance guidelines

Rationale• Fluid balance is an essential tool in

determining hydration• If there are problems with fluid balance

then it may indicate warning signs that the patient is actually or potentially acutely ill

• If fluid balance is not done correctly then, such signs can be missed resulting in:

• Late referral & missed opportunities• Unexpected deterioration• Prolonged stay• In some cases - Death

Bottom Line

• The acutely ill competencies put forward by NICE (2008) cite fluid balance as a key requirement for staff to demonstrate skill

• All health care staff within this Trust have to assume responsibility to ensure that they are competent and that they are meeting national and local guidelines regarding this

Key Factors for Fluid Balance

Timely and appropriate rational for starting and stopping

One set method for recording detailed and accurate input/output

Insensible loss (part of output) Appropriate application/use of the

fluid balance monitoring

When to start fluid balance?

Actual or potential dehydration

Nil by mouth Diarrhoea Excessive vomiting Excessive surgical loss Excessive wound exudate

When to start fluid balance?

Commencing IV fluid

Actual or potential acute illness Risk of level 2 or 3 care Sepsis EWS triggered/patient unstable

When to start fluid balance?

Routine post op management

Fluid restriction Unstable cardiac failure Liver failure Acute renal failure

Doubt over fluid status

When to stop fluid balance? Reason for commencement has resolved End of life care

Stopping fluid balance is the decision of a senior clinician or sister/charge nurse only

Patients must be assessed thoroughly before making such a decision

Accurate Input - IV

If IV fluids are running without a pump (e.g. drip rate), write on the chart the name of the fluid only (not the volume). The volume is only entered once the fluid is complete

If IV fluids are running through a pump, then the hourly rate needs to be entered…

Accurate Input - IV

Time Input Output

Oral IV Other Urine Drains Other

0100 1000ml

0200 150ml

0300

0400

0500

IV fluid commenced here

How not to document fluid going through an IV pump

Accurate Input - IV

Time Input Output

Oral IV Other Urine Drains Other

0100 Nacl 1 litreCommenced

0200 125ml 150 ml

0300 125ml

0400 125ml

0500 125ml

How to document fluid going through an IV pump

Accurate Input - IV

The practice of documenting the full volume of fluid on commencement has a larger margin for error

Make it clear on the chart the name of the fluid that has gone up

Don’t forget to flush IV lines with saline before and after bolus drugs and record the flush amount (it can add up to a lot in some patients)

Accurate Input - IV

When IV infusions are commenced it is an important opportunity to record observations of the cannula (VIP score)

If you are using a CVP or Hickman line – there are similar opportunities

Accurate Input - Oral Clearly document all other forms of input Oral input should not be guesswork if you can help it.

You can: Get patients and/or relatives to chart it Make sure everyone is aware of those patients who

are drinking less and pay closer attention to that patient – this may mean reviewing their chart more regularly (e.g. 2-3 hourly)

Ensure people are aware of what is in a cup or jug (or pot is sips are used)

Alert domestic staff to patients ‘of concern’ so they can tell you before removing or replenishing jugs

Ensure that if the jug is half empty its not because the jug has been spilled!

How much?

How much is in these containers if they are full?

About 150ml

Standard Cup

How much?

How much is in these containers if they are full?

About 200ml

Standard Glass

How much?

How much is in these containers if they are full?

About 1000ml

Standard Jug

How much?

How much is in these containers if they are full?

About 60ml

Gallipot

Standard Glass = 200ml Standard Cup = 150ml

Standard Jug = 1000ml Standard Gallipot = 60ml

Accurate Input – Sips!

Do not document ‘sips’. Document in mls

If you use a gallipot for sips its 60ml

Complete the running total column

Accurate Input – Running TotalTime Intake (ml) Output (ml)

Oral IV Other RunningTotal

Urine NG Other(Drain)

Running Total

2400 83 83

0100 83 166

0200 83 249 300 300

0300 83 332 60 360

0400 50 83 465

0500 83 548 150 510

0600 150 83 781 100 610

0700 100 83 964

Accurate Input – Running Total This might seem more complicated than it really is.

Simple maintenance of the chart for very brief moments during the day will make this easy. Leave it all for night staff to do and then it becomes a very difficult task indeed

Let’s look at the input side: You can see at 2400 the patient has had 83ml To keep the running total going, add this onto the

next hours input So, 83+83 = 166 and so on At 0400, its not just 83ml to add, the patient also had

50ml orally, so for that hour they had 133ml Added to the previous hours running total of 332 this

gives an hourly total of 465

Insensible Loss

The process whereby fluids are lost through sweating, breathing and so on

This can add up to a surprising amount

Take the example of a 100kg man…

Insensible Loss

100kg man Divide the figure in half This is what he is losing PER HOUR Multiply this by 24 and you get:

1200ml lost Just from normal sweating & breathing!

Insensible Loss

It is unrealistic to expect staff to work out this calculation for every patient, (it has been tried!)

