STANDARDS FOR FLUID BALANCE MONITORING

Ensure that patient and health care provider safety standards are met during this procedure including:

• Risk assessment and appropriate PPE
• 4 Moments of Hand Hygiene
• Procedural Safety Pause is performed
• Two patient identification
• Safe patient handling practices
• Biomedical waste disposal policies

STANDARD OF NURSING CARE FLUID BALANCE

 1.

Monitor Intake

All patients in CCTC will have hourly intake and output measured and recorded. 

Patients who are ready for transfer to the ward or who have had a long and stable length of stay without fluid or diuretic interventions may be appropriate for Q12H output, however, IV intake will continue to be recorded hourly.

Intake and output monitoring may be discontinued for patients without any continuous IV infusions or a Foley catheter, or who are ready for transfer to home or Mental Health.

Document all IV and enteral intake in the eHR fluid balance section (Intake and Output record).

 2.

Monitor Output

The total output should reflect all losses, including urine, NG, residuals, dialysis, chest tubes and drainage tubes.

Enter urine output directly into the fluid balance section of the eHR. Output from sources such as Chest Tube Drainage, CSF output and CRRT fluid removal is entered in the appropriate Dynamic Grouper and will be pulled directly into the output section of the Intake and Output record.

Report urine output < 0.5 ml/kg/hr, or downward trends in symptomatic patients to physician.