Measuring Intake and Output

ASSESSMENT:
 Client’s ability to provide Subjective and
Objective data
 Color, odor, and consistency of the It tells us if its okay or there’s something wrong
output with the output

 Urinary or fecal incontinence to help identify the causes of, and factors
contributing to, urinary and fecal symptoms.
 Recent rectal or perineal surgery

 Indwelling catheter  The Common reasons to have an

indwelling catheter are urinary
incontinence (leakage), urinary
retention (not being able to urinate),
surgery that made this catheter
necessary, or another health problem.
2. DETERMINE
 Assistive devices that will be required  We should determine, So we can
perform the procedure appropriately. It
also provide for patient and nurse
safety.

 Encumbrances to movement, such as an  We need to determine the burden or

IV obstacles that we might encounter to
determines what approach we should do
or needed for instruction.

 Medications the client is  We need to know what are the

receiving, as certain medications that the patient is taking and
medications may alter the I & O what will they take before and after the
procedure.

 Assistance required from other health  We will determine if we will be needing

care personnel an assistance from other health care
personnel or nurses because there are
situations that you can’t assist your
patient on your own
PLANNING
Assemble equipment and supplies:  Before performing, we need to know
 Assistive devices such as overhead the equipment that we will be using for
 trapeze the procedures.
 Disposable Gloves (if necessary)
Laboratory form
 Bedpan or urinals
 Toilet paper as required
Graduated container
IMPLEMENTATION
1. Explain to the client what you are going to  This is to aware our patient on what
do, why it is necessary, and how she can are we going to do with them and
cooperate. also, for them to know how they can
 All fluids taken orally must be recorder cooperate with us.
on client’s intake and output form.

2. Wash hands and observe appropriate This is to prevent the spreading of germs
infection control which can may cause infections to the
procedures. client. It is for our client and our safety.

If we don’t have sink, we can use alcohol to

sanitize our hands.

3. Provide for client privacy. This step is to gain the trust of the patient
and also to promotes patient’s dignity.
4. Client must void into bedpan or urinal, not into
toilet
5. Toilet tissue should be disposed of in
plastic-lined container,
not in bedpan.
6. Measure all oral fluids in accord with
institution policy. Record all IV fluids as they are
infused.
7.Record time and amount of all intake and
output in designated
space on bedside form (oral, tube feeding, IV
Fluids).
8. Transfer 8-hour total fluid intake to graphic
sheet on 24-hour I&O record on client’s chart.
9. Record all fluid intake in appropriate column of
24-hour record
10. Complete 24-hour intake record by adding all
8hour totals
11. Output When you have anticipating contact with
Apply nonsterile gloves. (If necessary) blood or body fluid, non-intact skin,
secretions, excretions,
equipment/environmental surfaces
contaminated with the above blood or body
fluids.
12. Empty urinals, bedpan, or Foley drainage
bag into graduated container or commode hat.
13. Remove gloves. Wash hands/hand hygiene it is still important to wash your hands
after you remove them, as it is likely germs
from the gloves touched your hands or wrists
as you were removing the gloves
EVALUATION AND DOCUMENTATION
14. Record time and amount of output (urine,
drainage from nasogastric tube, drainage tube)
on I&O record.
15. Transfer 8-hour output totals to graphic
sheet or 24-hour I&O
record on client’s chart
16. Complete 24-hour output record by totaling
all 8-hour totals
17. Wash hands/hand hygiene