Improving Fluid Balance Charts (and Hypervolaemia v Hypovolaemia)

Fluid balance charts are an important piece of documentation with a poor reputation.

Despite offering valuable information that may help prevent patients from becoming seriously ill, healthcare staff are notorious for leaving them incomplete and inaccurate (Vincent & Mahendiran 2015).

Dehydration is a prevalent issue in hospitals and care settings, with many patients relying on staff to manage their fluid intake, but time constraints and inaccuracies are putting these people at risk (Litchfield, Magill & Flint 2018).

It is essential that fluid balance charts are accurately completed in order to determine a patient’s fluid input and output and identify any potential fluid loss or gain that could be detrimental, requiring escalation of care.

What is Fluid Balance?

Fluid balance, also known as fluid homeostasis, describes the balancing of the body’s fluid input and output levels to prevent the fluid concentration from changing (Payne 2017; Bannerman 2018).

In order to maintain the necessary balance of nutrients, oxygen and water, the adult body generally requires an intake of two to three litres per day, with approximately the same output (Bannerman 2018).

Balance is naturally maintained through thirst when fluid is too concentrated and passing urine when fluid is less concentrated. However, illness or injury can alter these natural mechanisms, requiring monitoring and intervention (Payne 2017; Bannerman 2018).

You must ensure patients are adequately intaking and excreting fluid in order to maintain homeostasis.

What is a Fluid Balance Chart?

A fluid balance chart is used to document a patient’s fluid input and output within a 24-hour period. This information is used to inform clinical decisions (such as medication and surgical interventions) from medical staff, nurses and dieticians, who all expect accurate figures in exact measurements (Georgiades 2016).

When completing a fluid balance chart, you should record any fluid intake by the patient in exact quantities, as well as the type of fluid. For example, if you give the patient a 200mL glass of water, you will record that information. You should also keep a running total (CQC 2019).

Output (urine, loose stools, vomit etc.) should also be measured in exact quantities (Georgiades 2016).

A sample fluid balance chart from the NHS can be accessed on their Patient Information Leaflets page.

While the concept of a fluid balance chart seems simple, in practice it can be difficult, and many issues with the recording process have been identified.

What’s Going Wrong?

A study in 2015 found that nursing staff were not only unaware of the importance of fluid balance but were also conducting unnecessary monitoring - with 47% of monitoring being performed without a clinical indication (Vincent & Mahendiran 2015).

Furthermore, the study found that the average completion rate of fluid balance charts was only 50% (Vincent & Mahendiran 2015).

A different study found that although nursing staff acknowledged the importance of fluid balance, monitoring patients’ hydration was ‘one of several competing priorities’ subject to time pressures. Passive, independent patients were found to be the most adversely affected by this, as they had the capacity to manage their own fluid intake but were too anxious to request fluids from staff in fear of seeming ‘difficult’ (Litchfield, Magill & Flint 2018).

Clearly, there is significant room for improvement in fluid balance monitoring by staff. It has been suggested that a daily medical review of fluid charts would allow for more efficiency and accuracy, and reduction of unnecessary workloads, however, educating staff about the importance of fluid balance would be required in order to implement such a system (Vincent & Mahendiran 2015).

Positive and Negative Fluid Balance

It is crucial to use fluid balance charts in order to identify if a patient’s fluid balance is positive or negative, as these imbalances will need to be remedied (Bannerman 2018).

If confronted with either kind of imbalance, remember to escalate care if the patient deteriorates and perform basic life support if required. The patient may require critical care services.

Positive Fluid Balance (Hypervolaemia)

A positive fluid balance indicates that the patient’s fluid input is higher than their output (Bannerman 2018). The condition describing excess fluid is known as hypervolaemia or fluid overload.

Hypervolaemia causes excess fluid in the circulatory system, which may overwork the heart and lead to pulmonary oedema (Granado & Mehta 2016).

Causes of Hypervolaemia:

• Excessive fluid administered intraoperatively;
• Congestive cardiac failure;
• Fluid resuscitation; and
• Kidney injury.

(Knott 2019)

Signs and Symptoms of Hypervolaemia:

• Pulmonary oedema;
• Oedema (swelling);
• Rapid weight gain;
• High blood pressure; and
• Heart problems (including congestive cardiac failure).

(Fresenius Kidney Care 2019; Granado & Mehta 2016)

Treating Hypervolaemia:

The following are some methods for treating and managing hypervolaemia, depending on the cause and medical advice received.

• Offload the excess fluid - consider diuretics;
• Consider dialysis in the case of kidney failure;
• Monitor the patient’s heart rate; observe electrolyte imbalances and obtain blood tests;
• Support any breathing complications;
• Apply continuous haemodynamic monitoring; and
• Perform an ECG.

(Fresenius Kidney Care 2019)

Negative Fluid Balance (Hypovolaemia)

A negative fluid balance indicates that the patient’s fluid output is higher than their input (Bannerman 2018). The condition describing inadequate fluid is known as hypovolaemia.

