Hospital Patient Data: Vital Signs, Fluid Balance & Charts

Posted on Jan 19, 2025 in Biology

Identifying Patient Data

This section outlines the key components of patient data typically found in hospital records:

  • Patient Identification: This may include an anagram of the patient’s name, unit, and identification number.
  • Hospitalization Details: Month, year, date, or day of hospitalization.
  • Allergies: A record of any known patient allergies.

Representation of Vital Signs

Vital signs are crucial indicators of a patient’s health status. They are typically represented graphically and include:

  • Respiration (R)
  • Blood Pressure (BP)
  • Pulse (P)
  • Temperature (T)

The grid used to record these signs often shows separate divisions between shifts (e.g., MTN for morning). Thick lines may indicate the parameters of different scales, while fine lines represent values within those intervals.

Log of Inputs and Outputs (Fluid Balance)

This section meticulously records all fluid intake and output for the patient.

  • All fluid intake is recorded, including fluids administered through a feeding tube.
  • All outputs or losses are also documented.
  • Registration is typically in cubic centimeters (cc).
  • The patient’s intake is recorded for each shift.
  • Diet is encoded.
  • Total volume of fluid ingested and removed is calculated for 24 hours.
  • Daily and accumulated fluid balances are tracked.

Registration Number

This section includes a variety of patient data points:

  • Weight
  • Height
  • Diet
  • Oxygen levels
  • Norton Scale Index (measures the individual’s capacity for autonomy)
  • Dependency level
  • Special examinations
  • Therapeutic interventions (specify shifts, e.g., MTN for morning)
  • Medication and administration routes
  • Nursing care plan and evolution
  • Observations and activities not reflected elsewhere in the record

Types of Medical Charts

  • Ordinary: These charts, often used for routine monitoring, can be created weekly or monthly and serve as legal documents.
  • Special: Used for a single day (24 hours), these charts contain detailed information and are common in intensive care, emergency departments, triage, and operating rooms. They record frequent vital signs, fluid balance, level of consciousness, pupil status, analytical data, medication, control of IV lines, and ventilator settings.

Recording Data on Clinical Charts

  • Vital signs are recorded as a point or vertical line.
  • Arterial voltage is recorded in the designated space.
  • Time (e.g., MTN for morning) is noted.
  • Blood pressure is represented by the union of two points: systolic and diastolic.

Water Balance

Water constitutes a significant portion of body weight:

  • 50-70% in adults
  • 80% in infants

Water balance is the difference between fluid intake and fluid output. The daily water requirement is approximately 2.5 to 3 liters.

Fluid Sources

The body obtains fluids from three primary sources:

  1. Swallowed liquids: Water, etc. (1000-1500 ml/day)
  2. Liquid from solid food: (900-1000 ml/day)
  3. Water from metabolic reactions: (200-300 ml/day)

Total: 2100-2800 ml/day

Fluid Losses or Exits

The body loses fluids through various mechanisms:

  • Respiration
  • Skin
  • Kidneys
  • Stool (minimal volume)
  • Insensible losses (respiration and sweat)

Factors Affecting Fluid and Electrolyte Balance

  • Age: Younger individuals experience greater fluid losses and alterations in renal function.
  • Inadequate intake
  • Impaired gastrointestinal tube
  • Hemorrhage
  • Burn injuries
  • Stress: Increases metabolism and sweating.
  • Climate: High temperatures increase fluid loss.
  • State of health: Vomiting, etc.
  • Physical activity: Increases fluid loss.

Indications for Fluid Control

  • All hospitalized patients (generally performed).
  • Critically ill patients (burns, etc.).
  • Patients with chronic diseases (diabetes, cancer, etc.).
  • Postoperative patients with significant fluid losses.
  • Patients with drainage.

Measurement of Fluid Intake

  • Oral ingestion (natural or via nasogastric tube)
  • Fluid therapy: All amounts of different solutions administered.
  • Transfusion: Any blood component administered.
  • Balance: Oral intake and intravenous intake.

Measurement of Fluid Loss

  • Diuresis
  • Insensible losses
  • Vomiting