demonstrated by claire walker, lecturer, university of

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ObservationsAdults

Assessing and measuring fluid balance(in an inpatient setting and in the community)

Demonstrated by Claire Walker, Lecturer, University of Liverpool

©2018 Clinical Skills Limited. All rights reserved

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Green para repeats preceding para? And can be cut

Need to check throughout that we are using hypovolaemia and hypervolaemia, not hypovolemia/hypervolemia, as both were present...

Total body water

Water is essential to life. Around 52 per cent of a woman’s total body weight and 60 per cent of a man’s is comprised of fluid that contains water and electrolytes such as potassium, sodium and chloride (Mooney, 2007). Potassium is vital for the function of nerves and muscles: fluctuations in potassium levels can lead to abnormal heart rhythms. Sodium, present in all body fluids, helps to regulate the amount of water in the body and control blood pressure. Chloride works alongside other electrolytes to maintain the normal acid–base balance of the body. (See Lab Tests Online, 2018.)

Two-thirds of the total body fluid sits within the cells of the body, referred to as the intracellular compartment, and the remaining third sits in the extracellular compartment which includes plasma (intravascular) and interstitial spaces. There are also small pockets of fluid in transcellular compartments such as in the pleural space, within the spine and the peritoneum, and within the gastrointestinal system, including gastric juices and pancreatic secretions. Although these compartments are often discussed separately, fluid moves continuously between all of these spaces (Timby, 2008).

Total body water volume = 40 L, 60% body weight

Extracellular fluid volume = 15 L, 20% body weight

Intracellular fluid volume = 25 L, 40% body weight

Interstitial fluid volume = 12 L, 80% of extracellular fluid volume (ECF)

Plasma volume = 3 L, 20% of ECF volume

Fluid compartments of the body

We could decide to create two pix out of this caption. First would be male and female outlines with first two sentences of caption. Second would be the fluid compartments pic. Happy to discuss. This might be a good idea because some of the splits I suggest later are push-ing it a bit

Fluid balance refers to the amount of fluid the body gains and the amount of fluid the body loses in a 24-hour period (Chung et al., 2002). Recording fluid intake and output on a fluid balance chart (see page 7 and procedure on “Filling in a fluid balance chart”), is an important tool used to assess a patient’s condition. The chart can guide healthcare professionals’ decisions relating to medication, intervention and the recognition of deterioration (Scales & Pilsworth, 2008).

Effective fluid management is directly related to good-quality and safe patient care (McGloin, 2015). This is particularly true for surgical patients, who are prone to postoperative sodium and water overload (Powell-Tuck et al., 2011). If the patient’s fluid status is under or overestimated, the consequences can include fluid overload (hypervolaemia, see page 8), dehydration or volume depletion (hypovolaemia, see page 9), electrolyte imbalance or administration of the wrong type of fluid. All, unless corrected, can lead to organ dysfunction.

The risks of fluid imbalance are serious for patients—and for the NHS. Poor hydration can lead to increased risks for the patient, such as acute kidney injury, infection, confusion and falls, pressure ulcers, catheter-acquired urinary tract infections and venous thromboembolism (NICE, 2013; McIntyre et al., 2012; NCEPOD, 2009). NICE (2013) estimates that the costs to the NHS of acute kidney injury alone are between £434 million and £620 million per year—more than the costs of breast cancer. It is therefore lamentable that some healthcare professionals in hospitals fail to keep accurate records of fluid intake (CQC, 2011).

Staff must have an understanding of fluid management and know how to recognise deterioration in a patient so that they can implement the correct strategies to prevent further deterioration or harm. The required skills include clinical assessment, obtaining the patient’s history, documenting and reviewing the fluid balance chart, and interpreting blood chemistry results. In one regional trauma centre, which implemented an education programme to improve completion of fluid balance charts, the number of acute kidney injury alerts fell from 50 a month to 19 a month over 11 months (Davies et al., 2017). Clinical guidelines highlight the importance of accurate and robust fluid balance assessment and documentation and recommend that intravenous

fluids should be included on a fluid balance chart (NICE, 2017). Although urine output is not included in the observations that form part of the National Early Warning Score (NEWS) (RCP, 2017), many organisations include it in their modified NEWS (MEWS) charts.

