1. Fluid Balance Charts Amanda Thompson Learning & Development Lead Educator (professional and clinical practice)

2. What is Fluid Balance? The balance of input and output of fluids in the body to allow metabolic processes to function correctly Fluid inFluid out

3. Why is Fluid Balance Important?

4. Fluid Balance Achieving optimal hydration is an essential part of holistic care Dehydration and over hydration can have serious clinical consequences

5. Body Water Content age + body mass + body fat = Total body water The body water content of men is about 60% and is 50% in women where there is relatively more body fat and less skeletal muscle Body water declines throughout life and is generally around 45% of total body mass in old age A fluctuation of 5-10% can have a serious impact on health. Depending on amount - loss of body mass leads to impaired cognitive function, headache, fatigue, dry skin, hypovolaemia, shock, organ failure and ultimately death

6. Fluid Compartments Cells There are two main fluid compartments in the cells of the body: the intracellular compartment contains slightly less than two-thirds by volume The remaining third is distributed in the extracellular fluid.

7. How do we gain fluid? How do we loose fluid? How much fluid do we need each day?

8. Average recommended Daily input and output of fluid Water gain=Water loss Intake: 2500ml Output: 2500ml Metabolic (200ml/day) GI Tract (100ml/day) Ingested moist food 800ml/day Skin (600ml/day) Ingested liquids 1500ml/day Kidneys (1500ml/day)

9. In Hospital …Who is at risk of gaining too much fluid ?

10. Fluid Overload Patients with heart failure Patients with renal failure Patients with liver failure Increased antidiuretic hormone (ADH) secretion – e.g. following head injury or major surgery. Over hydration (Iatrogenic)

11. Presentation – Fluid overload Breathlessness (Dyspnoea) Oedema Reduced or increased urine output Raised Blood Pressure / Low Blood Pressure

12. In Hospital …Who is at risk of loosing too much fluid ?

13. Dehydration Inadequate intake of nutrition and fluids Dementia, Frailty, Fear of incontinence Excessive fluid loss : Diarrhoea, Vomiting, Haemorrhage, Sepsis, Fever, Burns What does thirst feel like?

14. Presentation-Dehydration? Dry mouth Poor skin turgor Low Blood Pressure Raised heart rate Raised respiratory rate Poor urine output

15. Clinical assessment of fluid balance ObservationFluid DepletionFluid Overload WeightLossGain BPLowered (Smaller Pulse pressure) Normal, low or raised RespirationsRapid, shallowRapid, moist cough PulseRapid. Weak and ThreadyRapid Urine OutputReduced / concentratedIncreased or decreased SkinDry, less elasticOedematous SalivaThick, viscousCopious, frothy TongueDry and coatedMoist ThirstPresentNo disturbance FaceSunken eyes (severe)Periorbital oedema TemperatureMay be raisedNo disturbance

16. Negative Fluid Balance Deficit in fluid volume = Output is greater than input / insufficient input Positive Fluid Balance Fluid intake is greater than output / insufficient output

17. Fluid Balance Charts Are legal documents and may be used in a court of law Must be completed in full, accurately and legibly

18. Who is accountable for the assessment and monitoring of fluid balance? Who is accountable for the recording of fluid input and fluid output?

20. Completing a fluid balance chart accurately RCHT Policy Practice

21. the patient’s intake and output must be recorded accurately. Ambiguous comments, for e.g. pu’d ++. is not acceptable Use every tool available to assure the best information. If not possible, use estimated amounts Patient monitoring and review of the daily fluid balance chart should take place as often as required. Nursing staff should include in the shift handover a clear indication of the patient requiring fluid balance monitoring and any who present concerns as this may mean reviewing the patient and completing the chart more regularly

22. Barriers to accurate completion Poor compliance Skill-Poor understanding Skill-Lack of training Time

23. Solutions? Nurse led assessment on admission Appropriate placement on fluid balance charts Training, education and support Frequent monitoring and on going assessment Follow the hospital policy

24. Summary Incorrect or poorly completed fluid balance charts and ineffective monitoring can result in detrimental effects on patient outcomes including; delayed medical review, unexpected patient deterioration, over or under- prescribing of fluids, prolonged hospital stay and in some cases, result in patient morbidity and mortality (NICE, 2007).

25. Questions?