Completion of Fluid Balance Charts - PowerPoint by mkb58051

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									          Learning Outcomes
By the end of the session you should be able
to:

A. Discuss the importance of fluid balance
B. Highlight causes & symptoms of fluid loss/overload
C. List key factors important to carrying out fluid balance
D. Explain insensible loss and its role in fluid balance
E. Identify common problems with fluid balance
F. Discuss completion & review of fluid balance
- Discuss key points in management
                     Tees Valley and South Durham
                         Critical Care Network
A
      Importance of Fluid Balance
    • 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
                         Tees Valley and South Durham
                             Critical Care Network
A
      Importance of Fluid Balance
    • 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 have to assume the
      relevant responsibility to ensure that they are
      competent and that they are meeting national
      and local guidelines regarding this


                      Tees Valley and South Durham
                          Critical Care Network
A
      Importance of Fluid Balance
    • This is an important part of ABCDE assessment.
      Without this you are missing key information. Do
      you give fluids or with-hold?
    • Inaccurate fluid balance can mean problems can
      be overlooked for a very long time resulting in
      disastrous scenarios. Therefore, some problems
      can be prevented by careful assessment of fluid
      balance
    • If problems do occur they can be rectified by
      simple interventions and careful fluid balance

                     Tees Valley and South Durham
                         Critical Care Network
A
      Importance of Fluid Balance
    • Some specific examples where fluid balance is
      important include:




                     Tees Valley and South Durham
                         Critical Care Network
A
      Importance of Fluid Balance
    • Secretions
      – Your patient has an increased risk of
        consolidating chest secretions and getting a
        chest infection if they are dry
      – Such patients do not need less - they need
        more! (providing there is no cardiac history -
        where a more careful assessment needs to be
        done)

                     Tees Valley and South Durham
                         Critical Care Network
A
     Importance of Fluid Balance
• Urine Output
    – If the patients’ urine output is not recorded
      accurately if at all you need to look a lot closer
       • Ensure that the patient is passing urine!
       • If they are – is it enough?
         • If not – what are you going to do about it?
    – If the patient is catheterised and you know the
      patient’s urine is borderline some charts allow
      for documentation of urine output on the track
      & trigger observations chart
                     Tees Valley and South Durham
                         Critical Care Network
A
      Importance of Fluid Balance
    • Previous Balance
      – You may find a patient is positive 1500ml
      – You could decide therefore to cut out fluids
      – Think again
      – You may find that for the previous 7 days the
        patient has been negative 500ml each day
      – This could be 3500ml negative overall!



                      Tees Valley and South Durham
                          Critical Care Network
B
         Symptoms of Fluid Loss
    • Weight loss                      • Cool peripheries
    • Weakness                         • Pale skin
    • Fatigue                          • Higher resp. rate
    • Confusion                        • Lower Oxygen sats
    • Dry/flaking skin                 • Tachycardia
    • Dry/coated tongue                • Lower blood pressure
    • Dry oral membranes • Reduced urine output
    • Thirst                           • Negative fluid balance
    • Low CVP                          • Dark urine output
                         Tees Valley and South Durham
                             Critical Care Network
B
      Symptoms of Fluid Loss
• Bloods:
    Urea
    • Increased urea is usually an early sign of
      dehydration
    Createnine
    • An increase in createnine occurs as a
      prelude to Pre-Renal Failure - which may
      result in increased sodium and potassium
      that can (unchecked) be lethal
                  Tees Valley and South Durham
                      Critical Care Network
B
     Symptoms of Fluid Overload
• Peripheral oedema           • Frothy/watery sputum
• Disorientation              • Tachycardia
• Confusion                   • Low O2 sats
• Decreased                   • +ve fluid balance
  responsiveness
                              • Raised CVP
• Breathlessness



                   Tees Valley and South Durham
                       Critical Care Network
B
        Kidneys & Blood Pressure
    • The kidneys need a high percentage of the
      blood pressure to filter the urine
    • In the fluid depleted patient - there is little urine
      to filter and the kidneys being to fail
    • If blood pressure is also low due to fluid
      depletion, the kidneys have less pressure to filter
      what little urine there is
    • This combination can accelerate renal failure


                        Tees Valley and South Durham
                            Critical Care Network
C
     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


                      Tees Valley and South Durham
                          Critical Care Network
C
      When to Start Fluid Balance
    • Actual or potential dehydration

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


                    Tees Valley and South Durham
                        Critical Care Network
C
      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



                    Tees Valley and South Durham
                        Critical Care Network
C
      When to Start Fluid Balance
    • Routine post op management

    • Fluid restriction
      – Unstable cardiac failure
      – Liver failure
      – Acute renal failure


    • Doubt over fluid status
                    Tees Valley and South Durham
                        Critical Care Network
C
      When to Stop Fluid Balance
    • Reason for commencement 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

                     Tees Valley and South Durham
                         Critical Care Network
D
                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…




                     Tees Valley and South Durham
                         Critical Care Network
D
                 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!


