Clinical. Food, Fluid and Nutritional Care Policy

Transcription

1 Clinical Food, Fluid and Nutritional Care Policy SECTION 1.2 PROTOCOL FOR THE ASSESSMENT AND MANAGEMENT OF HYDRATION IN ADULTS FLUID BALANCE MONITORING Policy Manager Joyce Thompson Dietetic Consultant in Public Health Nutrition Policy Group Food Fluid & Nutritional Care (FFNC) Policy Review Group Policy Established Policy Review Period/Expiry 31 May 2018 Last Updated 28 June 2016 This policy does / does not apply to Medical / Dental Staff (delete as appropriate) UNCONTROLLED WHEN PRINTED

2 Version Control Version Purpose/Change Author Date Number 1.0 First Draft Victoria Hampson/ 03/05/2012 Kerry Queen 2.0 National Hydration Group review Victoria Hampson/ 01/10/2012 Kerry Queen 2.1 Review from comments from National Victoria Hampson/ 22/11/2012 Hydration Group Kerry Queen 3.0 Formatting Lorna Murray 10/04/ Second Draft from PDSA Test 1 Kerry Queen 16/10/ Formatting Sue Smart 05/11/ Final Draft from PDSA Test 2 and Kerry Queen 14/03/2014 Critical Readers 7.0 Changes from roll out sessions Kerry Queen 06/10/ Updated appendices Kerry Queen 26/02/ Additional Standard Operating Kerry Queen 20/06/2016 Procedure and update to SOP/Hydration card 9.1 Formatting Sue Smart 28/06/2016 Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 2 of 30 Review Date: May 2018

3 CONTENTS SECTION Page Number 1. PURPOSE AND SCOPE 5 2. RESPONSIBILITIES AND ORGANISATIONAL ARRANGEMENTS 5 3. BACKGROUND 5 4. ROLES AND RESPONSIBILITIES Senior Charge Nurse/Midwifery Team Leaders Registered Nursing Staff/Midwives Non-Registered Nursing Staff and Midwives (including Student Nurses/Midwives) Other Non-Registered Staff/Allied Health Professionals Medical Staff Person Centred and Patient Involvement Role of Carers/Relatives 7 5. HYDRATION CARD 7 6. BLUE AND GREEN LIDS ON JUGS 8 7. FLUID BALANCE CHART Patient identification 8 8. COMPLETION OF FLUID BALANCE CHART Indications for commencement/discontinuation of Fluid Balance Monitoring Recording of Intake Output Other forms of Output CONSENT AUTHORISED PROFESSIONALS 11 Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 3 of 30 Review Date: May 2018

4 11. EDUCATION AND TRAINING LEGAL LIABILITY REFERENCES STANDARD OPERATING PROCEDURES Fluid Balance for Adult In-Patients Fluid Balance for Haematology/Oncology Patients APPENDIX 1: Prescription & Fluid Balance Chart APPENDIX 2: Fluid Balance Chart Audit Tool APPENDIX 3: NHS Scotland Making Hydration Matter Poster 24 APPENDIX 4: Hydration Card APPENDIX 5: Volume of Drinking Vessels 27 APPENDIX 6: Instructions for Weighing Incontinence Pads 28 APPENDIX 7: Haematology & Oncology Prescription & Fluid Balance Chart Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 4 of 30 Review Date: May 2018

