Fluid Balance Monitoring

WHAT IS FLUID BALANCE? WHO IS RESPONSIBLE: MONITORING AND ESCALATION

Fluid balance is a term used to describe In order to maintain homeostasis, the adult human body needs a fluid Trained Nurses Doctors
intake of 2-3 litres (25-30ml / kg per day), allowing it to keep a balance of
the balance of input and output of fluids in the nutrients, oxygen and water, which are necessary to preserve a stable • Identify patients who need fluid balance monitoring and communicate • Daily review:
the body, to allow metabolic processes to healthy internal environment. Output should be roughly equal, though via whiteboard behind bed, handover Indication for monitoring, is it still necessary?
Goal – document with special instructions such as restrictions or
function properly. ‘insensible losses’ may give a slightly positive balance on charts. • Clarify up-to-date plan with medical team and communicate to patient
frequency of monitoring
and visitors, wider MDT including HCAs: SALT, housekeeping, physio
What does water do for you? and any colleague who may assist with, provide or remove fluids Charts – current balance
Escalation plan or the need for it
Forms saliva Needed by the brain to • Ensure accuracy using charts and calculating cumulative
Human body is Although these fluid (digestion) manufacture hormones measurements 6 hourly
55-60% fluid compartments are classed as and neurotransmitters Patients
separate, water and fluids are Keeps mucosal • Escalate promptly to medical team in case of developing imbalance,
constantly moving between deterioration or concern • Must demonstrate capacity (understand information, retain and recall
membranes moist Regulates body
them all, powered by different when asked) concerning their fluid balance monitoring if they are to
temperature (sweating complete charts independently.
processes such as diffusion Allows body’s cells to and respiration)
2/3 total (movement of particles) grow, reproduce HCA’s and Student Nurses
1/3 is osmosis (movement of water)
• Trained nurses to calculate cumulative measurements
body fluid is and survive Acts as a shock
extracellular hydrostatic pressure (gravity • Teamwork, Communicating with MDT to ensure accurate
intracellular absorber for brain
and cardiac function) and measurements – eg SALT, housekeeping, physio
Flushes body waste, and spinal cord
oncotic pressure (proteins)
mainly in urine • Ensure chart is complete and accurate – use of appropriate equipment
Converts food to
This fluid consists of water and e.g. scales, urometers etc
electrolytes – particles which components needed
80% extracellular 20% extracellular Lubricates joints for survival - digestion • Inform trained staff or NIC with changes deterioration or concerns
carry an electrical charge – an Cup 160mls
fluid is fluid is in imbalance in these can cause
Glass 200mls Beaker 200mls Jug 750mls
interstital the plasma cardiac arrhythmias. Water is the major Helps deliver oxygen
component of most all over the body WHEN: INDICATIONS FOR FLUID BALANCE MONITORING
body parts
Increased fluid output Reduced urine output
WHY MONITOR FLUID BALANCE? HOW DO WE MONITOR FLUID BALANCE? Diarrhoea and vomiting – risk of dehydration, malnutrition and significant Oliguria – low urine output ↓0.5mls per kilogram per hour. Oliguria can be
Injury or Illness can alter fluid balance. Hypoperfusion of vital organs Knowing the signs and symptoms of Fluid Imbalance in the body is a electrolyte disturbances including hyperkalaemia an early sign of poor renal perfusion. Most common causes: hypotension
may occur with lower circulating volumes caused by dehydration, crucial aspect of hospital care and assessment. It is assessed in 3 ways: High urine output – polyuria -↑200mls /hr – leads to dehydration if or hypovolaemia. Anuria - absence of urine: ↓100mls over 24 hours.
or redistribution of within the body during an inflammatory response fluid balance charts, physical assessment of fluid balance and unmanaged. Common causes: diabetes, resolving AKI, excessive diuretics Acute Kidney Injury (AKI) /Chronic Kidney Disease
post trauma, in Cancer or during Sepsis, requiring fluid replacement. monitoring of blood results. Patients with raised creatnine blood levels combined with a low urine
High output stoma – increased frequency or ↑1 litre in 24 hrs
Alternatively an ‘overload’ may occur as a result of poor cardiac or renal output may have an AKI: the kidneys are not effectively filtering blood,
function, or excessive fluid intake orally or IV. Urinary catheter, convene, urostomy or irrigation – volumes must reabsorbing vital elements and excreting others. Prompt identification of
Overload may present with: tachycardia, hypertension, be measured. Incontinent patients may self-limit input in attempt to an AKI is crucial as it can lead to serious complications if left untreated.
Vital increased respiratory rate/effort/noise/moist cough. Fluid intake is regulated by manage problem.
Mucous membranes signs thirst – which is a natural Medications which increase risk of AKI (patients on these need fluid
dry/moist – mouth, Fluid depletion may present with hypotension, postural drop, response to fluid depletion. As Post-operative patients should be closely monitored balance monitoring)
Facial/
tongue, conjuntiva, a lowered ‘pulse pressure’, rapid, shallow respirations, rapid, the osmotic pressure of blood
oral
increases (due to higher ratio • Large open wounds: output should be estimated if an accurate output • Contrast medium – monitor fluid balance for 24 hrs before and
saliva – thick, sticky in weak thready pulse.
depletion or copious
assessment of molecules to H2O) water is is not possible after procedure
drawn from cells into blood.
and frothy in overload.
Osmoreceptors in the brain
• Drains: pleural, wound, ascitic • Chemotherapy – monitor Fluid Balance during therapy
Sunken facial features
particularly around
are dehydrated, and stimulate • Increased ‘insensible losses’: sweating, sustained pyrexia of 38°C or • Antibiotic therapy – many antibiotics can cause renal impairment
Physical Thirst release of anti-diuretic hormone a sustained respiratory ↑rpm. Each example can lead to a fluid loss of
eyes indicate severe (Check BNF). High risk are: Gentamycin, Aciclovir and Vancomycin.
depletion... or are there assessment and sensation of thirst. Adrenal
↑500 mls in any 24 hour period Fluid balance should be monitored throughout therapy and for 24hrs
glands produce Aldosterone
signs of oedema? of fluid status – stimulating reabsorbtion of post last dose
Skin elasticity – ‘tissue turgour’. sodium, and then water, from
the kidneys – less is excreted • ACE inhibitors and diuretics - often held in acute kidney injury
Skin • skin is dry and less elastic with dehydration
Weight • presence of oedema indicates overload Thirst is often a LATE indicator Unconcious
Capillary refill time of hydration, and this response patients
• good indicator of intravascular pressure/ volume becomes weaker and more
Patients
(and hydration). Blood should return to area delayed with increasing AGE. Diagnosis, Paralysis
Urine with
post gentle pressure in less than 2 seconds or at risk of
If serial weights same output • is skin warm, pink? impaired
malnutrition
time each day swallow
Jugular/venous pressure Decreased Poor memory Poor vision
• raised in overload
oral
intake Loss of
An imbalance of electrolytes in the blood can lead to fluid imbalance. FLUID BALANCE CHARTS NBM/
Impaired thirst
reflex - this can
independence
Laboratory blood tests such as urea and electrolytes, glucose, magnesium, restricted worsen with age and
calcium will determine discrepancies and lead to the right treatment. Identifying a postitive (↑input) or negative (↑ output) balance is essential, as diets increase risk
of dehydration
redressing any imbalance is vitally important. As well as aiding assessment,
Intravenous
LABORATORY RESULTS ASSOCIATED WITH together with other vital signs it allows us to evaluate and adapt our care,
fluids/enteral Stroke Delirium
replacing and restricting fluids appropriately to achieve stability. Maintaining an feeding
FLUID IMBALANCE accurate fluid chart can present challenges:

Communication with Patient Dementia

Fluid loss Fluid gain • Aware of plan, and any restriction to intake?
• Increased serum osmolality • Reduced plasma urea • Able to use equipment independently? Acute illness hypovolaemia. Generally caused by
• Compliant, possibly able to self document? Monitoring fluid balance helps monitor altered capilliary permeability (leaky blood
• High urine osmolality and • Reduced haematocrit acute illness or with early recognition of vessels) secondary to ischaemia, trauma
specific gravity Communication with MDT? further deterioration. In some illnesses or inflammation, conditions include: Heart failure
• MDT aware of monitoring? (SALT, Physio, volunteers) the fluid may move out of the vascular • Sepsis Acute Heart Failure (HF) is most commonly caused by cardiac dysfunction due to
• Raised haematocrit • Use whiteboard behind bed to convey any specific instructions system and into extracellular spaces • Bowel obstruction muscle damage, valvular dysfunction, or arrhythmias. The heart does not pump
• Increased plasma-urea outside the bloodstream. This fluid is • Acute pancreatitis (or acute on enough blood to meet all the needs of the body, and it can be complex to manage
Accuracy still in the body but no longer in a useful chronic) fluid balance for these patients. In acute new onset HF or acute decompensation of
concentration • Liver failure Chronic HF, renal function, weight and Fluid Balance should be closely and accurately
• Volumes measured specifically, awareness of volumes of different space and patients may develop low
drinking vessels urine output due to hypotension and • Malnutrition monitored, to ensure appropriate diuretic therapy or fluid management (NICE 2014).
• If patient is using pads these can be weighed with mg converted to ml
Clodagh Bannerman 2018