Improving The Monitoring Of Fluid Balance In Clinical Settings - Nursing Case Study

Describe about the Nursing Case Study (Improving the Monitoring of Fluid Balance in Clinical Settings)?

Water is the most important part of life and maintenance of proper water balance is of utmost important in order to lead a healthy life. Imbalance in water leads to a number of health consequences. Again, in case of the critically ill patients and post-operative patients, maintaining fluid balance is very important in order to improve their health condition. One of the main roles of the nurses assigned in the ICU department of a health care organization is to monitor the fluid balance of the patients. Adverse health condition may arise if there is a fluctuation of 5-10% in the fluid balance of a patient (Glade, 2010). Various procedures are followed to monitor the fluid balance of the critically ill patients all over the world. According to a study carried out by Bontant et al. (2014), in a critical care unit, the frequency of incorrect calculation of the balance of fluid in patients is 70%. The study also showed that the nurses who work in the critical care units do not perform the monitoring of the fluid balance accurately or correctly. So, in this assignment we are going to discuss the monitoring of the fluid balance of the patients who are admitted to the ICU department of a hospital and also look for the ways by which, the monitoring techniques can be improved in order to decrease the inaccuracy that occurs while monitoring the fluid balance.

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As defined by Elliot et al. (2007), the ICU is that department of the hospital in which patients suffering from life threatening diseases or illness are treated. According to the World Federation of Critical Care Nurses or WFCCN, a nurse who works in the ICU and offers services to the critically ill patients should have proper understanding of the situation of the patients, should be capable of making necessary decisions for the patients and should be able to provide advanced and quality care in order to restore the health of the patient (WFCCN, 2007).

The term fluid balance is used to state the input and output balance of fluid in the body that is essential for the proper functioning of the metabolic processes of the body (Welch, 2010). In case of women, around 52% of the body weight is fluid and in case of men the percentage of body fluid is 60% of the weight and the body fluid consist mainly of water and electrolytes (Louden, 2015). In case of healthy people, the maintenance of the balance of fluid is a dynamic process that is controlled by the body with the coordination of the renal and the hormonal system (Scales and Pilsworth, 2008). An increase in the fluid in human body leads to overloading of fluid which in turn may cause pulmonary oedema. On the other hand, a decrease in the fluid volume in the body can lead to dehydration related complications including hypotension. A fluid volume deficit is termed as negative fluid balance, whereas excess fluid in the body is termed as positive fluid balance (Scales and Pilsworth, 2008).

Importance of Monitoring Fluid Balance in Critically Ill Patients

According to Pikwer et al. (2012), the fluid balance of a patient is the indicator of the clinical status of the patient. In case of critically ill patients admitted to the ICU department, the normal fluid balance is disrupted. So, restoring the fluid balance is the major concern for the nurses caring for the patient. In these kinds of patients, optimal tissue perfusion requires proper fluid balance and a disruption in the tissue perfusion may result in the failure of multiple organs causing the death of the patients (Khwannimit, 2008). Any inaccuracy in the fluid balance measurement may result in inaccurate data regarding the fluid status of the patient which in turn lead to improper treatment of the patient (Koonrangsesomboon and Khwannimit, 2014).

In the body, the maintenance of fluid balance is the function of hormones and renal system (Scales and Pilsworth, 2008). The three hormones that are associated with the function include ADH or anti- diuretic hormone, the other name of which is the vasopressin and is secreted from the pituitary gland; ANP or the atrial natriuretic peptide and aldosterone, secreted from the adrenal gland present in the kidney (Payen et al., 2008). The ADH is associated with the re-absorption of fluid from the kidney and returns it to the blood stream. This hormone is also associated with the decrease in the volume of urine and increase in the concentration of urine (Thornton, 2010). The ANP hormone causes the kidney to eliminate of the sodium and water. Aldosteron on the other hand is associated with the re- absorption of sodium in exchange of potassium ion (Queisser, 2010). The renal system maintains the electrolyte balance through filtration, secretion and re-absorption (Lumbers, Boyce and Gibson, 2007).

