الفهرس 
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Abstract
The fluids management is one of the vital and essential roles of the critical care nurses in the ICUs. Ensuring fluids balance could be a part of the scope of the ICU nurses’ practice. The National Institute for Health and Care Excellence (NICE) provides positive guidance for fluids management. The new five Rs of the IV fluids therapy consisted of fluids resuscitation; routine fluids maintenance; fluids replacement; fluids redistribution; and fluids reassessment. Fluids resuscitation aims to immediate restoration for the vital organs perfusion. Fluids maintenance indicates meeting the basic physiologic needs of the patient with enteral or parenteral route, while fluids replacement indicates the normal physiologic losses and abnormal fluids loss as vomiting and diarrhea. Fluids reassessment includes assessment of the fluids imbalance manifestations, findings of the laboratory investigations and the cumulative fluids balance.
The aim of the current study is to determine the effect of implementing fluids management guidelines on the cumulative fluids balance among critically ill patients.
To fulfill the aim of this study a quasi-experimental research design was done. This study was carried out in three ICUs at the Alexandria Main University Hospital, namely: unit I included 14 beds, unit II 6 beds and unit III 15 beds. The nursing ratio to the critically ill patients in all these units was 1:2. These ICUs receive patients who have variety of disorders in acute stage of illness admitted directly from the emergency room or transferred from the other hospital departments.
A convenience sample of 60 newly admitted critically ill adult patients to the previously-mentioned settings were included in the current study, aged from 18-60 years. The patients were assigned into two equal groups 30 each: group A the control group who received the routines fluids management, group B: the intervention group who received the intervention fluids management guidelines. The patients that need neurosurgery; severe chronic kidney, end stage liver; and diabetic ketoacidosis were excluded from the study.
To accomplish the aim of the current study; two tools were used to collect the data in this study. Tool one namely critically ill patient’s fluids balance assessment that was developed by the researcher after reviewing the relevant literature. It consisted of four parts. Part I included patient’s profile data; part II assessed the factors associated with fluids imbalance; part III assessed critically ill patients’ therapeutic modalities; and part IV assessed critically ill IV fluids need and prescription assessment including the five RS ” fluids resuscitation, routine maintenance, replacement, redistribution and reassessment” based on NICE fluids management guidelines. Tool two namely fluids balance evaluation that consisted of three parts, part I included the cumulative fluids balance bar chart; part II assessed fluids imbalance manifestations; part III covered laboratory test findings used to evaluate fluids imbalance including hemoglobin, hematocrit, and serum osmolarity.
After approval of the ethical committee to conduct the study from the Faculty of Nursing; an official permission from the administrative authorities was obtained to collect the necessary data from the selected settings after explanation of the aim of the study. The study tools were tested for content validity by 5 experts in the field of the study. Reliability of the two tools were measured using Cronbach Alpha test, the reliability coefficient values were (r =0.932) and (r 0.827) which are acceptable. A pilot study was carried out on 6 patients (10% of the sample) in order to test the applicability of the tools. The necessary modifications were done accordingly. Data were collected by the researcher during approximately eight months starting from September 2018 to May 2019.
Data collection was done as the following steps:
All newly admitted critically ill patients were assessed by the researcher for meeting the inclusion criteria on the first day of admission. They assigned into control and intervention groups. Patient’s characteristics and clinical data were assessed; and were recorded using part I tool one. Factors associated with fluids imbalance were assessed; and were recorded using part II tool one. Critically ill patients’ therapeutic modalities were assessed; and were recorded using tool one part III for each patient in the both groups.
The control group was assessed for the routine fluids management for three consecutive days from the first admission day. Fluid resuscitation in the routine fluids management was prescribed by authorized physician, after IV access, more than 2000 of crystalloid at once, if the patients still hemodynamic unstable another more additional fluids were given until hemodynamic stability. Inotropic and vasopressors medications were later prescribed. After hemodynamic stability, enteral feeding was prescribed. Routine daily fluids management in the previously mention unit was assessed for the three consecutive days for each patient in the control group. The data were recorded using part IV tool one.
The intervention group received fluids management guidelines that based on the guidelines of the National Institute for Health and Care Excellence (NICE) for three consecutive days from the first admission day. Daily fluids management plan was done for the three consecutive days using the five Rs fluids management guidelines. The data were recorded using part IV tool one. The first R for the fluids resuscitation included initial assessment using ABCD approach to determine stability of the patients. The second R for the fluids routine maintenance, it is used for patient who are hemodynamic stable who able to meet fluids need through oral, enteral, or parenteral route. The third R for the fluids replacement used for patient who needs fluids according to the lab results of sodium and potassium throughout the observation days. The fourth R for the fluids redistribution used for patient who had abnormal albumin level. The fifth R for the Reassessment used to evaluate fluids status for each patient in the both study groups. The fluids balance evaluation was assessed for each patient in the both groups. The data were recorded using tool two on the three parts as the following:
Cumulative fluids balance was assessed using cumulative fluids bar chart; the data were recorded using part I tool two. Fluids imbalance manifestations; the data were recorded using part II tool two. Laboratory test findings were assessed; and the data were recorded using part III tool two daily for each patient in the both groups for three consecutive observation days.
Results and conclusion of the current study:
The main results and conclusion of the current study indicated hypothesis acceptance.
Patients who are subjected to the NICE fluids management guidelines exhibited less fluids volume used in the fluids resuscitation and routine maintenance than patients who are subjected to the routine fluids management. Regarding the fluids status reassessment, patients who are subjected to the NICE fluids management guidelines experienced less fluids imbalance manifestations than patients who are subjected to the routine fluids management. Concerning cumulative balance, the both groups experienced positive cumulative fluids balance; but the patients who are subjected to NICE fluids management guidelines experienced less fluids accumulation than patients who are subjected to the routine fluids management (One liter was used as a cutoff point).
In light of the current study findings, the following recommendations are suggested:
• Include the fluids management guidelines in the curriculum of the under graduates nursing students.
• Notify the health team members about the findings of the current study in order to be more vigilant and provide high quality and safe care to the critically ill patients.
• Conduct in-services training programs for the critical care nurses regarding the fluids management guidelines (NICE).
• Provide the NICE fluids management guidelines with the current study findings to the administrative authorities of the hospital.
• Encourage administrative authorities to use cumulative fluids balance bar chart in monitoring the fluids balance for the critically ill patients.
• Replications of the current study on larger sample size for generalization.
• Measure the deleterious outcomes of the fluids imbalance among the critically ill patients.