Fluid balance in nursing

What is fluid balance ?

Positive / negative balance fluid overload
(over hydration, hypervolemia) / fluid loss
(dehydration, hypovolemia)
Causes and symptoms of hypervolemia/
hypovolemia
How to asses fluid balance ?
Rationale for keeping an accurate fluid
balance chart.

What is a fluid balance ?

- fluid balance is the balance of the input and output of fluid in the
body enabling metabolic processes to function correctly
( Welch, 2010)
- the balance between fluid intake and output is controlled by the
kidneys.
- 52 % of total body weight in women and 60 % in men is fluid
which consists from water and other molecules containing
sodium chloride and potassium (Mooney, 2007).
- electrolytes : sodium, chloride, potassium, calcium, magnesium
and bicarbonate .
- plasma electrolytes are balanced correct concentration of ions
in the blood, for instance, if there is too much/little of
sodium/magnesium/potassium can lead to cardiac arrhythmias
(Docherty, 2006)

Positive /negative fluid balance

- maintenance of an adequate fluid balance is essential to health .

- healthy person the amount of fluid taken and the amount of
fluid lost is usually in balance

- inadequate fluid intake / excessive fluid loss = dehydration

affecting cardiac and renal function and electrolyte
management.

Fluid intake < fluid output = negative fluid balance

- inadequate urine production = volume overload, renal failure
and electrolyte toxicity.
Fluid intake > fluid output = positive fluid balance
- attention to fluid intake /output + correct completion of fluid
balance charts = essential elements of nursing practice

- in health people feel thirsty and drink fluids

- in illness patients rely on healthcare professionals to provide
the adequate amount of fluids.
(Scales and Pilsworth, 2008)

Causes and symptoms of loss or gain of fluid

Hypovolemia ( dehydration)
Symptoms of dehydration :
- impaired cognitive function
- reduced physical performance
- headaches
- fatigue
- less elastic skin.
If dehydration continues the circulating volume of blood can
drop, leading to: hypotension, tachycardia, weak thready pulse,
cold hands and feet, reduced urine output ( oliguria) =
hypovolemic shock ; if not corrected = organ failure and
death (Waugh and Grant, 2006).

Causes of dehydration :
- inadequate fluid intake
- diarrhoea and vomiting
- sweating / fever
- haemorrhage
- diuretics
(Mooney, 2007).

Hypervolemia (fluid overload)

Signs and symptoms of fluid overload:
- increase weight
- peripheral oedema (swelling in arms and legs) and ascites (fluid
in abdomen)
- shortness of breath
- fatigue
Causes of fluid overload:
- Na retention
- heart failure
- renal failure
Heart +lung + kidneys = affect body fluid and Na regulation impact on the fluid balance ( Liang KV et al, 2008; Ricci Z. and
Ronco C., 2010; Bouchard J., Mehta R.L., 2009)

How to assess fluid balance ?

a) clinical assessment

Check if the patient is thirsty; control intake if patient has

impaired ability

Oral assessment

Vital observations

Capillary refill time (CFT)

Skin elasticity ( turgor)(Scales and Pilsworth, 2008)

Body weight

Urine output not acceptable practice to record it as passed

urine +++ or out to the toilet (Mooney, 2007)

- minimum acceptable urine output is 0.5 ml/kg/hr (Scales and

Pilsworth, 2008).

Check urinary catheter ( if there is one)

b) review of fluid balance keep an accurate record of fluid

intake and fluid output on the fluid charts.
NMC (2008) record keeping is an essential part of nursing care.
c) review of blood chemistry
Scales and Pilsworth (2008) analysis of blood chemistry may be
useful in the assessment of hydration status.
Wolfson (2009) sodium, potassium , chloride, bicarbonate,
blood urea nitrogen are blood electrolytes that help in
determining the hydration status of a patient.

Rationale for keeping an accurate fluid balance

chart

- promote adequate hydration and prevent complications of

dehydration / overhydration
- it is an essential part of the holistic patient care
- safe practice and effective standard nursing care (NMC, 2008)
- provides information about patients' state of hydration, renal
function and cardiovascular function
- patients records can be used as evidence by the courts, the
Health Service Commissioner or locally to investigate any
complaints; anything that refers to the care of the patient can be
required as evidence ( NMC, 2007)

References:

Bouchard J., Mehta R L (2009), Fluid accumulation and acute kidney injury
consequence or cause, Critical Care, 2009.
Davies A. (2010) How to perform fluid assessments in patients with renal
disease, Journal of Renal Nursing, 2 : 2, 77 -80
Docherty B. (2006) Homeostasis part 4- fluid balance, Nursing Times.
Docherty B, McIntyre L (2002) Nursing consideration for fluid management in
hypovolemia Professional Nurse, 17:9
Liang K. V. Williams A. W., Greene E. L. et al. (2008), Acute decompensated
heart failure and the cardiorenal syndrom, Critical Care Med, 2008.
Nursing Midwifery Council (2008), The Code, Standards of conduct and
performance and ethics for nurses and midwives.
Ricci Z., Ronco C. (2010), Pulmonary /renal interaction, Critical Care.
Scales K, Pilsworth J. (2008) The importance of fluid balance in clinical
practice, Nursing Standard 22.
Waugh A., Grant A, ( 2006) in Ross and Wilson (eds.), Tenth Edition
(2006), Anatomy and Physiology in Health and Illness, Edinburgh, Chuchill
Livingstone, Elsevier.
Wolfson A. (2009) Harwood Nuss' Clinical Practice of Emergency Medicine,