Follow local policy on which patients need a fluid balance chart recorded. Many organisations will start a chart for all patients admitted to hospital but will review the need for it regularly. All acutely ill patients will need accurate assessment and documentation of fluid balance, including all those receiving intravenous fluids. Other reasons for starting close fluid balance monitoring include: • The patient is unable to eat or drink;• The patient is having enteral or parenteral feeding;• Fluid imbalance due to sepsis, acute kidney injury, fluid loss, electrolyte imbalance, or liver, kidney or heart disease;• Increased temperature;• An increasing NEWS score;• Surgery during the previous 24 hours; or• Following an emergency admission to hospital. The chart must be subtotalled every 6 hours. Any concerns about fluid imbalance should be escalated to the medical team. Staff should use the chart during the handover of patient care at the end of their shift.

Correct documentation of a fluid balance chart is vital to the provision of safe and competent care (Georgiades, 2016). It is a legal record of fluid management (see page 7). The chart is, however, difficult to maintain accurately (see Chung et al., 2002) for reasons relating to compliance, time, accuracy and education (Vincent & Mahendiran, 2015). To support staff in delivering safe care through appropriate fluid management, consider implementing an education programme (Davies et al., 2017; McIntyre et al., 2012). This procedure covers some of the basics relating to fluid homeostasis, assessing the patient for the signs and symptoms of dehydration and fluid overload, observations and blood chemistry results in relation to fluid balance, types of inputs and outputs and how to measure these, and how to correctly fill in a fluid chart.You will find case histories of patients with hyper- and hypovolaemia on pages 8 and 9 respectively.

Potassium Chloride 0.15% w/v and Sodium Chloride 0.9% w/v Solution for Infusion BP

pH 4.5 -7.0 (approx) Hypertonic

Sodium Chloride 9.0g Potassium 20 Potassium Chloride 1.50g Sodium 154 Water for Injections qs Chloride 174

Osmolarity 388 m)sm/l (approx) Formula per 1000 ml mmol per 1000 ml (approx)

IV administration Read package leaflet before use

PL00116/0337 PA167/52/12 UN-35-01-531 1

POM 07 5 413760 137544 LOT EXP 12BO4E2B 01 / 2020

Keep out of reach and sight of children Do not remove from overwrap until ready for use Do not use unless solution is clear without visible particles and container undamaged Do not reconnect partially used bags

Contains UN-55 01 -069 20 mmol potassium 1000 ml

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Water lossWater gain

Total = 2550 mL

Drinks = 1200 mL

Food = 1000 mL

Metabolic water = 350 mL

Total = 2550 mL

Skin and lungs = 1200 mL

Faeces = 100 mLSweat = 50 mL

Urine = 1500 mLDATE

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ObservationsAdults

Assessing and measuring fluid balance

Fluid balance Physical assessment: (a) Is the patient thirsty?

(b) Check for dry lips and mucous membranes (c) Inspect the tongue

(d) Check skin turgor (e) Assess the patient for a change in mental state

Fluid balance refers to the amount of fluid the body gains and loses in a 24-hour period (Ruxton, 2012; Chung et al., 2002). Fluid intake includes oral and nasogastric feeds, intravenous infusions and fluids, as well as subcutaneous or rectal infusions. Fluid output includes urine, vomit, drain fluid, stoma output and aspirate from nasogastric tubes and diarrhoea, as well as “insensible” losses—which cannot be measured—such as sweat and moisture lost via the lungs. In order to maintain fluid homeostasis, the amount of fluid taken in must equal the amount lost.

Assessing a patient’s fluid balance should involve a clinical assessment, a review of the current fluid balance chart and an awareness of any blood chemistry results (Scales & Pilsworth, 2008). If a patient is able to control their fluid intake, ask them if they are thirsty and get them to recall any fluid intake and output. Carry out this assessment alongside other observations, such as pulse, temperature and respiratory rate (see page 3). (See also “The A-G Assessment Tool”.)

Alternatively, look at the patient’s tongue. In patients who are well hydrated, the tongue will have one long furrow, as shown. In patients who are dehydrated, the tongue will show multiple furrows and it may also appear dry (Vivanti et al., 2008). As well as feeling thirsty, patients may complain of headaches or that their skin feels dry (Dunn, 2015).

Observe patients for signs of dehydration such as dry mouth and cracked lips (McMillen & Pitcher, 2010), and dry eyes (inset). They may complain of difficulties with chewing and swallowing caused by drying of the mucous membranes of the mouth.

