1. Running head: The Absence of Nursing Documentation for Fluid Balance on Spinal Cord Injured Patients 1
The Absence of Nursing Documentation for Fluid Balance on Spinal Cord Injured Patients
Indira Miller
VALOR Student RN
McGuire VA Medical Center

2. Running head: The Absence of Nursing Documentation for Fluid Balance on Spinal Cord Injured Patients 2
Abstract
Insufficient nursing documentation of fluid intake and output (I&O) among spinal cord injury
(SCI) patients puts them at risk for serious urinary complications. The lack of I&O data delays
development of bladder management programs and care of medically unstable SCI patients.
Fluid balance is vital for Spinal Cord Injury patients as urinary retention or dehydration can lead
to serious complications to include bladder overdistention, urinary tract infections and autonomic
dysreflexia. Utilizing a readily available flowsheet could help reduce the risk of those
complications and could be very resourceful when critical and time-sensitive situations arise.
Recently, a focus group of SCI physicians and registered nurses created a template to suit SCI&D
specific intake and output needs. It is not consistently being filled out when taking care of Spinal
Cord Injured patients. Education for staff on proper documentation and use of the SCI Intake and
Output Flowsheet will better help monitor fluid balance and reduce the risks of urinary
complications. In addition, enforcing that 1 SCI Intake and Output Flowsheet be completed
every shift (8 hours) on SCI&D patients with strict I&O orders will better help monitor fluid
balance.

3. Running head: The Absence of Nursing Documentation for Fluid Balance on Spinal Cord Injured Patients 3
Situation
Inconsistent nursing documentation of fluid balance among spinal cord injury (SCI)
patients is an increasing threat to patient health and nursing. The Spinal Cord Injury & Disorders
(SCI&D) unit did not have an Intake and Output (I&O) template and patients that have suffered a
spinal cord injury may not sense the need to urinate. A full bladder can have serious
complications, some that can lead to death (Klebine, 2008). Without an appropriate form of
documentation of the patient’s intake and output, developing a bladder management program
proves a lengthy process. In addition, that information can be crucial when life-threatening
situations arise (“Bladder Management”, 2006). Documentation of fluid intake and output is a
valuable record of hydration status and many know that ‘if it wasn’t documented then you didn’t
do it’. Insufficient documentation challenges the patient’s safety and thus the credibility of the
nurse (Austin, 2011). An SCI&D specific I&O flowsheet provides an identified source for
providers to locate and document patient I&Os throughout a shift.
Background
Fluid Balance is crucial for a healthy life. From the amount we take in to the amount we
eliminate, fluid balance is important for organ function and health (Shepherd, 2011). In order for
the urinary system to work there needs to be brain control of the voluntary muscles in the bladder
and sphincter. Individuals with spinal cord injuries may not have that control and therefore
cannot anticipate the filling bladder (Klebine, 2008). The message is not received by the brain
indicating that the bladder is full and the patient may not have any sensation below the level of
the spinal cord injury. Likewise, the sphincter muscles are not told to relax and release the urine.
This could lead to urinary system complications to include bladder overdistention, urinary tract

4. Running head: The Absence of Nursing Documentation for Fluid Balance on Spinal Cord Injured Patients 4
infections, urinary incontinence, and autonomic dysreflexia (AD) (“Bladder Management”,
2006).
Over time bladder distention causes urine to backflow into the kidneys potentially
leading to renal failure. Urinary tract infections can develop into sepsis which can result in shock
and death. Urinary incontinence can cause psychological problems for the patient to include
depression and lower self-esteem (Klebine, 2008). Among the list of complications is autonomic
dysreflexia. AD is a serious medical condition that causes a sudden elevation in blood pressure
and ultimately can lead to stroke, myocardial infarction and death (Wan, D., & Krassioukov, A.
V., 2014).
Bladder care is one of the many nursing and physician priorities for spinal cord injury
patients. It takes as little as five percent of fluctuation in fluid volume to cause an adverse event
such as dehydration (Shepherd, 2011). Hence, determining the level of control that the patient
has over their urinary system aids in selecting the best method of bladder management and better
limits the occurrence of a fluid volume inconsistency (“Bladder Management”, 2006).
Management options such as indwelling catheters, condom and intermittent catheters are chosen
based on bladder function and fluid I&O.
Similar to a great hand of other hospital issues, lack of appropriate nursing
documentation has been examined as the primary source of causation to many medical errors and
deaths, and lawsuits (Austin, 2011). Lack of documentation of the nursing care provided
compromises the patient’s safety by impeding the continuation of care and treatment for the
patient. It also hinders in making a medical decision in the event of an adverse event. Austin
(2011) mentions “no matter how skilled or experienced you are, inaccurate or incomplete nursing

