Fluid balance is a common term in the nursing practices used to describe the balance between input and output of bodily fluids to permit the proper functioning of bodily metabolic processes (Welch, 2010). According to Shepherd (2010) around 52% of the total body weight in women, as well as 60% of men is mainly fluid, which consists of water and molecules that contain, for example, potassium and sodium chloride. Fluid balance is essential for good hydration, which as Shepherd (2011) asserts, is a primary tool that can be used in assessing the health status of a patient. In the healthcare sector, fluid balance is maintained with the help of fluid balance charting. For this reason, it is essential in ensuring that the patients have a quick recovery, as well as aid in the identification of the underlying health-related issues. For instance, poor hydration is a cause of slow wound healing process while over hydration can lead to poor cardiac health (Waugh and Grant, 2010). However, the fluid charts are difficult to understand, and thus, they are often interpreted inaccurately. As Thornton (2010) and Bennett (2010) posit, inaccuracy in fluid charting leads to poor hydration, and thus, this presents a common problem in the hospital environment.
It can be derived that accurate and regular fluid balance recording is vital for assessing patients, planning and implementing favorable fluid balance initiatives for patients, as well as evaluating their treatment of health conditions (Ronco, 2010). However, nursing practice reveals that it is difficult to measure a patients fluid intake and output because nurses do not always see how much each patient drinks throughout the day or in instances when a patient happens to have an accident in bed, how they can measure the incontinence as output. As there is no guide or documentation that guides nurses to measure a patients output and intake accurately, this variation leads to inconsistency. For this reason, there is a need for change, which can be achieved via changing fluid balance charts to make easier to understand, adding color on to jugs, as well as educating staff.
The purpose of the project is to educate all employees on the importance of accurate fluid balance charts and correctly to fill in the charts especially health care assistants. In essence, this is important as it increases the accuracy of the fluid balance, thereby ensuring that the patients recover faster. Also, it will also highlight the significance of adding the patients weight at the top of the chart so that staff can calculate how much the patient is passing ml per hour according to their weight to establish if the patient should have a positive or negative urine output. The project will offer a fluid monitoring improvement package which combines education of staff, change of documentation to an improved Fluid Balance Chart and instigation of colored jugs for oral fluid monitoring.
Literature Search Strategy
Since the project uses a qualitative research design, which capitalizes on relevant secondary data from CINHAL, NMC, Cochrane, Nursing Times, CQC, NICE. The keywords that were used in the search criteria include fluid balance, fluid balance charts, improvement of fluid balance jugs, the importance of accurate fluid balance, color codes for fluid balance, and nurse education of fluid balance, as shown in Appendix 3.
According to Meiner (2002), documenting correctly the patients intake and output of fluids serves as an indicator to nurses of illness recovery or progression. In addition, McGloin (2015) also articulates that staffing shortages for nursing practitioners and the lack of education contribute to inaccurate fluid balance charting because the nurses are not always in the room to administer to a single and specific patient. For this reason, educating them on the importance of accurate fluid balance charts and correctly filling in the charts especially health care assistance is vital. In essence, this is because many prescriptions and orders from physicians depend on an accurate account of the fluid balance and intake.
Educating nurses on the accurate fluid balance is important especially for those patients at a risk of urinary retention because the nursing staff should be able to know when they should administer diagnostic procedures for urinary retention, for example, straight catheterization and bladder scanning (Johansson et al., 2012). Scales and Pilsworth (2009) identified three main elements that are required in assessing hydration and fluid balance status, which are clinical assessment, reviewing patient blood chemistry, and reviewing fluid balance charts. In clinical assessment, the patients should be asked whether they are thirsty, but this is not an effective strategy especially for those patients that have the ability to control their fluid intake. However, according to McMillen and Pitcher (2010), patients with an impaired capability of controlling fluid intake include those afflicted with confusion, depression and speech difficulties, and thus, would benefit from accurate fluid charting. In addition, older people can also have impaired perception about thirst. In cases where there is an inaccurate fluid balance among patients, it can result in dehydration, which consequently causes the mouth, as well as the mucous membranes to become dry and the lips will also crack. For this reason, nurses need to perform an assessment of oral mucosa and mouth to look for these aspects, which would be helpful in noting instances of dehydration. Fluid balance charts can be used in monitoring fluid balance in patients, thus, ensuring that patients are not dehydrated.
