Measuring and managing fluid balance | Nursing Times

Assessing hydration condition and measuring fluid balance wheel can ensure optimum hydration


Shepherd A ( 2011 ) Measuring and managing fluid balance wheel. Nursing Times ; 107 : 28, early on-line publication .
Ensuring patients are adequately hydrated is an essential partially of nursing caution, yet a holocene report from the Care Quality Commission found “ appalling ” levels of worry in some NHS hospitals, with health professionals failing to manage dehydration .
This article discusses the importance of hydration, and the health implications of dehydration and overhydration. It besides provides an overview of fluid balance, including how and why it should be measured, and discusses the importance of accurate fluid balance wheel measurements.

Author:  Alison Shepherd is tutor in breastfeed, department of basal care and child health, Florence Nightingale School of Nursing and Midwifery, King ’ s College London .
Keywords: Fluid remainder, Input, Output, Dehydration, Overhydration

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Water is all-important for animation, and maintaining the correct libra of fluid in the body is all-important to health ( Welch, 2010 ) .
however, according to a holocene report from the Care Quality Commission ( 2011 ), some hospital patients are not being given enough water system to drink. The report suggests fluids are being left out of compass, or are not being given at all for long periods .
This article provides an overview of fluid balance, including what fluid poise is, and how and why it is measured. It besides discusses the importance of measuring fluid balance accurately, and the health implications of dehydration and overhydration .

What is fluid balance?

Fluid proportion is a term used to describe the balance of the input signal and output of fluids in the body to allow metabolic processes to function correctly ( Welch, 2010 ) .
Around 52 % of full body weight in women and 60 % in men is fluid. This consists of water and molecules containing, for example, sodium, chloride and potassium ( Mooney, 2007 ). These compounds disassociate into particles which carry
an electrical agitate ; these particles in solutions are called electrolytes. For exercise, sodium chloride ( NaCl ) dissolves in solution to form an equal number of positively charged sodium ( Na+ ) ions, and negatively charged chlorine ( Cl- ) ions ( Waugh, 2007 ) .
Plasma electrolytes are balanced as it is important to have the right concentration of ions in the blood, particularly sodium, potassium and magnesium. Too much or besides little of these electrolytes can cause cardiac cardiac arrhythmia ( Docherty, 2006 ) .
To make a competent appraisal of fluent balance, nurses need to understand the fluid compartments within the body and how fluid moves between these compartments ( Davies, 2010 ). Two-thirds of full body fluid is intracellular, and the remaining one-third is extracellular fluid, which is divided into plasma and interstitial fluid ( Docherty and McIntyre, 2002 ) ( Fig 1 ). There is besides a third space, known as “ transcellular fluid ”, which is contained in body cavities, such as cerebral spinal fluid and synovial, peritoneal and pleural fluids ( Day et aluminum, 2009 ) .
It is significant to remember that, although these fluid compartments are classed as offprint areas, water and electrolytes continually circulate between them ( Timby, 2008 ) .

Movement of fluids

Fluid circulates between compartments by dispersion. This is “ the random motion of particles from regions where they are highly concentrated to areas of first gear assiduity. Movement continues until the assiduity is equally distributed ” ( Casey, 2004 ) .
This is normally a passive procedure but it can be facilitated by a carrier wave atom, normally a specialist protein ( Davies, 2010 ) .
Fluid besides moves by osmosis, defined by Montague et alabama ( 2005 ) as “ the flow of water system across a semipermeable membrane from a dilute solution to a more concentrate solution until constancy is reached ” .

Formation of tissue fluid

distribution and motion of urine between the intracellular and interstitial spaces is determined by hydrostatic and osmotic pressures ( Day et aluminum, 2009 ) :

  • Hydrostatic pressure is created by the pumping action of the heart, and the effect of gravity on the blood within the blood vessels (Scales and Pilsworth, 2008);
  • Osmotic pressure is generated by the molecules in a solution (Day et al, 2009). When generated by the presence of protein molecules in solution it is called colloid oncotic pressure. Osmotic pressure created by dissolved electrolytes in solution is called crystalloid oncotic pressure (Scales and Pilsworth, 2008).

