Nutrition and Fluids
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Safety
- Follow Standard Precautions for infection control when in contact with bodily fluids and discharge.
- Weigh patients daily at the same time of day, using the same scale, and wearing comparable clothing.
- To maintain accuracy, record the patient’s intake as soon as you measure it.
- To measure output (including urine and wound, gastric, or chest tube drainage), each patient should have a separate graduated container that is clearly marked with the patient’s initials and bed location and is used only for the patient indicated.
- Apply clean gloves. Measure the drainage at the end of your shift or as indicated, using the appropriate containers and noting the color and characteristics of the drainage. If splashing is anticipated, wear a mask, eye protection, and/or a gown.
- Report to the health care provider any urine output less than 30 mL/hr or any significant changes in a patient’s daily weight.
Equipment
(Roll cursor over items to see labels)
Graduated measuring container
Bedpan
Urinal (for male patient)
Specipan
Clean gloves
PrintableDelegation
Do not delegate the assessment of I&O totals at the end of each shift, the comparison of 24-hour totals over several days, the monitoring and recording of infusion of parenteral fluids (I.V. therapy) and wound or chest tube drainage, or the administration of tube feedings. The measurement and recording of oral intake, urine output, and wound drainage device output may be delegated to nursing assistive personnel (NAP). Be sure to inform NAP of the following:
- The need to follow Standard Precautions, measure and record I&O accurately, and use the metric system with standard containers
- When to measure and record I&O
- The type of fluid order prescribed and any special equipment or measures needed
- Variations required for the patient, such as emptying a urine collection bag rather than a urinal
- Information to be reported, such as a significant change in intake or in the color, amount, or odor of output
- The importance of being sensitive to the patient’s need for privacy
- How to measure and record the patient’s oral intake, urinary output, liquid diarrheal stools, vomitus, and wound drainage device output
- The need to report changes in the patient’s condition, such as alterations in intake or changes in color, amount, or odor of output
Preparation
- Identify patients with conditions that increase the risk of fluid loss, such as a fever, diarrhea, vomiting, surgical wound drainage, chest tube drainage, gastric suction, major burns, or severe trauma.
- Identify patients with impaired swallowing, unconscious patients, and patients with impaired mobility.
- Identify patients on medications that influence fluid balance, such as diuretics and steroids.
- Assess for signs and symptoms of dehydration and fluid overload, including bradycardia versus tachycardia, hypotension versus hypertension, and reduced skin turgor versus edema.
- Weigh patients daily at the same time of day, using the same scale, and wearing comparable clothing.
- Monitor patients’ laboratory reports:
- Urine specific gravity (normal is 1.002 to 1.030)
- Hematocrit (Hct) (normal range is 38% to 47% for females and 40% to 54% for males).
- Assess the patient’s and family’s knowledge of the purpose and process of I&O measurement.
- Explain to the patient and family why measuring I&O is important.
Follow-up
- Note the patient’s I&O balance or imbalance, and report to the health care provider a urine output of less than 30 mL/hr or a significant change in the patient’s daily weight.
Documentation
Document the intake and output values.
Review Questions
1. A patient is told the home care nurse will be measuring and recording intake and output (I&O) at home. What will the home care nurse do first?
Supply a urine hat.
Explain to the patient why I&O has been ordered.- Assess the patient’s ability to self-monitor and record I&O.
- Provide the patient’s family with instructions.
2. What output will the nurse direct nursing assistive personnel (NAP) to measure for a hospitalized patient for whom intake and output measurement is prescribed?
3. Which statement reflects the nurse’s understanding of the importance of accurate urinary output measurement for a patient with acute renal failure?
- “If the output begins to decrease, I will notify the physician immediately.”
- “Increasing his fluid intake both orally and intravenously should boost his urine output.”
- “I will use a collection system with an hourly measurement device added.”
- “I will explain to the patient and family why the I&O is being measured and recorded.”
4. A patient has consumed three 100-mL cups of ice chips and 4 ounces of ginger ale. What will nursing assistive personnel (NAP) document as this patient’s oral intake?
5. A patient is admitted to your unit for dehydration. Which of the following assessments would the nurse identify as a possible sign of fluid imbalance?
- Heart rate at 80 beats per minute
- Capillary refill of less than 2 seconds
- Reduced turgor of the skin
- B/P of 118/78 mmHg
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