Fluid Chart on Fluid Intake Management Adherence among

Hemodialysis Patients: A Literature Review

Zaky Mubarak

, Endang Mahati

and Anggorowati

Master of Nursing Student, Faculty of Medicine, Diponegoro University, Indonesia

Lecturers of the Faculty of Medicine, Diponegoro University, Indonesia

Masters of Nursing Lecturers, Faculty of Medicine, Diponegoro University, Indonesia

Keywords: Fluid Chart, Adherence, Haemodialisis Patient.

Abstract: The purpose of this literature is evaluate the effect of fluid chart on fluid intake management adherence

among haemodialysis patients. The method that was used in this writing is a literature review study and the

analytical method that was used here is PICOT (Population, Intervention, Comparison, Outcome, dan

Time). This literature review used five bibliography databases (CINAHL, Scientdirect, Proquest, Pubmed,

and MEDLINE) from their inception in Januari 2010 to Desember 2017. The Inclusion criteria in this study

are articles published in 2010 to 2017 that are available in full text and in English laguange. The subject of

the study was patients in Hemodyalisis. A total of 27 articles had been identified and a total of 21 articles

excluded. Finally, there are 6 studies met the criteria. The results of all of the articles mention that the fluid

management of patients undergoing haemodialysis can be enhanced with paper-based monitoring

interventions. The majority of old haemodialysis patients is the basic reason why paper-based monitoring is

considered effective. Fluid Chart was one of the conventional monitoring media that has long been used by

health workers. Cost effectiveness and practicality were advantages of conventional reminder systems.

Strategies that were directed towards improving compliance behavior must target the barriers that underlie

compliance. Therefore, reminders provide useful additions to compliance improvement strategies.

1 INTRODUCTION

Management of limiting poor fluid intake will have

an impact on weight gain between two dialysis

times. Fluid restriction is less obeyed in self-

management of CKD patients (McLafferty et al.,

2014). Weight gain between two dialysis times

(IDWG) is influenced by several factors, namely:

environment, nutrition, behavior, physiology, and

psychology (Hung et al., 2008). Juan (2005) reveals

that the more the percentage of IDWG, the worse the

long-term prognosis and the resulting high blood

pressure predialysis.

New hemodialysis patients in Indonesia from

2007 to 2012 increased significantly with details of

4977 people (2007), 5392 people (2008), 8193

people (2009), 9649 people (2010), 15353 people

(2011), 19621 people (2012 ) The number of new

patients in East Java alone in 2012 reached 11672

people with 2796 people being patients with

terminal kidney disease. This number is the second

highest after West Java Province (Indonesian et al.,

2015).

Complications often occur in hemodialysis

patients are weight gain between two hemodialysis

times (Interdialytic weight gain = IDWG) caused by

the inability of the kidney excretion function, so that

whatever amount of fluid is consumed by the

patient, weight gain will always be present. In other

words, zero ml weight gain is impossible. Adding

too high an IDWG can cause negative effects on the

patient's condition, including hypotension, muscle

cramps, hypertension, shortness of breath, nausea

and vomiting, and others (Kugler, Maeding and

Russell, 2011).

Excess fluid complications in

patients with CKD are hypertension, peripheral

edema and ascites. The ideal weight gain between

two hemodialysis times is 1.5 kg (Bame, Petersen

and Wray, 1993).

Fluid balance refers to the balance between the

volume of water lost from the body and the volume

of water (McLafferty et al., 2014). Fluid Chart has

been a document in the health care system for more

than 50 years and is a non-invasive tool to assess the

104

Mubarak, Z., Mahati, E. and Anggorowati, .

Fluid Chart on Fluid Intake Management Adherence among Hemodialysis Patients: A Literature Review.

DOI: 10.5220/0008203801040109

In Proceedings of the 1st International Conference of Indonesian National Nurses Association (ICINNA 2018), pages 104-109

ISBN: 978-989-758-406-0

hydration status of patients (Malster, Dougherty and

Lamb, 1999). Fluid Chart This is a chart

documenting the input and output that the patient

has taken in and out in a 24-hour period (Chung,

Chong and French, 2002).

Kaveh & Kimme (2000) and Abuelo (1998)

reveal that good fluid management is due to

restrictions on fluid intake, limiting up to 1 liter per

day is important to reduce the risk of excess volume

of fluid between dialysis times. Kimmel (2000),

Leggat (1998), Port (2004), Saran (2003) in Welch

(2006) suggested that a person with CKD who does

not adhere to fluid restriction can worsen the

prognosis of the disease with a high rate of

morbidity and mortality.

This article aims to find out that conventional

media in this case is illustrated by a fluid chart that

can help hemodialysis patients to achieve fluid

fulfillment in accordance with how to adhere to a

defined fluid management.

