Fundamentals of Nursing (RLE) n
Lesson 09
Intake and Output
Ma. Elena O. Aguilar, MAN
Intake
● any measurable fluid that goes into the patient's ● Average adult intake
body ○ 2500-3000mL. Per day.
● Average output
● Types of Intake ○ 2500-3000mL. per day.
○ Oral fluids
○ IV fluids
○ Hyperalimentation / TPN feedings Fluid Balance
Tube feedings (N/G tube, gastrostomy ● Fluid balance is maintaining equal input and
tube, etc.) output -- taking in and eliminating equal amounts
○ Medications of fluids
Output Monitoring Fluid Balance
● any measurable fluid that comes out of the body. ● Required for People with:
● Adults usually lose about 500 milliliters (ml) a ○ renal failure
day through perspiration and moisture exhaled ○ electrolyte imbalance
in breathing. ○ severe vomiting and diarrhea
○ nasogastric tubes and drainage
● Types of Output collection devices
○ Urine ○ intravenous therapy
○ Vomit (emesis) ○ those taking medicines such as diuretics
○ Bloody drainage and corticosteroids
○ Loose stool ● Importance
○ N/G tube drainage ○ to help evaluate a person’s fluid and
○ Perspiration electrolyte balance
○ to suggest various diagnosis
Intake and Output (I&O) ○ to allow for prompt intervention to
● The two measurements should be equal. (What correct the imbalance
goes in...must come out!)
● Know the sizes of the containers your facility Purposes of Intake and Output Calculation
uses 1. Ensure accurate record keeping.
● Metric system 2. Prevent circulatory overload.
○ used for fluid measurement recorded in 3. Prevent dehydration.
ml. (milliliters). 4. Aids in analyzing trends in fluid status.
5. Contributes to accurate assessment record.
Fundamentals of Nursing (RLE) n
Records of all intake and output (I&O) Monitoring Fluid Balance
● Must be kept meticulously in an Intake and ● The person is said to be in negative fluid
Output Chart (I/O Chart). balance if his output is greater than his intake.
● All amounts must be measured and recorded in ● Conversely, a positive fluid balance occurs when
milliliters. intake is greater than output.
● Do not estimate the amount. ● If the difference is alarming, consult your doctor.
● If the person is able to cooperate, he should be ● Keep the chart to show to the doctor, and start a
encouraged to help in keeping an accurate fresh one for the next 24-hours.
record of his daily fluid intake and output.
● At the end of a 24-hours period add up the total
intake and output Common metric conversions used
● Evaluate the person's fluid status in relation to ● 1cc = 1ml 1ounce = 30ml 1L = 1000 ml.
the disease process, medication regimen, diet, ○ To convert from ounces to ml multiply by
and activity ordered by your healthcare 30
professionals. ○ (Ex. 6oz. x 30ml = 180ml)
● To convert from cc/ml to ounces divide by 30
○ (Ex. 240cc / 30cc = 8 oz.)
Intake and Output Monitoring sheet ● Sizes of containers vary.
○ Know your facility's container
measurement system.
Common Conversions
15 drops 1 ml 1cc
1 teaspoon 5 ml 5 cc
1 tablespoon 15 ml 15 cc
2 tablespoons = 30 ml 30 cc
1 oz
1 cup = 8 oz 240 ml 240 cc
1 pint = 16 oz 500 ml 500 cc
1 quart = 32 oz 1,000 ml 1,000 cc
Fundamentals of Nursing (RLE) n
Dosage Calculation Conversions Grains (gr) 1 65 milligrams
1 liter (L) 1000 milliliters (ml) Celsius to Fahrenheit Multiply by 1.8 and add
32
1 ounce (oz) 30 milliliters (ml)
Fahrenheit to Celsius Subtract 32 and divide by
1 ounce (oz) 2 tablespoons (tbsp)
1.8
1 milliliter (ml) 1 cubic centimeter (cc)
1 teaspoon (tsp) 5 milliliters (ml)
Intake: Nursing Managements
1 tablespoon (tbsp) 15 milliliters (ml) ● By Mouth
○ all fluids and foods that are liquid at
1 tablespoon (tbsp) 3 teaspoons (tsp)
room temp.
1 gram (g) 1000 milligrams (mg) ○ Measure any fluids offered to the patient
and make a note of how much the
1 pint 500 milligrams (mg) person drinks and the time of the day at
which it is drunk.