5. Running head: The Absence of Nursing Documentation for Fluid Balance on Spinal Cord Injured Patients 5
documentation can mean serious trouble for your patients—and for you if you’re ever involved
in a lawsuit”.
Assessment
Noting the lack of centralized chart location for SCI I&O data, a small team of SCI
physicians and registered nurses created a specific SCI Intake and Output Flowsheet. It has the
appropriate sections to fully provide adequate and thorough documentation on fluid balance. The
flowsheet provides easy access drop-down boxes, comment boxes for individual sections in the
flowsheet as well as an option to add comments before signing the template as a note. Intake
values such as intravenous site flushes, liquid medications and tube feedings are easily identified
in the flowsheet. Output values such as surgical drains or emesis can be readily assessed. The
flowsheet has a sufficient array of options that allows you to provide a detailed fluid I&O
documentation.
Recommendation
The next step was to train a small group of nurses how to use the flowsheet. First it is
important for a nurse to identify the obstacles that may cause inaccurate measurements for fluid
intake and output as well as obstacles that delay appropriate documentation of patient fluid
balance. Then to ensure continued education among users it would be beneficial and simpler to
create a “train the trainer” plan to educate SCI physicians and registered nurses (Blumberg,
2009). The education should be given to nurses on how to appropriately and efficiently
document fluid intake and out through a mock patient. Through visuals, demonstration and
teach-backs, staffing cooperation, patient safety and nursing trustworthiness can remain assured
and untarnished (Blumberg, 2009).

6. Running head: The Absence of Nursing Documentation for Fluid Balance on Spinal Cord Injured Patients 6
Results
Upon identifying this problem, I reviewed charts to locate I&Os that used the old method.
Then I began to familiarize myself with the new flowsheet through I&O documentation for a
mock patient. Subsequently, I prepared an adult-learner education model and training plan to
showcase the flowsheet. Nursing staff were then provided the mock patient flowsheet in the
computerized chart. Then they were demonstrated another intake and output documentation. This
mock patient flowsheet presents as a forum for staff to explore the flowsheet as well as visualize
a documentation present. This opportunity allows staff to practice utilizing the flowsheet and
minimize the worry of making an error in a patient’s chart. Physicians were also offered a review
of the new flowsheet and the special features that it provides. Throughout this project, a
combination of group discussion and research with my preceptor, individual research,
powerpoint presentation, and interactive flowsheet training sessions were held.
Conclusion
A lag in fluid volume documentation for spinal cord injured patients has become an
overwhelming danger to patient safety and nursing credibility. Monitoring hydration status is
important for spinal cord injured patients since they are unaware of a filling bladder and the need
to urinate. Serious complications can arise with a substantial amount of urine retention to include
autonomic dysreflexia which a quick elevation in blood pressure that can cause a stroke, heart
attack or death. A SCI&D Intake and Output Flowsheet was created to easily provide a source of
options and features that can help ensure a detailed and complete fluid balance documentation.
Through education and training of the new flowsheet, nursing staff and physicians are more
aware of the significance of utilizing this flowsheet as well as given the opportunity to practice

7. Running head: The Absence of Nursing Documentation for Fluid Balance on Spinal Cord Injured Patients 7
and familiarize themselves to the new charting system. In the end, staffing receptiveness to the
flowsheet shows promise to increase documentation of fluid balance on spinal cord injured
patients.

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References
Austin, S. (2011, April). Stay out of court with proper documenation. Nursing 2011, 41(4), 24-
29.
Bladder management for adults with spinal cord injury: A clinical practice guideline for health-
care providers. (2006). Washington, DC: Consortium for Spinal Cord Medicine.
Blumberg, P. (2009). Developing learner-centered teaching: A practical guide for faculty. San
Francisco: Jossey-Bass.
Klebine (2008). Bladder Care and Management. UAB Department of Physical Medicine &
Rehabilitation.
Shepherd, A. (2011, July 19). Measuring and managing fluid balance. Nursing Times, 107(28).
Wan, D., & Krassioukov, A. V. (2014, January). Life-threatening outcomes associated with
autonomic dysreflexia: A clinical review. The Journal of Spinal Cord Medicine, 37(1), 2-
10.