2 METHODS

2.1 Search Strategy

Our search (Table 1) is limited to the PUBMED

database, CINAHL Science Direct, and Medline. We

use the Fluid chart search terms '' and 'Fluid

management' or 'fluid blocking compliance' AND

'hemodialysis patients', and we limit the search to

full text articles published between January 2010

and 2018. To be considered as candidate articles for

review, Fluid chart '' AND 'Management of fluids'

or' adherence to repair of fluids' AND 'patients with

hemodialysis must be stated in title or abstract.

Studies are included in our review if they focus on

Fluid charts, fluid management or compliance with

fluid restriction and hemodialysis patients. Because

we are interested in conventional (paper based)

media as a medium to meet fluid management,

especially compliance with fluid restriction in

hemodialysis patients. Morbidity and mortality of

hemodialysis patients depend on patient compliance

in carrying out hemodialysis treatment regimens,

one of which is fluid management. We also check

the reference list of papers included to identify

possible additional studies that might be missed

during database searches.

Literature analysis using PICOT (Population,

Intervention, Comparison, Outcome, and Time).

Based on the analysis found 2 themes, namely fluid

management in hemodialysis and fluid chart patients

as a fluid management compliance medium.

2.2 Search Outcome

The search resulted in six candidate publications,

which are briefly described in Table 2. 5 studies

discussed fluid charts and 1 drastic study of fluid

management in hemodialysis patients. Three studies

were completed in England (Jeyapala et al., 2015)

(Chung, Chong and French, 2002) (Tang and Lee,

2010); two in Australia (Georgiades, 2016) (Daffurn

et al., no date); and one in Hong Kong (Chung,

Chong and French, 2002).

Table 1: Search Strategy.

Stage 1: initial search

Keywords

Fluid chart AND fluid management

Results 55737

Keywords

Fluid chart AND fluid management

fluid

adherence retrictions

Results 10275

Keywords

Fluid chart AND fluid management

fluid

adherence retrictions and hemodialysis

patient

Results 360

Stage 2: screening

Filter

Fluid chart AND fluid management

fluid

adherence retrictions and hemodialysis

patient

2010 - 2018/Full text articles

Results 159

Filter

Fluid chart AND fluid management

fluid

adherence retrictions and hemodialysis

patient

Title/Abstract/2010-2018/Full text

articles

Results 27

Filter

Title/Abstract/‘Related articles’ examined for

rele

vance

Results 12 and 8 ‘related’

Filter

inclusion/exclu

sion

criteria

Articles examined for relevance. ‘Related

articles’

of relevant articles examined for

relevance. Manual

searching in bibliographies

of relevant articles.

Consultation of experts

Results 6

Criteria

Inclusion

Fluid chart AND fluid management

fluid

adherence retrictions and hemodialysis

patient

Exclusion

Nutrition management on hemodialysis patient

Chart on industri building

2.3 Appraisal

There is little consensus on how to assess qualitative

and quantitative articles. Quantitative studies are

Fluid Chart on Fluid Intake Management Adherence among Hemodialysis Patients: A Literature Review

105

assessed in terms of relativity and validity, while the

evaluative criteria for qualitative studies are based

on trust. Thus, we use some interesting general

points, as presented by Dixon-Woods et al 2010. and

Kearney 2007, to evaluate the accuracy of the study

included.

One qualitative study provides an explanation of

the effectiveness and suitability of fluid balance

charting by Lai Har Chung who analyzed 250

medical records and opinion surveys, 55 doctors and

98 nurses participated in this survey. The result is

that 50% of medical records have fluid balance

charts and in this case they make 12-16%

themselves in medical records. Infusion fluids and

urine catheter production were recorded in almost

70% of the reasons for using fluid balance charts.

32% of FB charts were found to be incomplete and

inaccurate. 46% of doctors and nurses report that

they believe FB charts do not always provide if not

needed. Doctors believe that so far only those who

have to stop the FB chart, nurses cannot provide

intervention except with the doctor's approval. The

end result is that the design of the chart must be

modified to accommodate different goal. Regarding

quantitative studies, fluid input / output charts in

hospitalized patients is a valuable source of

information for doctors who review intravenous

fluid prescriptions, but are known to be incomplete

and inaccurate. The lack of awareness of the

importance of fluid balance between nursing staff

and the advantages of unnecessary monitoring are

two factors that contribute to this problem. Vincent

conducted a quality improvement project on the

respiratory ward in a large district general hospital

which aimed to specifically address these two

factors. Pre-intervention audits show that only 53%

of input / output monitoring is clinically indicated,

with an average 50% graph completion. By using e-

Learning and verbal presentations to raise awareness

about fluid balance, we implemented a new system

where daily medical reviews of charts lead to

rationalization of monitoring. Post-intervention

audits show a 93% reduction in unnecessary

monitoring, with appropriate improvements in

completion (40%) and accuracy (48%) of the

remaining charts. In conclusion, education has

allowed cultural changes in wards that drastically

improve the quality of monitoring fluid balance.

