Download Fluid Balance Chart - ICID (Salisbury)

Fluid Balance Chart
Date:_______________
Name:__________________________________________________
Hosp No.____________________
Age_________________
D.O.B_____________________
NHS No._ ________________________
Cons.___________________ Ward______________________________
Indication for fluid chart:
---------------------------------------------------
Previous 24hrs balance
Time
Urine Output Trigger
When urine output falls below 0.5 mls/kg/hr
for
2 consecutive hours
+/- ____________________mls
Patient’s weight _____________________(Est/Act)
Minimum hourly urine output: _________________
Minimum 12hrly urine output: _________________
Minimum 24hrly urine output: _________________
OUTPUT
INPUT
Oral
Salisbury
NHS Foundation Trust
Total
Input
Urine
Total
Ouput
Bowels
Nursing Intervention
Hourly
Balance
01:00
02:00
03:00
04:00
05:00
06:00
07:00
08:00
09:00
10:00
11:00
12:00
12hr balance +
Total
RN Sig.
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
24:00
12hr balance +
Total
For PDSA Cycle Use
ESCALATION
YES
NO
Document on escalation record
Only
Leucocytes
Nitrate
Protein
PH
Urine Dipstick
Blood
Specific Gravity
Ketones
Glucose
RN Sig.
Escalation Record
Date
Time
Previous 2hrs U/O + Fluid
Balance
Action Taken & Rationale
Sign & Grade
Guidelines
Please refer to the ‘Fluid Balance Policy’ on
ICID for further information & advice
Kg
Stone
Hrly
12
hrs
24
hrs
Documentation
40
6.3
20
240
480
45
7.1
23
270
540
50
7.9
25
300
600
55
8.6
28
330
660
60
9.4
30
360
720
65
10.2
33
390
780
70
11.0
35
420
840
75
11.8
38
450
900
80
12.6
40
480
960
85
13.4
43
510
1020
90
14.1
45
540
1080
95
14.9
48
570
1140
100
15.7
50
600
1200
105
16.5
53
630
1260
110
17.3
55
660
1320
115
18.1
58
690
1380
120
18.9
60
720
1440
 If the fluid balance starts or finishes at a
specific time other than midnight, draw a
line through the unused columns
 Complete the running total column
 The daily fluid balance amount must be
entered clearly at the end of the 12 and 24
hr period
 Escalate when indicated
Intravenous Fluids
 For IV fluids the actual amount infused
each hour should be documented
 If a pump is not available document the
name of the fluid & the time commenced &
record the total amount at the end of the
infusion
 Include each saline flush given between
bolus of IV drugs on the fluid chart
Drains & Stomas
 Enter accurate stoma or drain output
Indications for Fluid chart
.
1.
Scoring 3 or more on the EWSS
2.
Patients who are nil by mouth/need assistance with drinking or eating
3.
Patients with diarrhoea and / or vomiting
4.
Patients experiencing any excessive fluid loss from surgical drains/ cavity drains, wounds /stomas.
5.
Patients discharged from ICU / HDU for a minimum of 48 hours post transfer.
6.
Patients with a temperature greater than 38 degrees Centigrade.
7.
Post-operative patients as part of routine post-surgery patient management.
8.
Patients on Intravenous Fluids and / or parenteral nutrition
9.
Patients on a restricted fluid intake, with known or suspected renal impairment or cardiac conditions i.e.
electrolyte imbalance, or upward trend in urea and creatinine etc.
10.
Patients with urinary catheters, except for those patients with long term catheters who do not have an acute
onset of illness.
11.
Estimation of fluid balance
 Do not use symbols such as +++ or PU’d
 In cases of incontinence, estimate using
the charts of weigh pads
 Oral fluids must not be estimated, refer to
receptacle measurement chart
 Do not document ‘sips’, use a gallipot
 Do not document ‘OTT’, give patients
receptacles for urine collection &
measurement
 Estimate the amount lost due to vomiting.
Type 7 diarrhoea or blood loss
Urinary Irrigation
Patients receiving a blood transfusion.
12.
Patients who are not catheterised and it is documented on the observation chart that they have not passed
urine within 12 hours.
13.
When any doubt exists over fluid status.
14.
For 24hrs following contrast for radilological procedures
 Calculate the urine output by measuring
the total output & subtracting the total
irrigation infused
Minimum Urine Output Guide
0.5mls / Kg / hr