The Assessment of Nurses’ Knowledge and Practices about Fluid and Electrolytes Monitoring and Administration among Cardiac Surgery Patients: A Case of Punjab Institute of Cardiology

Background: In order to maintain the health, the homeostasis dynamics and balance process is most important. Among the critically ill cardiac surgery patients the homeostasis is imbalance and results in insufficient tissues perfusion and many organs of the body lead to the failure condition. It is necessary to monitor actively the intake and output during electrolytes administration in the cardiac surgery patients. Objectives: To assess the knowledge and practice of the registered nurses about fluid and electrolytes monitoring and administration in the cardiac surgery patients. Methodology: This study is of descriptive and cross sectional study design. The questioner of knowledge and practices regarding fluid and electrolytes administration was adopted from the article of Vijayan (Vijayan, 2011) which is based on 5-point Likert scale. The data was collected from 208 nurses of Punjab Institute of Cardiology, Lahore, Pakistan. Conclusion: The findings of the current study show that the nurses have poor knowledge and practices of nurses, so, public hospital’s administration should focus on the strategies and activities which become helpful to increase the knowledge and practices of nurses regarding fluid and electrolytes administration.


Introduction
Water is the chief component of the body accounting for 45-80% of the body weight. The percentage varies with age , sex and body build (Ellis, 2000). The balance between input and output is known as fluid balance which is the essential to perform the metabolic function effectively (Welch, 2010).
In cardiac surgery patients, crystalloids solution is infused to restore the circulating volume. After cardiac surgery, the patient will pass a large amount of diluted urine within the first 2-6 hours and will excrete the large amount of potassium. Cardiac surgery patients frequently required potassium supplementation to maintain the S/K+ ( serum potassium ) and its normal range is 3.5 -4.5 mEq/l (Shen et al., 2011). As per protocol after cardiac surgery the patient potassium level needs to frequently monitor and replace as per patient condition. The knowledge and practices of nurses about fluid monitoring and electrolytes administration is necessary to provide the good quality of patient care and this is the responsibility of all registered nurses to closely observe and monitoring the all parameters of cardiac surgery patients (Vijayan, 2011).
The fluid therapy may be in oral intake form, medication administered form, the output include urine, vomit, stools, bleeding and drainage (Scales & Pilsworth, 2008). Proper and accurate documentation of intake fluid and output is essential to prevent the complications of fluid imbalance in critically ill patients. Inaccuracy in monitoring and recording of fluid and electrolytes may lead to the poor management (Diacon, 2012) .
However, during cardiac surgery a huge amount of blood loss occurs (Repine, Perkins, Kauvar, & Blackborne, 2006). Cardiopulmonary bypass can cause many physiological abnormalities like electrolytes abnormalities, acid base imbalances etc. In nursing the concept of a framework is applied for the best practices and evidence base practices. These concepts links to research with practice to enhance Research Article patient care (Diacon, 2012). Best practices mainly develop through experience (Vijayan, 2011).
Furthermore, knowledge and practices of nurses about fluid monitring and electrolyte administration in cardiac surgery patients is necessory to provide the good quality of care and helps to reduce the morbidity and mortality rate. Morever, the evidence base practices can be applied if nurses have knowledge and practices to provide the quality of care to the patients. In addition, there is need to investigate the knowledge and practices of nurses about fluid and electrolytes monitoring and administration among cardiac surgery patients due to the poor healthcare services among the public hospitals. Thus, current study examines the level of knowledge and practices of nurses about fluid and electrolytes monitoring and administration among cardiac surgery patients due to the poor healthcare services among the public hospitals.
Objectives 1) To assess the knowledge of registered nurses about fluid and electrolytes monitoring and administration in the cardiac surgery patients 2) To assess the practices of registered nurses about fluid and electrolytes monitoring and administration in the cardiac surgery patients.

Literature Review
To assess the patient status about fluid balance intake and output a fluid balance chart has been organized to document the record on it. It is easier and noninvasive strategy to measure the fluid balance. Fluid balance sheet is like a chart that document the patient intake and output in 24 hours. The fluid balance chart recorded as necessary to guide the decisions making about medical and surgical interventions. The accurate fluid balance monitoring is required for the effective management of the patients. Inaccurate fluid balance monitoring or inaccurate documentation may lead to the complication and patient condition may become worse. (Scales & Pilsworth, 2008).
Moreover, health professionals like doctors, nurses, surgeons and dieticians etc. requires accurate fluid balance record to make the further plan of patient's treatment. It is necessary to know the exact measures of urine, drainage and vomiting output for quality treatment. Such information is also important to prevent the patients from complications like fluid overload (Jeyapala, Gerth, Patel, & Syed, 2015). Similarly, the study noted that fluid monitoring improves the practices of accurate fluid balance documentations (Scales & Pilsworth, 2008). The nurses knowledge about the administration of fluid and electrolytes is most important to prevent the patient from the complication and assurance of the quality of care among the cardiac surgery patients (Eastwood et al., 2012).
However, lack of education and inadequate training is a significant factor that impair the fluid balance documentation. Novice nurses, new graduate nurses and student nurses may become the reason of inaccurate fluid balance documentations. The nurses should be allocated for the accurate fluid balance monitoring who is expert in documentation of the accurate information about fluid balance and patient's status. Time should be calculated as per shift to complete and accurate the fluid balance documentation and handover to the next shift staff. However, time is required for accurate fluid balance documentation and insufficient time may lead to inaccurate documentations and thus patient's safety may be compromised (Scales & Pilsworth, 2008).