                      Tees Valley and South Durham
                          Critical Care Network
D
                 Insensible Loss

    • It is unrealistic to expect staff to work out this
      calculation for every patient although it is
      important for severely under or overweight
      patients
    • Some 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

                       Tees Valley and South Durham
                           Critical Care Network
E
         Addressing the problems
    • We all know there are practical issues of
      difficulty with fluid balance
    • There are serious problems with maintaining
      fluid balance charts in practice
    • Given the importance of fluid balance does that
      mean we just give up?

      Or we do tackle the problems?


                     Tees Valley and South Durham
                         Critical Care Network
E
        How can we tackle these?
    • ‘He goes to the toilet & doesn’t tell me’




                    Tees Valley and South Durham
                        Critical Care Network
E
                    Solution?
    • ‘He goes to the toilet & doesn’t tell me’

    • Give the patient something to take & put
      his name on it for starters?




                    Tees Valley and South Durham
                        Critical Care Network
E
        How can we tackle these?
    • ‘He goes to the toilet & doesn’t tell me’
    • ‘The relatives keep giving her drinks so I
      don’t have a clue what is going in’




                    Tees Valley and South Durham
                        Critical Care Network
E
                    Solution?
    • ‘The relatives keep giving her drinks so I
      don’t have a clue what is going in’

    • Give the relatives a sheet with the
      amounts on. Get them to document the
      amounts on fluid balance. This works for
      some patients too


                    Tees Valley and South Durham
                        Critical Care Network
E




    Standard Glass = 200ml                     Standard Cup = 150ml




    Standard Jug = 1000ml                      Standard Gallipot = 60ml
                             Tees Valley and South Durham
                                 Critical Care Network
E
        How can we tackle these?
    • ‘He goes to the toilet & doesn’t tell me’
    • ‘The relatives keep giving her drinks so I
      don’t have a clue what is going in’
    • ‘How do I know what is in a pad if its wet?’




                    Tees Valley and South Durham
                        Critical Care Network
E
                    Solution?
    • ‘How do I know what is in a pad if its wet?’
    • We recommend that if the patient is
      incontinent of urine or diarrhoea you
      consider weighing as a means of
      getting the amount - especially in
      severely fluid deprived patients
       or…
                    Tees Valley and South Durham
                        Critical Care Network
E
                          Solution?

    • Try this technique:

      – Pick two incontinence pads
        • Pour in 200mls in one
        • Pour in 600mls in the other

      – Get someone to estimate



        It sounds ridiculous, but staff get expert really quickly

                          Tees Valley and South Durham
                              Critical Care Network
E
    Solution?


                                      You will be
                                       surprised how
                                       easy it gets after
                                       2 or 3 tries
                                      So if its that easy
                                       why not record
                                       your estimate?




    Tees Valley and South Durham
        Critical Care Network
E
        How can we tackle these?
    • ‘He goes to the toilet & doesn’t tell me’
    • ‘The relatives keep giving her drinks so I
      don’t have a clue what is going in’
    • ‘How do I know what is in a pad if its wet?’
    • ‘Well, if he’s been incontinent all over the
      bed I can only put that he’s passed urine’



                    Tees Valley and South Durham
                        Critical Care Network
E
                    Solution?
    • ‘Well, if he’s been incontinent all over the
      bed I can only put that he’s passed urine’

    • If weighing the sheet is an impractical
      proposition, (and most often it is), try
      estimating. Is this so impossible?



                    Tees Valley and South Durham
                        Critical Care Network
E
                 Solution?

    • Wet on the bed?

                                       –    How much do you think this is?
                                       –    Its been there for 5 minutes…




                                            About 50ml


                  Tees Valley and South Durham
                      Critical Care Network
E
                 Solution?

    • 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


                  Tees Valley and South Durham
                      Critical Care Network
E
        Addressing the problems
    • These tell you NOTHING:
     – “Wet +++”
     – “Pad changed”
     – „Pu‟d‟


     So how can you do an accurate ABCDE?



                   Tees Valley and South Durham
                       Critical Care Network
E
        How can we tackle these?
    • ‘He goes to the toilet & doesn’t tell me’
    • ‘The relatives keep giving her drinks so I
      don’t have a clue what is going in’
    • ‘How do I know what is in a pad if its wet?’
    • ‘Well, if he’s been incontinent all over the
      bed I can only put that he’s passed urine’
    • ‘The pump keeps alarming so I don’t know
      if the hourly input is accurate’
                    Tees Valley and South Durham
                        Critical Care Network
E
                  Solution?
    • ‘The pump keeps alarming so I don’t know
      if the hourly input is accurate’

    • The pump tells you how much has gone in




                   Tees Valley and South Durham
                       Critical Care Network
E
    How can we tackle these?