New fluid balance charts will have an averaged amount stencilled into the output

Insensible loss is added to the patients output

So, if the patient’s output is 1500ml and insensible loss is 600ml – overall output is 2100ml

Detailed & Accurate Output

All forms of fluid loss must be accounted for with as much accuracy as is reasonably possible

Poor documentation can be life threatening, especially when one is dealing with urine output

Running totals must be completed during the day (as seen earlier when discussing input)

Output - Urine

It is unacceptable to write ambiguous comments for urine output (unless they have passed into the toilet)

If patients meet the criteria for fluid balance then they meet the criteria for accuracy

Patients must be encouraged to use receptacles for urine collection and measurement

Output - Urine Acute staff must be able to estimate

urine output in cases of incontinence

What does this mean in terms of accuracy?

inc PU’d ++

Output - Urine

Try this technique:

Pick an incontinence pad Pour in 200mls. How does that feel when you hold the pad? Pour in 600mls. How does that feel when you hold the pad?

Output - Urine

You will quickly learn to estimate

Go ahead - try it You will be

surprised how easy it gets after 2 or 3 tries

So if its that easy why not record your estimate instead of writing the meaningless ‘pu’d’?

Of course, if it was real urine, she would be wearing gloves and an apron…

Output - Urine

Wet on the bed? Its too hard to estimate Or is it? How much do you think this is? Its been there for 5 minutes…

About 50ml

Output - Urine

Wet on the bed?

How much do you think this is? Its been there for 5 minutes… Still hasn’t had a chance to soak in. By the time it has your

talking about half the sheet!

About 200ml

Output - Urine

Wet on the bed? Try it for yourself:

Pick an empty bed and pop a sheet on Pour on half a glass of water Go back in 5 minutes See how much your colleagues guess

Generally: 100ml gives about 1/3 of a wet sheet 200ml gives 1/2 – 2/3 of a wet sheet 300ml+ gives almost a fully wet sheet

Output - Urine

Emergencies: If the patient is catheterised and you

know the patient’s urine is borderline (e.g. on or near 30ml/hr) you can write the urine output as an observation on the track & trigger observations chart

If the urine is less then 30ml/hr for up to three hours in a row you can then award it an Early Warning Score of 4

If added to other parameters this could add up to a high EWS indeed!

Output - Urine

EWS of 4 or more: This would merit an immediate call to

the patient’s primary team doctor AND critical care outreach team

Output - other

Enter stoma or drain output carefully Take care with multiple episodes of

diarrhoea or vomiting that attempts are made to arrive at an estimated volume

Don’t forget to account for blood loss and/or wound exudates (as with urine ouput – its best estimate)

Completing fluid balance The nurse must sign to say he/she

has started the chart The nurse completing the chart and

working out the balance has to sign for completion at the end of the 24 hour period – this is usually night staff

If night staff have not done this it falls to the next shift

Completing fluid balance

Total Intake(a)

Total Output Balance (a-d)

Output (b) Insensible (c) Both b & c (d)

1863 1925 600 2525 - 662

Complete the total intake (a) Complete the output (b) Add in the insensible loss (c) Add the output & insensible loss together (b+c) to make d Subtracting the output from the intake (a-d) to enable the final amount in the balance box as either zero, minus or plus

When to Review Fluid Balance

Routinely Emergencies EWS Triggers Concern

Reviewing - Nurse

Routinely review yesterdays balance at the start of the shift

Review new fluid balance during the middle of the shift or as often as required

Review immediately if the patient develops an emergency, EWS trigger or if you have concerns

Reviewing - Nurse Immediately refer to the doctor if:

Concern over fluid balance Poor oral intake Poor urine output (less than 30mls for

three hours in a row). If this occurs – also call Critical Care Outreach

Greater than 150ml hour for three hours in a row and no diuretics have been given

No IV present and patient is nil orally

Reviewing - Doctor

Routinely review yesterdays balance during routine review and/or ward round

Review immediately if the patient develops an emergency, EWS trigger or if you have concerns

Reviewing - Communication On shift handover nursing staff must ensure

that they clearly indicate which patients are on fluid balance and which present concern

When patients are transferred between wards and departments – verbal and written documentation must include fluid balance and any concerns

F1 doctors must alert an F2 doctor immediately if there are concerns about fluid balance which cannot be resolved

Quality Initiatives

Any deviation from the guidelines that lead to deterioration of the patient require an incident report and consideration as a serious untoward incident

Areas will be subject to regular audits of fluid balance

Quality & Audit If accuracy on audit is less than 80% then

managers for each area will be expected to submit an action plan to the Critical Care Outreach Team (CCOT) Leader

All critical care areas not meeting 80% accuracy will be subject to random audit by CCOT and Senior Nursing Management

Areas above 80% will be subject to annual audit

Responsibility for audit compliance lies with the Senior Clinical Nurses/Matrons or directors

Quality & Audit Thoroughly evaluate priorities in your area If increasing performance on fluid balance

causes a decreased in performance on other aspects of care, then report it appropriately

Set up meetings and awareness sessions with staff

Identify ward champions to re-train staff using this tool and the guideline

Accountability is with individuals and personal responsibility framework should be considered for persistent non compliance

Objectives Armed with what you now know:

Can you?

Articulate why fluid balance is important State which patients should start fluid balance Critique a badly completed fluid balance chart Demonstrate how to approximate input and

output if exact amounts are not known State that you have read and understood the

fluid balance guidelines