Reading, understanding, and appreciating original nursing research literature is essential for evidence-based practice (AACN, 2008; QSEN, 2018)


Reading, understanding, and appreciating original nursing research literature is essential for evidence-based practice (AACN, 2008; QSEN, 2018). This assignment provides a learning activity for students to read an original research study and complete a worksheet to demonstrate understanding of the study purpose, design, sample, data collection, analysis, limitations, conclusions, and the importance of reading research literature.
Course Outcomes

This assignment enables the student to meet the following Course Outcomes.

CO1: Examine the sources of evidence that contribute to professional nursing practice. (PO 7)

CO2: Apply research principles to the interpretation of the content of published research studies. (POs 4 & 8)

CO4: Evaluate published nursing research for credibility and significance related to evidence-based practice. (POs 4, 8)

CO5: Recognize the role of research findings in evidence-based practice. (POs 7 & 8)
Due Date

Submit the completed RRL Worksheet
Assignment Directions

Read over each of the following directions, the required Reading Research Literature worksheet, and grading rubric.
Review the following link which contains a tutorial for your Week 6 Assignment. Tutorial may look slightly different session to session. Grading criteria and rubric will be the same. Click here for transcript. (Links to an external site.)

Download and complete the required Reading Research Literature (RRL) worksheet (Links to an external site.). This must be used.
Download or access the required article below. This must be used.

Diacon, A. & Bell, J. (2014). Investigating the recording and accuracy of fluid balance monitoring in critically ill patients. Southern African Journal of Critical Care, 30(2), 55-57. (Links to an external site.)

This assignment contains:
Purpose of the Study: Using information from the required article and your own words, summarize the purpose of the study. Describe what the study is about.
Research & Design: Using information from the required article and your own words, summarize the description of the type of research and the design of the study. Include how it supports the purpose (aim or intent) of the study.
Sample: Using information from the required article and your own words, summarize the population (sample) for the study; include key characteristics, sample size, sampling technique.
Data Collection: Using information from the required article and your own words, summarize one data that was collected and how the data was collected from the study.
Data Analysis: Using information from the required article and your own words, summarize one of the data analysis/ tests performed or one method of data analysis from the study; include what you know/learned about the descriptive or statistical test or data analysis method.
Limitations: Using information from the required article and your own words, summarize one limitation reported in the study.
Findings/Discussion: Using information from the required article and your own words, summarize one of the authors’ findings/discussion reported in the study. Include one interesting detail you learned from reading the study.
Reading Research Literature: Summarize why it is important for you to read and understand research literature. Summarize what you learned from completing the reading research literature activity worksheet.
You are required to complete the worksheet using the productivity tools required by Chamberlain University, which is Microsoft Office Word 2013 (or later version), or Windows and Office 2011 (or later version) for MAC. You must save the file in the “.docx” format. Do NOT save as Word Pad. A later version of the productivity tool includes Office 365, which is available to Chamberlain students for FREE by downloading from the student portal at (Links to an external site.). Click on the envelope at the top of the page.
Submit the completed Reading Research Literature Worksheet to the Week 6 Assignment.

Investigating the recording and accuracy of fluid balance

monitoring in critically ill patients A Diacon, MCur; J Bell,’ 3 MCur, BCur, PGDN

1 Division o f Nursing, Faculty o f Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

3 TASK Applied Science, Karl Bremer Hospital, Bellville, Cape Town, South Africa

3 Department o f Nursing Science, School o f Clinical Care Sciences, Faculty o f Health Sciences, Nelson Mandela Metropolitan University,

Port Elizabeth, South Africa

Corresponding author: A Diacon (

Background. The accurate assessment o f flu id balance data collected during physical assessment as well as during monitoring and

record-keeping forms an essential part of the baseline patient information tha t guides medical and nursing interventions aimed at

achieving physiological stability in patients. An informal audit o f 24-hour fluid balance records in a local intensive care unit (ICU) showed

that seven out of ten flu id balance calculations were incorrect.

Objective. To identify and describe current clinical nursing practice in fluid balance monitoring and measurement accuracy in ICUs,

conducted as part of a broader study in partial fu lfilm ent of a Master o f Nursing degree.

Methods. A quantitative approach utilis ing a descriptive, exploratory study design was applied. An audit of 103 ICU records was

conducted to establish the current practices and accuracy in recording o f flu id balance monitoring. Data were collected using a

purpose-designed tool based on relevant literature and practice experience.

