Day-to-Day Care

 

Observation:  Fluid Balance

 

 

 

Overview
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When the amount of fluid lost from the body is equal to the amount of fluid taken in, the body is in fluid balance.  Fluid in our body is found within the body cells (intracellular), surrounding the cells (interstitial) and within the blood vessels (intravascular).  It is our bodies' principal chemical component, comprising, on average, 60 percent of our weight. In obese individuals and the elderly, total body fluid can be significantly lower.

 

Fluid is constantly being lost by the body through perspiration, expired air (as water vapour), urine, feaces, and negligible amounts in tears and saliva.  It is replaced in our daily basic intake of food and drink.  There is no easy answers as to how much water a person is required to drink each day.  Studies have produced varying recommendations over the years, but in truth, each individual water requirements depend on many factors, including his health and how active he is.

 

 

 

Monitoring Fluid Balance

  

Monitoring of fluid balance is required for patients with renal failure, electrolyte imbalance, or severe vomiting and diarrhea.  It is also necessary for patients with nasogastric tubes and drainage collection devices.  In addition, patients receiving intravenous therapy and those taking medicines such as diuretics and corticosteriods also need to have their fluid balance monitored. 

 

These measurements are important to help evaluate a patient fluid and electrolyte balance, to suggest various diagnosis, and allows for prompt intervention to correct the imbalance.  Records of all intake and output must be kept meticulously in an Intake and Output Chart (I/O Chart).  All amounts must be measured and record in milliliters.  Do not estimate. If the patient is able to cooperate, he should be encouraged to help in keeping an accurate record of his daily fluid intake and output.

 

At the end of a 24-hours period, add up the total intake and output. Evaluate the patient's fluid status in relation to the disease process, medication regimen, diet, and activity ordered by your healthcare professionals.  The patient is said to be in negative fluid balance if his output is greater than his intake.  Conversely, a positive fluid balance occurs when intake is greater than output.  If the difference is alarming, consult your doctor.  Keep the chart to show to the doctor, and start a fresh one for the next 24-hours.

 

 

 

Items Required for Measuring Intake and Output

 

Two jugs marked in milliliters, one for intake and the other for output.  You can also work out the capacity of any container and mark it.

 

Gloves (for handling excretions such as urine and vomitus)

 

Intake and output chart to record all measurements and remarks.

 

 

 

 

Reference Chart for Measuring Utensils

 

 

Utensil & Measurement

Quantity in Milliliter

1 cup

*150 ml

1 large glass

*240 ml

1 ounce

30 ml

1 tablespoon

15 ml

1 teaspoon

5 ml

1 soup bowl

*180 ml

                         *Quantity may varies with different utensils.

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Measuring Intake

 

Fluid intake refers to all fluid entering the patient's body.  It also includes foods that are liquid at room temperature, such as ice chips, ice-cream, and certain beverages.

 

Measure any fluids offered to the patient and make a note of how  much the patient drinks and the time of the day at which it is drunk.

 

If the patient is drinking from a jug, obtain the total intake by subtracting the fluid remaining in the jug at the end of the day plus any fluid added.

 

You can also pre-measure the drinking glasses or bowls most commonly used by the patient.  So when the patient tell you that he had "one glass of water," you will know the amount.

 

Measure ice chips by multiplying the volume by 0.5; when melted, the volume of ice is approximately half its previous volume.

 

For yogurt, ice cream, gelatin, packet or canned drinks, measure the amount printed on the labels.

 

Measure the amount of feeds through nasogastric tube by noting the volume of the bag at the beginning of the feeding and then subtracting he amount left at the end of the feeding.  Remember to include any feeding that is added during the day.

 

Intravenous intake (drips) can also be measure using the above method.

 

If water is used to flush the nasogastric tube, record the amount used for irrigation in the intake and output chart.

 

 

 


Measuring Output

 

Fluid output refers to all fluid that leaves the patient's body.  This includes urine, loose stools, vomitus, aspirated fluid, excessive perspiration, and drainage from surgical drains, nasogastric tubes, and chest tubes.

 

Use a container marked with milliliters to collect fluid output.  Be sure to label the container "FOR MEASURING OUTPUT ONLY" to prevent confusion with intake container.

 

Always wear gloves when handling body fluids.

 

Any amount not measured due to any reasons such as patient passed urine while in the toilet should be documented, otherwise the chart becomes inaccurate and misleading.

 

In cases such as vomits or diarrhoea, record the number of time it was passed.  For such cases, check with your doctor in advance if it is necessary to measure the exact amount.

 

It is also important to make a note of the fact if the patient is sweating.

 

If the patient has drainage, record the amount of the drainage.  It is important to document the source of the drainage especially if he has more than one drainage site.

 

If patient is on intermittent or continuous irrigation, calculate the true output by measuring the total output and subtracting the total irrigation infused.

 

 

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Dehydration

 

Dehydration can be defined as "the excessive loss of water from the body."  It can be caused by losing too much fluid (as in vomiting and diarrhea), not drinking enough water, or both.

 

The best way to treat dehydration is to prevent it from occurring.  Always encourage the patient to drink during an illness, and remember that a person's fluid needs are greater when he has fever, vomiting, or diarrhea.  If you suspect excessive fluid loss during an illness, inform your doctor immediately.  DO NOT wait for signs of dehydration.

 

Signs of dehydration include:

 

Flushed and dry skin*1

Dry lips

Dry and furred tongue

Increasing thirst

Low or no urine output

Concentrated urine appears dark yellow

Sunken eyeballs

Sunken fontanelles (the soft spot on the top of the head) in an infant

Increase breathing and heart rate

Low blood pressure causing lightheadedness (worsening on standing)

Delayed capillary refill*2

Poor skin turgor*3

Shock

Delirium or unconsciousness in most serious cases

 

*1 Dry skin in an elderly is not a reliable indication of dehydration as skin automatically loses moisture and elasticity with age.  A better barometer is the color of urine: clear or light-colored urine means well hydrated, whereas a dark concentrated color usually signals dehydration.

 

*2 A capillary nail refill test can be done by pressing firmly on a fingernail bed for 5 seconds and measure the speed at which blood returns after the pressure is released.  In normal person, capillary refilling should take less than 3 seconds.

 

*3 You can test the hydration state of your patient by simply pinching up the skin on his hand into a fold.  If dehydrated, the skin may lack its normal elasticity and sag back into position slowly.  Normally, skin springs right back into position.

 

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