The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [253]
Action Rationale
1 Determine sources of fluid output (see Table 8.2) and note them on the fluid balance chart.
To ensure all possibilities have been considered to ensure accurate (as possible) output determination (Scales and Pilsworth 2008, E).
Procedure
2 Explain to the patient that it is necessary to monitor volume of fluid excreted, including that from the bowel, particularly if the stool is loose/watery.
To keep the patient informed about current care and observations, to ensure co-operation in monitoring fluid output (Bryant 2007, E).
3 Provide the patient with bedpans, even if able to mobilize to the bathroom; ask them to place the bedpan over the toilet bowl.
To enable inspection and measurement of fluid lost via the bowel. E
4 If stool is loose enough, this can be transferred into a jug and the volume measured, or use scales.
To quantify fluid output from stool (Scales and Pilsworth 2008, E).
5 If the stool is formed and it is not possible to accurately quantify, still note on fluid balance chart that bowels were opened.
To take into account any insensible losses (Mooney 2007, E).
6 A rectal tube may be suitable in some patients; please refer to local policy regarding use of rectal tube. Note any output on the fluid balance chart.
To ensure correct use of tube and to quantify any fluid losses from the bowel. E
7 Add losses to the previous losses for the hour.
To calculate hourly fluid output (Sumnall 2007, E).
Postprocedure
8 Once all output has been determined, noted on chart and total hourly output calculated, subtract total output from total input.
To calculate hourly fluid balance (Levi 2005, E).
Procedure guideline 8.7 Fluid output: monitoring output from stoma sites
Essential equipment
Measuring jugs (with volume indicators)
Gloves, apron, goggles
Preprocedure
Action Rationale
1 Determine sources of fluid output (see Table 8.2) and note them on the fluid balance chart.
To ensure all possibilities have been considered to ensure accurate (as possible) output determination (Alexander et al. 2000, E).
Procedure
2 Explain to the patient that you are monitoring hourly output.
To ensure the patient understands why their stoma is being checked hourly. To ensure they are up to date with current care (Bryant 2007, E).
3 Check that the stoma bag is drainable; if not, change (see Chapter 6 for further information and procedure guidelines on stomas and changing stoma bags).
To ensure ease of draining bag contents and to reduce the number of times the adhesive flange is removed, in order to protect the skin. E
4 Using protective equipment, empty the contents of the stoma bag into the measuring jug, noting volume.
To determine output from stoma for 1 hour and prevent cross-infection (Fraise and Bradley 2009, E).
5 Dispose of contents using protective equipment, adhering to local policy.
To ensure correct disposal of contents and prevent cross-infection (Fraise and Bradley 2009, E).
6 Note volume of stool on chart; add to other losses for the hour.
To ensure correct documentation of output and allow calculation of fluid balance (Sumnall 2007, E).
7 Add hourly total (all outputs) to cumulative output (see Figure 8.2).
To enable fluid balance determination (Sumnall 2007, E)
Postprocedure
8 Once all output has been determined, noted on chart and total hourly output calculated, subtract total output from total input.
To calculate hourly fluid balance. E
Problem-solving table 8.1 Prevention and resolution (Procedure guidelines 8.1–8.7)
Postprocedural considerations
Every hour the findings of fluid monitoring should be recorded; any deficit or change in fluid balance should be reported. Any imbalance noted will require action and a management plan. The nurse recording the fluid balance should have an appreciation of the importance of fluid imbalance management and should notify the appropriate person.
Complications
Correct fluid balance monitoring is essential in the successful management of actual or potential fluid balance disturbances (Jevon and Ewens 2007). Over- or underestimation