Assess the patient for level of consciousness, including new onset of confusion, disorientation and/or agitation (RCP, 2017) or increased falls, which may indicate hypovolaemia (Rushing, 2009).

The turgor, or elasticity of the skin, can be a useful sign of dehydration. Gently pinch a fold of skin and if the patient is well hydrated, it will immediately return to its normal position. Davies (2010) suggests the best place to do this is over the sternum or at the inner thigh. Take great care to maintain the patient’s privacy and dignity and not to damage the skin or inflict pain. In older patients, this assessment may be unreliable because of reduced skin elasticity (Large, 2005).

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DaisyChaine

StaffNurse

The Royal Victoria and Beckham

Hospitals NHS






PL00116/0337 PA167/52/12 UN-35-01-531 1

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Observations

Adults

(f) Check capillary refill time (g) Use capillary refill time with caution

(h) Check for signs of hypervolaemia (i) Body weight

(j) Effect of inputs and outputs on body weight Observations

CRT can be used to rapidly assess circulatory status when managing deteriorating patients (Mrgan et al., 2014), but factors such as age, temperature, poor light, pressure applied and the healthcare professional’s level of experience can affect the assessment of distal perfusion and therefore the test’s accuracy. Therefore, use the CRT in conjunction with other assessment tools when assessing fluid status (Pickard et al., 2011).

Capillary refill time (CRT) is the time that a capillary bed in a distal limb takes to regain its colour after blanching caused by applying pressure (Pickard et al., 2011). Apply pressure to the nail bed for 5 seconds, then release; the nail bed should regain its colour within 3 seconds. If it takes longer, the patient could be hypovolaemic. (See also clinicalskills.net procedure, “The A-G assessment tool.”)

Changes in body weight, especially if rapid, can be a simple indicator of changes in total body water. In hypovolaemia in older adults, a weight reduction of more than 8 per cent can be a sign of severe dehydration (Wotton et al., 2008). It is important, however, to know the patient’s initial body weight and be able to measure their weight at the same time of day using the same set of calibrated scales (Ferry, 2005).

Accurate assessment of patients presenting with symptoms of fluid overload is important, as they will need further investigation. Indications of hypervolemia include; new or worsening peripheral oedema, an increase in body weight, shortness of breath (dyspnoea), difficulty breathing while supine (orthopnoea) and increased jugular vein distension (Albert, 2012). See also page 8.

The patient’s blood pressure, pulses and respiratory rate may all be altered by their fluid status. Patients who are hypovolaemic can present with a fast pulse, a fall in blood pressure (particularly from lying to standing) and a fast respiratory rate if the fluid loss is severe (Shepherd, 2011). However, some of these signs may be absent in elderly patients.

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Changes in body weight can also be influenced by the patient’s bowel movements, and fluid and food intake. It is also difficult to regularly measure body weight in patients who are immobile or critically ill, or in patients who are confused or distressed (Shepherd, 2011).

I got to here

Assessing and measuring fluid balance Page 3

The prevention and detection of AKI, and care of those who develop it, are vitally important for patient health and to avoid development of preventable chronic illness. AKI occurs in 10–20 per cent of all emergency hospital admissions. On discharge from hospital, many patients continue to suffer chronic kidney disease (Think Kidneys, 2016).

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Date Normal ValuesHb 11.8 - 16.7Wcc 3.5 - 11.0Hct 36 - 50%Platelets 150 - 400Neutrophils 2.0 - 7.5Prothrombin time 12.2 - 15.5Thrombin time 10.5 - 15.5APTT 25 - 36Fibrinogen 1.5 - 4.5D Dimer <500

Sodium 133 - 146Potassium 3.5 - 5.0Chloride 9.5 - 108Bicarbonate 22 - 29Urea 2.5 - 7.8Creatinine 50 - 130Calcium 2.2 - 2.6Phosphate 0.8 -1.5Alk Phos 35 - 130Total Protein 60 - 80Albumin 35 - 50Bilirubin <21ALT 0 - 35Corrected Calcium 2.2 - 2.6Anion Gap 6 - 16 GGT <50Glucose 3.5 - 6Magnesium 0.7 - 1.0eGFR >60

Lactate 0.5 - 2.2Amylase <150CR Protein <5

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Observations

Adults

Blood chemistry results Creatinine and urea

Detection of acute kidney injury Be alert to the possibility of acute kidney injury

Types of inputs Do not estimate volumes of oral fluid intake

If available, review the patient’s blood chemistry, particularly plasma levels of the waste products urea and creatinine (from protein breakdown and normal muscle breakdown respectively). Both are usually processed by the kidneys and excreted in urine. Normal levels depend on age, race, gender and body size, but if these rise, it can indicate that the kidneys are impaired or injured.