In healthy people, protein molecules are normally besides large to pass out of the capillaries into the interstitial fluid. This is because of the taut intracellular junctions between adjacent endothelial cells in the capillary wall ( Rassam and Counsell, 2005 ). Compromising the integrity of these fast intracellular junctions allows protein molecules to pass to the interstitial spaces. The subsequent accretion of tissue fluid is known as edema ( Ganong, 2000 ) .
edema can be caused by a number of diseased mechanisms, such as venous congestion. This increases venous hydrostatic coerce, park in disorders such as cardiac failure ( Paulus et alabama, 2008 ). A decrease in plasma oncotic press causes the edema associated with common nephritic disorders, such as glomerulo-nephritis, nephrotic syndrome and liver bankruptcy ( Schrier, 2007 ; Waugh, 2007 ) .

Maintaining fluid balance

entire fluid bulk fluctuates by less than 1 %, and fluid intake should be balanced by fluid personnel casualty ( Scales and Pilsworth, 2008 ; Thomas and Bishop, 2007 ) .
Water consumption is obtained from fluid and food in the diet, and is largely lost through urine end product. It is besides lost through the skin as fret, through the respiratory tract, and in faecal count ( Waugh 2007 ). Fig 2 shows the convention balance of water intake and output .
Fluid inhalation is chiefly regulated by thirst, a natural reception to fluid depletion, and is accompanied by decrease secretion of saliva and dispassion of the oral mucous membrane ( Waugh, 2007 ) .
As the osmotic concentration of the blood increases, this draw water system from the cells into the blood. This dehydrates specific mind cells called osmoreceptors, which stimulate drink and the unblock of antidiuretic hormone ( ADH ). ADH reduces water loss by lowering urine bulk, producing urine that is more concentrated ( Thornton, 2010 ). When water consumption is high, less ADH is produced, so the kidney produce large quantities of diluted urine ( Scales and Pilsworth, 2008 ) .
During times of fluid insufficiency, the adrenal glands produce the hormone aldosterone, which stimulates the resorption of sodium from the distal nephritic tubules and collecting ducts. This resorption of sodium causes the body of water in the collect ducts to be reabsorbed, maintaining homeostasis .
urine lost through faeces, perspiration and dehydration can not be regulated in the like way by the body, and is influenced by dietary inhalation, illness and the environment ( Scales and Pilsworth, 2008 ) .
A fluctuation in fluid volume of equitable 5-10 % can have an adverse effect on health ( Large, 2005 ). A deficit in fluid book is known as a damaging fluid counterweight and, if fluid intake is greater than output, the body is in incontrovertible fluid balance ( Scales and Pilsworth, 2008 ) .


dehydration is defined as a 1 % or greater loss of body mass as a leave of fluent loss, where the soundbox has less water than it needs to function by rights ( Madden, 2000 ) .
The physical symptoms of meek dehydration include :

  • Impaired cognitive function;
  • Reduced physical performance;
  • Headaches, fatigue, sunken eyes and dry, less elastic skin (Welch, 2010).

If dehydration persists, the go around book of blood can drop. This leads to :

  • Hypotension;
  • Tachycardia;
  • Weak, thready pulse;
  • Cold hands and feet;
  • Oliguria (reduced urine output) (Large, 2005).

These symptoms of dehydration are the beginnings of hypovolemic shock which, if not corrected, can lead to electric organ failure and death. Allowing control dehydration to become chronic can cause a general deterioration in health ( Mulryan, 2009 ; Thomas et aluminum, 2008 ; Bennett et alabama, 2004 ) .

Causes of dehydration:

According to McMillen and Pitcher ( 2010 ), the main causes of dehydration are inadequate fluid intake, excessive fluent loss or both .
Inadequate fluid intake can be caused by a refusal to drink due to fear of incontinence, dementia or Alzheimer ’ sulfur disease, fluid limitation for conditions such as heart failure, and increased infirmity ( see Box 1 ) .
Box 1. inadequate fluid intake causes

  • Refusal to drink for fear of incontinence;
  • Dementia, Alzheimer’s disease or cognitive impairment;
  • Reliance on health professionals to provide adequate fluids;
  • Physical weakness or increased frailty;
  • Pre-operative fasting;
  • Medication, such as laxatives or diuretics;
  • Illness causing physical and mental stress;
  • Reduced sensation of thirst in older people;
  • Fluid restriction for conditions such as heart failure or renal disorders

Diarrhoea and vomiting are major causes of excessive fluid personnel casualty. Polyuria can besides cause dehydration unless fluid intake is increased to compensate for such. Polyuria is normally caused by hyperglycemia, diabetes or overexploitation of diuretic drug therapy ( Large, 2005 ). other causes of excess fluid loss include bleeding, sweating, fever and dangerous burns ( Mooney, 2007 ) .