5 1.2.2 FLUID BALANCE MONITORING 1. PURPOSE AND SCOPE This document outlines the protocol for fluid balance monitoring in all adult in-patients within hospitals. To provide instructions on accurate completion of fluid balance charts. To provide instructions for monitoring and review of patients who have been commenced/discontinued on a fluid balance chart. Ensure patients are provided with optimum person centred care. It includes flow charts for the management of fluid balance and a Standard Operating Procedure for reducing risk and promoting safe practice. All clinical staff have a duty to follow this evidence based practice (Appendix 1 Fluid Balance Chart and flow charts). 2. RESPONSIBILITIES AND ORGANISATIONAL ARRANGEMENTS General Managers/Associate Directors (or equivalent) have responsibility for distribution of this protocol to staff within their area/directorate, ensuring that staff have the opportunity to access the Food, Fluid and Nutritional Care Policy. Clinical Directors, Senior Nurses and Midwifery Team Leaders have a responsibility to ensure that the Food, Fluid and Nutritional Care (FFNC) policy is implemented within their area of responsibility and monitor compliance, ensure all staff groups are educated to the required level, whilst keeping up to date with current practice. All clinical staff are responsible and accountable for their own compliance with the policy and delivery of accurate fluid balance contained within this protocol, identifying their own training needs and attending appropriate training when provided. All clinicians must ensure that for all patients under their care there is adherence to the protocol and relevant flow charts 3. BACKGROUND Fluid balance is a term used to describe the balance of the input and output of fluids in the body to allow metabolic processes to function correctly (Welch, 2010). Timely and appropriate fluid balance observation and recording is an essential tool in determining adequate hydration, (Scales & Pilsworth 2008). When patients are acutely ill they may show early warning signs, (such as, decreased urine output) which can be detected through accurate fluid balance monitoring. Successful fluid balance is dependent upon: Timely/appropriate rationale for commencement/discontinuation. Detailed and accurate measurement of intake/output. Consideration of insensible loss. Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 5 of 30 Review Date: May 2018

6 4. ROLE AND RESPONSIBILITIES OF STAFF 4.1 Senior Charge Nurse/Midwifery Team Leaders Ensure implementation of the protocol and ensure that all staff have access to and have read the Food, Fluid and Nutritional Care Policy. Ensure that regular audit of fluid balance charts is undertaken and appropriate action plans implemented to improve compliance (see Appendix 2 Fluid Balance Chart Audit Tool). Display National Making Hydration Matters awareness poster (see Appendix 3 NHS Scotland Making Hydration Matters Poster). Ensure staff undertake education and training commensurate with their role and responsibilities. 4.2 Registered Nursing Staff/Midwives An accurate recording and monitoring of fluid balance is generally regarded as being a nursing responsibility. It is expected that all registered nursing staff will ensure: the individual patient remains the central focus of care and due consideration should be given to their comfort at all times it is expected that all patients will be assessed on a continuing basis (using the Traffic Light Assessment, if in use) each shift for their fluid and hydration needs it is expected that patients will have their nutrition and hydration needs met, and steps should be taken to facilitate a plan of care to achieve optimum hydration patient hydration risk status and risk update is communicated through personcentred handover/safety brief if patient requires active fluid balance monitoring ensuring there is a review of patients clinical condition a minimum of daily, with early recognition of change in clinical status using the Scottish Early Warning Score (SEWS) clear, timely and accurate completion of fluid balance charts practice in line with this policy 4.3 Non-Registered Nursing Staff/Midwives (including Student Nurses/Student Midwives) Some aspects of fluid balance recording may be delegated to non-registered nursing staff if deemed competent by the Senior Charge Nurse/Midwifery Team Leader/Registered Nurse/Midwife/Mentor. The non-registered nursing staff/midwife may: offer/give oral fluids as directed by the registered nurse/midwife record oral fluids accurately taken by the patient record fluid output accurately: including urine/bowels/stoma/vomit/drains complete cumulative totals and report any findings to registered nursing staff responsible for the patients care escalate any concerns they may have regarding the patients intake/output escalate any concerns regarding vital signs through SEWS monitoring (including urine output) 4.4 Other Non-Registered Staff/Allied Health Professionals (AHPs) No aspect of fluid balance should be delegated to these staff members however if the patient has been assisted to drink/given oral fluids, toileted/removal of vomit bowls etc; then it is their responsibility to inform the nursing team in order to ensure accurate fluid balance completion. Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 6 of 30 Review Date: May 2018