An early indication of hypovolaemia is a rising urea level but a normal creatinine level (a): in this case, the patient will need reviewing and monitoring. If urea and creatinine levels both rise (b), with a sudden reduction in renal function, this is an indication of acute kidney injury (AKI) (Scales & Pilsworth, 2008). (The red dotted line indicates normal levels.)

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Diagnosis and staging of AKI is based on both blood creatinine levels and the patient’s urine output (NICE, 2013). A patient with AKI will find it difficult to maintain fluid, electrolyte and acid-base balance.

• Fluids ingested from drinks

• Fluids gained from food

• Enteral feeds, such as nasogastric feeds

• Intravenous fluids (including blood and blood products)

• Parenteral nutrition

• Nutritional supplements

• Oral medication

• Intravenous medication

• Rectal infusions/enemas or electrolyte supplements

1 jug = 1000 mL

1 beaker = 200 mL 1 glass = 180 mL 1 cup = 170 mL

Become familiar with the volumes of local containers. Never estimate volumes. It is inaccurate to record “sips”. If a patient cannot manage normal volumes, provide a drink in a gallipot and record the amount taken.

Fluid inputs include many more types of fluids than just drinks. Fluid intake includes oral and nasogastric feeds, intravenous infusions and fluids (NICE, 2013), as well as subcutaneous or rectal infusions.


• A rise in serum creatinine of 26 micromol/litre or greater within 48 hours

• A 50 per cent or greater rise in serum creatinine known or presumed to have occurred within the past 7 days

• A fall in urine output to less than 0.5 mL/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people

• A 25 per cent or greater fall in eGFR (estimated glomerular filtration rate—a key indicator of renal function) in children and young people within the past 7 days

• Urine

• Faecal losses

• Vomit

• Nasogastric drainage

• Wound drainage and rectal drainage

• Stoma output

• Insensible losses (such as sweat) may also be included: follow local policy/guidelines

When handling body fluids, wear non-sterile gloves, apron and—if there is a risk of splashing—goggles (McGloin, 2015).

Urine should be a pale, odourless, straw colour in healthy patients: the colour of the patient’s urine can be a useful indicator of fluid status (Benelem, 2010). If the patient is hypovolaemic the body will conserve water and urine will be dark, concentrated and of poor volume (Scales & Pilsworth, 2008). Urine should be the colour of champagne rather than dark beer! Staff need to be aware that certain drugs and food colourings can alter the colour of urine. (See also procedures on “Urine testing”.)

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© 2009 Chelsea and Westminster Hospital NHS Foundation Trust Developed by Dan Ford, Critical Care Outreach Team (CCOT) — September 2009

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DaisyChaineStaffNurse

The Royal Victoria and Beckham Hospitals NHS






PL00116/0337 PA167/52/12 UN-35-01-531 1

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PEPPER

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80 kg = 40 mL urine per hour

50 kg = 25 mL urine per hour

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Observations

Adults

Patients who cannot eat or drink without assistance Types of output

Personal protective equipment Observe the colour of the patient’s urine

Monitor the volume of the patient’s urine Minimum desired urine output

Those patients who may require assistance with eating and drinking should be supported in order to maintain their intake and staff should record the input after help has been given (Scales & Pilsworth, 2008). Patients may gain useful fluid intake from foods such as soup, jelly, yoghurt and icecream.

Measure all outputs as far as practicable (see below). Follow local guidelines on which outputs to include. Fluid output includes urine, vomit, sweat, drain fluid, stoma output, aspirate from nasogastric tubes and diarrhoea. (See also NICE [2013] for details of electrolytes lost from different outputs.)

Calculate the minimum desired urine output according to the patient’s weight. Less than 0.5 mL of urine per kilogram body weight per hour indicates oliguria, or diminished urine output (Resuscitation Council [UK], 2015). NICE (2007) specifies that urine output of less than 0.5 mL/kg/h for more than 6 hours in adults and more than 8 hours in children and young people is an indicator for AKI. For example, a patient weighing 80 kg should pass a minimum of 40 mL/h and one weighing 50 kg should pass at least 25 mL/h.

