INTAKE AND OUTPUT (I and O) MONITORING

Brief Description: I and O monitoring is the process of measurement of a patient's fluid

intake by mouth, feeding tubes, or intravenous catheters and output from kidneys,
gastrointestinal tract, drainage tubes, and wounds.
Purpose: Strict I and O monitoring promotes accurate 24-hour measurement as an
essential part of patient management, considering that proper intake of fluid and nutrients,
and determining adequate output of urine as well as normal defecation is important to
ensure the patient with liver cirrhosis.

Nursing Responsibilities

NURSING RESPONSIBILITIES RATIONALE

1. Verify the doctor’s order, and To determine the correct intervention to be

confirm catheter and balloon size. rendered to the patient.

2. Gather and prepare all necessary Saving time and effort ensures smooth flow
materials to include a calibrated of doing the procedure.
container for accurate
measurement, and clean gloves to
use in performing the procedure.

3. Identify the patient and explain the In order to gain the patient’s cooperation.
procedure.

4. Monitor the patient’s fluid intake by To ensure accurate intake measurement.

measuring fluids and foods he
intakes by using appropriate
measuring containers.

5. Monitor the patient’s output by To ensure accurate output measurement.

measuring his urine, feces, and
clysis by using appropriate
measuring containers.

6. Perform hand hygiene. To avoid cross-contamination.

7. Document in the patient’s chart the To ensure that monitoring is strictly done,
 results of I and O measurement, as and to keep accurate records for legal
well as the interventions rendered. purposes.
Endorse every after shift.

INDWELLING FOLEY CATHETER (IFC)

Brief Description: IFC is a closed sterile system with a catheter and retention balloon
that is inserted either through the urethra or suprapubically to allow for bladder drainage.

Purpose: IFC is inserted in the patient through his urethra to treat urinary retention
associated to liver cirrhosis.

Nursing Responsibilities

NURSING RESPONSIBILITIES RATIONALE

1. Verify the doctor’s order. To determine the correct intervention to be

rendered to the patient.

2. Prepare all the necessary materials Saving time and effort ensures smooth flow
for inserting and removing the IFC. of doing the procedure.

3. Identify the patient, then explain the To gain the patient’s cooperation.
procedure.

4. Ensure privacy and good lighting. Privacy must always be kept, and comfort
must be provided.

IFC Insertion

5. Have the patient lie on his back Correct positioning provides comfort to the
(supine) with his thighs slightly patient.
apart, and place the underpad under
the patient's buttocks.

6. Perform hand hygiene, don clean Maintaining aseptic technique is essential.

gloves, drape the patient and
cleanse the perineal area with sterile
water for cleansing from front to
back.

7. Remove gloves and perform hand To avoid cross-contamination.

hygiene.

8. Prepare a sterile area on a clean Maintaining sterile technique is necessary;

bedside table using sterile as well as ensuring the completeness of
technique. Ensure all supplies are materials to be used.
conveniently positioned.
9. Aspirate 10-15 cc of sterile water Adherence to sterile methods reduces the
depending on the foley catheter. risk of acquiring a catheter associated
Then, put on sterile gloves. infection.

10. Apply sterile lubricant to the catheter Proper clamping allows urine drainage
tip. Consider attaching a catheter to freely.
the drainage system now, if not
already attached, and ensure the
drainage bag emptying port is
clamped.

11. With the non-dominant hand, hold Always ensure urine is flowing before
the penis perpendicular with the inflating the balloon.
patient's body and keep the hand in
this position until after the urine is
flowing after catheter insertion.

12. With the dominant (sterile) hand, Using force damages the urethra.
insert the catheter slowly into the
urethra until there is return of urine.
Then advance the catheter 2-3
inches more. (Do not force the
catheter through the urethra).

13. Hold the catheter with the non
dominant hand to fully inflate the
catheter balloon with the 10 cc
sterile water. Gently pull on the
catheter after balloon inflation to feel
resistance. Secure catheter to the
patient’s inner thigh with micropore,
remove gloves and perform hand
hygiene.
If urinary catheters are not secured
appropriately, they can lead to severe
trauma of a patient's urethra, potential
damage to bladder neck, infection and
inflammation, pain and irritation, possible
bypassing, accidental dislodging of a
catheter and a cleaving.

14. Assist the patient to a comfortable To provide comfort to the patient.

position and cover with linen.

15. Ensure tubing is not kinked and the Keeping the drainage bag lower than the
drainage bag is below the level of bladder is important, so that urine does not
the bladder. flow back up into the bladder.

16. Remove used equipment and Proper disposal of used equipment, as well
dispose of used supplies in trash per as the safe use and disposal of sharps
facility policy. Place the syringe in a reduces the risk of injury and acquisition of
sharp container. infection.

17. Perform hand hygiene. To maintain aseptic technique.

18. Document the following details in the To keep accurate records of the
patient’s chart: interventions performed, and for legal
a. Type and size of catheter documentation purposes.
balloon.
b. Amount of fluid inserted in
the balloon.
c. How the patient tolerated the
 procedure.
d. Amount of urine obtained
and its characteristics.
e. Name of person performing
the insertion and date it was
completed.

IFC Removal

1. Don gloves and check for the Note that if there is pain in checking the
placement of the catheter by gently placement, it could indicate the catheter is
pulling the catheter. not in the bladder.

2. Empty the contents of the urine bag To have an accurate measurement of the
into the calibrated urinal and take urine output.
note of the amount of urine drained.

3. Change into a new pair of clean Adherence to aseptic methods reduces the
gloves and using the 10 cc syringe risk of acquiring a catheter associated
aspirate the sterile water from the infection.
balloon, note for the amount of
sterile water aspirated. Then gently
pull out the catheter.

4. Discard the catheter and urine bag Proper disposal prevents the occurrence of
following agency protocol. cross-contamination or infection.

5. Document the procedure in the To keep accurate records of the

patient’s chart. interventions performed, and for legal
documentation purposes.

6. Monitor the patient for the next Note that if there is no urine output for four
hours for spontaneous voiding. hours, it is essential to refer to the
physician.