7 4.5 Medical Staff All medical staff are clinically accountable for reviewing individual patient s fluid and hydration needs on an ongoing basis and this must be documented in the patients case notes. Steps must be taken if the patient s condition deteriorates to undertake a review, with timely communication and escalation to senior medical staff (if required). In addition: it is expected that medical staff jointly with registered nursing staff will calculate the daily fluid target, taking into account any fluid restrictions, for each patient and document the amount of oral or intravenous fluid required in millilitres (mls) on the fluid balance chart review blood results for Urea & Electrolytes (U+E s) prior to prescribing any intravenous fluids prescribing of Intravenous/Subcutaneous fluids on the fluid balance chart taking into account cumulative totals/u&e s, fluid balance and SEWS ensure prompt review of the patients if nursing staff raise any concerns refer to Guidance on Tips to Better Fluid Prescribing, prior to prescribing fluids for each patient (see page 2 of Appendix 1 - Tips to Better Fluid Prescribing) transfer and prescribe fluids onto current/recent fluid balance chart 4.6 Person Centred and Patient Involvement Encouraging the patient to participate and take ownership of the management of their hydration status (where possible) is regarded as being beneficial and can improve compliance with monitoring of fluids input and output and therefore enhanced accuracy of fluid chart completion (Chung et al 2002, Reid 2004). If the patient is able then he/she should be encouraged to complete their own fluid charts i.e. Hydration card (see Appendix 4). 4.7 Role of Carers/Relatives Carers/relatives have a vital role in supporting more dependent individuals to drink. Carers/relatives who are willing should be encouraged to support and assist in accurate fluid balance recording they should be made aware of the individuals need for fluid and encourage them to drink, and asked to inform nursing staff/midwife if fluids are given, and then the nurse can record this accurately on the fluid balance chart. 5. HYDRATION CARD The Hydration Card may be used for patients that require monitoring of oral intake only and do not require full and accurate monitoring of fluid intake/output. These cards are laminated and cleaned for re-use and kept in the patient s record or on the clipboard at bottom of their bed. The cards have 8 pictures of glasses of water (although this can be any fluid e.g. tea/coffee/juice). This is the recommended daily amount of fluids that patients should drink every day, (RCN 2010), except for patients that have fluid restrictions or are Nil by Mouth. After each glass/cup of fluids taken, clinical staff, or the patient themselves (if able) or relative can mark a cross or write on the glass. If less than all taken, either staff, relative or the patient themselves can write over each glass/cup to signify this what has been taken e.g. half or quarter (see Appendix 4 Hydration Card). The Hydration Card can be ordered from Tayside Print Department, quoting THB (MR) 178. Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 7 of 30 Review Date: May 2018

8 6. BLUE AND GREEN LIDS ON JUGS The Blue lids on jugs are used for patients who are independent with fluid balance. The Green lids on jugs may be used for patients who have cognitive impairment and/or require to be prompted or assisted with oral intake and are having their intake monitored. 7. FLUID BALANCE CHART This fluid balance chart excludes, ICU/HDU/ONCOLOGY/HEAMATOLOGY as they have their own version. (See Appendix 7) 7.1 Patient identification 1. Patient s full name. 2. Patient s date of birth. 3. Community health Index (CHI) number. 4. Gender. 5. Hospital Ward. Should also include: Patient s recent weight - to maximise the accuracy of fluid balance the patient s current weight should be taken on admission. Subsequent weights should preferably be taken at the same time of day using the same scales, which should be calibrated, (McMillan and Pitcher 2010). Calculated daily fluid target in mls per Kg in 24 hours jointly with medical staff taken into account any fluid restrictions (medical staff should prescribe fluids using this). Time and reason for Commencement / Discontinuation it is expected that this will be completed, to allow for assessment and review of the patient fluid status. Preferred Drink if applicable. This information is valuable if patients have a cognitive impairment or communication need (QIS 2003). 8. COMPLETION OF FLUID BALANCE CHART 8.1 Indications for commencement/discontinuation of Fluid Balance Monitoring Registered nursing staff/midwives will assess if patients require fluid balance monitoring using the Risk Factor Flow Chart, on the reverse side of chart (see page 2 of Appendix 1 - Risk Factor Flow Chart). If the patient has any of the risk factors, continue with the fluid balance chart. If no risk factors identified then following review of the Daily Assessment Flow Chart by the registered nurse/midwife, the fluid balance chart can be discontinued and filed and secured in the medical notes. The patient should continue to be reassessed on a shift by shift basis using the Traffic Light Assessment (if in use) or if any change or deterioration in the patients clinical condition on the SEWS. Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 8 of 30 Review Date: May 2018