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A reduced urine output is not an absolute indicator of failing renal function or perfusion but can be the first indicator of fluid and electrolyte imbalance; if left untreated, it can lead to AKI or chronic kidney disease (Elliott & Coventry, 2012). Urine output is no longer included in the revised National Early Warning System chart (NEWS2; see RCP, 2017). Larger local observation charts should, however, include parameters such as urine output, according to the clinical environment (RCP, 2017).

Patient on scalesCould do sitting scales


Encourage patients who do not have a catheter to urinate in bedpans or urinals so that staff can accurately measure the volume of urine passed.

Do not estimate the volume, measure it accurately by pouring the urine into a measuring jug before disposing of it.

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Monitor urine output: (a) (b)

Collect urine in bedpans or urinals Measure volumes carefully

Weigh incontinence pads Other types of fluid loss

It may be difficult to closely monitor urine output if a patient is incontinent or does not have an indwelling catheter, for example. If the patient does have an indwelling catheter and urine output suddenly stops, check the catheter to see if it is kinked or blocked (Scales & Pilsworth, 2008). If the patient has a urinary catheter, use of a urometer will allow hourly measuring and recording.

A urometer makes it easy to take accurate measurements of even small volumes of urine at specific intervals (Bouwhuijsen et al., 2012). Staff can record the amount of urine passed since the last measurement, then release the valve to empty the urine from the graduated container into the collection bag. Empty the collection bag regularly and change it when clinically indicated, following local and manufacturers’ guidelines (NICE, 2014).

Do not forget that the patient may lose fluid via a nasogastric tube or via a stoma, for example. Liquid stool, for example that produced from an ileostomy, can be measured in the same way as urine. It should be easy to measure blood loss if the patient has a collection bag or drain in place. Where blood loss cannot be collected, as in trauma or suspected internal bleeding, the amount lost is difficult to calculate; instead, observe the patient for signs of deterioration such as hypotension and tachycardia (Matthias et al., 2010).

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Where the patient has faecal or urinary incontinence, if possible estimate the volume lost by weighing the incontinence pad. Specialist scales are available that will convert weight of urine into volume; alternatively, calculate the volume by measuring the difference in weight between an unused pad and the wet one. The weight of 10 mL of urine will approximate to 10 g (Galen, 2015). Using symbols such as “+++” or simply writing PU on the chart is not adequate.


Observations

Adults

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SPLIT

The fluid balance chart is a legal record of fluid management and should therefore be treated as such; it should be used to reflect the care, treatment and support a patient is receiving in a clear, accurate and timely manner (NMC, 2015). Follow local hospital policy for patients who must have fluid balance recorded (Pegram & Bloomfield, 2015). The chart should accurately reflect the patient’s total input and output. Completed accurately, it can aid healthcare professionals to identify any deficiency or excess in fluid intake or output (Dunn, 2015) and guide them towards further treatment or investigations. Inaccurate interpretation and documentation on this chart has the potential to increase morbidity and mortality (Tang & Lee, 2010). It is important to maintain the chart frequently in accordance with the patient’s condition, and review it in line with the observations schedule. The chart must be legible. Document and report any abnormal findings immediately (Shepherd, 2011), to ensure continuous assessment of the patient’s fluid status. (See “Reasons for concern” below.) It is not sufficient to review fluid status only at the end of a shift (Lecko, 2007). Report any clear incidents of fluid mismanagement (such as unnecessarily prolonged dehydration or inadvertent fluid overload due to intravenous fluid therapy) via the DATIX reporting system.

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FLUID BALANCE CHART

Fluid Input Fluid Output

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fluids Cumulativebalance+/-

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Tea 300 mL

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Reasons for concern Discontinuing the fluid balance chart

I took red �gure from the Rotherham chart but other �gures on this page are mL/kg/h which I think is more accurate, what should 110 mL/h be in mL/kg/h?

Consider discontinuing the chart when:

• The patient is eating and drinking normally

• The patient is passing good volumes of urine (1 mL/kg/h) and their chart is “in balance”

After stopping the chart, recording the patient’s weight daily may provide a good alternative method of continuing to monitor fluid loss or gain.