There are various studies that are focused on the importance of monitoring of fluid balance in critically ill patients.

According to Vincent et al. (2006), the monitoring of fluid balance influences the recovery of a patient in the ICU.

The basis of monitoring the fluid balance is the assessing, recording and calculating the input and output of fluid of a patient (Garrett, 2003). As per the study carried out by Chapelhow and Crouch (2007), fluid balance chart is very important to monitor the fluid balance of the patients. These charts include the recording of all measurable excreted as well as ingested fluids. According to the chart, the intake of fluid includes orally taken fluid, orally taken medications, application of intravenous fluid and any other types of fluid that are administered through any tube. On the other hand, the output fluid includes drainage, urine, vomit, secretion through nasogastric tube and measurable stools, collected in colostomy bag. According to Lobo, Macafee and Allison (2006), recognizing the excretion of fluid via respiration, perspiration, bowel activity and fever etc. is important while determining the fluid output. These types of outputs account for up to 600- 900 ml of fluid per day and these are not included in the fluid chart. Again, as per Godin, Bouchard and Mehta (2013), sometimes it is difficult to accurately measure the fluid balance in patients, such as in case of diarrhea where the amount of fluid is large and immeasurable. Again, according to Silversides et al. (2013), it is important to assess the clinical condition of the patient and the blood chemistry value along with the fluid chart in order to determine the fluid status of the patient.

Monitoring Techniques

Accuracy in the assessment and interpretation of the fluid status of the critically ill patients are very important for effective management of the health of the patient (Hindahl and Wilson, 2011). So, it is very important to carry out continuous monitoring of the fluid balance of the critically ill patients (Culleiton and Simko, 2011).

According to Foley (2008), one of the earliest indications of the disruption of the fluid balance is the urine production.  As per the studies by Foley, a volume of urine that is less than 0.5 ml/ kg body weight/ hour should be considered as the indication of fluid imbalance and the nurse should respond to the condition of the patient.

According to Knowles (2008), the vital signs of the patients are the important indicators of the fluid status of the patients. The vital signs include pulse rate, blood pressure, and rhythm of the heart, central venous pressure, breathing rate and body weight (Weissman and Landesberg, 2005). According to Dünser et al. (2013), a decrease in the blood pressure level may result in the decrease in the perfusion of the organs that may cause organ failure in the critically ill patients. Again according to Stevens (2007), tissue hypoperfusion may also results in the damage of organs. So, maintenance of proper tissue perfusion is very important to maintain the fluid balance of the patients. Another indicator that is used for checking the fluid balance in patient is the level and frequency of thirst of the patient (Garrett, 2003). Again, according to Armstrong et al. (2014), the laboratory report of blood cell count and the electrolyte count are able to provide additional information regarding the fluid status of the patient.

According to Besen (2015), the overload of fluid in patients can be indicated by high blood pressure, increased weight of the body, swollen neck veins, trachycardia, shortness of breath, cyanosis, increased rate of breathing, increase in the pulmonary arterial pressure and peripheral oedema. In case of severe overload of fluid, pulmonary oedema can result, which is a critical condition that needs immediate addressing and ventilations service (Hindahl and Wilson, 2011). According to Scales and Pilsworth (2008), generally a patient who shows the sign of fluid overload, generally have a history of liver, cardiac or kidney diseases. On the other hand, the dehydration in critically ill patients is clinically indicated by low blood pressure, loss of body weight, increase in the pulse rate, thirst, arrhythmia, and decrease in urination, skin dryness, weakness and drowsiness (Simmons, 2010).

Early Indications of Disruption in Fluid Balance

It is duty of the nurse to monitor the fluid balance of the patients accurately. As per the opinion of Culleiton and Simko (2011), monitoring the balance of fluid in critically ill patients is a challenging but important component of the health care sector, which is described by the authors as the “critical care shuffle”, as the critical medical condition of the patient often complicate the status of fluid in those patients. According to the authors the nurses in charge of the critical care unit should be able to recognize as well as react quickly to the fluid balance disturbance. A study carried out by Carlsen and Perner (2011), also showed the importance of proper fluid monitoring by the nurses or proper treatment of the patients.