9 Total fluid intake/output is measured at 06:00 hours for the previous 24 hours, it is expected that nursing staff/midwives will escalate any concerns to medical staff if required. If the patient is for palliative care and nearing the end of life and subcutaneous fluids are prescribed for comfort only, it is expected that medical staff will prescribe in the prescription section of the fluid chart. Nursing staff/midwives will record commencement of fluids in the prescription section and specify the reason for commencement. Nurses/midwives may then score a line across the fluid balance chart section, if intake/output is not required. 8.2 Recording of Intake Oral Intake It is expected that all intake will be measured in millilitres (mls). It is not acceptable to record sips and should not be a matter of guesswork. If medical staff instructs that a patient can have sips orally this will be measured and given in a medicine cup or gallipot and recorded either as 30mls or 60mls. Use a glass, cup or other vessels that have known or clearly marked volumes (see Appendix 5 Volume of Drinking Vessels). It is expected that nursing staff/midwives will document the amount of fluids offered/taken and any other relevant information relating to the patient s fluid status, using the Traffic Light Assessment (if in use) under Fluid Balance (FB) Code within the Record Of Ongoing Care Nursing Record/ Nursing notes. It is not acceptable to use phrases such as good/poor amounts taken, drinking well, and fair amounts. As far as possible actual amounts should be used. Intravenous/Sub-cutaneous Intake Once intravenous fluid is prescribed then this must be administered at the prescribed time/date. For intra-venous fluids via a medical device, it is expected that registered nursing staff will record the actual amount infused each hour, (e.g. 1 litre over 8 hours would be 125ml/hr). If the fluid is not running via a medical device, the total fluid volume infused is recorded at the end of the infusion. Record each saline flush given between bolus of IV drugs on the fluid chart (if a patient is on multiple IV drugs it can add up to a substantial amount over a 24hr period). The cumulative total is the cumulative or running total for the total amount of fluids given (oral/ IV/ NG etc) from the time the fluid chart commences and should be completed hourly if possible. Sepsis 6 Bundle If sepsis is suspected and or SEWS score more than 4 the Sepsis 6 bundle can be implemented and all intake/output will be recorded in the first 6 hours of fluid resuscitation and monitoring section, after the 6 hours, it is expected that the patient will be transferred onto the fluid balance chart and continue to be monitored. (Refer to Sepsis 6 Bundle and Sepsis Guidelines). Intravenous Insulin Management Guideline/Sliding Scale For patients that require intravenous insulin monitoring, it is expected that IV fluids will be prescribed on the fluid balance chart as per insulin management guidelines by Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 9 of 30 Review Date: May 2018

10 medical staff. Nursing staff/midwives will continue to monitor and record the actual amount infused each hourly. Transfusion of Blood Components Patients that require any blood components and require accurate intake/output, it is expected that nursing staff/midwives will continue to monitor intake/output and record this on the fluid balance chart. Nutrition Support It is expected that the following will be included within fluid balance monitoring and documented on fluid balance chart: Oral supplementary drinks (this will still be included on the Food Record Chart). Enteral nutrition (flushes and hourly rate). Parenteral nutrition (flushes and hourly rate) Output All forms of fluid loss should be accounted for with as much accuracy as possible. Inaccurate documentation can be life threatening for patients and is indefensible. Running output totals must be completed throughout the day with a final output calculated every 24 hours. All output should be measured in millilitres (mls). Urine Output It is unacceptable to document urine output ambiguously. If patients meet the criteria for fluid balance and urine volumes are required then it is expected that this will be documented accurately in mls. The amount of urine output should be recorded each hour (if catheterised) or whenever the patient passes urine if not catheterised, depending on the agreed frequency of monitoring. The cumulative running total of urine output should also be recorded and added to the total cumulative output. It is expected that patients will be given the appropriate containers for urine collection i.e. bedpan/urinal. If the patient is incontinent, incontinence pads must be used and weighed to calculate urine loss prior to discarding/changing (Appendix 6). Clinical staff should NOT estimate urine output in cases of incontinence. This should be recorded within the nursing record of ongoing care that the patient is incontinent and therefore unable to accurately document urine output on the fluid balance chart. It is NOT acceptable to write incontinent ++. It is expected that patients will be reassessed every 2 hours if incontinent If urine output is less than 2mls/kg over 4hrs or 0.5mls/kg/hr (exemption in chronic renal failure patients who are aneuric) then medical staff should be informed immediately and documented in the patients notes. A full description of any abnormalities of the urine i.e. colour, consistency, smell should be documented in the nursing documentation and urinalysis taken if appropriate. Check patency of urinary catheters each shift and document in the nursing notes. 8.4 Other forms of Output Any surgical drain output must be monitored and if emptied, the total calculated at that time or if the drain is changed. If the patient has more than 4 drains a further chart can be utilised or recorded on the Other column on the fluid balance chart. Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 10 of 30 Review Date: May 2018

