By Dimitra Georgiades

Fluid balance charting is not a new practice based issue in nursing. Evidence reveals that fluid balance charts have been poorly and inaccurately maintained since 1985 (Chung et al, 2002; Scales & Pilsworth, 2008).

What makes fluid balance charting so difficult is a question and concept that healthcare professionals constantly enquire about (Chung et al. 2002; Jeyapala et al. 2015; McGloin, 2015). Although fluid balance charting seems straightforward, the issue in nursing practice remains present with a number of external influences that effect the important role fluid balance charting has in patient care (Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008).

This paper identifies the issue of inaccurate fluid balance charting, the social, political and external factors that contribute to and effect this issue, and finally, recommendations to ensure consistency and continuous improvement for this issue.

Overview
Fluid balance refers to the balance between the volume of water lost from the body and the volume of water gained (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008; Mclafferty et al. 2014).

The fluid balance chart has been a document in the healthcare system for over 50 years and is a non-invasive tool to assess the hydration status of patients. It is a chart that documents a patients’ water input and output in a 24 hour period. The importance of this is to guide clinical decisions including medication administration and prescription as well as surgical interventions. The issue with fluid balance charting is that they can be counterproductive and extremely dangerous if the data is inaccurate or inadequate (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008; Castledine, 2003).

Medical staff, nurses and dieticians expect accurate fluid balance totals in order to plan appropriate care and reduce the risk of post-operative complications that may be associated with dehydration, malnutrition and electrolyte imbalances. Medical staff want to the know the exact measure of urine/diarrhoea output, intravenous therapy, oral intake, nasogastric aspiration and drainage, wound drainage and vomit in order to assess hydration and electrolytes, and avoid fluid overloading (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008).

Nursing practice does not remain consistent and thus keeping an accurate fluid balance chart becomes a balancing act in itself. The ability to enforce change requires empowering others to act on the vision in order to overcome obstacles for change. To enlist all staff to become empowered can be challenging given different backgrounds, contributing factors and the culture of the environment. The importance of identifying the recurring issue of inadequate and inaccurate fluid balance charting is to identify what inhibits the practice of maintaining accurate fluid balance charting, ways to improve the practice that will sustain and ensure that fluid balance charting is completed accurately in any practice environment (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008).

Analysis

Political
The practice of fluid balance charting seems simple; record the intake and output. However, based on diverse backgrounds and different ways fluid balance charting has been educated and taught, this creates a confliction between the correct and incorrect practice of recording fluid balance charting.

What constitutes being recorded or not remains a subject that is often open to debate. Whilst there are differing opinions about the correct practice of fluid balance charting, this creates an opportunity that encourages staff to share their knowledge and skills in order to improve their practice (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008).

Social
Education is an important aspect of the practice environment - the role of the clinical educator aims to facilitate education and learning for all staff on clinical and/or practice based issues that remain uncertain or questionable (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008; Warburton, 2010).

Inservices provide an opportunity to clarify what is required and to answer questions that staff may have. For staff to understand what is required for fluid balance charting, this information is retrieved and collected from the doctors that perform the surgeries. The senior doctors have clear and specific instructions of what care should be postoperatively and this information is then delivered during inservice or staff are made aware informally. Inaccuracy and the lack of compliance with maintaining fluid balance charts tends to infuriate both nurses and doctors, and this prompts to inititate a change in the workplace (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008; Castledine, 2003).

The ward that supports an environment where staff have the opportunity to engage in further education enables a more welcome use of initiatives to improve and reduce the uncertainty and inconsistency in regards to inadequate fluid balance charting. However, factors contributing to inadequate and inconsistent fluid balance charting such as lack of time, increased acuity and lack of education inhibit these workplace initiatives and therefore change is unsuccessful. These contributing factors decrease and effect the ward compliance in maintaining accurate fluid balance charting. In addition, these factors are universally acknowledged by evidence as the main issues that effect and inhibit accurate fluid balance charting (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008; Castledine, 2003).

Time related to acuity
Fluid balance charting is part of charting and managing clinical information and is therefore part of a nurse’s workload (NMBA, 2016). As a result, time should be allocated during the shift to complete fluid balance charting. However, evidence shows that due to lack of time related to increased acuity, information on the fluid balance chart is often either duplicated or omitted. Poor documentation leads to compromised patient safety and quality of care (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008; Castledine, 2003).

Maintaining and recording accurate documentation is part of providing safe and competent nursing care according to the Nursing and Midwifery Board of Australia. Anything outside of that scope could be considered negligent in providing patient care. Limited available time to record fluid balances that is related to patient care is inexcusable where patient monitoring and safety is concerned. Research states that nurses must understand and demonstrate the competence knowledge that caring for patients require, and this includes clinical indications and importance of a fluid balance chart (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008; Castledine, 2003; Daffurn et al. 1994; McLafferty et al. 2014).