Alert a senior colleague if: • The patient has a low urine output (< 0.5 mL/kg/h)• The patient is not on diuretics but has a high urine output (polyuria is defined as urine output >3 L/day) Bichet, 2017

• The patient appears to be more than 500 mL positive or negative on the running total• The patient has been nil by mouth for 6 hours (and has no intravenous infusion)• A patient without a urinary catheter has not passed urine for 6 hours• The patient is acutely ill or the trend of observations shows deterioration


In this column, take the running total of inputs and subtract the running total of outputs. Write down the difference to provide a cumulative fluid balance. A positive figure here indicates the patient’s input is more than their output (see case history on page 7). A negative figure here indicates the patient is losing more fluid than they are taking in (see case history on page 8).

Keep a running total for outputs here

Keep a running total for inputs here

The chart, either electronic or hard copy, should contain the patient’s name and date of birth, and the current date.

All inputs (see page 4) are recorded on the left. Record individual inputs at the time of intake. Record the time of the input in the first column.

All outputs (see page 5) are recorded on the right. Measure and record fluid output when clinically necessary or warranted (for example when a patient has passed urine into a urinal).

Filling in the fluid balance chart

18 5

14

2 1

ID Label or

Name

Hospital No,


FLUID BALANCE CHART




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Finch, R 345790 28/01/41 7/8/2018

Tea 170 mL

Tea 170 mL

Tea 170 mL

Juice 200 mL

Juice 200 mL

Water 200 mL

100 mL N. Saline 50 mL

40 mL

30 mL

55 mL

100 mL

50 mL +220 mL

90 mL +580 mL

220 mL+820 mL

275 mL+1165 mL

500 mL+1610 mL

270 mL 100 mL N. Saline 100 mL N. Saline 100 mL N. Saline 100 mL N. Saline 100 mL N. Saline 100 mL N. Saline 100 mL N. Saline 100 mL N. Saline 100 mL N. Saline

370 mL 670 mL 770 mL 1040 mL 1340 mL 1440 mL 1710 mL 1810 mL2110 mL 120 mL

CKD Stage 3

Observations

Adults

Hypervolaemia

Case study 1 Chart 1

of 9


In hypervolaemia, there is too much fluid in the blood. Excess water leaks from the vessels into the interstitial spaces, and forms oedema. The resulting swelling in the tissues of the lungs, limbs (Chan et al., 2014), and other organs, leads to organ dysfunction. Hypervolaemia can also lead to reduced perfusion and hypoxia of the tissues, due to dysfunction at a cellular level (Prowle et al., 2010).

Complications of hypervolaemia can include hypertension, congestive heart failure, left ventricular hypertrophy, pulmonary oedema, oedema in the tissues, delayed wound healing, impaired bowel function, and tissue breakdown. Hypervolaemia has also been related to increased mortality (Claure-Del Granado & Mehta, 2016).

Hypervolaemia can occur in patients with moderate to (particularly) late stages of chronic kidney disease and heart failure. Recognising hypervolaemia and restricting fluid intake in this group of patients is particularly important to prevent complications (Khan et al. 2016). Aggressive fluid resuscitation—during sepsis, for example—can also cause fluid overload (Gibney et al., 2008).

In patients with normal cardiac, renal and endocrine function, an increase in the volume of fluid in the body increases excretion of sodium and water by the kidneys in order to maintain a normal total body volume (Albert, 2012). However, some groups of patients may not be able to deal well with excessive fluids and may need additional supervision and treatment. For example, in patients with cardiac failure, this increased volume, combined with poor cardiac function, increases pressure, particularly in the left ventricle. As a result, pressure rises in the alveoli of the lungs, which in turn causes them to leak fluid into the interstitial space (Albert, 2012), causing pulmonary oedema. Signs of pulmonary oedema include sudden dyspnoea (shortness of breath), frothy sputum, cough, and pulmonary crackles on auscultation.

In those patients with abnormal renal function, the kidneys’ ability to excrete or reabsorb water is impaired by either disease or damage, putting them at risk of hyper- or hypovolemia. Patients with chronic kidney disease commonly struggle with fluid overload rather than depletion (Pace, 2007).

This is particularly true in patients with moderate or severe chronic kidney disease, who often also develop hypertension, oedema, congestive heart failure and left ventricular hypertrophy (Khan et al., 2016). Signs of left ventricular failure include dyspnoea, wheezing and tachycardia. Jugular vein distension can also indicate fluid overload.

A chest radiograph may help to identify signs of dilation in the vessels or lobes of the lungs along with effusions or oedema in the alveoli. However, the reliability of a chest radiograph to detect hypervolaemia will vary with the technique used to obtain the radiograph and the patient’s position—this is particularly true with portable chest radiographs or if the patient is lying down (Claure-Del Granado & Mehta, 2016).