11 All vomit/gastric aspirate must be measured as accurately as possible. A full description of the aspirate should also be recorded i.e. colour, consistency, amount and any relevant care in the patients record. It is expected that all bowel/ stoma output will be measured as accurately as possible. A description of the patients stools i.e. colour, consistency, and amount, may be recorded in nursing documentation recording the volume, if appropriate or recorded on a stool chart. For patients with severe leaking oedema/excessive wound exudates, if it possible to arrive at an estimate this should be recorded in the Other column on the fluid balance chart. 9. CONSENT The administration of fluids by intravenous/subcutaneous requires obtaining patient (carers) consent, this should be undertaken following the Informed Consent Policy, Adults with Incapacity Scotland Act (2000). 10. AUTHORISED PROFESSIONALS It is expected that all staff within that are involved in the preparation, provision and monitoring of hydration status will at all times act in accordance with their professional code of practice. 11. EDUCATION AND TRAINING It is expected that all registered nursing staff/midwives will have competent levels for record keeping as per Nursing Midwifery Council (NMC) Record Keeping Guidance and Record Keeping Policy and undertake any other training commensurate with their duties. 12. LEGAL LIABILITY It is expected that the provision of this protocol will be followed by members of nursing staff at all times. Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 11 of 30 Review Date: May 2018

12 13. REFERENCES BAPEN (1999), Hospital Food as Treatment, British Association of Parenteral and Enteral Nutrition, BAPEN Office. Egan, D., Ingleby, S., Jones, S., Pike, D., Eddleston, J. (2010). Central Manchester University Hospitals, NHS Foundation Trust: Fluid Balance Policy for Adult in-patient areas. Chung, L.H. Chong, S., French, P. et al (2002) The efficiency of fluid balance charting: an evidence-based management project. Journal of Nursing Management; 10: 2, NHS QIS (2003) Clinical Standards for Food, Fluid and Nutritional Care in Hospitals. NHS Quality Improvement Scotland. Kleiner, S.M. (1999) Water: an essential but overlooked nutrient, Journal of American Dietetic Association, 99(2): Lobo, D.N., Dube, M.G., Neal, K.R., Simpson, J., Rowlands, B.J., Allison, S.P. et al. (2001) Problems with solutions: drowning in the brine of an inadequate knowledge base. Clinical Nutrition; 20: McMillen, R., Pitcher, B. (2010) The balancing act: Body fluids and protecting patient health. British Journal of Healthcare Assistants; 5: 3, Mooney, G. (2007) Fluid balance: Available at [www. nursingtimes.net/nursingpractice-clinical-research/fluid-balance/ article]. (2013) Safe and Secure Handling of Medication Guidance. (2012) Record Keeping Policy. (2012) SEWS Chart. Parenteral and Enteral Nutrition Group (2012) PENG Pocket Guide. (2012) Policy for Records and Record Keeping for Registered Nurses, Midwives and Specialist Community Public health Nurses. NICE Guidance CG50 (2007) Acutely ill patients in hospital: Recognition of and response to acute illness in adults in hospital, National Institute for Health and Care Excellence. Nursing and Midwifery Council (NMC) (2010) Standards for Medicines Management. Nursing and Midwifery Council (NMC) (2012b) The code: Standards of conduct, performance and ethics for nurses and midwives. Patchett, M. (1998) Providing hydration for the terminally ill patient, International Journal of Palliative Medicine, 4 (3). Powell-Tuck, J., Gosling, P., Lobo, D.N., Allison, S.P., Carlson, G.L., Gore, M., Lewington, A.J., Pearse, R.M., Mythen, M.G. (2009) British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients, GIFTASUP. Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 12 of 30 Review Date: May 2018