2.4 Data Abstraction and Synthesis

All research included illustrates the experiences

experienced by victims of disability and returns to

work. To compare qualitative and quantitative

findings, the reviewer (CT) isolates and categorizes

the findings of the findings and summarizes them

into relevant themes (thematic analysis): fluid

management in hemodialysis and fluid chart patients

as a fluid management compliance medium.

Furthermore, quantitative in-depth and

complementary qualitative findings from

questionnaires were integrated and divided into

'Fluid charts' and' fluid management compliance.

This abstraction and synthesis process is also

discussed with fellow authors.

2.5 Fluid Chart on Fluid Adherence

Management in Hemodialysis

Patient

Table 2: Studies included in the literature review.

Tittle, Author, origin Design Sample Data collection Employment variables/themes

A Balancing Act:

Maintaining Accurate

Fluid Balance Charting,

Dimitra Georgiades

Australia

article - Critical appraisal

examined the contributing factors

that inhibit accurate fluid balance

charting such as lack of time related

to patient acuity and inadequate

training and education

Management of Fluid

Status in Hemodialysis

Patients: The Roles Of

Technology and Dietary

Advice

Elizabeth Lindley

et al. UK

Clinical

mangement

The implementation of bioimpedance

measurements to assist in the

optimisation of the patient’s target

weight, and the use of salt restriction

to avoid excessive fluid gains, should

enable most haemodialysis patients

to stay close to normal hydration

throughout the interdialytic period

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

106

Table 2: Studies included in the literature review. (cont.)

Tittle, Author, origin Design Sample

Data

collection

Employment variables/themes

Tittle,

Author,

origin

Improvement of fluid

balance monitoring

through education and

rationalisation, Masaki

Vincent, Thabo

Mahendiran, UK

Quantitative

study

117 patient:

Whether daily fluid

balance monitoring was

happening.

Whether daily fluid

balance monitoring was

clinically indicated.

Whether "totals"

boxes had been completed

(eg 12 hours total for oral

input, 24 hours total for

oral input, 12 hours total

for IV input, etc).

Whether "totals"

boxes were accurate. We

defined a sum as

"accurate" if the error in

the final sum was inferior

to 10% of the sum itself.

two main

group

interventions

Fluid balance monitoring can be

improved by the implementation

of a system where daily medical

review of fluid charts allows

rationalisation of monitoring,

reducing unnecessary workload

and improving chart completion

and accuracy in patients who

need it. In order to make such a

cultural change succeed on a

ward, it is crucial to raise

awareness and education around

the importance of fluid balance.

Statistical

analysis

Fluid balance chart: do

we understand i ?,

Vincent CY Tang and

Elaine WY Lee, UK

Quantitative

study

13 patient of surgical

patient requiring

intravenous fluid and

catheterized for urine

output monitoring from

all five surgical wards on

the same day

two main

group

interventions

Fluid balance chart is a useful

monitoring tool of patient

hydration status, however it can

be counterproductive and

dangerous if the documentation

is poor and interpretation

incorrect.

Statistical

analysis

The efficiency of fluid

balance charting : an

evidance – based

management project,

Lai Har Chung et al,

Hong Kong

Qualitative

study

250 medical records and

an opinion survey.

75 doctors and 98 nurses

participated in the survey.

Collection of

data the

survey method

In the case of fluid balance

charting in this study, it could be

said that the major cause of

inefficiency is that those who are

making the observation are not

empowered to make the decision

to terminate the chart when they

are thought unneccessary. In

addition, the design of chart does

not seem to encourage a

distinction record, output

observation and fluid balance

observation.

Conducted

all of the

interviews

and data

recording

Fluid Balance charts :

do they measure up ?,

Kathrine Daffurn et al,

Australia

Quantitative

study

The study was conducted

in two parts. The first part

used a questionnaire

designed in consultation

with a psychologist

attached to the critical

care research unit.

The second part of the

study involved groups of

nurses in a practical

exercise to estimate fluid

gains and losses. Forty-

five registered nurses

were selected, using a

random number table,

from the population of

nurses rostered on the

chosen

study date.

Conducted 2

parts

This study has shown that nurses

rate FBCs highly, although some

discrepancies were identified in

the way that they are used.

Nurses may be commencing

FBCs unnecessarily and doctors

do not always look at them.

Nurses can estimate fluid

volumes with reasonable

accuracy, which is encouraging

as they do not or cannot always

measure the fluids being

recorded.