To avoid fluid overload, it is important to accurately document all inputs and outputs, with the ultimate goal of removing the excess fluid without compromising the circulating volume (Claure-Del Granado & Mehta, 2016). In addition, implement strategies to reduce excess fluids, such as discontinuing intravenous infusions once the patient is able to maintain their fluid input with oral fluids or have accumulated fluids removed with the use of diuretics (Ogbu et al., 2015). Once circulatory volume appears to be normal and the patient is haemodynamically stable, return to oral fluid administration as soon as possible (Powell-Tuck et al., 2011).

Diuretics, particularly loop diuretics, can relieve symptoms and improve the patient’s status in hypervolaemia. Diuretics work by reducing sodium reabsorption at different points in the nephrons of the kidneys, resulting in increased urinary sodium and, as a consequence, increased water loss too (Wile, 2012). It is common for electrolyte disturbances to occur with the use of diuretics. Therefore, check the patient’s serum levels of potassium, magnesium, sodium and chloride at least daily and provide replacements if needed (Claure-Del Granado & Mehta, 2016).

Patients who are hypervolaemic and not responding to diuretic therapy or are critically ill may need extracorporeal therapies such as slow continuous ultrafiltration, continuous veno-venous haemofiltration or intermittent haemodialysis. The choice will depend upon resources, expertise, and the patient’s haemodynamic state (Claure-Del Granado & Mehta, 2016).

Rosemary is a 77-year-old woman with known chronic kidney disease stage 3. Five days ago Rosemary had a right hemicolectomy for a bowel tumour and today she has started drinking fluids. She still has a urinary catheter in place, she has opened her bowels and still has an intravenous infusion running at 100 mL per hour. It is 16.00 hours and you have been asked to review her fluid balance chart (see right).

Rosemary’s fluid balance chart demonstrates that she is currently in a positive fluid balance. She is receiving intravenous fluids and is drinking good amounts, meaning that her input is more than her output: the chart shows that she has taken in 1610 mL more than she has lost in outputs. It will be important to review her chart again later, to assess whether it is still appropriate for her to be having the intravenous fluids, as continued administration could pose a risk of fluid overload.


NAME.............

DATE OF BIRTH

WARD............

ID Label or

Name

Hospital No,


FLUID BALANCE CHART




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Drake, D 758901 16/04/50 18/02/2018

20 mL water

20 mL water

100 mL water

50 mL water

20 mL 35 mL 200 mL

300 mL

300 mL

100 mL

50 mL

10 mL 30 mL 30 mL 25 mL 20 mL 30 mL

70 mL

90 mL

190 mL

235 mL 245 mL 275 mL305 mL 730 mL 750 mL1130 mL

-215 mL

-205 mL

-640 mL

-940 mL

NONE

Observations

Adults

Hypovolaemia

Case study 2 Chart 2

of 9


Donald is a 67-year-old man with a history of diabetes. He has been admitted to the assessment unit with a 48-hour history of vomiting, diarrhoea and erratic blood sugars. Donald is still very nauseous and continues to vomit and pass a type 7 watery stool regularly (see “Stool specimen: assessment”). He can eat and drink if he feels able to. His recent observations reveal a regular pulse of 115 bpm and normal volume, a blood pressure of 90/50 mmHg, a temperature of 36.7 °C, and a respiratory rate of 18 bpm. He is responsive to voice. He has been passing urine into disposable urinals and using a disposable bed pan and receiver for stool and vomit respectively. You come to fill in Donald’s chart at 1pm. In the past hour, he has passed 30 mL of urine, 300 mL of liquid stool and vomited 50 mL.

Donald’s chart shows a patient in a negative fluid balance: his output due to diarrhoea and vomiting is more than his input. Donald is at risk of hypovolaemia as he is losing large amounts of liquid stools and vomit but only managing small amounts of water. It will be important to review his care with a view to supporting his fluid intake with intravenous fluid therapy. Patients who benefit from careful fluid-balance monitoring include postoperative patients, those patients whose fluid intake is restricted, those who are critically ill or deteriorating, those with acute or chronic kidney disease and those with cardiac failure. The fluid balance chart is a legal record of fluid management and should therefore be treated as such; it should be used to reflect the care, treatment and support a patient is receiving in a clear, accurate and timely manner (NMC, 2015).


