Fluid Balance for Adult In-patients Clinical Guideline
V1.0
May 2019
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 2 of 14
Summary
Fluid balance guide
Patient to commence fluid balance
Nursing team/Patient /Host informed
Fluid balance chart commenced
date + patient identity added
Input Intravenous
fluids/drugs NG/NJ/PEG
feed Oral Fluids
Output: Urine Stoma Vomiting N/G Aspirate
To be documented
Escalation: Acute patients with a urinary catheter output monitored hourly If patient produces <2mls/kg body weight/hr over 4hrs or <0.5mls/kg body
weight/hr exemption in CKD oliguria if agreed with medical team
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 3 of 14
1. Aim/Purpose of this Guideline
1.1. Fluid balance is an essential tool in determining hydration status. Recording intake and output tends to be one of the key activities undertaken at the bedside and is used in conjunction with the recording of vital signs and certain laboratory reports to set required fluid intake levels. Accuracy in recording fluid intake and output is vital to the overall management of certain patient groups and facilitates in the assessment and evaluating the patient’s condition. This will enable correct prescribing of intravenous and subcutaneous fluids. 1.2. The purpose of this policy is to raise staff awareness and provide clear standards in managing optimal hydration and maintaining effective fluid balance in the adult patient. The guidance aims to ensure that healthcare staff applies a safe and consistent approach to the assessment, recording and monitoring of an individual patient’s fluid intake and output which aims to:
Prevent or reduce adverse consequences associated with patient dehydration by establishing an effective standard and management for optimal hydration. Create one set method for recording detailed and accurate fluid input and output. Support staff to determine a timely and appropriate rationale for starting and stopping a fluid balance chart.
2. The Guidance
All inpatients within the Trust who meet the criteria for fluid balance measurement will have accurate and fully completed fluid balance charts as set out in this fluid balance policy. The following standards of practice will apply to all staff involved in patient monitoring and recording of vital signs and fluid balance charts.
Successful fluid balance is dependent upon: Timely/appropriate rationale for commencement/discontinuation One system for detailed & accurate measurement of input/output Consideration of sensible and insensible loss (sweating/vomiting/stoma output/diarrhoea)
2.1. Indications for commencing a Fluid balance chart
Fluid balance charts must be completed for the following patients unless a decision has been made otherwise by a medical practitioner or a senior registered nurse.
NEWS score >3 and/or risk of level 2 or 3 care Patients with sepsis
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 4 of 14
Patients discharged from Critical Care for a minimum of 48 hours post transfer or as indicated by outreach or medical/ surgical team. Temperature greater than 380 Centigrade. Excessive vomiting or nasogastric aspiration/drainage Diarrhoea and excessive output stoma/ ileostomy Post-operative patients. Excessive fluid loss from surgical drains/ cavity drains, wounds /VAC therapy Intravenous Fluids and drugs / or parenteral nutrition Enteral feeding i.e. PEG, NG, PEG-J, NJ Fluid restricted i.e. cardiac failure, liver failure, AKI, CKD Patients with urinary catheters, excluding patients with long term catheters in the absence of acute onset of illness. Sickle cell disease NBM > 12 hours When any doubt exists over fluid status. This is not an exhaustive list and other indications may be deemed necessary by the responsible healthcare professional
2.2 Completing a Fluid Balance Chart
See Appendix 3 Guide to documenting fluid balance See Appendix 4 Guide to Fluid Capacity of ward cups/beakers/jugs
2.3 Requirements over 24 hours
Clinicians are reliant on accurate 24 hour totals to inform clinical decisions in relation to fluid management including the prescription of intravenous fluids. This will prevent the serious complications associated with over or under hydration. Incorrect or poorly completed fluid balance charts and ineffective monitoring can result in detrimental effects on patient outcomes.
2.4 When to review and/or stop a Fluid Balance Chart
When patients are transferred to other wards / departments, a verbal and written handover must include whether the patient is on a fluid balance chart
Fluid Balance Charts must be reviewed in line with the patient’s clinical condition.
Frequency must be determined and recorded by the registered healthcare professional to ensure that fluid requirements are met and balance is maintained.
