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Do You Guess or Assess? Understanding Nurse’s Knowledge and Practice Around Fluid Management

Credits: None available.

Purpose: The focus of this study was to better understand the current knowledge level of medical-surgical nurses surrounding fluid management. To this end, a first-ever national survey of medical-surgical nurses was conducted through collaborative efforts with Academy of Medical-Surgical Nurses (AMSN) association to glean information on a national level.

Background/significance: Medical-surgical nurses’ knowledge surrounding intravascular fluid status monitoring and hemodynamics are limited. Multiple older studies have demonstrated that clinical confusion exists surrounding volume status and fluid responsiveness, leading to variations in monitoring therapies and use of technological aides. In most medical-surgical settings after a fluid bolus is administered, nurses currently rely on secondary hemodynamic responses like heart rate, blood pressure, and urine output to determine intravascular volume and response. Evidence has demonstrated that these are not reliable measures for volume status or responsiveness. Changes in stroke volume after a passive leg raise or fluid bolus demonstrates greater reliability. Accurate measurements are pivotal in fluid volume management because too little or too much volume have been associated with negative outcomes.

Method(s): A convenience sample survey of medical-surgical nurses was conducted through AMSN using avenues of email, The HUB, and the AMSN Online Community for member participation. In addition, collaborative efforts with other professional nursing organizations were used to deliver the survey to nurses in other clinical areas (ED, ICU, and periop). The survey was created using Research Electronic Data Capture (REDCap) and was emailed by the Department of Research of Barnes-Jewish Hospital, St Louis MO. IRB approval through Barnes-Jewish Hospital, St. Louis, MO. Descriptive statistics were used to measure the results of the survey. Post-hoc analysis of data for differences between clinical areas (ED, ICU, med-surg) and positions (staff RN, APRNs, directors) were also performed.

Results: 133 medical-surgical nurses participated in the full survey completion. Knowledge of stroke volume for determining fluid responsiveness was low for medical-surgical nurses, with a correct response of 25.6%. Nurses reported heart rate (78.7%), urine output (87.3%), and mean arterial pressure (78%) as most often used clinical parameters for assessing volume status and fluid responsiveness. Nurses reported these same parameters are the most useful in guiding fluid management decisions. 84.2% nurses reported having accurate measures to assess volume status is extremely important. At the same time, 70.7% reported that accurate assessment of volume status can be difficult.

Conclusions/implications: Nurses from 44 states were sampled. Medical-surgical nurses still rely on traditional methods of monitoring for evaluating both volume status and fluid responsiveness and reported that more help is needed in this setting for accurate assessment of fluid management. Results of this survey suggest the following areas of improvement:
1) Clearer standards and education for fluid volume management. The major professional nursing organizations working in collaboration may be best positioned to provide both standards and structured education as a first step for culture change for individualized fluid management monitoring in health care.
2) Examination of applicability regarding fluid management technology for the medical-surgical nurse.

Evidence-based references
1. Cannesson M, Pestel G, Ricks C, Hoeft A, Perel A. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Crit Care. 2011;15(4):R197
2. Connors AF Jr, Dawson NV, Shaw PK, Montenegro HD, Nara AR, Martin L. Hemodynamic status in critically ill patients with and without acute heart disease. Chest. 1990 Nov;98(5):1200-1206.
3. Douglas IS, Alapat PM, Corl KA, et al. Fluid response evaluation in sepsis hypotension and shock. Chest 2020;158(4):1431-1445.
4. Hoff RG, Rinkel GJE, Verweij BH, ET AL. Nurses’ prediction of volume status after aneurysmal Subarachnoid hemorrhage: A prospective cohort study. Crit Care 2008
5. Iregui MG, Prentice D, Sherman G, Schallom L, Sona C, Kollef MH. Physicians' estimates of cardiac index and intravascular volume based on clinical assessment versus transesophageal Doppler measurements obtained by critical care nurses. Am J Crit Care. 2003 Jul;12(4):336-342.
6. Monnet X, Marik PE, Teboul JL. Prediction of fluid responsiveness: an update. Ann Intensive Care. 2016;6(1):111.
7. Neath SX, Lazio L, Guss DA. Utility of impedance cardiography to improve physician estimation of hemodynamic parameters in the emergency department. Congest Heart Fail 2005 Jan-Feb;11(1):17-20.



Credits: None available.

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