Fluid overload

excessive fluid volume arises when there is retention of both electrolytes and water in symmetry to the levels in the extracellular fluid. This may be caused, for model, by sodium retention that leads to the retentiveness of water. As a result, surfeit fluent leaks into the interstitial spaces and forms oedema ( Waugh, 2007 ). This normally happens in people with long-run conditions, such as nephritic disability and liver disease ( Large, 2005 ) .
In patients with kernel failure, the reduce cardiac output fails to maintain adequate systemic blood pressure, causing reduced nephritic perfusion. This stimulates thirst, which acts as a short-run compensatory mechanism to increase consumption of fluent. The fluid is then retained in an attack to increase systemic lineage imperativeness, leading to oedema ( Scales and Pilsworth, 2008 ; Faris et aluminum, 2006 ).

Symptoms vary, depending on the austereness of fluid overload ; patients with acute fluid overload may present with a sudden onset of acute accent dyspnea secondary to pneumonic edema ( accumulation of fluid in the lungs ) .
The main symptoms exhibited by patients with a history of chronic fluid overload, such as those with heart failure, are fatigue, dyspnea and pitting edema ( Khan and Heywood, 2010 ) .

Assessing fluid balance

Scales and Pilsworth ( 2008 ) identified three elements to assessing fluid balance and hydration status :

  • Clinical assessment;
  • Review of fluid balance charts;
  • Review of blood chemistry.

Clinical assessment

Patients should be asked if they are thirsty, although this is only effective for patients who are able to control their fluid intake .
Patients with afflicted ability to control fluid inhalation include those with address difficulties, confusion or depression ( McMillen and Pitcher, 2010 ). Thirst perception can besides be impaired in older people ( Cannella et alabama, 2009 ) .
Dehydration will cause the mouth and mucous membranes to become dry, and the lips to become cracked so an appraisal of the talk and oral mucous membrane can be useful at this stage ( McMillen and Pitcher, 2010 ; Scales and Pilsworth, 2008 ) .
vital signs, such as pulse, blood press and respiratory rate, will change when a affected role become dehydrated .
Dehydrated patients may become tachycardic and, when a lie and standing blood pressure is recorded, they will show a postural drop, known as postural hypotension, which often accompanies a fluid deficit ( Waugh, 2007 ). The respiratory rate may become rapid but only if fluid loss is severe .
These observations should be measured as separate of the clinical assessment ( Mooney, 2007 ; Large, 2005 ) .
Capillary refill time
Capillary replenish clock time ( CRT ) is a adept measuring stick of the fluent present in the intravascular fluid book ( Large, 2005 ). It is measured by holding the affected role ’ mho hand at kernel tied and pressing on the pad of their middle feel for five seconds. The pressure is released and the time measured in seconds until normal color returns. normal filling time is normally less than two seconds ( Resuscitation Council UK, 2006 ). It should be noted that CRT assessment can sometimes be deceptive, particularly in patients with sepsis ( Scales and Pilsworth, 2008 ) .
Skin elasticity
The elasticity of skin, or turgor, is an indicator of fluid condition in most patients ( Scales and Pilsworth, 2008 ) .
Assessing skin turgor is a promptly and simple test performed by pinching a fold of skin. In a well-hydrated person, the bark will immediately fall back to its normal position when released. It is best commit to pinch the hide over the sternum or the inner thigh ( Davies, 2010 ) .
however, this assessment can be an treacherous indicator of dehydration in older people as skin elasticity reduces with long time ( Large, 2005 ) .
A good alternative to skin turgor is tongue turgor, as this is not age-dependent. In a well-hydrated individual, the tongue has one longitudinal furrow, but a person with consume fluids will have extra furrows ( Metheny, 2000 )
body weight
Acute changes in body weight, after imposed fluid restrictions or exert, is a good index of hydration status. however, this can be affected by intestine movements, a well as food and fluid, and would be difficult and unethical to measure in sick, fast stroke patients ( Vivanti et alabama, 2010 ). McMillen and Pitcher ( 2010 ) argued that to maximise the accuracy of weight appraisal in fluid balance, the measurement should be performed at the like time of day using the same scales, which should be calibrated regularly .
urine output
In healthy people, urine should be a pale straw color. It should be authorize, with no debris or olfactory property ( Smith and Roberts, 2011 ) .
In exsiccate patients the kidneys conserve body of water, producing urine that is dark, concentrate and reduced in volume ( Scales and Pilsworth, 2008 ). normal urine output is around 1ml/kg of body burden per hour, in a roll of 0.5-2ml/kg per hour. The minimum acceptable urine end product for a patient with normal nephritic routine is 0.5ml/kg per hour. Anything less should be reported ( McMillen and Pitcher, 2010 ; Scales and Pilsworth, 2008 ) .
When recording urine output on a fluid counterweight chart, it is not acceptable practice to record it as “ passed urine +++ ” or “ up to the toilet ”. Notes such as these are uninformative and do not give a clear indication of the amount of urine passed ( Mooney, 2007 ) .
The color of the urine should not be relied on as a marker of fluid balance as some drugs, such as tuberculosis medicine, can alter urine discolor and give a fake indication of urine concentration ( Scales and Pilsworth, 2008 ) .
If a patient has a urinary catheter and the output is depleted, it is sensible to check whether the catheter or tube is blocked or occluded in any way ( McMillen and Pitcher, 2010 ) .

