VITAL SIGNS

INTAKE & OUTPUT SHEET

HOSPITAL #:

PATIENT’S NAME: DELA CRUZ AGE: 67 SEX: MALE CIVIL STATUS: SINGLE WARD: MEDICAL ICU

VITAL SIGNS INTAKE OUTPUT

DATE TIME BP TEMP CR RR IV PO NGT TOTAL URINE STOOL
NGT
TOTAL
VOMITUS
8am - - - - Furosemide - 250 - - -
2 mL 40 mg mL
10 am - - - - - - 350 - -
mL
12 - - - - Furosemide - 250 250 - -
pm 5 mL mL mL
2 pm - - - - PNSS: 400 - - 200 - -
mL mL
4 pm - - - - - - - - - -
Total 407 mL - 500 8HI: 800 - - 8HO:
mL 907 mL 800
mL mL
8HR: 107 mL