Collection and analysis of patient data to regulate fluid balance.
Objective:
To measure the amount of fluids administered and eliminated by the patient, in a given time, to make the assessment of the hydroelectrolyte balance.
Equipment:
– Scale. – Wedge or bottle.
– Graduated container. – Urine bag holder.
Material:
– Non-sterile disposable gloves. – Urine bag. – Diaper-braga. – Nursing records.
Procedure:
– Preserve the patient’s privacy. – Inform the patient. – Request the collaboration of the patient and family. – Determine the amount, type of fluid intake and elimination habits. – Identify possible risk factors for fluid imbalance (hyperthermia, diuretic therapy, renal pathologies, heart failure, infection, polyuria, diarrhea, etc.). – Measure and record all fluid inputs: meals, oral medication, intravenous fluids, blood products, parenteral nutrition, etc. – Measure and record all outputs: urine, drainage, liquid stool, sweat, vomiting, gastric aspiration, etc. – Weigh every 24 hours. – Add insensible losses as outputs. Calculated according to the formula: PI= weight x no. hours/2 – Subtract outputs from inputs and note on the graph. – When closing the balance, count the quantity perfused and the quantity remaining to be perfused. – Note date and time of start and end of control.
Observations:
Observe the state of skin and mucous membranes, urine color, edema, ascites, etc.
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