MEASURING INTAKE AND OUTPUT

PROCEDURE CHECKLIST12345PE1.Assess the client’s risk factors for fluid overloadsuch as congestive heart failure, renal failure, orascites.2.Determine if the client is receiving fluids ormedications that would predispose him to fluidoverload such as large amounts of IV fluids orsteroid therapy.3.Assess the client’s risk factors for fluid loss suchas diaphoresis, rapid respirations, diarrhea,gastric suction, blood loss, or wound drainage.4.Determine if the client’s urine output is in excessof his fluid intake, because the kidneys excreteexcess fluid during periods of overhydration andconserve body water during periods of dehydration.5.Wash your hands6.Explain the rules of I & O record. All fluids takenorally must be recorded on the client’s intake andoutput form (sometimes called a fluid balanceflow sheet).a.Client must void into bedpan or urinal, not intothe toilet.b.Toilet tissue should be disposed of in plastic-lined container, not in bedpan.7.Measure all oral fluids in accord with agencypolicy; e.g., = 150ml, glass = 240 ml. Record allIV fluids as they are infused.8.Record the time and amount of all fluid intake Ithe designated space on the bedside form (oral,tube feedings, IV fluids). Record measurementsimmediately instead of waiting until the end of the shift.

Transfer the 8 hour total fluid intake from thebedside I & O record to the graphic sheet or24hour I & O on the client’s chart.10.Record all forms of intake, except blood and bloodproducts, in the appropriate column of the 24hour record.

11.

Complete the 24-hour intake record by adding all8 hour totals12.OUTPUT – Apply nonsterile gloves13.Empty the urinal, bedpan, or foley drainage baginto a graduated container or commode “hat”14.Remove the gloves and wash hands.15.Record the time and amount of output (urine,dressings, drainage from nasogastric tube,drainage tube) on bedside I & O record. Record