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SETTING Bristol Royal Hospital for Children

FOR STAFF All staff PATIENTS All patients that require a fluid management _____________________________________________________________________________

Guidance Fluid Balance is a term used to describe the balance of the input and output of fluids in the body to allow metabolic processes to function correctly. It is an essential tool in determining hydration status. Accuracy in recording fluid input and output is vital to the overall management of certain patient groups.

Standard and practice The gold standard is for all patients to have a completed fluid balance chart that require their input and output being measured. Fluid balance documentation should be:

• Timely – as condition dictates • Detailed and accurate measurement of input/ output • Consideration of insensible losses

Indication for commencing fluid balance chart Fluid balance charts must be completed for the following patients unless a decision has been made otherwise by a medical practitioner.

• Patients with sepsis • A patient who is clinically unstable or showing signs of deterioration • Patient discharged from High Dependency Unit (HDU) / PICU (Paediatric Intensive Care

Unit) for a minimum of 48 hours post transfer • Excessive vomiting or gastric output • Diarrhoea and excessive output stoma/ileostomy • Post-operative patients • Neurosurgical patients • Diabetes insipidus • Excessive fluid loss from surgical drains/ cavity drains, wounds/ VAC therapy, burns • Intravenous fluids and drugs, or parenteral nutrition • Enteral feeding • Fluid restricted patients such as cardiac failure, renal failure, acute kidney injury, chronic

kidney disease • Patients with urinary catheters • Sickle cell disease • All oncology patients • Nil By Mouth

Clinical Standard Operating Procedure (SOP)

FLUID BALANCE MANAGEMENT

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Documentation

The medical team will require an accurate 24 hour total to inform clinical decision in relation to fluid management.

Incorrect or poorly completed fluid balance charts can result in detrimental effects on patient outcomes.

When transferring a patient to other wards/ departments a handover must include whether the patient is on a fluid balance chart.

Input

Oral • Fluids must only be recorded as input once it has been ingested. Ensure everyone

involved is aware of volume and restrictions• Do not document sips, document in millilitres• Running totals must be completed for every entry

Enteral Feeds • Continuous enteral feeds must be recorded hourly• Include pre and post flushes as input• Aspirates must be recorded whether returned or discarded on additional columns• Running totals must be completed for every entry to the fluid chart

Intravenous • Intravenous (IV) fluids administered via a pump device should be charted hourly• All IV medications should be documented on fluid balance chart• Ensure IV flushes are recorded as input as they can accumulate to large volumes in some

patients• Running totals must be completed for every entry to the fluid chart

Output • All forms of losses must be documented as accurately as possible• Patients must be encouraged to use urine and stool collection to aid accurate

measurement• Urine output also requires documentation of mls/kg/hr as condition dictates• Record stoma, nasogastric and drain output• All attempts should be made to accurately measure all output. Estimations must be

documented clearly.• Stool type must be recorded with each bowel movement• Running totals must be completed for every entry to the fluid chart

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Balance • Total balances must be calculated with every entry to the fluid chart • Insensible losses should be considered when assessing fluid balance, ensure this is

assessed by the medical team.

To record fluid balance accurately, cumulative total output must be deducted from cumulative total input, as highlighted. A balance must be recorded hourly. A 24 hour balance can then be recorded and documented as highlighted below on the chart for the following day, to aid the appropriate medical team in their clinical decision.

Additional considerations of fluid status

• Daily weight • Blood pressure • Heart rate

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• Peripheral pulses for quality rate and rhythm • Respiratory rate and pattern • Heart sounds • Central and peripheral oedema • Renal function • Orthostatic symptoms of light-headedness, dizziness • Fluid losses related to diaphoresis and dialysis ultrafiltration • Cool peripheries with prolonged capillary refill time • Decreased skin Turgor (beware hypernatraemic dehydration) • Dry mucosal membranes • Sunken eyes • Sunken fontanelle • Irritability and lethargy • Deep (Kussmauls) breathing (secondary to metabolic acidosis)

Increased thirst Table A REFERENCES UHBristol (2012) Core care plan: Fluid Management

Nursing times (2011) Measuring and Managing Fluid Balance Vol 107 No 28

RELATED DOCUMENTS AND PAGES

Renal management and assessment of renal function Fluid replacement for gastric/stoma losses Burns - fluid management in paediatric burns Postoperative Maintenance Fluid Calculator For Children Meningitis Maintenance Fluid Calculator For Children Maintenance Fluid Calculator For Children Acute Respiratory Illness Maintenance Fluid Calculator For Children Intravenous Fluid Medication Infusion Administration Fluid Management In Paediatric Patients Availability Of Intravenous Infusion Fluids In Bristol Children Hospital Monitoring Feeding And Fluid Balance In The Term Infant

AUTHORISING BODY

Nurse practice group

SAFETY Importance of accurate documentation and assessment QUERIES AND CONTACT

Nurse in charge Appropriate medical team

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