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Documentation of a persons fluid
intake (oral, parenteral and
gavage) and fluid output (emesis,
urine, watery stools or drainage)
1. Assess the bodys fluid balance
2. Determine adequate fluid intake
3. Ensure an increased fluid intake
4. Ensure a restricted fluid intake
5. Determine voiding patterns and urinary
6. Assess the effectiveness of a medication
such as diuretic
7. Monitor intake and output for certain
laboratory examination of urine specimens
for diagnostic purposes.

It is commonly measured for patients who are:
1. Postoperative
2. NPO
3. Receiving intravenous infusions
4. With retention catheters and urinary drainage
5. Receiving diuretics
6. Suffering from diarrhea, vomiting
7. On fluid restriction
8. Renal or cardiac disease, diabetic
9. With burns
- Bedside I and O form and pencil
- Bedpan / urinal
- Calibrated cup or glass for measuring fluid
- Calibrated container for measuring fluid

1. Measure I and O accurately by providing the
patient with calibrated glass or container
2. Regulate IV flow rate accurately as ordered
3. Maintain medical asepsis in measuring I and

1.Explain the procedure.

NR: Explain to the patient that an accurate
measurement of his I & O is required, the
reason for it and the need to use a bedpan or
urinal (unless a urinary drainage is in place)

R: This will encourage the patient to participate in
measuring I & O.
2.To measure fluid intake; record on the I&O
form the amount of each fluid item taken

NR: Measure all obvious flfuids such as water,
milk, juice, soft drinks, coffee, tea, cream,
soup, wine, ice cream.

Include water that is taken with medications

3. Transfer 8 hours total fluid intake from
bedside I&O record to graphic sheet.

NR: Total the measurements at the end of the
shift and transfer theses totals to the proper
column on the permanent record. Include the
total volumes of intravenous fluids.

R: To assess fluid intake
4. To measure fluid output, empty urinal, bedpan
or Foley drainage bag into the measuring

NR: Note the amount and record it on the
bedside I&O form.
For patients with retention catheters, note
and record the amount of urine at the end of
the shift, and then empty the drainage bag.
Record any other output such as emesis,
liquid feces and other drainage.

R: To assess the total fluid output.
5. Transfer 8 hours total fluid output from
bedside I&O record to graphic sheet.

NR: Total the measurement at the end of the
shift and transfer these totals to the proper
column on the permanent record.

R: To assess the bodys fluid balance

ADMISSION the care which a patient
receives when he enters the hospital

1. Have the bed and the unit ready in advance, if
you know that the patient is coming.

NR: Delegate responsibilities to other members of
the health team properly.

R: This would make the patient feel wanted.
2. Greet the patient in a friendly way, receive
endorsement from the OPD personnel and take
the patient/relatives to the designated room or

NR:1. Address the patient with his name
2. Build rapport by introducing yourself.

R: 1. Greeting the patient warmly conveys to him
that he is welcome to the new environment.
2. To alley anxiety.
3. Introduce the patient to the other patients in
the room and to any staff members
encountered, even though the patient cannot
be expected to remember all names.

R: Introduction to roommates facilitates the
patients adjustment to the agency;
introduction to staff members helps the
patient recognize caregivers.
4. Screen the unit ( especially for semi-private or
ward accommodation).

R: To provide privacy to the patient thus showing
respect and interest in the patient as a person

5. Assist the patient to change into the hospital
gown or personal, sleeping garments where
agency policy allows this.

NR: Always account for every piece of clothing
no matter how worthless it may seem to you

R: Many patients do not require assistance
undressing but need to be informed which way
to put on a hospital gown i.e. with his tie at the

6. Assist the patient into a comfortable position
in bed.

R: To help conserve patients strength, prevent
accidents and prepares patient for receiving
7. Orient patient and support pesons to the
hospitals policies, rules and regulations.

R: Reduces anxiety and tension.
Knowledge of the agencys policies promotes
the patients and support persons feelings of
security and minimizes anxiety. Consideration
of support persons conveys understanding of
their concern and needs.
8. Push back screen after use.

9. If vital signs have been taken in OPD, dont
take it again unless requested by the physician.

NR: Explain to the patient the purpose of the

R: Doing the procedure only once or as
necessary minimize disturbance of patient
10. Attend to patients personal belongings.

NR: List every piece of valuables and inform
patient that they can be given to relatives for
safekeeping or deposited.

R: Losing items is upsetting to the patient and
can result to serious legal problems
11. Do necessary recording on the patients
record following agency policy obtain nursing

R: The information is an integral part of the
patients permanent record and I used to begin
patients care.

The nursing history provides a baseline data
for subsequent care planning
1. Date and time
2. Vital signs
3. Weight and height
4. Manner of arrival and general condition
5. Chief complaints: subjective and objective
6. Appetite, sleep, urination and bowel
( if normal- dont make any remarks)
1. Any specimens sent to the laboratory
2. Lists of physicians and other members of the
3. All medications and treatments done during
the admission period