There are various studies that have discussed the role and the accuracy of the nurses to monitor the fluid balance of the patients. There are practice guide lines regarding the education and training of the critical care nurses, proposed by the World Federation of Critical Care Nurses. According to Williams, Schmollgruber and Alberto (2006), only registered and trained nurses should be provided with the duty of care for the critically ill persons. A study carried out by Chari et al. (2011), showed that the main reason behind the inaccuracy in the monitoring of fluid balance is the unavailability of qualified nurses. Again, Whiteley et al.  (2009), emphasized on the fact that though several technologies are used for monitoring the fluid imbalance in patients such as alarms and other security features, it is still necessary that the critical care nurses are actively involved in the monitoring of fluid balance in order to provide quality services to the patients.

In a study carried out by Markmann (2011) on 147 patients who were under intensive care, the authors were concerned regarding the incorrect calculation of fluid balance and found that in about 33% of the cases, there was inaccuracy in the calculation of fluid balance of critically ill patients. The authors also suggested that more accurate measures should be developed in order to monitor the fluid balance properly. again the same result was shown by Kashiouris et al. (2013), who found that the cumulative fluid balance calculated by the registered nurses were not accurate.

There are various recommendations provided by various researchers to improve the accuracy of the monitoring of the fluid balance in the critically ill patients.

Vital Signs as Indicators of Fluid Status

In order to improve the monitoring of fluid balance, Rassam and Counsell (2005) suggested that there is a requirement of information notes that will be present on the bedside of the patients, nursing training that is focused on the fluid balance monitoring in order to increase the accuracy and there should be a balance sheet that is user friendly. The authors also suggested that, the signature of the nurse who has recorded the fluid balance data should be there in the balance sheet.

According to Scales and Pilsworth (2008), as the nurses are the main persons associated with the monitoring of the fluid balance of the critically ill patients, improvement of knowledge in the nurses regarding the monitoring of fluid is very important.

Again, Soutter-Green (2013) suggested that the recording charts should be simple in order to decrease the workload of the nurses and increase the accuracy of recording the data. They showed that increase in documentation in turn increases the workload on the nurses which in turn decreases the time for calculation leading to decreased accuracy in the calculation of fluid balance. Their study also showed that if there is regular auditing regarding the practice of monitoring of fluid balance, then the efficiency of the nurses increases considerably.

Bennett (2015) suggested that the fluid balance chart should be designed for individual patients in the ICU separately and reviewing of the chart should be done on a regular basis in order to use the chart accurately and efficiently.

According to Dewitte et al., (2015), measuring the total body water (TBW) can provide accurate data regarding the fluid balance of the critically ill patients. They suggested the use of bioimpedance techniques for measuring the TBW of the patients. They carried out their studies on 25 patients who were under mechanical ventilation. Their study showed that as a non-invasive way to measure the fluid balance of the critically ill patients, use of bioimpedance technique is reliable and provide accurate calculations, but for using the technique, the body weight of the patients should be known.

There are various automated devices available in the market for the accurate calculation of fluid balance. One of such devices is the digistat, offered by United Medical. The company assures that the uses of the device for measuring the fluid balance will significantly decreases the human errors and increase the patient outcome. This device is developed to overcome the shortcomings of the fluid balance chart.

Another such device is the volumetric pump. This device is used for measuring the fluid input in an hourly basis and is also attached with a warning device (Lopot, 2011). Another device that is used by the nurses in order to measure the volume of output fluid includes an urimeter. This device is used for measuring the urine volume and remains attatched with the indwelling urinary catheter (Lee et al., 2011).

