STANDARDS FOR FLUID BALANCE MONITORING

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

STANDARD OF NURSING CARE FLUID BALANCE

 1.

Monitor Intake

Identify the name of all solution at the top of each infusion column on the intake record.  Record the hourly volume (dose is recorded elsewhere, this is fluid balance monitoring only).

Record blood products 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. Intake and output is calculated at 0600 and 1800 hrs.

 2.

Monitor Output

Add a dialysis output (intermittent or continuous) column at the end of each shift and record the 12 hour output balance.

The total output should reflect all losses, including urine, NG, residuals, dialysis, chest tubes and drainage tubes.

Report urine output < 0.5 ml/kg/hr, or downward trends in symptomatic patients to physician.

 

 

Updated: February 1, 2020 (BM)