The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [250]
Although a very useful tool, fluid balance charting should not be used in isolation. When considering fluid and electrolyte balance, additional triggers such as physical assessment and monitoring plasma levels of electrolytes should be integral to the observation and care of a patient with actual or potential fluid and electrolyte imbalances (NICE 2007).
Nursing assessment is discussed in detail in Chapter 2 and the assessment of a patient’s fluid status should be an integral part of any admission and subsequent daily assessments, particularly if the patient is critically ill and/or a fluid deficit has been identified. See Table 8.3 for details of what should be included in a fluid status assessment.
Table 8.3 Assessment of fluid status
Within fluid management, and particularly fluid resuscitation, there is an ongoing debate surrounding the benefits of the use of colloids over crystalloid for fluid replacement. Perel and Roberts (2007) conducted a systematic review of the evidence and concluded that there is no apparent benefit to the patient when using colloid rather than crystalloid. The UK Adult Resuscitation Guidelines (Resuscitation Council 2005) agree that there is no benefit in choosing colloid over crystalloid but they do recommend that dextrose is avoided due to the redistribution of fluid from the intravascular space and because it may cause hyperglycaemia.
Rationale
Indications
Any patient who has shown signs or symptoms of a fluid imbalance or those having undergone surgery or acute illness that has led to critical care admission should have their fluid intake and output monitored and fluid balance calculated on an hourly basis (Mooney 2007). The decision to monitor fluid balance should be a multidisciplinary one; however, it is the responsibility of the bedside nurse to ensure this is done so accurately.
Legal and professional issues
The NMC Code (NMC 2008a) clearly states that clear and accurate records must be kept; this includes fluid balance charts. Nurses should have an understanding of the mechanisms of fluid balance and identify potential imbalances and the problems associated with these imbalances.
Preprocedural considerations
In order to monitor fluid balance, both input and output must be accurately measured. Below are procedural guidelines for measuring input and output. If the patient is awake, able to take oral fluids and is mobile, they must be educated about the fact that their fluid balance is being monitored and each drink must be recorded, as should each episode of passing urine, bowel motion or vomiting and so on. It is helpful to provide a cup with markings showing volume.
It is important to note that patients may have other means of urine output, for example an ileal conduit, ureteric stents, suprapubic catheterization, neo bladder. The same concepts can be utilized to measure the output, by attaching an urometer to the catheter or the urostomy bag.
Procedure guideline 8.1 Fluid input: measurement
Essential equipment
Fluid balance chart
Appropriate pumps for fluid or feeding
Preprocedure
Action Rationale
1 Educate the patient about the fact that their fluid input is being monitored and ask them to alert you to any oral intake.
To ensure the patient is aware of the need to record any oral intake so this can be noted accurately (Baraz et al. 2009, R4).
2 Obtain fluid balance chart and document patient’s name and the date commenced.
To ensure chart is correctly labelled for the correct patient, allowing accurate documentation (Powell-Tuck et al. 2009, C).
3 Ensure pumps available for