Results. Of the original recorded fluid balance calculations, 79% deviated by more than 50 mL from the audited calculations. Further-

more, a significant relationship was shown between inaccurate fluid balance calculation and administration of diuretics (p=0.01). Conclusion. The majority o f flu id balance records were incorrectly calculated.

S AfrJCrit Care 2014;30(2):55-57. DOI:10.7196/SAJCC.193

M ain ta in ing a balance between flu id intake and

output plays an im portant role in the management

o f a crit ica lly ill patient. The accurate assessment

o f the flu id balance data collected during physical

assessment as well as during m onitoring activities

and record-keeping forms an essential part o f the baseline patient

in fo rm ation tha t guides medical and nursing in terventions to

achieve physiological stability in a patient. Changes in a critically ill

patient’s fluid balance can complicate the patient’s clinical condition.

It is, therefore, necessary that flu id balance parameters are accu-

rately monitored and recorded for all patients in intensive care units


A daily observation sheet is used to record all vital signs, nursing

interventions, medical procedures and the fluid balance for each

24-h period of a day. The fluid balance record comprises records of

the intake and output of fluids by a patient over a 24-h period. The

difference between the volumes is calculated to provide the 24-h

fluid balance.121 The monitoring of a patient’s fluid balance is of great

importance in understanding and managing a patient’s clinical status

and, as such, accurate monitoring and recording of fluid balance data

plays an essential role in patient care management.131

Several studies have considered the relationship between

fluid imbalances and patient outcomes in critical care. The Sepsis

Occurrence in Acutely III Patients (SOAP) study by Vincent et al.,m

conducted across 198 ICUs in Europe in 2002, determined that a

positive flu id balance is a strong prognostic factor for death in criti-

cally ill patients. Similarly, research by Alsous et a/.,151 Boyd et al.m

and Payen et o/.I7] concluded that a more positive fluid balance

is associated w ith an increased risk o f mortality in patients w ith

septic shock or acute renal failure. Furthermore, Rosenberg et a/.181

determined that a cumulative negative fluid balance in patients

w ith acute lung in jury is associated w ith lower mortality. The

conclusions offered by these studies require that monitoring and

recording of flu id balance data must be complete and accurate,

w ith assessment o f a patient’s fluid balance being recognised as an

important component o f nursing any critically ill patient.

In South Africa (SA), the practice of a registered nurse is regulated

by the Scope of Practice drawn up by the SA Nursing Council.191

Chapter 2, section 2(i) of these regulations identifies that fluid balance

monitoring is part of the scope o f practice of a registered nurse.

Therefore, a registered nurse working in a critical care environment

is responsible and accountable for the accurate recording and

calculation of fluid balance when caring for and managing a critically

ill patient. Managing a patient’s fluid balance is as equally important

as carrying out any other patient care activity for the critically ill, such

as administering a medication prescription or providing nutrition.121

Fluid balance management in ICU patients is complex. Monitoring

and measurement of fluid balance requires close attention to ensure

that current methods are applied accurately and consistently to

provide the most complete data, upon which patient management

decisions can be based.

Based on practice experience and underpinned by an informal

audit of 24-h fluid balance charts in a local ICU, where seven out of

ten calculated totals were incorrect, the research question posed was:

What are the current practices o f registered nurses in ICUs w ith regard

to fluid balance monitoring?

Methods A quan tita tive approach u tilis ing an

exploratory, descriptive study design was

applied. The study was conducted in ICUs

across three purposively selected hospitals

of one private sector hospital group. The

ICUs of these hospitals were similar in terms

of their patient admission profiles, with the

same nursing documentation and policies

applied at all three hospitals.

An audit tool was developed from

relevant literature and clinical experience

to assess particular aspects of the sampled

fluid balance records. Two critical care nurse

experts evaluated the content and face

validity of the audit tool; no changes were

required. A pretest of the audit tool was

conducted at one additional ICU of the same

hospital group to determine the accuracy

and relevance of the measurements;

no changes were required. The pretest

data were not included in the study data.

A statistician determined the tool to be

appropriate and adequate for data collection

and analysis purposes.

Ethical approval for the study was

obtained from the Human Research Ethics

Committee at the Faculty of Medicine and

Health Sciences, Stellenbosch University,

as well as the relevant committee of the

hospital group.