According to Scales and Pilsworth (2008), blood chemistry analysis is good method to determine the fluid status of the patients. Again Wolfson and Harwood-Nuss (2005) stated that in the blood chemistry analysis, the measure of blood electrolytes such as blood urea nitrogen, potassium, sodium, bicarbonate and chloride etc. provides a clear view of the fluid status of a person. According to the author, if there any change in these electrolytes compared to the normal level, then it is the indication of the change of fluid status of the patient and the data should be used in order to prescribe any intravenous fluid administration in order to restore the balance of fluid in critically ill patients.

On the other hand, Vivanti, Harvey and Ash (2010) suggested that the blood chemistry analysis does not provide accurate information in case of minor dehydration in case of older people. So, the authors suggested that analysis of the physical signs will be a more effective measure in order to detect fluid imbalance.

With the advent of various methods for accurate detection of fluid balance of a patient, the nursing duty and responsibility for measuring the balance has changed over time. The implementation of newer methods has reduced the responsibilities to a great extent. Still, the nurses play a major role.

According to the NHS, the roles and responsibilities of a nurse include-

On admission, the patients are examined for their fluid balance, which includes measuring the weight, checking the vital signs, checking the thirst level etc. The baseline electrolytes and urea are also measured. The nurse should then assess the urine passed by the patient for the first time. The urine is tested using urimeter and also the color and smell of the urine are also checked. The nurse should document the results in details. The nurses should properly fulfil the fluid balance chart. The nurses should be well aware of the instruments and the procedures that are used for measuring the fluid balance. The laboratory results also play a very important role in detecting the fluid balance in recent times.

The body fluid balance theory was proposed by the ancient Greeks. According to the theory, in order to obtain a good health, one should maintain the balance of ‘humor’. The ways to balance humor was the removal of excessive body fluids by means of sweating, bleeding, purging and with the help of specific foods and medications (Britton, 2002). This theory was called humorism. The four humors are blood, black bile, yellow bile and phlegm. As per the theory, the deficiency of each humor leads to the disturbance of health and temperament of a person. The humor is also called cambium.

As a nurse in the ICU department, I feel that the patients in the ICU departments demand specialized care and services. Their conditions are critical and need proper and careful attention and monitoring (Lopot, 2011). According to the NHS guidelines, the fluid management of the patients should be done frequently and by the registered nurses. The guidelines also state that it is the responsibility of the nurses to monitor and calculate the fluid balance of the patients accurately and properly.

Monitoring of fluid balance is one of the major duties of the nurses working in the ICU department of a health care organization. In our ICU departments, the nurses have to maintain the fluid chart of each and every patient. Again there are emergency alarm and warning devices in order to detect any fluid disturbance of any patient. While working in the department I have felt that the fluid chart that we have to maintain for the patients should be simplified in order to ease the process of record and increase the accuracy (Soutter-Green, 2013). To my opinion, use of advanced devices is very helpful as they automated the monitoring procedure, but still the nurses should be aware of the fluid condition of the patients (Scales and Pilsworth, 2008). Through the discussion, arguments, and recommendations and also from my experience, I feel that, the nurses in the ICU department need specialized training and education regarding the proper and accurate ways of monitoring and calculating the fluid balance of the patients (Rassam and Counsell, 2005).

According to the NHS guidelines, the fluid management of the patients should be done frequently and by the registered nurses. The guidelines also state that it is the responsibility of the nurses to monitor and calculate the fluid balance of the patients accurately and properly.

Conclusion:

Maintenance of fluid balance is of utmost important for maintain the homeostasis of the patients and avoiding any negative health consequences. In case of the ICU patients, it is much more crucial, as both over-hydration and dehydration are dangerous for the health of the critically ill patients. With the advancement of time, newer technologies are introduced in the health care sector for improving the monitoring and reducing the calculation of fluid balance in the patients. But increasing technology does not decrease the responsibility of the nurses in monitoring the fluid balance. The nurses play a key role in the monitoring process. So, proper training and education of the nurses are very important to increase the accuracy and decrease the rate of error in calculating the fluid balance in the patients. The nurses should be much more responsible regarding their duty to the patients.

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