13 RCN Water UK (2005) Water for healthy ageing: hydration best practice toolkit for care homes, London: RCN Water UK. Reid, J. 2004, Improving the monitoring and assessment of fluid balance, Nursing Times, 100, (20): 36. Scales, K., Pilsworth, J. (2008), The importance of fluid balance in clinical practice, Nursing Standard. 5; 22(47):50-7; quiz 58, 60. Skipper, A. (1998) Dietitian's Handbook of Enteral and Parenteral Nutrition, Second Edition, Jones & Bartlett Learning. Smith, J., Roberts, R. (2011) Vital Signs for Nurses. An Introduction to Clinical Observations. Oxford: Wiley-Blackwell. Steiner, N., Bruera, E. (1998) Methods of Hydration in Palliative Care Patients. Journal of Palliative Care, 14(2):6-13NMC (2005). Waugh, A. (2007) Problems associated with fluid, electrolyte and acid-base balance. In: Brooker C and Nicol M (eds) Nursing Adults: the Practice of Caring. Edinburgh: Mosby. Welch, K. (2010) Fluid balance. Learning Disability Practice; 13: 6, Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 13 of 30 Review Date: May 2018

14 STANDARD OPERATING PROCEDURE - Fluid Balance for Adult In-Patients Policy: Food, Fluid and Nutritional Care Operation Policy Reference: The provision of fluid balance for adult in-patients Originator: Victoria Hampson and Kerry Queen Part Number/ Name Safety Tools/ Clothing This standard operating procedure is for the provision of fluid balance for adult in-patients being undertaken by all staff Universal precautions Aseptic Technique Tools/ Equipment Fluid Balance Chart Flow Charts Audit Tool Making Hydration Matters Posters Hydration Card Instructions for weighing incontinence pads No Main Operating Steps Rationale Evidence/support 1 Undertake a complete hydration assessment using SEWS chart and Traffic Light Risk Assessment (if in use), on admission, following re-admission, or if there is any change in condition that may cause the patient to be at risk for dehydration 2 Calculate the patients daily fluid goal: years of age - 35 mls/kg x body weight per day over 60 years of age - 30 mls/kg x body weight per day and document in MUST Record 3 Discuss treatment plan with patient and medical staff and initiate fluid prescription if applicable 4 Nurses/midwives will calculate patients total fluid balance from previous 24 hours (07:00 hours until 06:00 hours) and report abnormalities or concerns to the medical team 5 If fluid balance chart in use, nursing staff/midwives will document patient identification details 6 Patients recent weight and daily fluid balance target will be recorded daily on fluid balance chart If the patient is dehydrated, it is important to try to identify the underlying causes of the dehydration All patients should have individualised fluid goal determined by a documented standard for daily fluid intake Patient centeredness/ communication It is paramount that nursing/midwives and medical staff assess patients fluid status daily Patient safety/ principles of good record keeping To enable nursing staff/midwives to calculate a negative/positive fluid balance GIFTASUP (2009) Pachett (1998) Steiner & Bruera (1998) Skipper (1998) PENG (2012) RCN Water UK (2007) Kleiner 1999 Lobo et al (2001) NMC (2012) Safe and Secure Handling of Medicines Guidance (2008) Scales & Pilsworth (2008) NMC (2012a) Record Keeping Policy (2012) Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 14 of 30 Review Date: May 2018

