Week 7 Patient Assessment

Intake/Output, Weight, Length, Temperature and Nutrition Label

Fluid Intake/Output

INTAKE OUTPUT

Oral fluids Urinary output

• Liquids e.g. water, milk, juice, tea, • verb “void”
coffee, soups • Foley catheter
• Ice chips (record as half volume)
vs ice pop (cold pop) (full volume)
Foods that become liquid at room Vomitus (Emesis)
temperature
• ice cream
• sherbet
• custard / pudding
• gelatin (Jell-O)
Tube feedings Tube drainage
• nasogastric (NG) tube feeding • nasogastric (NG) tube drainage
• gastrostomy (G) tube feeding • chest tube

Parenteral fluids (IV infusion) Liquid feces

• 0.9% NS (normal saline)
• D5W (dextrose 5% & water)
• LR (lactated ringer’s)
• TPN (total parenteral nutrition)
Intravenous medications Wound drainage, surgical drainage and
• e.g. ceftazidime 1 g in 50 mL of fistula drainage
NS • Hemovac
Catheter or tube irrigants
 Week 7 Patient Assessment
Intake/Output, Weight, Length, Temperature and Nutrition Label

In a 24 hour period, there are three 8-hour shifts: Nights, Days, and Evenings. At the end of
each shift, the nurse must complete the calculations for intake and output in the 8-hour shift. At
the end of 24 hours, the in/out calculations for all shifts is totalled and a final calculation for a
24-hour in/out is recorded.

The final calculation could be equal (intake=output), positive (intake>output) or negative

(intake<output). This calculation is useful data for the nurse to consider when analyzing a
patient’s assessment findings related to fluid balance.

The following is an example of an intake and output (in/out) record for Patient X.

The Night nurse has already documented the calculations for the 8-hour night shift.

ACTIVITY:
a) Calculate the Day and Evening shifts intake and output.
b) Calculate a final 24-hour total.
c) Determine: Is this 24 hour total (in/out) equal? Positive? Negative?

The Day nurse uses the following information to complete the Day record (0700-1500
hours):

Patient X ate breakfast and had 5 Tbsp of cereal with 125mL milk, one 180 mL mug of tea and
one slice of toast. He was up to the bathroom to void 200 mL of amber urine. He took his 1000
hours morning medications with 4 ounces of water. For lunch he drank a 150 mL glass of
tomato juice, had an egg salad sandwich on whole wheat bread, carrot sticks and a 75 mL dish of
ice cream. He finished his lunch with a ½ of a 180 mL mug of coffee. He voided 350 mL of
clear yellow urine. At 1430 hours, he felt nauseated and had 250 mL of dark green emesis. He
has an intravenous (IV) infusing at 50mL/hour and a wound drain (called a Hemovac) that
drained 50 mL of bloody drainage.

The Evening nurse uses the following information to complete the Evening record (1500 –
2300 hours):

For dinner, Patient X had 100 mL of soup, a chicken leg, 3 Tbsp mashed potatoes and green
beans, plus 125 mL of jello. His IV was infusing at 50 mL/hour until 1900 hours and then was
discontinued. Before bed, the client had 275 mL of water with medications and had a 240 mL
cup of ice chips. His wound (Hemovac) drain was emptied for 40 mL of yellow clear (serous)
drainage at bedtime. He was up to the bathroom to void twice: once at 1730 hours for 250 mL
and then at 2215 hours for 300 mL. At 2000 hours, he had one loose stool of 150 mL.
 Week 7 Patient Assessment
Intake/Output, Weight, Length, Temperature and Nutrition Label

Enter answers in millilitres.

Intake
Shift IV Oral Other (what TOTAL
would be an
“other”?)

Nights
400 mL 75 mL
Days

Evenings

Total

Output
Shift Other (what TOTAL
Urine Emesis Stool Drain would be an
“other”?)

Nights
375 50 75 50
mL mL mL mL

Days

Evenings

Total

What is the 24 hour total fluid intake? ______________

What is the 24 hour total fluid output? ____________ _
What is the 24 hour total fluid balance? ____________ _
*fluid balance must include a (+) or (-) sign
 Week 7 Patient Assessment
Intake/Output, Weight, Length, Temperature and Nutrition Label

Ogden, S.J. & Fluharty, L.K. (2020). Calculation of drug dosages: a work text (11th ed). Canada: Elsevier.
Chapter 7 Calculations Used in Patient Assessments, page 151 Question #21
 Week 7 Patient Assessment
Intake/Output, Weight, Length, Temperature and Nutrition Label

Word Problems
1. On the follow day, Patient X needed to drink the target goal of 600 mL during the day
shift. At breakfast he drank 1/3 of the target shift volume and at lunch, he drank 1/2 of
the target shift volume.

a) What is the fractional amount the patient has taken in with breakfast and lunch? Write
the answer as a proper fraction or a mixed number in lowest terms. Do not include the
unit in the answer. Answer: __________

b) What is the total volume in millilitres the patient has taken in with breakfast and lunch?
Include the abbreviated unit in the answer. Answer: __________

c) What is the fractional amount the patient needs to drink before the day shift ends? Write
the answer as a proper fraction or a mixed number in lowest terms. Do not include the
unit in the answer. Answer: __________

d) What is the remaining amount of fluid in millilitres the patient needs to drink to meet the
target goal for the day shift? Include the abbreviated unit. Answer: __________

2. On the following day during the day shift, Patient X was receiving IV NS fluid 100 mL
each hour from 0900 - 1330 h.

a) How many hours was the patient receiving IV NS fluid? If answer is not a whole
number, write as a decimal and include the abbreviated unit. Answer: __________

b) How many millilitres of IV NS fluid did the patient receive during the day shift? If
answer is not a whole number, write as a decimal and include the abbreviated unit
Answer: __________
 Week 7 Patient Assessment
Intake/Output, Weight, Length, Temperature and Nutrition Label

Weight – round to tenth (if answer is not a whole number)

▪ 120 lb = __________ kg
▪ 70 kg = __________ lb

Length – round to tenth (if answer is not a whole number)

▪ 5 ft + 4 in = __________ cm
▪ 180 cm = __________ ft

Temperature – round to tenth (if answer is not a whole number)

▪ 98 ℉ = __________ ℃
▪ 40.8 ℃ = __________ ℉

Word Problems
2
1. A patient’s goal is to walk a total of 9 miles by walking 1 3 miles each day.
2
a) How many days will the patient be able to walk his full 1 3 miles each day? Write
the answer as a whole number with the unit. _______________

b) On his last day, how many miles will he have left to complete?
Write the answer as a mixed number or proper fraction in lowest terms and include
the unit. _______________

2. For a fundraiser, the residents are making picture frames. Each picture frame program
5 4
requires 6 feet of ribbon to make a picture frame. There is 8 7 feet of ribbon in the supply
cupboard.

a) How many picture frames can be made?

Write the answer as a whole number with the unit. _______________

b) How many feet of ribbon will be remaining? Write the answer as a mixed number or
proper fraction in lowest terms and include the abbreviated unit. _______________

Nutrition Label Problems

*review nutrition label problems under Ratio and Proportion