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R GHIERR Y O S T g s TRNSTIT Lt s s VL T ) SR A BN o 5 i W TS Tl A A= =X T Y ———— —— ——— At AN 3 e i DTN T o) e o -y e IV CHAPTER 19) 424 Calculating Intake and Output LEARNING OUTCOMES Calculate oral intake and output, n Document intake and output. 14 Identify the equipment used to measure intake. ' Identify the equipment used to measure output. The measurement of intake and output (I & 0) during the shift and within a 24-hour period provides important information about a patient's fluid and electrolyte balance. The health-care provider may order the measurement of intake and output for the patient, or the nurse may independently place the patient on intake and output. Calculating Oral Intake Calculating intake is a simple process. The nurse measures the amount of liquid the pa- Example: The patient is on I & O. For breakfast, the patient drank 120 mL of Jjuice, 240 mL of coffee, and 375 mL of water. To calculate the patient’s intake for breakfast, the nurse Jjust adds the numbers: 120 mL (juice) 240 mL (milk) + 375 mL (water) 735 mL

CHAPTER NINETEEN Calculating Intake and Output 425 In the clinical setting, the nurse Glass Milk carton Cup Tablespoon will encounter eating utensils, such ) | | | \ as the teaspoons, tablespoons, and | ({ | E i et ; standard food containers that are filled to a certain capacity, such as 4 oz, 6 oz, and 8 oz, on a patient’s meal tray (Fig. 19-1). Hospitals, skilled nursing facilities, and other healthcare facilities identify the amount of liquid for the standard { containers (cup, glass, soup bowl, etc.) g used in their facility. For prepackaged foods such as ice cream, gelatin, and popsicles, the nurse can identify the - amount on the package or on the lid of the container. 3 ounces Soup bowl Gelatin Teaspoon 4 ounces Figure 19-1. Common containers and utensils on a patient's meal tray. Converting to mL Because nurses record a patient’s intake in mL, household measure- Table 19-1. Metric Equivalents for Household ments, such as the teaspoon, ta- Measurements blespoon, glass, cup, and ounce, need to be converted to mL. Metric HOUSEHOLD METRIC equivalent measurements for com- MEASUREMENTS ABBREVIATION EQUIVALENTS mon household utensils are iden- tablespoon Ths, tbs, T 15 mL tified on TFable 19-1. teaspoon tsp, Tsp, t 5ml Knowing the equivalent measure- ounce oz 30 mL ments helps the nurse to accurately convert the units. Although the ratio and proportion and dimensional analysis methods can be used for converting units of measurement, the nurse can calculate the number of mL by simply multiplying the household measurement in the problem by the metric equivalent. Look at the household to metric equivalent problems in Table 19-2. Notice how multiplication is used to convert the numbers. i ;f’:%" -i;} o7 TR Table 19-2. Using the Metric Equivalent Measurements to Calculate Oral Intake ~ ’r:} CALCULATING ORAL INTAKE (METRIC EQUIVALENT) MULTIPLY INTAKE (ML) 1'_.., The patient drank 3 oz of milk. loz = (B0mD 30mLx 3 90 mL ey How many mL of milk did the patient drink? -f The patient ate 5 tsp of gelatin. Ttsp = G mD S5mLx5 25 mlL i How many mL of gelatin did the patient eat? ‘5" % Il The patient took 7 Tbs of broth. 1 Tbs (5 mb 15mlx7 105 mL How many mL of broth did the patient take? s ST T ' . — ......