Education
Evidence illustrates that lack of education or inadequate training is a significant contributor to poorly maintained fluid balance charting. New staff, new graduate nurses and even nursing students and senior staff members may find it difficult to know what to record or not record and how to record properly. This could be due to the ever-changing practice environment and need for further professional development to understand more about fluid balance charting.

For example, when a patient is on a fluid balance chart, urine measure must be recorded. It is quite common to see the abbreviation “PUIT”, which stands for ‘passing urine in toilet’, or “PU” for ‘passed urine’, used as substitutes for actual values of measurement. This is neither recording nor maintaining a fluid balance accurately nor is it recording urine measure accurately, as the urine must be measured. This is where further education is required for staff to understand how and what to record and to reinforce and provide education to the patient about the importance of keeping an accurate fluid balance (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; Chavin & Chow, 2008; Daffurn et al. 1994; McLafferty et al. 2014; NMBA, 2016; Stanley et al. 2008).

Recommendations for best practice

Patient involvement
There are many inexpensive initiatives that nursing staff can implement on the ward to improve the practice of fluid balance charting. Best practice recommends that patient involvement is key in enabling more accurate fluid balance charting. The major focus in providing patient care is, of course, the patient. Including the patient in their own care while in hospital exerts a feeling of independence and autonomy and promotes a level of control for the patient in an otherwise well-controlled environment.
Promoting and encouraging autonomy in the provision of care for a patient is a key ingredient in enhancing patient care and satisfaction. Education the patient and suggesting they monitor their intake for the day (given they are alert and oriented) enables more accurate charting the patient is able to recall what they have had (Chung et al. 2012; Jeyapala et al. 2015; NMBA, 2016).

Pamphlets/Posters/Signs
Developing fact sheets or posters that can be kept inside the patient chart and around the ward again promotes education for both staff and patients. Additionally, signs that alert staff that a patient needs to have a fluid balance maintained can be stuck on the front of the chart of written on the patient identification boards on the bedside. Providing staff with education sessions, such as inservices, on fluid balance monitoring, can assist in improving educational and clinical gaps in providing care. One study found that high staff turnover and shift patterns affect fluid balance charting. Therefore, the application of promoting further education will assist in overcoming this barrier (Chung et al. 2012; Jeyapala et al. 2015; NMBA, 2016).

These education sessions can be 10 minutes in duration and cover the most relevant information for staff including calculating balances every four hours and avoiding abbreviations, such as ‘PU’ and ‘PUIT’, for passing urine. This same strategy could be adopted and used at handover over a month so that staff have the benefit of getting regular updates and being able to ask questions about fluid balance charting.

Developing pamphlets, posters and signs, and conducting education sessions are inexpensive strategies that cost little to nothing to overcome this practice based issue whilst enhancing education and knowledge for both staff and patients (Chung et al. 2012; Jeyapala et al. 2015).

Auditing
Auditing the number of charts that are correctly filled out and assessing the knowledge healthcare workers have regarding fluid balance monitoring can aim to assist in reducing inadequate fluid balance charting. Auditing can assist in showing where strengths and weaknesses are in fluid balance charting and where improvement is required. It is a good tool to use prior to implementing a change on the ward and then at the end of the initiative to extrapolate data and compare results. This can enable the ward to regularly review their practice as part of achieving and sustaining change as well as meeting quality and safety requirements for patient care (NMBA, 2016; Chung et al. 2002; Jeyapala et al. 2015; Stanley et al. 2008).

Conclusion
The fluid balance chart has been a longstanding tool that assists clinicians in monitoring and assessing the euvolemic status of a patient. The importance and role of accurate fluid balance charting is often forgotten or neglected and thus has become a pratice based issue that requires constant review, intervention and attention. This paper has examined the contributing factors that inhibit accurate fluid balance charting such as lack of time related to patient acuity and inadequate training and education.

In summary, a number of recommendations have been suggested to improve the practice of accurate fluid balance charting. These include enhancing and promoting patient involvement; the use of posters and signs on the ward, in the patient chart and on the patient identification boards in the bedside; conducting group staff education sessions at change of shift times; and finally, auditing in a timely manner to determine where improvement, education and further interventions are required to overcome barriers associated with inaccurate fluid balance charting (Chung et al. 2012; Scales & Pilsworth, 2008; Jeyapala et al. 2015; McGloin, 2015; McLafferty et al. 2014; Astle, 2005).

By implementing these changes to the practice environment, successful achievement of maintaining and increasing ward compliance with accurate fluid balance recording can be sustained for more diligent and safer patient care.



About the Author
Dimitra Georgiades is a Registered Nurse at the Royal Brisbane and Women’s Hospital (Bachelor of Nursing, Master of Nursing specialising in Acute Care).

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