15 7 The patients reason for fluid balance commencement will be recorded on fluid balance chart 8 Intravenous or subcutaneous fluids will be checked/dated/timed/signed by two registered nurses/midwives prior to administration of any additives being added 9 All oral/intravenous/subcutaneous input and output will be recorded in millilitres 10 Appropriate drinking vessels will be used and all nursing staff will know the volume of these vessels 11 If appropriate nursing staff/midwives will encourage and give clear instructions that will allow patient/relative to document oral input on the hydration card 12 Clinical observations should be measured as part of the clinical assessment of all patients and all nursing staff will adhere to NHST SEWS Guidance 13 Once Intravenous/subcutaneous fluids are prescribed by medical staff, nursing staff/midwives will administer this as soon as possible 14 Nursing staff/midwives will record the amount in millimetres of intravenous fluid infused each hour if pump in use, if pump not in use the total amount will be recorded as near the actual time when finished 15 The accurate amount of actual oral intake will be recorded as near to the actual time of the patients consumption 16 The accurate amount of output will be recorded as near to the actual time of patients output 17 If fluid monitoring is no longer required the reason for discontinuation should be written on the chart Principles of good record keeping Professional Accountability Patient safety/ principles of good record keeping Accuracy of completion of fluid balance charts NMC (2012a) Record Keeping Policy (2012) Safe and Secure Handling of Medicines Guidance (2013) Smith and Roberts (2011) NMC (2012a) Mooney (2007) NMC (2012b) (2012) Record Keeping Policy Person centeredness Chung et al (2002) Reid (2004) Vital signs will change when a patient becomes dehydrated and is a sign of the deteriorating patient Accountability/ principles of good record keeping Accuracy of completion of fluid balance charts Accuracy of completion of fluid balance charts Accuracy of completion of fluid balance charts Waugh (2007) SEWS Chart (2012) NMC (2012b) NMC (2012b) (2012) Record Keeping Policy Smith and Roberts (2011) Mooney (2007) NMC (2012b) (2012) Record keeping Policy Mooney (2007) NMC (2012b) (2012) Record Keeping Policy NMC (2012b) (2012) Record Keeping Policy Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 15 of 30 Review Date: May 2018

16 STANDARD OPERATING PROCEDURE - Fluid Balance for Haematology/Oncology Patients Policy: Food, Fluid and Nutritional Care Operation Policy Reference: Originator: Heather Whatley/ Lynne Clarke/ Alison Inglis/Kerry Queen The provision of fluid balance for Haematology/Oncology patients Part Number/ Name Safety Tools/ Clothing This standard operating procedure is for the provision of fluid balance for Haematology/Oncology patients being undertaken by all staff Universal precautions Aseptic Technique Tools/ Equipment Fluid Balance Chart Flow Charts Audit Tool Making Hydration Matters Posters Hydration Card Instructions for weighing incontinence pads No Main Operating Steps Rationale Evidence/support 1 Undertake a complete hydration assessment using SEWS chart and Traffic Light Risk Assessment (if in use), on admission, following re-admission, or if there is any change in condition that may cause the patient to be at risk for dehydration 2 Calculate the patients daily fluid goal: years of age - 35 mls/kg x body weight per day over 60 years of age - 30 mls/kg x body weight per day and document in MUST Record 3 Discuss treatment plan with patient and medical staff and initiate fluid prescription if applicable 4 Nurses will calculate patients total fluid balance from previous 24 hours (12:00 midday until 12:00 midday) and report abnormalities or concerns to the medical team 5 If fluid balance chart in use, nursing staff will document patient identification details If the patient is dehydrated, it is important to try to identify the underlying causes of the dehydration All patients should have individualised fluid goal determined by a documented standard for daily fluid intake Patient centeredness/ communication It is paramount that nursing and medical staff assess patients fluid status daily Patient safety/ principles of good record keeping GIFTASUP (2009) Pachett (1998) Steiner & Bruera (1998) Skipper (1998) PENG (2012) RCN Water UK (2007) Kleiner 1999 Lobo et al (2001) NMC (2015) Safe and Secure Handling of Medicines Guidance (2013) Scales & Pilsworth (2008) NMC (2015) Record Keeping Policy (2012) Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 16 of 30 Review Date: May 2018