Methodology
This study is of descriptive and cross sectional study design. The questioner of knowledge and practices regarding fluid and electrolytes administration was adopted from the article of Vijayan (Vijayan, 2011) which is based on 5-point Likert scale. The self-administered questionnaire (Section 1: Demographics, Section 2: Knowledge and Practices) was distributed to 208 nurses. The data security was ensured to the study participants. SPSS 21 was used to do the analysis of the data

Practice
There are many other patient care activities that are more important for me to attend than recording the intake and output every hour Table 18 shows that n=33 (15.87%) nurses responded regarding nurses having the practices to monitor the fluid in post-operative cardiac patients as strongly agree, n=52 (25%) were agree, n=24 (11.54%) were neutral, n=56 (26.92%) were disagree and n= 43 (20.67%) were strongly disagree. There are too many people who fill in one patient's fluid balance chart Table 19 shows that n=57 (27.40%) nurses responded regarding nurses having the practices to monitor the fluid in cardiac surgery patient that there are many people who calculate the one patient's fluid chart as strongly agree, n=43 (20.67%) were agree, n=58 (27.88%) were neutral, n= 31 (14.90%) were disagree and n=19 (9.13%) were strongly disagree. 13.46 Total 208 100 Table 20 shows that n=20 (9.62%) nurses responded regarding nurses having the practices to monitor the fluid in cardiac surgery patient that nurse responsible for more than one patient and so it is difficult to supervise all the fluid balance activities as strongly agree. On the other hand, n=71 (34.13%) were agree, n=24 (11.54%) were neutral, n= 41 (19.71%) were disagree and n=52 (25%) were strongly disagree.  Table 21 shows that n=41 (19.71%) nurses responded regarding nurses having the practices to monitor the fluid in cardiac surgery patient that nurses satisfaction the design of fluid balance chart sheet, were strongly agree, n= 94 (45.19%) were agree, n=13 (6.25%) were neutral, n=35 (16.83%) were disagree and n=25 (12.02%) were strongly disagree. Fluid balance assessment is important to guide nursing care in critically ill patients Table 22 shows that n=52 (25%) nurses responded regarding having the practices to monitor the fluid in cardiac surgery patient that fluid balance assessment is important to guide nursing care in critically ill patient as strongly agree, n = 75 (36.06 %) were agree, n=18 (8.65%) were neutral, n= 33 (15.87%) were disagree and n=30 (14.42%) were strongly disagree.  Table 23 shows that n=64 (30.77%) nurses responded regarding having the practices to monitor the fluid in cardiac surgery patient that inaccurate fluid balance calculation can be a risk for the critically ill patient, were strongly agree, n=71 (34.13%) were agree, n = 12 (5.77%) were neutral, n= 37 (17.79%) were disagree and n=24 (11.54%) were strongly disagree.  Table 24 shows that n= 63 (30.29%) nurses responded regarding having the practices to monitor the fluid in cardiac surgery patient that fluid balance information is recorded in too many different places as were strongly agree, n=71 (34.13%) were agree, n=22 (10.58%) were neutral, n= 31 (14.90%) were disagree and n=21 (10.10%) were strongly disagree.  Table 25 shows that n=43 (20.67%) nurses responded nurses having the nurses practices to monitor the fluid in cardiac surgery patient that the final 24 hours fluid balance is correctly calculated all the time as strongly agree, n= 65 (31.25%) were agree, n=25 (12.02%) were neutral, n=47 (22.60%) were disagree and n=28 (13.46%) were strongly disagree.   Table 27 Cronbach's alpha scale is commonly use to analysis the reliability. It is simple and easier method to measure the reliability (Cortina, 1993). Table 27 shows that Cronbach alpha value meet the standard value is > 0.7 is consider more acceptable values indicator of internal consistency reliability (Santos, 1999;Bryman & Cramer, 2005;Pallant, 2007;Hair et al., 2006). The variable knowledge having Cronbach's alpha value is 0.710 and second variable practice having Cronbach alpha value .637 are more than 0.70% that is near to 1 and it shows that these variables are strongly reliable

Discussion and Conclusion
The objectives of the study were to assess the knowledge and practices of registered nurses about fluid and electrolytes monitoring and administration in cardiac surgery patients. Therefore, the knowledge and practices of nurses' regarding fluid and electrolytes administration among the nurses is overall low which should be considered to alleviate the quality care among the public hospitals. The administration of Punjab institute of Cardiology and other public cardiac institutes should emphasize on the awareness, education and training of the nurses regarding fluid and electrolytes after cardiac surgery.
The study was conducted to investigate the changes in serum electrolytes levels and its effect to cause the atrial fibrillation in cardiac surgery among 12 patients. Patients were distributed in groups and namely was Group 1 and Group 2. The Group 1 was included the patients with cardiac surgery atrial fibrillation and Group 2 included the patients who were having the sinus rhythm after the cardiac surgery. After analysis of the both groups the results shows that overall incidence of atrial fibrillation was 26.83%. The study depicts that the incidence of atrial fibrillation is higher due to serum electrolytes imbalance in cardiac surgery patients. These electrolytes may varies after the cardiac surgery mainly phosphate and lower calcium levels may lead to cardiac dysrhythmias (Svagzdiene, Sirvinskas, & Benetis, 2006). Thus, fluid and electrolytes monitoring is compulsory for the effective management of the patients. Inaccurate fluid balance monitoring and inaccurate fluid balance recording can become critical for survival of patient (Elliott et al., 2007). Similarly, the study noted that inaccurate fluid balance monitoring and recording may