CHAPTER NINETEEN ® Calculating Intake and Qutput 427 FORMULA TUBE FEEDINGS ARE PART OF THE ORAL INTAKE There are times when a patient is not able to take fluids orally and requires formula feed- ing through a tube for a period of time. Feeding tubes can be placed in the stomach, duo- denum, or jejunum. The specific nutritional needs for a patient with a feeding tube necessitates the development of a nutritional plan to ensure that the patient receives the appropriate nutrients, calories, and water. Collaboration between the health-care provider who orders the formula, the nutritionist who assesses the patient and develops the nu- tritional plan, and nurse who implements and monitors the tube feedings helps to assure that the nutritional and fluid needs of the patient are addressed. i‘ The type of formula and the rate of the formula feedings are determined by the I health-care provider. The formula tube feeding may be ordered as a continuous feeding ,' (Example 1) or the formula feeding may be ordered on an intermittent feeding schedule I (Example 2). th i Example 1: Electronic Medical Record Provider Orders Ed| | To calculate intake for I a patient receiving B Name C.Patient Age 76 Gender F DOB 9-12-xx formula continuously through a feeding MR # 46300 Allergies NKDA Room 208 pump: Date 3-09xx <= # | | «Multiply the hourly Provider T>.7|5h_ysicia;1'.rMD‘ M ‘ - rate (mL/hr) by the j ¥ Order number of hours that I = ; — ] the formula infused - |Give Pulmocare tube feedingfoonfinuousiylat 50 m/hr via l during the shift, ¢ | a feeding pump. '» g pump — — — Record the total in l I 0 ;J the | & O record. Example 2: | Electronic Medical Record Provider Orders kd| | To calculate intake for a patient who is on | Name B.Patient Age 83 Gender F DOB 10-02-xx an intermittent ! : X formula feeding | MR # 34210 Allergies NKDA ~ Room 112 schedule: hi2 £ oz Date i_QES-Txx-_Q- =p ¢ Add the total - Franhy amount of formula , ¥ Order given during the shift. ‘ : - NS » Give Pulm tube feeding 250 mL[every 6 ho slat “ f Ve S lop el LR ; Record each feeding (0600 -1200-1800-2400) || | andthetotalinthe | § | & O record. ) A patient who is receiving formula tube feedings will periodically be given water through the feeding tube. Water can be given after administration of medications, after adminis- tration of intermittent formula feedings, or at other times throughout the shift. The amount of water is measured and recorded as part of the intake for the patient. In the following example, the nurse records the formula tube feedings for the 0700 to 1500 (7 a.m. to 3 p.m.) shift. Notice how the 50 mL of water is added twice for the shift, after the 0800 feeding and after the 1400 feeding, as intake on the worksheet. The total intake for the shift is 500 mL, which includes the water given during the shift. When recording the intake on the electronic medical record, the nurse selects the type of feeding tube from a list provided and enters the total intake.

428 UNIT SEVEN ® Intake and Output Example: Electronic Medical Record. Provider Orders. k4 Name G. Patient MR 67811 pate 2-01-wx \ LU =8 % Name G.Patient Age 77 Gender M DOB 8-15-xx ! g Intake and Output Worksheet 5 MR# 67811 Allergies NKDA Room 322 A ’; = AL e | Shift Oral Tube Urine | Emesis Other 1 Provider = H. Physician, MD ‘Date 2-01-xx ; ] ‘ B D il >0 B | (Feeding) | 'V Order 200 | | Start Nepro tube feedings 200 mL every 6 hours at _I 50 I (0800 — 1400 ~ 2000 — 0200). L ’ 2‘5)8 | lAdminister 50 mL of water after each feeding.l i | e e b M f I'§ | ‘i Total ‘ (mL) 500 1 o] | APPLY LEARNED KNOWLEDGE 19-2 Read the clinical situation and decide whether the Intake and Output record is correct or incorrect. 1. The nurse documents intake after the patient ate 4 Tbs of gelatin, Intake and Output Correct Incorrect Worksheet w | Shift | Oral | Urine | \ 7-3 20 | ) ] \ | Total {mL) | | 2. The patient drinks 8 oz of ice chips. The intake is recorded on Intake and Output the | & O form. Worksheet Correct Incorrect shift | oral Urine 7-3 240 Total (mL)

