Intake and Output Assessment

Assess patient for conditions that can increase fluid loss...

  1.  or decrease fluid intake and for medications that can upset fluid balance.
  2. Assess patient for signs and symptoms of dehydration and fluid overload. Obtain daily body weight and monitor urine specific gravity and hematocrit.
  3. Measure and record all fluid intake, including liquids with meals, high-fluid foods (recorded as 50% of measured volume), liquid medicines, tube feedings, parenteral fluids, blood components, and total parenteral nutrition.
  4. Instruct patient and family to call nurse to empty contents of urinal, urine hat, or commode after each use and to report incontinence, vomiting, and excessive perspiration to nurse.
  5. Inform patient and family that the nurse or assistive personnel are responsible for measuring and recording output from Foley catheter drainage bag and wound, gastric, or chest tube. For measurement, use a graduated container clearly marked with patients name and bed location.
  6. Apply disposable gloves. Measure drainage at the end of the shift, using appropriate containers and noting color and characteristics. If splashing is anticipated, wear mask, eye protection, and/or gown.
  • Urine drainage is measured using a hat into which patient voids or a graduated container.
  • Observe color and characteristics of urine in Foley tubing. Sometimes a special device is used to measure hourly urine output.
  • Measure Jackson-Pratt drainage using a medicine cup.
  • Chest tube drainage is measured by marking and recording time on the collection chamber specified intervals.
  • Measure a larger drainage pouch with a graduated cup with a 240-ml capacity.
Calculate total intake and output as specified by institution. Note I&O balance or imbalance.
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