1 milligram (mg) 1000 micrograms (mcg)
○ If the person is drinking from a jug,
1 kilogram (kg) 1000 grams (g) obtain the total intake by subtracting the
fluid remaining in the jug at the end of
1 kilogram (kg) 2.2 pounds (lb) the day plus any fluid added.
○ Pre-measure the drinking glasses or
"1 inch (in) ("")" 2.5 centimeters (cm)
bowls most commonly used by the
8 ounces (oz) 1 cup (c) person. So when the person tell you that
he had "one glass of water," you will
8 ounces (oz) 240 milliliters (ml) know the amount.
○ Measure ice chips by multiplying the
grains (gr) X 650 milligrams (mg)
volume by 0.5; when melted, the volume
grains (gr) V 325 milligrams (mg) of ice is approximately half its previous
volume.
1 dram 4 milliliters (ml) ○ For yogurt, ice cream, gelatin, packet
or canned drinks, measure the amount
1 coffee cup 6 ounces (oz)
printed on the labels.
1 quart (qt) 1 liter (L)
● Tube Feeding:
1 quart (qt) 2 pints (pt)
○ Recorded as oral intake or a special
1 centimeter (cm) 10 millimeters column
○ Used for patients who are unable to
1 glass 12 ounces (oz) swallow, the unconscious or comatose
Fundamentals of Nursing (RLE) n
○ Given through nasogastric or Fluid Intake
gastrostomy tube
○ Measure the amount of feed through the Time Oral Parenteral
nasogastric tube by noting the volume of
IV Fluids Medication
the bag at the beginning of the feeding
and then subtracting the amount left at
7:00 AM – 1 cup coffee –
the end of the feeding. Remember to
8:00 AM 160 ml
include any feeding that is added during
the day. 8:00 AM – 1/2 glass of
9:00 AM water – 120 ml
● Irrigation
○ If water is used to flush the nasogastric
tube, record the amount used for 9:00 AM – 100 ml
irrigation in the intake and output chart. 10:00 AM
○ Any fluid removed after irrigation is not
intake 10:00 AM lactulose – 30
○ If a nasogastric tube is irrigated with 80 – 11:00 AM ml
mL of solution and exact amount is
11:00 AM – 1 bowl of soup Cefuroxime
drawn back out, this is not recorded as
12:00 NN – 240 ml – 5cc
intake.
○ However, if 60 mL is drawn back out, 20
mL is recorded as irrigation intake 12:00 NN –
○ Measurement Is Responsibility of Nurse 1:00 PM
or other legally authorized team
member. (IV, Irrigation, tube feeding) 1:00 PM – 1 tablespoon
○ Intravenous intake (drips) can also be 2:00 PM Robitussin – 15
measured using the above method. ml
○ Fluids given into a vein Includes blood
units, plasma, and other solutions
2:00 PM – 100 ml
3:00 PM
Fundamentals of Nursing (RLE) n
Output: Nursing Managements ○ Drainage included from NG tube, chest
● Output tube, other tubes
○ refers to all fluids eliminated by patient ○ Type, color, and other facts are noted in
○ Examples : remarks column
■ loose stools ○ Excess is recorded as output.
■ Vomitus
■ aspirated fluid ● Use a container marked with milliliters to collect
■ excessive perspiration fluid output. Be sure to label the container "For
■ drainage from surgical drains Measuring Output Only" to prevent confusion
■ nasogastric tubes, and chest with the intake container.
tubes ● Keep container level on a flat surface while
measuring
● Bowel Movement (BM) ● Always wear gloves when handling body fluids.
○ Liquid BM measured and recorded ● Any amount not measured due to any reasons
○ Solid or formed BM is usually noted in such as the person passing urine while in the
remarks toilet should be documented, otherwise the chart
○ column or described under feces. becomes inaccurate and misleading.
● In cases such as vomits or diarrhea, record the
● Emesis number of times it was passed.
● For such cases, check with your doctor in
○ Material vomited is measured and
advance if it is necessary to measure the exact
recorded
amount.
○ Color, type, and other facts are noted in
● It is also important to make a note of the fact if
remarks
the person is sweating.
○ Nurse may measure/record
● Urine
Records must be accurate
○ All urine voided is measured and
● All amounts are measured in graduates
recorded
● Container made of plastic or stainless steel
○ Urine drained by catheter is measured
● Has calibrations for milliliters/cubic centimeters
and recorded
and/or ounces on the side
○ Nurse may measure/record
● Similar to a measuring cup
○ Urine output of less than 30 mL per hour
● Graduate should be held at eye level or placed
must be reported
on solid surface and viewed at eye level to
accurately record amounts
● Irrigation
● Be careful adding or totaling
○ Irrigation or suction drainage is
● Totals are for 8-hr and 24-hr
measured and
○ recorded
Fundamentals of Nursing (RLE) n
Recording I’s & O’s ● Graduate must be used for one patient only, and
● Some agencies keep record at bedside discarded or sterilized when output is no longer
● Team members note I and O of patient measured.