Statistical

Analysis

Fluid Chart on Fluid Intake Management Adherence among Hemodialysis Patients: A Literature Review

107

3 RESULTS

3.1 Management of Fluid in

Hemodialysis Patients

Fluid management is a skill in identifying problems,

setting goals, solving problems, making decisions in

response to fluctuations in signs and symptoms,

taking action in response to physiological responses

to lack of body fluids, monitoring and managing

symptoms (Lindberg, Wikström and Lindberg,

2010). It is important to remember about the causes

of thirst. Thirst is a direct result of too much salt in

water, food and also salt added to food. Too much

salt diet will cause sodium levels to increase and

activate the thirst mechanism in the brain, for that it

is necessary to drink enough liquid to normalize

sodium. A more important aspect of maintaining

normal IDWG in patients with hemodialysis and

peritoneal dialysis is to reduce the amount of salt

and use spices and spices to add flavor (Santos and

Peixoto, 2008).

The advantages of IDWG may not always be the

cause of the patient's lack of understanding about

limiting fluid intake. Increased fluid-filled food and

appetite for patients will increase IDWG, and this

fact can be obtained in detail in dietary studies,

indications of high protein and calories such as

fluids in jelly, ice cream, sauces and soup. Excess

IDWG can be prevented by daily fluid intake of 500-

750 ml in the situation of dry urine production.

Sodium intake of 80-110 mmol per day, will be

enough to control thirst and help patients regulate

fluid (Sezer et al., 2002).

3.2 Fluid Chart as a Fluid

Management Compliance Media

Fluid charts are widely used in most hospitals as a

guide to the patient's fluid status. The time the nurse

uses to map fluid intake and output can be very

significant in some cases (Chung, Chong and

French, 2002).

Paper graph based reminders are conventional

media from the support system of clinical decision

making (Decision Support System / DSS).

According to Kawamoto et al., A significant

increase in clinical practice can be found if the DSS

contains all of the following special features: (1)

provision of decisions as part of the clinical

workflow; (2) providing recommendations and not

just assessments; (3) providing decision support at

the time and location of decision making; and (4)

computer-based decision support.

This reminder

system processes the first three characteristics of

successful DSS but not computer-based or assisted

by informatics. However, Ansari et al. shows that

simple reminders on input - output fluid reports can

increase physician compliance with the use of drugs

which regulate fluid intake and output for patients

with chronic renal failure with Hemodialysis.

Paper-based graphs prove that conventional

reminder systems are attached to paper charts during

Clinical workflows can facilitate the awareness of

doctors and nurses to evaluate current fluid status.

4 DISCUSSION

Fluid Management Monitoring is done by recording

fluid intake and expenditure and body weight.

Liquid intake includes the type and amount of food

and liquid. While fluid expenditure is the amount of

urine, vomiting and diarrhea. Fluid Chart is one of

the conventional media that has long been used for

fluid management, especially patients with chronic

diseases. Patients with CKD with Hemodialysis are

very at risk with fluid calculations, factors of patient

disobedience to fluid management are found in the

clinical domain. Fluid Chart is useful for calculating

the management and fluid balance of hemodialysis

patients. By recording all the liquid consumed by the

patient and recording all the fluids released by the

patient, both from the urine, sweat and vomit of the

patient. Patients who follow and carry out the

instructions to maintain fluid balance can help

maintain IDWG 2.5% to 3.5% dry weight or not

exceed 5% dry weight. The IDWG value

(interdialytic weight gain) is calculated based on the

patient's body weight before hemodialysis (wet

weight) minus weight after hemodialysis (dry

weight). The normal value of IDWG is less than 3%

dry weight (Malster, Dougherty and Lamb, 1999).

Factors of patient adherence in adhering to the

amount of fluid consumption determine the

achievement of optimal dry weight (Riyanto (2011).

Kimmel, et al (2000) showed that age is a strong

factor in the level of patient adherence. Patient aged.

Fefendi (2008) explained that patients with

productive age feel motivated to recover, have a

higher life expectancy and as the backbone of the

family (Cvengros, Christensen and Lawton, 2004).

5 CONCLUSIONS

Fluid Chart is one of the conventional monitoring

media that has long been used by health workers.

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

108

Cost effectiveness and practicality are advantages of

conventional reminder systems. Repeated telephone

calls, text messages, pager systems, or advanced

appointments for a condition, require relatively high

costs and labor to be prepared. Repeated monitoring

can also be seen as instructive rather than helpful

(Hung et al., 2008).

Fluid management of patients undergoing

hemodialysis can be improved by paper-based

monitoring interventions. Hemodialysis patients who

are mostly elderly are the basic reasons why paper-

based monitoring is considered effective. The

physiological aging process which includes a blurred

vision, decreased memory, and a lack of knowledge

about modern technology is a consideration for the

use of conventional media as a monitoring medium.

Strategies that are directed towards improving

compliance behavior must target the barriers that

underlie compliance. Therefore, reminders can

provide useful additions to compliance improvement

strategies (Kugler, Maeding and Russell, 2011).

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