The population for this study was critical

care patient records. The study sample was

drawn from fluid balance records according

to the following inclusion criteria:

• Nursing records of admissions to ICUs for

the first 48 h of the patient’s stay, from

1 July to 31 December 2011

• Patients over the age of 18 years as per

the definition of an adult in the Children’s

Act No. 38 of 20051’01

• Patients classified as ‘intensive care’:

activity 1 or 2 on the patient classification

system of this hospital group. This

classification was used by the doctor

to determine financial charges to the

patient. No w ritten policy regarding

this classification was available from the


A simple random sampling technique was

implemented to select patient records for

the audit: all the admission numbers of

patients meeting the inclusion criteria were

identified through the hospital informa-

tion system and admission record book

of the ICU. The patient record file that

was connected w ith every third patient

admission number was drawn until the

required sample was achieved. The sample

size was calculated to ensure adequate

precision in population estimates, using 95%

confidence intervals (CIs). A sample size of 80

fluid balance records would have resulted in

6% precision in the 95% Cl width, assuming

a 10% error rate in the calculation ofthefluid

balance. This was well within the accepted

precision of between 5% and 10%. A sample

size of N= 103 was selected and divided

specifically among the various units under

the guidance of the statistician (Table 1).

Descriptive statistics were recorded and

the Mann-Whitney U-test was used to test

associations between recorded variables

and fluid balance calculation accuracy.

Data were recorded on the study audit

tool by the researcher and a field worker

together in the three hospitals. The fluid

balance calculation recorded in each

patient record for a 24-h period during

the first 48 h of a patient’s stay was noted

on the audit tool. A control calculation of

each recorded fluid balance total was done

by the researcher and verified by the field

worker. These audited calculations were

recorded in the audit tool. The deviation

between the original calculations and the

audited calculations was determined and


In addition to the fluid balance

calculation, baseline vital sign data, modes

of fluid output (e.g. diarrhoea), specific

data regarding the administration of blood

products, and the number of continuous

intravenous infusions were recorded on

the audit tool.

Results 24-h calculated fluid balance totals The original recorded 24-h fluid balance

total was compared with the audited fluid

balance total performed by the researcher

and field worker. The difference in calcula-

tion was referred to as the deviation in fluid

balance calculation, and is presented in

Table 2 for descriptive reasons.

In the audit of 103 fluid balance

documents, a total of 71 (68.9%) recorded

calculated fluid balance totals were within

a 500 mL deviation from the fluid balance

calculated by the researcher. Fourteen

recorded calculations (13.5%) were found

Table 1. S am pling fram ew o rk

Hospital Intensive-care beds, n


July – December 2011 , n Records sampled, n

A 26 1 020 34

B 28 1 027 34

C 38 1 022 35

D 12 300 Pilot study

Table 2. Deviation in fluid balance (A/=103)

Calculated deviation


0 – 3 706 0 – 50 51 – 500 501 – 1 000 1 001 – 2 000 >2001 No record

n 98 22 49 14 7 6 5

Percentage 95.1 21 48 13.5 6.8 5.8 4.9

Median deviation (mL) 167 20 146 754 1 249 3 310 –

Mean deviation (mL) 493 21 184 754 1 371 3 116 –

Range (mL) 0 – 3 706 0-46 61 -463 501 – 984 1 008- 1 928 2 260 – 3 706 –

Table 3. Comparison of accurate and inaccurate fluid calculation

Inaccurate flu id calculation, median (IQR)

Variab le Yes No p-value

Received blood products 180.5 (60- 1 312) 167 (61 -530) 0.95

CVP measured 202.5 (90 – 764) 119 (41 -320) 0.09

Matched doctor’s prescription 155 (60 – 530) 201 (63 – 708) 0.61

Diuretic administered 279(102-996) 106 (46 – 350) 0.01

Received >2 intravenous drugs 257 (75 -708) 138 (60-435) 0.16

IQR = in te rqua rtile range; CVP = central venous pressure.

to deviate between 500 mL and 1 000 mL,

while seven recorded calculations (6.8%)

were found to deviate between 1 000 mL

and 2 000 mL. Six recorded calculations

(5.8%) were found to have a deviation of

>2 000 mL.

There was a significant association

between the administration of diuretics

and inaccurate fluid balance calculation

(p=0.01), but there was no association

between other variables and the outcome

of interest (Table 3).

Discussion The definition of a net positive fluid balance

as a volume >500 mL used in the study by

Alsous eta/.151 was applied in this study. Of

great concern were the 27/103 documents,

more than 25% of the sample, w ith a

deviation of >500 mL between the recorded

calculation and the control calculation.