● Record measurements on I and O record ● Areas contaminated by body fluids must be
● At times, patients are taught to record I and O wiped with a disinfectant
● Other agencies keep record in patient chart
● Measurements are noted on a sheet of paper
and reported. Basic principles for completing I and O records
● Nurse, unit sec., or authorized team member ● Use a blue or black ink pen
records info on Is and Os. ● Find correct time
● Give careful instructions for I’s and O’s ● Find correct column (oral intake, urine output)
● Patient must inform healthcare worker when ● Record correct amount
they drink fluids ● Recheck all entries
● Can record glasses of water or quantity ● Enter observations: color, types
remaining in a filled pitcher. ● All information for an 8-hr time period is
● Health Care Providers must think about fluid recorded, total each column separately to
intake every time a glass, cup , or water pitcher calculate the 8 hr total
is removed from the room. ● When all 8-hr time periods have been totaled,
● Amounts must be recorded if a guest brings in add the 3 8-hr totals for each separate column
fluids. ○ This gives a 24 hr total
● Females: used a bed pan or specimen hat ○ Some charts are 24-hr without 8-hr
● Males: use a urinal increments
● Patients must not place toilet tissue or expel ● Recheck all addition
BMs into bedpan or urine collector ● Error: draw one red line through error, initial in
● If patients are given correct instructions, they red
can cooperate so accurate records can be ● Final check: All entries correct, comments are
maintained. noted in remarks column, addition is accurate,
entries are neat and legible.
Standard Precautions
● Includes Urine, emesis, liquid bowel Common Problems
movements, and drainage. ● Fluid volume excess or EDEMA
● Gloves must be worn when fluids are measured ○ a surplus, an amount greater than that
and discarded. which is normal or that which is required
● Hands must be washed frequently and ● Fluid volume deficit or Dehydration
immediately after removal of gloves ○ the excessive loss of water from the
● If splashing or spraying of fluids is possible, a body
mask, eye protection, and a gown must be worn ○ caused by losing too much fluid (as in
vomiting and diarrhea), not drinking
enough water, or both.
Fundamentals of Nursing (RLE) n
○ The best way to treat dehydration is to ● clear or light-colored
prevent it from occurring. urine means well
○ Always encourage the person to drink hydrated
during an illness, and remember that his ● dark concentrated color
fluid needs are greater when he has usually signals
fever, vomiting, or diarrhea. dehydration
○ If you suspect excessive fluid loss ■ Capillary nail refill test
during an illness, inform your doctor ● done by pressing firmly
immediately. on a fingernail bed for 5
○ Do not wait for signs of dehydration. seconds and measuring
the speed at which
○ Signs of dehydration blood returns after the
■ Flushed and dry skin pressure is released.
■ Dry lips ● In normal people,
■ Dry and furred tongue capillary refilling should
■ Increasing thirst take less than 3
■ Low or no urine output seconds.
■ Concentrated urine appears ■ Testing hydration
dark yellow ● pinching up the skin on
■ Sunken eyeballs his hand into a fold.
■ Sunken fontanels (the soft spot ● Dehydrated - skin may
on the top of the head) in an lack its normal elasticity
infant and sag back into
■ Increase breathing and heart position slowly.
rate ● Normal skin - springs
■ Low blood pressure causing right back into position
lightheadedness (worsening on
standing)
■ Delayed capillary refill Types of IV Solutions
■ Poor skin turgor ● Crystalloids
■ Shock ○ are solutions with small molecules that
■ Delirium or unconsciousness in flow easily from the bloodstream into
most serious cases cells and tissues.
■ Dry skin for elderly is not a ○ Crystalloid solutions can be categorized
reliable indication of dehydration based on whether they are:
as skin automatically loses ■ Hypertonic Crystalloids
moisture and elasticity with age. ● have a tonicity greater than
■ A better barometer - color of that of intracellular fluid
urine: making it draws fluids from
the intracellular space,
Fundamentals of Nursing (RLE) n
causing cells to shrink and and outside the cells, so they
the extracellular space to neither shrink or swell with
expand. fluid movement.
