Nursing Procedure 7.1
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
When monitoring strict I&O, account for incontinent urine, emesis, and diaphoresis, if possible. Weigh soiled linens to determine fluid loss, or estimate it. Enlist the aid of family members in obtaining accurate I&O measurements. Explain the rationale and procedure for monitoring I&O. When measuring output, always wear gloves to protect against exposure to body fluids. Consult pharmacology and treatment references if effects of medication or other therapy on fluid loss or gain are uncertain. Initiation of I&O is an independent nursing action. Initiate recordings if a client has risk factors for fluid loss or gain, such as not eating, receiving diuretic therapy, a diagnosis associated with fluid or blood loss, or excessive drainage from a wound.
Weigh diapers to give a rough estimate of output (1 g of weight = 1 mL of fluid).
For incontinent clients, weigh linens, waterproof pads, or incontinence briefs as a rough estimate of output (1 g of weight = 1 mL of fluid). Anticipate the need for monitoring I&O for older clients who are at risk for dehydration because of poor fluid intake, thin and fragile skin (more prone to environmental insults), and decreased response to thirst, among other factors.
Consider the desires of the client and family, doctor's orders, and agency policies related to fluid and nutrition therapy for end-of-life clients; food and drink are associated with health, comfort, and love by many clients and families. Assess dying clients for dehydration, such as from a decreased ability to swallow and a subsequent decrease in blood volume.
If the homebound client has difficulty understanding units of measure or seeing calibration lines, make an I&O sheet including columns for common household measurement devices, such as drinking glasses, cups of ice, or bowls of Jell-o and soup to represent intake; the client can cross off or check these off. Have client measure output by number of voidings.
In various cultures, health, comfort, and love are associated with food and drink through traditions and rituals. Exercise cultural sensitivity when caring for clients who are on various food and fluid restrictions, and allow the client and family to verbalize concerns.
Measuring I&O is often delegated to unlicensed personnel. However, IV intake must be added to intake totals, and the nurse must always check the information gathered and report any evidence of fluid overload or deficit.
| Action | Rationale | |
|---|---|---|
| 1 | Perform hand hygiene and organize equipment. | Reduces microorganism transfer; promotes efficiency |
| 2 | Post pad on door or in room and instruct team members to record I&O. Instruct client and family on use of I&O record with return demonstration. (If calorie count is in progress, list type of food and fluid consumed as well.) | Ensures complete, accurate record of I&O allows dietary department to calculate caloric intake correctly based on standard institutional serving sizes |
| 3 | Measure oral intake: | Takes into account the wide variety of fluids consumed orally |
| Ensures consistency and common units of measurement and minimizes error | |
| Provides measurement of foods that would be liquid at room temperature | |
| Provides measurement of water intake | |
| When melted, the volume of ice is approximately half its previous volume. | |
| Includes all sources of ingested fluids for accurate measurements | |
| 4 | Measure nasogastric (NG) or gastric tube feeding: | Maintains accurate record by including gastrointestinal (GI) intake in addition to oral intake |
| Ensures accuracy of measurement to include all fluids given; indicates volume infusing during current shift; prevents feeding from hanging for more than 8 hr | |
| Provides measurement of NG or gastric tube intake | |
| Maintains complete I&O measurement | |
| 5 | Measure all IV intake using same methodology as in Step 4. Volume of each type of intake is often designated on flow sheet (e.g., colloids, blood products). | Ensures complete and accurate monitoring of all intake regardless of source |
| 6 | If NG irrigation is performed and irrigant is left to drain out with other gastric contents, enter irrigant in intake section of flow sheet (or subtract irrigant amount from total output; see Step 10). | Ensures accurate accounting of retained fluid |
| 7
| Measure output: | Ensures measurement of output using standardized measurement units |
| Prevents use of cup for measuring intake | |
| Helps to maintain standardized measurement units to promote accuracy | |
| Ensures measurement of all sources of output | |
| Promotes complete measurement | |
| 8 | At the end of each shift, or hourly if needed, wear gloves and empty drainage into graduated container. Alternatively, mark the level of drainage on a tape strip on the container with date and time (Fig. 7.1), or calibrate in intervals of desired number of hours. When container is nearly full, empty it or dispose of it and replace with new container. | Minimizes exposure to body fluids during measurement; allows monitoring on a more frequent basis; ensures uninterrupted measurement of output |
| 9 | Record amount and source of drainage, particularly with drains from different sites. | Identifies drainage amounts from specific sites |
| 10 | If intermittent or ongoing irrigation is performed, calculate true output (urinary or NG) by measuring total output and subtracting total irrigant infused. | Eliminates double counting of output |
| 11 | At the end of a 24-hr period, usually at end of evening or night shift, add total intake and total output. Report extreme discrepancy to doctor (e.g., if input is 1–2 L more than output). Correlate weight gains with fluid intake excesses. | Provides an indication of I&O status over a 24-hr period; identifies possible fluid overload situations; helps determine if third spacing is occurring |
| 12 | Clean containers and store in client’s room. | Reduces microorganism transfer; prepares equipment for future use |
| 13 | Remove and discard gloves and perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include:
The following should be noted on the client's record:
Transcultural