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Fluid Balance Monitoring

WHAT IS ? WHO IS RESPONSIBLE: MONITORING AND ESCALATION

Fluid balance is a term used to describe In order to maintain , the adult 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 , 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? – 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 Goal and visitors, wider MDT including HCAs: , housekeeping, physio frequency of monitoring 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% 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 when asked) concerning their fluid balance monitoring if they are to them all, powered by different temperature (sweating processes such as diffusion complete charts independently. Allows body’s cells to and respiration) 2/3 total (movement of particles) grow, reproduce 1/3 is HCA’s and Student Nurses • Trained nurses to calculate cumulative measurements body fluid is osmosis (movement of water) and survive Acts as a shock extracellular hydrostatic pressure (gravity • with MDT to ensure accurate intracellular absorber for brain Teamwork, Communicating and cardiac function) and and spinal cord measurements – eg SALT, housekeeping, physio oncotic pressure () Flushes body waste, mainly in • Ensure chart is complete and accurate – use of appropriate equipment This fluid consists of water and Converts to e.g. scales, urometers etc – particles which components needed 80% extracellular 20% extracellular Lubricates joints carry an electrical charge – an for survival - digestion • Inform trained staff or NIC with changes deterioration or concerns fluid is fluid is in Glass 200mls Beaker 200mls Cup 160mls Jug 750mls imbalance in these can cause 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 – risk of , 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 disturbances including hyperkalaemia an early sign of poor renal perfusion. Most common causes: or hypovolaemia. - absence of urine: ↓100mls over 24 hours. Acute Heart Failure (HF) is most commonly caused by cardiac 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 Anuria or redistribution of within the body during an inflammatory response fluid balance charts, physical assessment of fluid balance and unmanaged. Common causes: , resolving AKI, excessive Acute Injury (AKI) / dysfunction due to muscle damage, valvular dysfunction, or post trauma, in Cancer or during Sepsis, requiring fluid replacement. monitoring of blood results. Patients with raised blood levels combined with a High output stoma – increased frequency or ↑1 litre in 24 hrs creatnine low urine 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, arrhythmias. The heart does not pump enough blood to meet all the 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 needs of the body, and it can be complex to manage fluid balance for 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. these patients. In acute new onset HF or acute decompensation of Mucous membranes signs – which is a natural Medications which increase risk of AKI (patients on these need fluid dry/moist – mouth, response to fluid depletion. As Post-operative patients should be closely monitored Facial/ Fluid depletion may present with hypotension, postural drop, balance monitoring) Chronic HF, renal function, weight and Fluid Balance should be closely tongue, conjuntiva, the osmotic pressure of blood oral a lowered ‘pulse pressure’, rapid, shallow respirations, rapid, • Large open wounds: output should be estimated if an accurate output saliva – thick, sticky in weak thready pulse. increases (due to higher ratio • Contrast medium – monitor fluid balance for 24 hrs before and assessment is not possible and accurately monitored, to ensure appropriate therapy or depletion or copious of molecules to H2O) water is after procedure drawn from cells into blood. and frothy in overload. • Drains: pleural, wound, ascitic • Chemotherapy – monitor Fluid Balance during therapy fluid management (NICE 2014). Sunken facial features in the brain are dehydrated, and stimulate particularly around • 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 eyes indicate severe a sustained respiratory ↑rpm. Each example can lead to a fluid loss of (Check BNF). High risk are: Gentamycin, Aciclovir and Vancomycin. assessment and sensation of thirst. Adrenal depletion... or are there glands produce ↑500 mls in any 24 hour period Fluid balance should be monitored throughout therapy and for 24hrs signs of oedema? of fluid status – stimulating reabsorbtion of post last dose Skin elasticity – ‘tissue turgour’. , and then water, from the kidneys – less is excreted • ACE inhibitors and diuretics - often held in 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 with Urine post gentle pressure in less than 2 seconds or at risk of If serial weights same impaired output • is skin warm, pink? malnutrition time each day swallow Jugular/venous pressure Decreased Poor memory Poor vision • raised in overload oral An imbalance of electrolytes in the blood can lead to fluid imbalance. intake Impaired thirst Loss of FLUID BALANCE CHARTS NBM/ reflex - this can Laboratory blood tests such as urea and electrolytes, glucose, magnesium, restricted worsen with age and independence will determine discrepancies and lead to the right treatment. Identifying a postitive (↑input) or negative (↑ output) balance is essential, as diets increase risk redressing any imbalance is vitally important. As well as aiding assessment, of dehydration Intravenous LABORATORY RESULTS ASSOCIATED WITH together with other vital signs it allows us to evaluate and adapt our care, Stroke Delirium replacing and restricting fluids appropriately to achieve stability. Maintaining an fluids/enteral 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 system and into extracellular spaces • Bowel obstruction muscle damage, valvular dysfunction, or arrhythmias. The heart does not pump • Use whiteboard behind bed to convey any specific instructions enough blood to meet all the needs of the body, and it can be complex to manage • Increased plasma-urea outside the bloodstream. This fluid is • Acute (or acute on chronic) fluid balance for these patients. In acute new onset HF or acute decompensation of concentration Accuracy still in the body but no longer in a useful • Volumes measured specifically, awareness of volumes of different space and patients may develop low • Liver failure Chronic HF, renal function, weight and Fluid Balance should be closely and accurately monitored, to ensure appropriate diuretic therapy or fluid management (NICE 2014). vessels urine output due to hypotension and • Malnutrition • If patient is using pads these can be weighed with mg converted to ml Clodagh Bannerman 2018