    ‘We just don’t have time’




            Tees Valley and South Durham
                Critical Care Network
E
                     Solution?
    • ‘We just don’t have time’

    •   Prioritise appropriately
    •   Remember why fluid balance is important
    •   Poor fluid balance can actually kill
    •   Use a prioritisation tool to help you think
        clearly or help you evidence you are doing
        everything you can
                      Tees Valley and South Durham
                          Critical Care Network
E
        1st Attempt to Prioritise
         Can the observations charts and fluid balance be completed accurately and on time?




       Yes                                      No                                               Check:
                                                                            What do you feel has come first before
                                                                            observations and fluid balance?
                                                                            What is being missed as a result of prioritising
                                                                            observations and fluid balance?
    Continue                          Have you attempted to                 Would patient safety be compromised further by
                                      prioritise?                           prioritising these other cares as secondary?




                                      No              Yes




                                                         Seek help from a senior
                   Prioritise                         Be prepared to articulate exactly
       If you are not sure what to do, seek           what your rationale is.
       help from a senior




                                      Tees Valley and South Durham
                                          Critical Care Network
 E
                          2nd Attempt to Prioritise
                              Can the observations charts and fluid balance be completed accurately and on time?




                                                                  Check:
                              Yes                       Are staff nurses helping to                            No
                                                        get the observations and fluid
                                                        balance done if the HCA’s
                                                        are struggling?

                                                                                                             Have you attempted to
Document what aspects of care
                                                                                                             prioritise?
have been delayed or missed
and be prepared to submit                                                     Out of Hours
incident report if it is warranted               In Hours                      Alert PSM
                                               Alert Manager


                                                                                                             Yes                   No


                                                        Satisfactorily Resolved?

Submit Incident Report
                                                                                                                       Prioritise
                                                        No                     Yes                         If you are not sure what to do, seek
                                                                                                           help from PSM or Manager
Prioritise patients at risk



                                                     Tees Valley and South Durham
                                                         Critical Care Network
E
               A Word of Caution
    • In a complaint about patient care, poor recording
      of fluid balance was cited as a contributing factor
    • This was upheld by the Health Service
      Ombudsman
    • The nurse was held accountable by NMC
    • She was struck of the register




                      Tees Valley and South Durham
                          Critical Care Network
F
        Completing Fluid Balance
    • 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




                      Tees Valley and South Durham
                          Critical Care Network
F
    Completing Fluid Balance

     Total Intake                   Total Output                Balance
     (a)                                                        (a-d)
                       Output      Insensible      Both b & c
                       (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


                          Tees Valley and South Durham
                              Critical Care Network
F
    When to Review Fluid Balance
     • Routinely

     • Emergencies

     • EWS Triggers

     • Concern



                   Tees Valley and South Durham
                       Critical Care Network
F
              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



                     Tees Valley and South Durham
                         Critical Care Network
F
             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 if available
      – Greater than 150ml hour for three hours in a
        row and no diuretics have been given
      – No IV present and patient is nil orally

                    Tees Valley and South Durham
                        Critical Care Network
F
             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




                     Tees Valley and South Durham
                         Critical Care Network
F
      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

                     Tees Valley and South Durham
                         Critical Care Network
F
              Quality Initiatives
    • If fluid balance omissions lead to
      deterioration of the patient, this requires
      an incident report and consideration as a
      serious untoward incident
    • Areas should arrange regular audits of
      fluid balance



                    Tees Valley and South Durham
                        Critical Care Network
F
               Quality Initiatives
    • Thoroughly evaluate priorities in your area
    • If increasing performance on fluid balance
      causes a decreased performance on other
      aspects of care, then report it appropriately
    • Set up meetings and awareness sessions
    • 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
                     Tees Valley and South Durham
                         Critical Care Network
Any Questions?




  Tees Valley and South Durham
      Critical Care Network
        Key Management Points
- Identify „at risk‟ patients
- Monitor fluid balance
- Check previous fluid balance status
- Increase observations if fluid balance is dire
- Inform doctor/Critical Care Outreach if problems occur
- Investigations (bloods) if fluid balance is dire
- Maintain adequate oxygen saturation if fluid balance is dire
- Maintain adequate circulation to keep the kidneys perfused
- Evaluate/review the effectiveness of interventions


                          Tees Valley and South Durham
                              Critical Care Network
          Learning Outcomes
By the end of the session you should be able
to:

A. Discuss the importance of fluid balance
B. Highlight causes & symptoms of fluid loss/overload
C. List key factors important to carrying out fluid balance
D. Explain insensible loss and its role in fluid balance
E. Identify common problems with fluid balance
F. Discuss completion & review of fluid balance
- Discuss key points in management
                     Tees Valley and South Durham
                         Critical Care Network

								
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