Fluid Balance Charts
Your patient with heart failure requires a 1.5L FR, why would they require a FBC?
To ensure accurate documentation of fluid intake and assist with assessment of fluid status (patients exceeding FBC may not see a reduction in symptoms or weight.
Your patient is admitted from home with a dressing.
When would you change the dressing? and why?
As soon as is possible, unless you have a clear wound management plan and wound assessment.
Important to assess patient on admission including skin - opportunity to find evidence of infection
What is the FRAT? and why do we use it?
Falls Risk Assessment Tool - generates information regarding who is at risk and prompts implementation of strategies
How would you determine if a patient had a preexisting PI on admission?
Skin inspection
Clear documentation
If a patient is admitted with a PI a VHIMs is also completed that states 'present on admission'
What is the 4AT?
Validated screening tool used for rapid assessment of delirium and cognitive impairment
Why would an accurate FBC be important for a patient with a CBWO?
To monitor fluid in and out and be able to accurately calculate urine output.
to be able to identify early if the catheter is blocked
How soon after admission would you inspect a patient's skin?
ASAP
Who requires a FRAT completing?
Anyone indicated at risk from the PAARS
Anyone over 65yrs
Clinical concern
Why is a skin inspection on admission essential?
Can identify preexisting PIs/other wounds
Allows for assessment of factors that can contribute to PI (oedema/PVD)
Who requires the 4AT completing?
4AT is completed on all patients over 45years old
What is fluid balance?
Homeostasis - balancing of input and output
You have redressed a wound. What documentation/form is required on the EHR?
Wound Management Chart
When is a FRAT completed initally?
ASAP - within 8 hours
How often is skin inspection required (and assessment findings documented)
Ideally every shift
SSKIN bundle requires documentation of skin inspection and must be done am & pm for anyone who has a FRAT score regardless of whether low, moderate, high or very high
Mod/high/very high: during each turn (these pts are turned every 2-6hrs and require a PAC chart)
Includes checking bony prominences and under medical devices such as NGT/TEDs/IDC
When is a 4AT required?
Within 8 hours for all patients over 45yrs
Required daily for any patients:
With a 4AT score of 1 or more
Those over 65 (ATSI over 45)
Severe acute illness
History of delirium
Present of cognitive impairment (past or present) or dementia
What should be documented on the FBC?
Input: Oral fluids/IVT/Blood/TPN etc/SC fluids
Ouput: Urine/Blood/stoma contents/wound drainage/ascitic fluid/vomit/diarrhea
When documenting a wound assessment, what would you include?
Length, depth, width, excudate, odour, appearance of wound/colour and surrounding skin, pain
Other than on admission, when does a FRAT require completing?
Immediately after a fall
If patient condition changes
On transfer to new ward or site
Weekly
Who requires a FRAT completing? and when?
Anyone indicated by PAARS
Clinical Concern
Completed within 8 hours of admission, on day 2 of admission and then weekly. Also completed if patient's condition changes or they develop a pressure injury
What score on the 4AT is suggestive of delirium?
4 or more
Name 5 occasions when you would start and maintain an accurate fluid balance chart for your patient.
Patient on fluid restriction/retaining fluid
Patient requiring accurate urinary output measurement (poor output (less than 30ml/hr) newly inserted catheter catheter/ post retention/hypertension/sepsis)
Patients on IVT/TPN
Patients losing fluids (bleeding/ascitic tap/drain/D & V/Stoma/sweating/wound exudate)
Patients unable to maintain adequate nutrition/ hydration (NBM/PEG/PEJ/Delerium/Dementia/paralysis/reduced conscious level)
When documenting dressing changes required, what requires documentation?
Cleaning solution
Primary and secondary dressing type and securement
If wound packed requires a dressing count
Other than falls risk assessment, what other documentation is required for falls?
Patient education
Strategies implemented
Falls and Post falls management
Referrals
When is a PAC chart required?
Patients who score moderate, high or very high on the PRAT require regular PAC and therefor require a PAC chart
A patient score 0 on the 4AT on admission however has deteriorated since. Would the patient require rescreening using the 4AT?
Yes