Hypovolaemia occurs when there is a reduction in circulating volume due to loss of fluid from the intracellular or the extracellular space (McGee et al., 1999). It can arise as a serious complication of dehydration—which is defined as the excessive loss of water and other fluids from the body. The causes of dehydration include: • Refusal to drink due to fear of incontinence;• Decreased intake of fluids due to dementia and cognitive impairments; • Reduced sensation of thirst in older people; • Being reliant on healthcare professionals to provide adequate fluids;• Fluid restriction for heart failure or renal disorders; • Preoperative fasting; • Nausea;• Increased outputs (such as vomiting and diarrhoea, or blood loss following trauma); • Shifts in fluids—for example, if fluid leaks out of the blood vessels and into interstitial spaces that normally hold little or no fluid. This situation can occur in burns, liver failure, sepsis and conditions in which there are low levels of albumin in the blood. Patients affected in this way may present with oedema or ascites, but are technically hypovolaemic due to their low circulating fluid volume (Schiavo, 2007).

If dehydration is not adequately recognised and corrected, complications can arise, such as electrolyte and acid–base disturbances, lethargy and, ultimately, hypovolaemic shock (Tidy, 2014). Hypovolaemic shock can be defined as a decrease in intravascular volume (Gutierrez et al., 2004), leading to reduced tissue perfusion and acidosis, which develops following anaerobic metabolism in the absence of oxygen. If left untreated, hypovolaemia will cause a decline in function of the organs of the body, progressing to permanent tissue damage and ultimately organ failure (Kreimeier, 2004).

Hypovolaemic shock is one of five types of shock (Resuscitation Council [UK], 2015). It can be classified as mild, moderate or severe (Schiavo, 2007). In mild, or compensated, hypovolaemic shock, the patient has lost 15 per cent or less of normal body fluid volume. The body responds by increasing the heart rate to maintain perfusion; blood pressure may drop slightly and patients may appear restless or anxious. Loss of 15 to 30 per cent of volume represents moderate hypovolaemic shock; as well as altered observations as before, patients will complain of increased thirst and will appear more irritable. Severe, or decompensated, hypovolaemic shock

occurs with a loss of fluid volume greater than 30 per cent of normal, resulting in decreased perfusion to the brain and heart.

These signs can, however, present differently in older patients and in children, for example. In elderly patients, underlying cardiac disease can affect their ability to respond to shock, and common signs such as tachycardia and prolonged capillary refill time may not be present (Colwell et al., 2006). In children, hypotension is a late development and can signal impending cardiac arrest (Pomerantz & Roback, 2018). With both groups, it is important to undertake a full assessment and history, to ascertain possible signs of and causes for deterioration.

Note that impact of volume lost depends upon the patient’s size and sex. For example, a female patient weighing 70 kg, with an approximate total blood volume of 4.5 litres, could develop severe hypovolaemic shock following a blood loss of only 1.35 litres (Schiavo, 2007).

In patients with cardiac, renal and other complicating factors, fluid resuscitation should be carried out with caution, alongside advanced monitoring and the use of vasopressors (Pellicori et al., 2015). However, the Resuscitation Council (UK) (2015) clearly recommends that hypovolaemia should be treated quickly with intravenous fluids. NICE (2017) recommends that crystalloid fluids containing 130–154 mmol/L sodium are used in the fluid resuscitation of adults; these fluids include sodium chloride 0.9% and Hartmann’s solution. A bolus of 500 mL over less than 15 minutes should be given, followed by assessment of the patient’s response.

Clinical assessment will help to determine the cause and severity of the patient’s hypovolaemia, and their response to treatment. The Resuscitation Council (UK) (2015) recommends assuming that hypovolaemia is the primary cause of almost all medical and surgical emergencies until proven otherwise. Patients who are hypovolaemic may have cool, pale peripheries and a prolonged capillary refill time. Assess their pulse for rate, rhythm and quality, and check for the presence of both peripheral and central pulses (Resuscitation Council [UK], 2015). Patients may have a low blood pressure with an increased pulse and respiratory rate and may also complain of dizziness, blurred vision or cool clammy skin (Jarvis, 2016). Physical assessments, along with strict monitoring of fluid balance, will allow the healthcare professional to assess the response to fluid resuscitation and ensure that the kidneys are receiving enough perfusion to produce urine (O’Neill et al., 2016).

demonstrated by claire walker, lecturer, university of

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