Hypovolaemia is caused by significant fluid loss (hypovolaemic shock is defined as a loss of more than 20%), preventing the heart from circulating enough blood around the body. This can result in organ failure. Hypovolaemic shock is life-threatening (Nall & Gotter 2016).

Causes of Hypovolaemia:

• Significant and sudden blood loss (e.g. from wounds, accidents, endometriosis);
• Excessive diarrhoea;
• Excessive vomiting;
• Excessive sweating;
• Surgery;
• Severe burns; and
• Administration of diuretics.

(Nall & Gotter 2016; Taghavi & Askari 2019)

Signs and Symptoms of Hypovolaemia:

• Hypotension;
• Tachycardia/arrhythmias;
• Decreased urine output;
• Altered mental state;
• Fluid and electrolyte imbalance;
• Deranged clotting factors;
• Signs of dehydration;
• Cold and clammy skin;
• Weak or absent pedal pulses (caused by blood being redirected to vital organs as there is not enough fluid in the circulatory system).

(Bannerman 2018; Procter 2019; Nall & Gotter 2016)

Treating Hypovolaemia:

• Administer intravenous fluid replacement therapy;
• Administer intravenous blood products if required;
• Replace electrolyte imbalance;
• Support any breathing complications;
• Apply continuous haemodynamic monitoring; and
• Perform an ECG.

(Nall & Gotter 2016)

Preventing Fluid Imbalance

In order to curb any preventable fluid imbalances, it is crucial to correctly record your patients’ fluid input and output. Having a well-documented fluid balance chart allows nurses to recognise trends that indicate a patient may be heading in a downward spiral.

Early detection of an imbalance will allow appropriate reversal and will reduce the risk of patients being admitted into critical care.

In order for this task to be performed adequately, it is essential that staff are educated about the importance of fluid balance, and that any necessary interventions are made to ensure that the process is completed properly.

Additional Resources

• NHS, Fluid Balance Monitoring poster, https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2019/01/Fluid-Balance-Monitoring-Poster.pdf
• NHS, Sample Fluid Balance chart, https://www.therotherhamft.nhs.uk/Patient_Information/Patient_Information_Leaflets/
• Fluid and Electrolyte Imbalances course, https://www.ausmed.com.au/cpd/courses/fluid-and-electrolyte-imbalance

References

• Bannerman, C 2018, Fluid Balance Monitoring, NHS Brighton and Sussex University Hospitals, viewed 8 May 2020, https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2019/01/Fluid-Balance-Monitoring-Poster.pdf
• Care Quality Commission 2019, Fluid Administration Charts, Care Quality Commission, viewed 8 May 2020, https://www.cqc.org.uk/guidance-providers/adult-social-care/fluid-administration-charts
• Fresenius Kidney Care 2019, Understanding Hypervolemia and Fluid Overload, Fresenius Kidney Care, viewed 8 May 2020, https://www.freseniuskidneycare.com/thrive-central/hypervolemia
• Georgiades, D 2016, A Balancing Act: Maintaining Accurate Fluid Balance Charting, HealthTimes, viewed 8 May 2020, https://healthtimes.com.au/hub/nutrition-and-hydration/42/practice/nc1/a-balancing-act-maintaining-accurate-fluid-balance-charting/2167/
• Granado, R C & Mehta, R L 2016, ‘Fluid Overload in the ICU: Evaluation and Management’, BMC Nephrol, viewed 12 May 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970195/
• Knott, L 2019, Fluid Overload, Patient.info, viewed 8 May 2020, https://patient.info/doctor/fluid-overload#nav-2
• Litchfield, I, Magill, L & Flint, G 2018, ‘A Qualitative Study Exploring Staff Attitudes to Maintaining Hydration in Neurosurgery Patients’, NursingOpen, vol. 5 no. 3, viewed 8 May 2020, https://onlinelibrary.wiley.com/doi/full/10.1002/nop2.154
• Nall, R & Gotter, A 2016, Hypovolemic Shock, Healthline, viewed 8 May 2020, https://www.healthline.com/health/hypovolemic-shock
• Payne, J 2017, Osmolality, Osmolarity and Fluid Homeostasis, Patient.info, viewed 8 May 2020, https://patient.info/treatment-medication/osmolality-osmolarity-and-fluid-homeostasis-leaflet
• Procter, L D 2019, Intravenous Fluid Resuscitation, MSD Manual, viewed 8 May 2020, https://www.msdmanuals.com/en-au/professional/critical-care-medicine/shock-and-fluid-resuscitation/intravenous-fluid-resuscitation
• Taghavi, S & Askari, R 2019, Hypovolemic Shock, StatPearls, viewed 8 May 2020, https://www.ncbi.nlm.nih.gov/books/NBK513297/
• Vincent, M & Mahendiran, T 2015, ‘Improvement of Fluid Balance Monitoring Through Education and Rationalisation’, BMJ Quality Improvement Reports, vol. 4 no. 1, viewed 8 May 2020, https://www.researchgate.net/publication/286492187_Improvement_of_fluid_balance_monitoring_through_education_and_rationalisation