17 6 Patients recent weight and daily fluid balance target will be recorded daily on fluid balance chart 7 The patients reason for fluid balance commencement will be recorded on fluid balance chart 8 Intravenous or subcutaneous fluids will be checked/dated/timed/signed by two registered nurses prior to administration of any additives being added 9 All oral/intravenous/subcutaneous input and output will be recorded in millilitres 10 Appropriate drinking vessels will be used and all nursing staff will know the volume of these vessels 11 If appropriate nursing staff will encourage and give clear instructions that will allow patient/relative to document oral input on the fluid balance chart 12 Observations should be measured as part of the clinical assessment of all patients and all nursing staff will adhere to NHST SEWS Guidance 13 Once Intravenous/subcutaneous fluids are prescribed by medical staff, nursing staff will administer this as soon as possible 14 Nursing staff will record the amount in millimetres of intravenous fluid infused each hour if pump in use 15 Nursing staff will complete the IV Fluid chart on page 2 accurately, with time commenced, fluid type, any additions, batch number and amount of fluid is administered 16 When the bag is taken down, accurate amount of fluid actually infused will be recorded to ensure all prescribed fluid is administered 17 A cumulative total should be recorded after each bag To enable nursing staff to calculate a negative/positive fluid balance Principles of good record keeping Professional Accountability Patient safety/ principles of good record keeping Accuracy of completion of fluid balance charts NMC (2015) Record Keeping Policy (2012) Safe and Secure Handling of Medicines Guidance (2013) Smith and Roberts (2011) NMC (2015) Mooney (2007) NMC (2015) (2012) Record Keeping Policy Person centeredness Chung et al (2002) Reid (2004) Vital signs will change when a patient becomes dehydrated Accountability/ principles of good record keeping Accuracy of completion of fluid balance charts Accountability/ principles of good record keeping Bags of fluid are often taken down before they are completed to allow infusion of blood products and IV antibiotics therefore there needs to be somewhere to record this to ensure all fluids are given as prescribed Accuracy of completion of fluid balance charts Waugh (2007) SEWS Chart (2012) NMC (2015) NMC (2015) (2012) Record Keeping Policy Smith and Roberts (2011) Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 17 of 30 Review Date: May 2018

18 18 The accurate amount of actual oral intake will be recorded as near to the actual time of the patients consumption 19 The accurate amount of output will be recorded as near to the actual time of patients output 20 If fluid monitoring is no longer required the reason for discontinuation should be written on the chart Accuracy of completion of fluid balance charts Accuracy of completion of fluid balance charts Accuracy of completion of fluid balance charts Mooney (2007) NMC (2015) (2012) Record keeping Policy Mooney (2007) NMC (2015) (2012) Record Keeping Policy NMC (2015) (2012) Record Keeping Policy Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 18 of 30 Review Date: May 2018

19 APPENDIX 1: Prescription & Fluid Balance Chart Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 19 of 30 Review Date: May 2018

20 Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 20 of 30 Review Date: May 2018

21 APPENDIX 2: Fluid Balance Chart Audit Tool Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 21 of 30 Review Date: May 2018

22 Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 22 of 30 Review Date: May 2018

23 Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 23 of 30 Review Date: May 2018

24 APPENDIX 3: NHS Scotland Making Hydration Matter Poster Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 24 of 30 Review Date: May 2018

25 APPENDIX 4: Hydration Card Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 25 of 30 Review Date: May 2018

26 Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 26 of 30 Review Date: May 2018

27 APPENDIX 5: Volume of Drinking Vessels Vessels Approximate volume mls ( in medicine cup/gallipot) 150mls 150mls 1000 mls/ 1 litre Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 27 of 30 Review Date: May 2018

28 APPENDIX 6: Instructions for Weighing Incontinence Pads INSTRUCTIONS FOR WEIGHING INCONTINENCE PADS To measure accurate amount of urine output from wet pads: Place wet pad in plastic bag Turn on scales Wait until single 0 appears Weigh pad on scales Deduct dry weight of pad: White pad Blue pad Yellow pad 30 gram 59 gram 77gram Calculate the difference between wet and dry pads - each gram difference = 1 ml of urine output Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 28 of 30 Review Date: May 2018

29 APPENDIX 6: Instructions for Weighing Incontinence Pads APPENDIX 7: Haematology &Oncology Prescription & Fluid Balance Chart Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 29 of 30 Review Date: May 2018

30 Policy Manager: Joyce Thompson, Dietetic Consultant in PH Nutrition Page 30 of 30 Review Date: May 2018