Stopping fluid balance is the decision of the responsible clinician or registered nurse. Patients must be assessed thoroughly before making such a decision
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 5 of 14
3. Monitoring compliance and effectiveness
Element to be monitored
Ward areas to be compliant 100% with completion of accurate fluid balance documentation Including input, output , totals and balance
Lead Fluid balance working group / Critical Care Outreach Team / Ward managers/matrons
Tool Audit carried out by critical care outreach/ Fluid balance working group Datix incident reporting – review of related incidents
Frequency Fluid Balance documentation audits yearly for those areas complying with standard those below standard will be monitored quarterly.
Reporting arrangements
Nutrition steering group
Acting on recommendations and Lead(s)
Nutrition Steering Group monthly meetings. Fluid balance working group.
Change in practice and lessons to be shared
Required changes to practice will be identified and actioned through Matron/ Sister meetings
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.
4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 4.
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 6 of 14
Appendix 1. Governance Information
Document Title Fluid Balance for Adult In-patients Clinical Guideline V1.0
Date Issued/Approved: 1st March 2019
Date Valid From: May 2019
Date Valid To: May 2022
Directorate / Department responsible (author/owner):
Susan C. Kennedy Clinical Lead Renal Dietitian
Contact details: 01872 252424
Brief summary of contents
This document provides the framework for clinical staff in the management of patient hydration and monitoring of fluid balance. The document ensures that staff are guided by the expected standard set by the organization.
Suggested Keywords: Fluid Balance Adults In-patients
Target Audience RCHT CFT KCCG
Executive Director responsible for Policy:
Medical Director
Date revised: November 2018
This document replaces (exact title of previous version):
New document
Approval route (names of committees)/consultation:
Nutritional Steering Group Feb 2019 Therapies Clinical Governance Forum Feb 2019
Care Group General Manager confirming approval processes
Robin Jones
Name and Post Title of additional signatories
Not Required
Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings
{Original Copy Signed}
Name: Kevin Wright Clinical Support Care Group
Signature of Executive Director giving approval
{Original Copy Signed}
Publication Location (refer to Policy on Policies – Approvals and
Internet & Intranet Intranet Only
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 7 of 14
Ratification):
Document Library Folder/Sub Folder Clinical/Dietetic
Links to key external standards
NICE Nutrition Support for adults cg32 (updated 2017) NICE Intravenous fluid therapy in adults in hospital cg174 (updated 2017) NICE Acutely Ill patients in hospital: Recognition of and response to acute illness in adults in hospital. cg50
Related Documents: BMJ Quality Improvement Reports 2015: Improving fluid balance monitoring on the wards Milton Keynes S.Jeyapala et al
Training Need Identified? Yes - Learning and Development Department to be informed
Version Control Table
Date Version
No Summary of Changes
Changes Made by (Name and Job Title)
November 2018
V1.0 Initial issue Susan Kennedy Lead Renal Dietitian
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 8 of 14
Appendix 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed
Fluid Balance for Adult In-patients Clinical Guideline V1.0
Directorate and service area: Nutrition Support Team
New or existing document: New
Name of individual completing assessment: Susan C. Kennedy Clinical Lead Renal dietitian
Telephone: 01872 252409
1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?
To provide the framework for clinical staff in the overall management of maintaining patient hydration and accurate monitoring of fluid balance. The document ensures that staff will be guided by the expected standard set by the organisation
2. Policy Objectives*
Create one set method for recording detailed and accurate fluid input and output.
Support staff to determine a timely and appropriate rationale for starting and stopping a fluid balance chart.
Support person centred planning
3. Policy – intended Outcomes*
Prevent or reduce adverse consequences associated with patient dehydration or fluid overload by establishing an effective standard and management.
4. *How will you measure the outcome?
Adverse events associated with clinical care are captured through Mortality Review and Serious Incidence. Any issues relating to hydration and fluid balance will be identified through these processes
5. Who is intended to benefit from the policy?
All adult in patients and clinical staff
6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.
Workforce Patients Local groups
External organisations
Other
Yes Yes
Please record specific names of groups RCHT Strategic Nutrition group Senior matrons Ward managers Critical care outreach steering Fluid balance working group
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 9 of 14
Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence
Age X
Sex (male,
female, trans-gender / gender reassignment)
X
Race / Ethnic communities /groups
X
Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.