● Hypertonic solutions are ● Indication: These are
fluids that have an osmolality ordered for patients who
greater than 308 mOsm/kg. suffered from blood loss
● Indication: These are (surgery, etc) dehydration
ordered for patients who from vomiting or diarrhea to
suffered from swollen cells replace the fluid loss from
as in the case of cerebral the extracellular
edema. compartment.
● Side-effect: cells will shrink, ● Example:
fluid overload resulting in ○ Dextrose 5% in water
pulmonary edema. (D5W) – has 252
● Example: mOsm/kg. The dextrose
○ D5 0.45% Sodium metabolizes quickly,
Chloride (D5 0.45% however, acting like a
NaCl / D5 0.45% NSS) hypotonic solution and
○ D5 0.9% Sodium leaving water behind.
Chloride (D5 0.9% ○ 0.9% Sodium Chloride
NaCl / D50.9% NSS) (0.9% NaCl / 0.9%
○ Dextrose 5% in Saline/0.9% PNSS) –
Lactated Ringer’s has 308 mOsm/kg. It
Solution (D5LR) contains only the
○ Dextrose in 10%W electrolytes sodium and
(D10%W) chloride.
○ 3% Sodium Chloride ○ Lactated Ringer’s
(3% NaCl / 3% Saline / Solution (PLR / PLRS)
3% PNSS) - has 273 mOsm/kg. It
○ 5% Sodium Chloride contains sodium,
(5% NaCl / 5% Saline / potassium, calcium,
5% PNSS) chloride and lactate.
● Dextrose 5% in
■ Isotonic Crystalloids 0.225% Sodium
● have a concentration of Chloride (D50.225%
dissolved particles, or NaCl)
tonicity, equal to that
● of intracellular fluid.
● Osmotic pressure is
therefore the same inside
Fundamentals of Nursing (RLE) n
■ Hypotonic Crystalloids ● Don’t give: Increased ICP
● have a tonicity less than that (can further cause brain
of intracellular fluid, so these swelling), burns and trauma
must be given cautiously (hypovolemic).
because fluid then moves ● Example:
from the extracellular space ○ 0.45% Sodium Chloride
into cells, causing them to (1/2 Normal Saline)
swell. ○ 0.45% Sodium Chloride
● That fluid shift can cause (1/2 Normal Saline)
cardiovascular collapse from ○ 0.225% Sodium
vascular depletion. Chloride (1/4 Normal
● It can also cause increased Saline)
intracranial pressure (ICP) ○ Dextrose 2.5% in water
from fluid shifting into brain (D2.5%W)
cells. Therefore, it should not
be given to patients at risk of Common IV Fluids
increased ICP – for example ● 0.9% Sodium chloride
those who have had stroke, ○ 0.9% NaCl / PNSS
head trauma, or ● 2. 5% Dextrose in 0.9% Sodium Chloride
neurosurgery. ○ D5 0.9% NaCl / D5NSS
● It also shouldn’t be used for ● Lactated Ringer’s Solution
patients who suffer from ○ PLR / PLRS
abnormal fluid shifts into the ● 5% Dextrose in Lactated Ringer’s Solution
interstitial space or the body ○ D5LR / D5LRS
cavities – for example as a ● 5% Dextrose in 0.3% Sodium Chloride
result of liver disease, a ○ D50.3% NaCl
burn, or trauma. ● Balance Multiple Replacement Solution with
● Hypotonic solutions are fluids 5% Dextrose Eurosol R
that have an osmolality less ○ D5NR
than 250 mOsm/kg. ● Balance Multiple Maintenance Solution with
● Indication: These fluids are 5% Dextrose Eurosol M
given to patients suffering ○ D5NM
from cell dehydration like in ● Balance Multiple Maintenance Solution with 5%
the case of diabetic Dextrose Euro Ion
ketoacidosis (DKA) and ○ D5IMB
hyperosmolar ● 5% Dextrose in Water
hyperglycemia. ○ D5W
● Side-effects: cell lysis and
deplete circulatory system
fluid (hypovolemic)
Fundamentals of Nursing (RLE) n
IVF Computation
● Total Volume
○ depends on the doctor’s order
● Drop Factor
○ depends on the IV set being used by the
hospital you are affiliated with.
● Macroset = 10 gtts/mL, 15 gtts/mL, 20 gtts/mL
● Microset = 60 gtts/mL
mgtts/gtts Total Volume in mL (TV) x drop factor (Df)
min Total Time in Hours (TT) x 60 minutes
ml Total Volume in mL (TV)
hr Total Time in Hours (TT)