Fluid balance chart

Monitoring a affected role ’ s fluid balance to prevent dehydration or overhydration is a relatively simple task, but fluid balance read is ill-famed for being inadequately or inaccurately completed ( Bennett, 2010 ) .
A study by Reid ( 2004 ), which audited the completion of fluid balance charts on different wards, found the major reasons fluid balance charts were not completed appropriately were staff shortages, miss of education, and miss of time .
According to the nurse and Midwifery Council ( 2007 ), read keeping is an integral part of harbor care, not something to be “ fitted in ” where circumstances allow. It is the province of the breastfeed care for a patient to ensure observations and fluid poise are recorded in a seasonably manner, with any abnormal findings documented and reported to the nurse in charge ( Scales and Pilsworth, 2008 ) .
Smith and Roberts ( 2011 ) said that all fluid intake and end product, whatever the source, must be documented using quantifiable amounts. This means it is important to know how many millilitres of fluid are in an intravenous medication, a glass of water or a cup of tea. How frequently the fluid balance chart data should be recorded – such as hourly or two hourly – should be clearly documented. It is not acceptable practice to use shorthand .
Fig 3 shows best drill when completing a fluent libra chart and Fig 4 shows an case of unacceptable commit ( Smith and Roberts, 2011 ) .
The use of fluid remainder charts that show accumulative input and output is immediately being debated in the literature ( Bennett, 2010 ). A late study by Perren et aluminum ( 2011 ) suggested that for a big proportion of patients, specially those in critical care, accumulative fluid balance charts are not accurate and their use should be questioned .

Blood chemistry and hydration status

While Scales and Pilsworth ( 2008 ) suggest that the analysis of blood chemistry may be utilitarian in the appraisal of hydration status, the testify surrounding this is equivocal. According to Wolfson ( 2009 ) sodium, potassium, chloride, bicarbonate, lineage urea nitrogen ( BUN ) are helpful blood electrolytes to measure when determining hydration status. Wolfson proposes that if any of these electrolytes are found to be outside normal parameters, their levels should be used to guide the prescription of intravenous fluids required to restore homeostatic fluid poise .
In contrast, Vivanti et alabama ( 2008 ) argue that there is circumscribed value in the analysis of biochemical indicators such as these for less severe dehydration, particularly in older people, and suggest that physical signs may be more promise indicators .


Achieving optimum hydration is an essential character of holistic patient care. Maintaining fluid balance wheel is important to avoid complications such as dehydration and overhydration, both of which can have dangerous clinical consequences .
The nurse manage for a finical patient is responsible for ensuring that fluid poise charts are recorded regularly and with accuracy, using the adjust notation throughout. To promote adequate hydration, and dependable and effective nursing worry, nurses should constantly report any significant abnormalities identified in patients ’ fluid record .

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Key points

  • Fluid balance is the balance of the input and output of fluids in the body to allow metabolic processes to function
  • To assess fluid balance, nurses need to know about fluid compartments in the body and how fluid moves between these compartments
  • Dehydration is defined as a 1% or greater loss of body mass as a result of fluid loss. Symptoms include impaired cognitive function, headaches, fatigue and dry skin. Severe dehydration can lead to hypovolaemic shock, organ failure and death
  • The three elements to assessing fluid balance and hydration status are: clinical assessment, body weight and urine output; review of fluid balance charts; and review of blood chemistry
  • Fluid balance recording is often inadequate or inaccurate often because of staff shortages, lack of training or lack of time

Bennett C (2010)