Equally of concern were the five patient

records where no fluid balance calculation

was available at all. These findings repres-

ent a risk for the critically ill patient when

one considers the findings of previous

studies related to positive fluid balance and

patient mortality.14’81 The findings of this

study showed that fluid balance calculation

is not treated as a priority in the nursing

management o f a critica lly ill patient.

The incorrect calculation of fluid balance

means tha t every patient management

decision utilising these fluid balance data

was influenced by inaccurate information.

Perren et al.1″ 1 performed a similar study in

Switzerland and expressed their concern

about the accuracy o f fluid balances in

critically ill patients.1111

Additionally, the significant association

between inaccurate fluid balance calcula-

tion and diuretic administration (p=0.01)

suggests that when diuretics are adminis-

tered, there is a higher chance of the

calculated fluid balance being incorrect.This

finding supports the researcher’s concern

that a careful and accurate approach to

fluid balance does not enjoy high priority

in managing critically ill patients in this

context. Diuretic therapy is a commonly

prescribed therapeutic modality; in this

study, 38.8% (40/103) of critically ill patients

had diuretics recorded as being adminis-

tered during the first 48 h of their admission.

Inaccurate fluid balance data may result in

inappropriate application of diuretic therapy,

resulting in fluid imbalances that affect the

haemodynamic stability of patients.

The findings of this study are limited by

the focus on one hospital group and may

be regarded as a pilot study for further


Conclusions in this study, the majority of audited 24-h

fluid balance calculations were shown to

be incorrect; 79% (81/103) of the original

recorded fluid balance calculations deviated

by >50 mL from the audited calculation. The

accuracy of the 24-h balance calculated is

questionable, with only 21% of the original

fluid balance totals deviating by <50 mL

from the audit calculations. This is of great

concern. Several studies14'81 have noted

a relationship between flu id imbalance

and mortality in critically ill patients. The

findings indicate that treatment decisions

are often based on inaccurate fluid balance

information, which may lead to negative

consequences for the patient.

A significant association was shown

between the administration of diuretics and

inaccurate 24-h fluid balance calculations.

With diuretics prescribed specifically to

manage fluid imbalance, this finding

indicates that the accuracy of the calculated

fluid balance must be confirmed prior to

diuretics being prescribed or administered.

Within the context of limited resources, any

clinical recommendations must be realistic

and practical. One suggested example

is instituting a system of checking fluid

balance calculations at specific intervals,

such as during patient handover at shift

change, during the patient assessment

process or during patient management

discussions. Awareness around the poten-

tial consequences of calculation errors must

be reinforced during patient discussions

and continuing education sessions.

The requirement to provide accurate,

correct fluid balance monitoring and

recording as part of the patient's vital sign

data must be established as a fundamental

standard of practice for every nurse

practising in an ICU. Regular outcome-

driven audits will assist in identifying

where and when errors occur, allowing for

specific interventions to be designed and


Further studies may assist in refining

the particular challenges of accurate fluid

balance recording, for instance cumulative

fluid balance over more than 24 h.


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2. Scales K, Pilsworth J. The importance of fluid balance in clinical practice. Nursing Standard 2009;22(47):50-57. []

3. Elliot D, Aitken L, Chaboyer W. ACCCN's Critical Care Nursing, 1st ed. Marrickville, Australia: Mosby Elsevier, 2007:440,445-446.

4. Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European intensive care units: Results o f the SOAP study. Crit Care Med 2006;34(2):344-353.

5. Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Negative fluid balance predicts survival in patients with septic shock: A retrospective study. Chest 2000;117(6):1749-1754.

6. Boyd JH, Forbes J, Nakada T, Walley K, Russell JA. Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39(2):259-265. [http://dx.doi.Org/10.1097/CCM.0b013e3181 feebl 5]

7. Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 2008;12(3):R74. content/12/3/R74 (accessed 27 October 2014). [http://]

8. Rosenberg AL, Dechert RE, Park PK, Bartlett RH, National Institutes of Health-National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network. A review of a large clinical series: Association of cumulative fluid balance on outcome in acute lung injury: A retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med 2009;24(1):35-46. [http://]

9. South African Nursing Council. R2598, Regulations relating to the scope of practice o f persons who are registered or enrolled under the Nursing Act, 1978. Regulation of the Nursing Act, 2005 (Act No. 33 o f 2005). Pretoria: Government Gazette, 491,2006:34.

10. South African Government. Children's Act 38 o f 2005. childrensact.pdf (accessed 27 October 2014).

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