X
Religion / other beliefs
X
Marriage and Civil partnership
X
Pregnancy and maternity
X
Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian
X
You will need to continue to a full Equality Impact Assessment if the following have been highlighted:
You have ticked “Yes” in any column above and
No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or
Major this relates to service redesign or development
8. Please indicate if a full equality analysis is recommended. Yes No X
What was the outcome of the consultation?
Approved.
7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 10 of 14
9. If you are not recommending a Full Impact assessment please explain why.
Not indicated
Date of completion and submission
November 2018.
Members approving screening assessment
Policy Review Group (PRG) APPROVED
This EIA will not be uploaded to the Trust website without the approval of the Policy Review Group. A summary of the results will be published on the Trust’s web site.
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 11 of 14
Appendix 3. Guide to documenting fluid balance
If patients meet the criteria for fluid balance then they meet the criteria for accuracy!
All members of the nursing team should be alerted to commencement of a fluid balance chart.
The Trust fluid balance chart should be used All fluid balance charts to be completed with the patients name,
date, and ward and hospital number. Oral input:
Ensure ward team is aware of patient risk of dehydration. Fluid must only be recorded as input once it has been consumed. The patient should be informed why he/she has commenced a fluid
balance chart. The patient and/or visitors should be encouraged to chart fluid input where applicable and mental capacity has been established.
Ensure ward team nurses /Heath Care Assistants/hosts/medics are aware of fluid capacity of cups and jugs used on the ward (see appendix 3)
Alert ward hosts when a patient has commenced a Fluid balance chart on ”Patient Nutrition & Hydration Prompt / hand-over sheet” (see appendix 4). This will enable assistance in documenting fluid intake. The Host team should alert the nursing team to concerns regarding a patient’s poor fluid intake. The hosts will note fluid consumed when replenishing water jugs and tea/coffee consumption.
Do not document in ‘sips’ - document in mls.
Intravenous Input:
Whenever possible IV fluids to be administered via a volumetric pump and rate charted hourly
Intravenous fluids not administered through a volumetric pump should be documented at the commencement of infusion with type of fluid
include IV drug volume and 0.9% Normal Saline flushes are recorded as input as this can accumulate to a large volume in some patients
Detailed & Accurate Output:
All team members must be aware to document fluid loss. All forms of sensible fluid loss must be accounted for with as much accuracy as is reasonably possible
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 12 of 14
Patients must be informed of the importance of documenting urine output and provided with receptacles for urine collection and measurement.
It is unacceptable to write ambiguous comments for urine output. However if the patient has gone out to the toilet this should be documented and patient encouraged to use urinary receptacles provided.
Document all stoma, nasogastric aspirate/drainage or drain output. Acute staff must be able to estimate urine output in cases of
incontinence The amount of each vomit If there have been multiple episodes of diarrhoea or vomiting
attempt to arrive at an estimated volume
Estimation of fluid balance:
As much as possible oral fluids should not be estimated, recognised measuring containers must be used (see Appendix 3) and actual volume documented.
Insensible loss should be considered when assessing the fluid balance
Urine output should be estimated in cases of incontinence. i.e. weighing of pads
Care must be taken in the case of vomiting, diarrhoea and blood loss that attempts are made to arrive at an estimate of volume.
Escalation:
Acute patients’ with a urinary catheter in situ must have their output monitored and measured hourly until the patient’s clinical condition has improved
If adult patient’s produce <2mls/kg body weight over 4hrs or < 0.5mls/kg body weight/hr then this is an automatic trigger for referral requiring primary medical and nurse responder review (exemption in chronic renal failure patients where the medical team is aware of oliguria – this would need to be confirmed by the medical team). (ex 70kg man <2mls/hr over 4hrs = <140mls or <0.5mls = <35mls/hr)
Running totals must be completed during the day as per fluid chart.
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 13 of 14
Fluid Balance for Adult In-patients Clinical Guideline V1.0 Page 14 of 14
Appendix 4. Patient Nutrition & Hydration Prompt Sheet