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Wolfson A (2009) Harwood Nuss’ Clinical Practice of Emergency Medicine. Philadelphia: Lippincott Williams and Wilkins. ( 2010 ) ‘ At A Glance ’ Fluid Balance Bar Chart. London : NHS Institute for Innovation and Improvement ( 2004 ) Unrecognized chronic dehydration in older adults : examining preponderance rates and risk factors. Journal of Gerontological Nursing ; 30 : 11, 22-28. ( 2009 ) Nutrition longevity and behavior. Archives of Gerontology and Geriatrics ; 49 : 1, 19-27. ( 2011 ) Dignity and Nutrition for Older People : review of Compliance. London : CQC. ( 2004 ) edema : causes, physiology and nurse management. Nursing Standard ; 18 : 51, 45-52. ( 2009 ) Brunner and Suddart Text Book of canadian Medical-Surgical nurse. Philadelphia : Lippincott Wilkins and Williams. ( 2010 ) How to perform fluent assessments in patients with nephritic disease. Journal of Renal Nursing ; 2 : 2, 76-80. ( 2006 ) Homeostasis separate 4 : fluent proportion. Nursing Times ; 102 : 17, 22. ( 2002 ) harbor considerations for fluid management in hypovolemia. Professional Nurse ; 17 : 9, 545-549. ( 2006 ) Diuretics for center failure. Cochrane Database for Systematic Reviews. The Cochrane Collaboration : Wiley. ( 2000 ) Review of Medical Physiology. Stamford ; Appleton and Lange. ( 2010 ) Fluid Overload. ( 2005 ) Fluid and electrolytes. In : Sheppard M, Wright M ( eds ) Principles and Practice of High Dependency Nursing. edinburgh : Elsevier. ( 2000 ) Nutritional benefits of drinks. Nursing Standard ; 15 : 13, 47-52. ( 2010 ) The balancing act : body fluids and protecting patient health. british Journal of Healthcare Assistants ; 5 : 3, 117-121. ( 2000 ) Fluid and Electrolyte Balance : nursing Considerations. Philadelphia : Lippincott Williams and Wilkins. ( 2005 ) physiology for Nursing Practice. London : Elsevier. ( 2007 ) Fluid counterweight. ( 2009 ) An introduction to shock. british Journal of Healthcare Assistants ; 3 : 1, 21-24. ( 2007 ) criminal record Keeping. steering for Nurses and Midwives. London : NMC. ( 2008 ) Causes and consequences of systemic venous high blood pressure. The american Journal of the Medical Sciences ; 336 : 6, 489-497. ( 2011 ) Fluid balance in critically ill patients. Should we rely on it ? Minerva Anestesiologica. ( 2005 ) Perioperative electrolyte and fluid balance wheel. Continuing education in Anaesthesia Critical Care and Pain ; 5 : 5, 157-160. ( 2004 ) Improving the monitor and assessment of fluent libra. Nursing Times ; 100 : 20, 36-39. ( 2006 ) Adult Advanced Life Support. London : RCUK. ( 2008 ) The importance of fluid balance in clinical practice. Nursing Standard ; 22 : 47, 50-57. ( 2007 ) Diseases of the Kidney and Urinary Tract. Philadelphia, PA : Lippincott Williams and Wilkins ( 2011 ) Vital Signs for Nurses. An introduction to Clinical Observations. oxford : Wiley-Blackwell. ( 2007 ) Manual of Dietetic Practice. London : Blackwell Publishing. ( 2008 ) Understanding clinical dehydration and its treatment. Journal of the American Dietetic Association ; 9 : 5, 292-301. ( 2010 ) Thirst and hydration : physiology and consequences of dysfunction. Physiology and Behavior ; 100 : 1, 15-21. ( 2008 ) Fundamental Nursing Skills and Concepts. Philadelphia, PA : Lippincott Williams and Wilkins ( 2010 ) Developing a flying and virtual screen to improve the recognition of poor hydration in geriatric and reconstructive care. Archives of Gerontology and Geriatrics ; 50 : 2, 156-164. ( 2007 ) Problems associated with fluid, electrolyte and acid-base balance. In : Brooker C and Nicol M ( eds ) nurse Adults : the Practice of Caring. edinburgh : Mosby ( 2010 ) Fluid balance. Learning Disability Practice ; 13 : 6, 33-38. ( 2009 ) Harwood Nuss ’ Clinical Practice of Emergency Medicine. Philadelphia : Lippincott Williams and Wilkins.

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