430 UNIT SEVEN @ Intake and Output Calculating Output Measuring output is part of the intake and output. Any liquid drainage produced by the body is counted in the output. Fluid drainage produced by the body and measured ag output includes: m Urine B Emesis (vomitus, vomit) ® Gastric drainage (nasogastric tube, jejunostomy tube, or gas- tric tube drainage) m Wound drainage (drainage obtained from wound drainage devices) m Chest tube drainage ® Diarrhea m Colostomy or ileostomy drainage ® Fluid that is removed through special procedures (thoracente- sis or paracentesis drainage) Emesis basin Graduated cylinder In the clinical setting, containers for collecting output drainage have Wound . Wall drainage calibrations that allow direct meas- drainage device Urinary catheter bag suction container urement of output (Fig. 19-2). Figure 19-2. Common measuring containers. Recording Output Output is recorded in mL, and is identified under specific categories, such as urine, gastric drainage, emesis, wound drainage, and others. For urine output, the amount measured at each voiding is entered in the I & O worksheet and the total is entered in the I & O record at the end of the shift. The same is true each time the patient vomits. Gastric and wound drainage containers are usually emptied and measured at the end of the shift. When recording the output on the electronic medical record, the nurse selects the category (urine, emesis, gastric drainage, etc.) from a list provided and enters the total output for each category. If using a printed Intake and Output form, the nurse writes in the category if it is not identified on the form.

Example: CHAPTER NINETEEN =& Calculating Intake and Output 431 The patient voided 225 mL at 4 p.m. At 8:00 p.m., he vomited 300 mL of clear fluid and voided 75 mL at 10:00 p.m. The nurse emptied the end of the shift. 50 mL from the wound drainage device at The nurse records the amount of output for each category, then adds each type of out- put to arrive at the total amount for each category. Name V. Patient VR 67809 Date 4-20-xx fixtake and Output fecord X} Intake and Output Worksheet Name V.Patient Age 58 Gender M DOB 10-05-xx MR # 67809 Allergles NKDA Room 125 Shift Oral Urine Emesis | Drainage | Other e I e ‘ Provider C. Physician, MD 'Date 4-20-xx 3-11 (Wound) : _y T T YD ey ‘- »L- 225 300 Intake Output s Drainage Oral | IV | IVPB |Urine | Emesis (Wiung) 300 300 50 i Total 1 = | (mL) 300 300 50 APPLY LEARNED KNOWLEDGE 19-3 Circle “True” if the output recorded and calculated is correct. Circle “False” if the output recorded and calculated is incorrect. 1. The patient has a gastric tube that drained 425 mt during the evening shift. The patient voided 300 mL. True False Intake and Output Worksheet Shift Oral Urine Emesis | Drainage | Other 3-11 (Gastric) 425 300 Total {mL) 425 300 Continved

CHAPTER NINETEEN Caleulating Intake and Output 433 APPLY LEARNED KNOWLEDGE 19-3 —cont’d 5. The patient had emesis of 325 mlL at 0700. I X} A nasogastric (NG) tube drained 350 mL e tiac during the shift. The patient voided 250 mL shift | Oral | Urine | Emesis | Drainage | other | af 0800 and 415 mL at 1400. 7-3 (NG) True False 250 415 325 Total (mL) 665 325 350 THE PATIENT WITH BLADDER IRRIGATION There are times when the physician orders bladder irrigation for a patient. Bladder ir- rigations are ordered for various medical conditions. However, more commonly, bladder ' jrrigations are ordered after prostate or bladder surgery. Bladder irrigation involves the instillation of a solution or irrigant into the bladder through a urinary catheter. The urinary r catheter is a flexible tube that is inserted into the bladder to allow urine to drain freely into a urinary drainage bag. Pa- tients with continuous bladder irriga- tions have a specifically designed urinary catheter, known as a 3-way catheter, which has a third opening or lumen that allows for the instillation of the irrigant (Fig. 19-3). The purpose of the irrigation is to min- imize small blood clots from forming in the bladder and to wash out blood clots that may obstruct the catheter and block the flow of urine after bladder or prostate surgery. The physician orders the type of irrigant and the rate for instilling the irrigant into the bladder. The bladder ir- rigation can be ordered as a continuous irrigation or as an intermittent irrigation. After the instillation of the irrigant into the bladder, the irrigant flows out of the bladder and into the catheter. The ir- rigant, combined with the urine, drains into the urinary drainage bag (Fig. 19-4). [ Catheter tip Inflated balloon helps to secure the catheter in the bladder. Balloon inflation port Drainage port Irrigation port Figure 19-3. Three-way urinary catheter.