Even though monitoring fluid balance in a patient to prevent instances if overhydration or dehydration seems to be a simple task, using fluid balance charts as Bennett (2010) notes can be notoriously inaccurate or inadequate. Reid (2004) after auditing fluid balance charts for different wards, found that the reason why they were not completed appropriately was inadequate staff, time, and training. Even so, nurses, as the Nursing and Mid-wifery Council (2007) articulates. They need to keep accurate records, which is an integral part of the nursing practice. Also, they need to realize that it is not something that should be fitted in or recorded without absolute care. According to Scales and Pilsworth (2008), it is the nurses responsibility responsible for a particular patient to ensure that make fluid balance observations and record them accurately. The researchers stress that the records should be timely, and the nurse has the responsibility of documenting and reporting abnormal findings to the nurse in charge.
In essence, the nurses should be notified and educated about the importance of keeping a daily observation sheet for a 24-hour period. The records should comprise of accurate intake and output of the fluids for the period. As Scales and Pilsworth (2008) articulate, the difference in the volumes is then calculated to subsequently give the 24-hour fluid balance. For this reason, they should accurately record the intake and output in the fluid balance charts. Leach, Brotherton, Stroud & Thompson (2013) pointed out that it is important to adopt staff and nurse education on matters of hydration management. The change should promote fluid balance chart consistency, safer patient practice, and accuracy through accurate fluid balance monitoring and recording.
Diacon and Bell (2014) after realizing the inaccuracies of fluid monitoring, especially involved with improper recording of fluid balance charting recommended that hospitals should institute a system whereby the nurses can check fluid balance calculations at specified intervals, for example, during a shift change where a patient is handed over from one nurse to another. Also, the researchers also recommended that the calculations should also be made during discussions of patient management or the assessment process of the patient. In addition, Diacon and Bell (2014) also pointed out that nurses should be made aware of the potential adverse consequence brought forth by erroneous fluid balance calculations, which should be a major discussion point, as well as in a continuous training or education sessions in the hospital. Besides, it should be made a requirement that nurses should provide accurate fluid balance charts that will allow correct monitoring of fluid balance. Furthermore, outcome-driven audits should also be made part and parcel of the nursing practice as they will allow timely error identification, thereby allowing the necessary interventions to be designed and implemented. Also, the nurses should support able patients to participate and manage their hydration status if it is possible, which can subsequently improve compliance and accuracy in monitoring fluid intake and output, thereby eliminating erroneous fluid chart completion (Reid et al., 2004; Chong & French, 2002).
Further, as Smith and Roberts (2011) noted, all fluid input and output should be documented I the fluid balance charts using quantifiable amounts. As such, it is vital for the nurses to know and record the amount of fluid in milliliters in intravenous medication, a glass of water or tea, and even the amount of urine the patient discharges. Besides, the fluid balance charts should be recorded in continuous intervals, for example, in an hour or two hours, and these intervals should be strictly observed. Appendix 1 and two highlights are acceptable and unacceptable fluid balance charting as documented by Smith and Roberts (2011). The format is easily understandable.
Also, calibrated and colored jugs should be used in measuring output, thereby ensuring accurate measurement. In addition, the patients should be weighed on a daily basis, and the weight versus fluid intake and output should be recorded on top of the fluid balance chart. Weighing patients is a reliable method of assessing the patients risk of fluid imbalances, such as overhydration and dehydration. Also, nurses should use blue lids on jugs for those patients independent of fluid balance problems. However, green lids should be used for patients with a certain type of cognitive impairment and require assistance in oral intake, as well as have their bodily fluid intake monitored. Also, the use of red jugs can also be used as it will provide more understanding of fluid balance charts and promote more accuracy (Hollis, 2010).
Change Process: PDSA model of change
To ensure that change has occurred to increase fluid balance charting accuracy, there are various models that can be used, but the most effective one is the PDSA cycle. The acronym stands for Plan-Do-Study-Act. It is shown in the figure below:
Figure 1: PDSA Cycle. Source: Kerridge (2012).
According to the National Health Service (2013), the model has been tested and can be used in helping teams plan on how to implement various intervention proposed in a nursing change process. Besides, as Holland and Rees (2010) articulate, the model capitalizes on evidence-based practice before implementing the change process, which is a key element in the nursing practice.
As shown in figure 3, the first step is planning. The objective of the proposal is to educate nursing practitioners on how to effectively perform accurate fluid balance charting and monitoring to ensure that the patient is nor over hydrated or dehydrated, which might be severe their recovery process. Also, it is intended to ensure that the nurses collaborate with the patients, and in particular, thos...
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