Lakeland Community College Nursing Intake & Output PDF

Intake and Output Lakeland Community College Department of Nursing NURS 1090  Course Student Learning Outcomes Provide safe, Demonstrate a patient-centered, beginning level of evidence-based cri...

Intake and Output Lakeland Community College Department of Nursing NURS 1090  Course Student Learning Outcomes Provide safe, Demonstrate a patient-centered, beginning level of evidence-based critical thinking and nursing care to clinical reasoning adults at the basic strategies to provide level guided by the quality patient care. Caritas philosophy.  Course Competencies Use the nursing process at a basic Identify the level to deliver rationale used to patient-centered make clinical nursing care to judgments that diverse adult populations ensure accurate experiencing and safe patient common health care. alterations.  Assessment Concepts Metabolism Fluid & Electrolytes Elimination Clinical Decision Making  Demonstrate the ability to safely and accurately Unit measure height and Outcomes weight. Demonstrate ability to accurately measure and record a patient’s intake and output.  Intake & Output The measurement of all fluid intake and output during a 24-hour period note TRENDS Measured to assess fluid and electrolyte balance Nursing responsibility Can be done as a nursing measure or with a physician order Measure accurately from all sources Intake – oral, enteral, IV Output – urine, drains, liquid stool, emesis Intake & Output Required for all patients with: IV therapy Any type of drainage (urinary catheter, Nasogastric tube) Certain medical conditions Following a procedure Patients whose conditions are unstable Patients who are febrile Fluid restriction Diuretic therapy Chronic cardiopulmonary or renal illnesses, diabetes Malnutrition  Conditions that alter fluid intake  NPO  Dyspnea  Nausea/Vomiting  IV fluids  Anorexia  TPN (total  Dysphagia parenteral nutrition)  Pain  Tube feedings  Age > 85 years  Fever  Malnutrition Conditions that alter fluid output  Dehydration  Urine  Excessive  Incontinent vomiting  Urinary Catheter,  Diaphoresis indwelling (Foley)  Tachypnea  Ability to get to  Chronic diseases toilet, bedside  Kidney, commode cardiopulmon  Bowel ary, diabetes  Diarrhea  Diuretic therapy  Constipation  Assessing fluid balance  Edema (check hands, feet, lungs, sacral area)  Wt. loss or gain - daily weights  Skin – turgor, moisture  Mucous membranes (inspect)  Drainage from wounds  Poor appetite  Inability to chew or swallow  Tube feedings  Assessing fluid balance (continued) If intake > output = fluid Intake = excess (overload) Output If intake < output = fluid (approximately deficit ) ± 200 mL (dehydration/hypovolemia) Conditions to 24 hr. intake < 500 mL report to 1 hr. urine output < physician 30 mL (720 mL/day)  Intake & Output (I & O) Record  Electronic and/or paper  May be kept in room  Column/chart format mL  24 hour total is tabulated  Measured in milliliters: mL  Equivalents to memorize:  30 mL = 1 oz  5 mL = 1 tsp  LAKELAND COMMUNITY HOSPITAL INTAKE & OUTPUT SHEET Patient name Date INTAKE OUTPUT Time Oral Tubefeeding IV Urine/Foley Emesis Other 0700 0800 0900 1000 1100 1200 1300 1400 1500 Shift Total 900780780 ORAL EQUIVALENT CHART Coffee cup................180 ml Water glass.................... 240 ml Jello.........................120 ml JuiceTotalTo glass................120 ml Coffee creamer units.........10ml Soup bowl................180 ml Milk carton...............240 ml Canned soda (large)........360 ml Canned soda (sm).....180 ml Measuring and Documenting I&O Intake  Oral  Fluids including anything that becomes liquid at room temperature  Tube feedings  Irrigation fluids  Intravenous solutions  Continuous  Intermittent Intravenous medications  Blood products  Measuring and Documenting I&O Output  Urine  Emesis  Liquid stool  Drainage – wounds, tubes  Blood loss  Intake: How to Measure  Note the volume in the container before liquid is consumed  After consumption:  Note if container is empty  If some liquid remains, measure, subtract volume left in container from overall amount of container  Document amounts consumed on I&O record  Nursing Interventions to maintain/restore fluid balance  Methods to  Methods to Increase fluids Decrease fluids  “Push” oral  Restrict liquid liquids intake per  Offer small order amounts at a  Ex. 1800 time ml./day  Offer variety  Ex. 600  IV fluids ml./shift  Nutritional Intake: Types of Diets (Pearson, Volume 3, p. 203)  Regular  Mineral restrictions  Salt/ potassium  Consistent Carbohydrate  Diabetic  Clear Liquid  Full Liquid  Pureed  Mechanical Soft  NPO Dietary Intake Measurement Refused - 0% Poor – 25% Fair – 50% Good – 75% All – 100% Nutritional Intake: Older Adults  Hospitalized older adults often have practical difficulties feeding themselves  Other factors  Anorexia  Poorly controlled pain  At risk for nutritional deficiencies  Associated with higher mortality  Assess older adult for problems with eating/feeding   Provide a selection of nutritious food  Favorite foods from home  Assist with food preparation  Offer fluids frequently to prevent Nutritional dry mouth Intake: Older  Allow patient time to eat and Adult rewarm food if needed Nursing  Request a modification in the form of food if difficulty chewing noted Interventions  Provide assistive devices  Provide oral hygiene before meals/dentures  Provide for elimination needs prior to mealtime  Output: How to measure  Gather output  Choose correct collection and measuring containers  Use Standard Precautions  Read amount (have at eye level)  Discard appropriately  Document on I & O flowsheet (record in mL)  Bedpan Urinal Measuring In-toilet collection device devices (“hat”) Catheter drainage bags Indwelling urinary catheter (Foley) Condom catheter Graduated containers Emesis basins Syringes  Measuring Devices Bedpans Urinals  Measuring Devices Graduate Urinary Catheter Drainage Bag  Catheters Indwelling Urinary External Catheter Urinary Catheter Female External Catheter Liberatomedical.com Youtube.com   Explain to pt. that you are measuring I&O  Assess ability to cooperate Involving the patient  Enlist help if capable to in I&O save and measure  Fill water pitcher full and measure amt.  Assess liquids consumed from food trays  Coffee, coffee creamers, gelatin, soup, etc.  Do not put toilet paper into urine containers