Critical Care Trauma Centre

FLUID BALANCE MONITORING STANDARDS

 

Ensure that patient and health care provider safety standards are met during this procedure including:

  • Risk assessment and appropriate PPE
  • 4 Moments of Hand Hygiene
  • Procedural Safety Pause is performed
  • Two patient identification
  • Safe patient handling practices
  • Biomedical waste disposal policies

 

  1. Monitor Intake

 

  1. Monitor Output

STANDARD OF NURSING CARE

RATIONALE FOR STANDARD

Ensure 4 moments of hand hygiene are met when performing assessments and/or managing monitoring equipment.

 Perform risk assessment and select appropriate PPE based on patient diagnosis and procedure being performed.

 1.

Monitor Intake

The drug name (dose not required) and solution used is identified at the top of each infusion column on the intake record.

Blood products may be recorded as a separate total to highlight large volume administration.  Include blood products, crystalloid, enteral feeding volumes and enteral flush volumes in the total IV intake.

At the end of the night shift, carry the 24 hour balance over to complete the cummulative total.

 

 1.



To accurately record intake balance.

The fluid balance record tracks only the volume of various solutions.  For continuous medication infusions of titrated drugs, the actual drug does is recorded each hour in cardiorespiratory section of the graphic record.  The drug concentration is recorded in the MAR.

 2.

Monitor Output

Sanguineous output is charted in red to highlight blood loss. Dialysis output (intermittent or continuous) is also documented. The total output should reflect all losses, including urine, NG, residuals, dialysis and drainage tubes.

Urine output < 0.5 ml/kg/hr and downward trends in symptomatic patients should be reported to a physician.

 

 2.


To accurately record fluid balance.

 

 

 

Normal urine output is > 0.5 ml/kg/hr.

 

Last Update: August 7, 2006, November 27, 2015

Last reviewed: March 30, 2010

Revised: January 20, 2017, November 7, 2018(BM)

References: