Date:_______________ Fluid Balance Chart Salisbury

NHS Foundation Trust

Indication for fluid chart: Urine Output Trigger
Name:__________________________________________________ Patient’s weight _____________________(Est/Act)
Hosp No.____________________ D.O.B_____________________ ---------------------------------------------------
When urine output falls below 0.5 mls/kg/hr Minimum hourly urine output: _________________
Previous 24hrs balance for
Age_________________ NHS No._ ________________________ Minimum 12hrly urine output: _________________
2 consecutive hours
+/- ____________________mls Minimum 24hrly urine output: _________________
Cons.___________________ Ward______________________________

INPUT OUTPUT
Nursing Intervention
Total Total Hourly
Time Oral Urine Bowels
Input Ouput Balance

01:00

02:00

03:00

04:00

05:00

06:00

07:00

08:00

09:00

10:00

11:00

12:00

Total 12hr balance + RN Sig.

13:00

14:00

15:00

16:00

17:00

18:00

19:00

20:00

21:00

22:00

23:00

24:00

Total 12hr balance + RN Sig.

Urine Dipstick
For PDSA Cycle Use ESCALATION YES NO Only Leucocytes Blood
Nitrate Specific Gravity
Document on escalation record Protein Ketones
PH Glucose
 Guidelines Minimum Urine Output Guide
Escalation Record Please refer to the ‘Fluid Balance Policy’ on 0.5mls / Kg / hr
Previous 2hrs U/O + Fluid Action Taken & Rationale Sign & Grade ICID for further information & advice Kg Stone Hrly 12 24
Date Time Balance
hrs hrs
Documentation 40 6.3 20 240 480
45 7.1 23 270 540
 If the fluid balance starts or finishes at a
specific time other than midnight, draw a 50 7.9 25 300 600
line through the unused columns 55 8.6 28 330 660
 Complete the running total column 60 9.4 30 360 720
 The daily fluid balance amount must be
entered clearly at the end of the 12 and 24 65 10.2 33 390 780
hr period 70 11.0 35 420 840
 Escalate when indicated 75 11.8 38 450 900
80 12.6 40 480 960
Intravenous Fluids 85 13.4 43 510 1020
90 14.1 45 540 1080
 For IV fluids the actual amount infused
95 14.9 48 570 1140
each hour should be documented
 If a pump is not available document the 100 15.7 50 600 1200
name of the fluid & the time commenced & 105 16.5 53 630 1260
record the total amount at the end of the
infusion 110 17.3 55 660 1320
 Include each saline flush given between 115 18.1 58 690 1380
bolus of IV drugs on the fluid chart 120 18.9 60 720 1440

Drains & Stomas

 Enter accurate stoma or drain output

Indications for Fluid chart Estimation of fluid balance

.

1. Scoring 3 or more on the EWSS  Do not use symbols such as +++ or PU’d
2. Patients who are nil by mouth/need assistance with drinking or eating  In cases of incontinence, estimate using
the charts of weigh pads
3. Patients with diarrhoea and / or vomiting
 Oral fluids must not be estimated, refer to
4. Patients experiencing any excessive fluid loss from surgical drains/ cavity drains, wounds /stomas. receptacle measurement chart
5. Patients discharged from ICU / HDU for a minimum of 48 hours post transfer.  Do not document ‘sips’, use a gallipot
6. Patients with a temperature greater than 38 degrees Centigrade.  Do not document ‘OTT’, give patients
7. Post-operative patients as part of routine post-surgery patient management. receptacles for urine collection &
measurement
8. Patients on Intravenous Fluids and / or parenteral nutrition
 Estimate the amount lost due to vomiting.
9. Patients on a restricted fluid intake, with known or suspected renal impairment or cardiac conditions i.e. Type 7 diarrhoea or blood loss
electrolyte imbalance, or upward trend in urea and creatinine etc.
10. Patients with urinary catheters, except for those patients with long term catheters who do not have an acute
onset of illness. Urinary Irrigation
11. Patients receiving a blood transfusion.
12. Patients who are not catheterised and it is documented on the observation chart that they have not passed  Calculate the urine output by measuring
urine within 12 hours. the total output & subtracting the total
13. When any doubt exists over fluid status. irrigation infused
14. For 24hrs following contrast for radilological procedures