9 ‘ APPLY LEARNED KNOWLEDGE 19-4 Circle “True” if the output is calculated correctly. Circle “False” if the output is calculated incorrectly. CHAPTER NINETEEN m Calculating Intake and Output 435 1. A continuous bladder irrigation with normal . . Intake and Output Worksheet saline was started to infuse at 50 mL/hr at 5:00 p.m. At 11:00 p.m., the nurse emptied Shift | Oral Urine | Emesis | Drainage | Other 800 ml from the urinary drainage bag. 3-11 (UA True False Total (mL) 500 2. The patient has a continuous bladder irrigation : — . Intake and Output Worksheet with normal saline infusing at 30 mL/hr from ) 3:00 p.m. to 11:00 p.m. The nurse emptied Shift | Oral | Urine | Emesis | Drainage | Other 775 mLat 11:00 p.m. from the urinary 311 (ua drainage bag. e True False Total (mL) 240 3. The patient has a continvous bladder irrigation Intak d Output Worksheet infusing at 75 mL/hr from 10:00 a.m. to e e 2:00 p.m. At 3:00 p.m., the nurse emptied Shift | Oral | Urine | Emesis | Drainage | Other 850 mL from the urinary drainage bag. 7-3 (ua True False stz Total (mL) 550 Continued

CHAPTER NINETEEN ®m Calculating Intake and Output 437 — Developing Competency Caleulate the intake for problems 1 through 5. 1. The patient drank 180 ml of coffee, & ounces of orange juice, and 180 ml water. What is the patient’s intake? 2. For lunch, the patient ate 3 oz of ice cream and drank 8 oz of milk and one 6 oz glass of ice chips. What is the pafient’s intake? 3. For breakfast, the patient takes 2 Tbs of gelatin, drinks 240 ml of coffee, and 4 ounces of apple juice. For lunch, the patient drinks 180 mL of milk and 450 mL of water. What is the patient’s total intake? 4. The patient has formula feedings through a feeding tube. She is given 300 ml every 4 hours (0400, 0800, 1200, 1600, 2000, 2400) around the clock. The nurse gives 100 mL of water dfter each feeding. How much intake will the patient receive in the 2300 to 0700 (11 to /) shift? 5. The patient has tube feedings. He is given 225 ml every 4 hours (0200, 0600, 1000, 1400, 1800, 2200) around the clock. The nurse gives 50 mL of water after each feeding. An addilional 100 ml of water is adminis- tered affer the medications are given at 1200. How much intake will the patient receive in the 0700 to 1500 (7 to 3] shift? Calculate the output for problems & through 10. 6. The patient voided 180 ml at 8:00 AM and 435 at 2:00 PM. Complete the patient's output record, Intake and Output Worksheet Shift Oral Urine Emesis | Drainage | Other 7-3 Total (mL) 7. The patient had emesis of 200 ml at 10:00 AM and voided 325 af 12:00 PM and 175 at 2:00 PM. Complete the patient's output record. Intake and Output Worksheet Shift Oral Urine Emesis | Drainage | Other ) 7-3 Total (mL)

436 UNIT SEVEN @ Intake and Output APPLY LEARNED KNOWLEDGE 19-4 —cont’'d 4. The patient has a continuous bladder irriga- tion infusing at 50 mL/hr from 7:00 a.m. Intake and Output Worksheet I to 10:00 a.m. and again from 12:00 to Shift Oral Urine Emesis | Drainage | Other ; 3:00 p.m. At 3:00 p.m., the nurse emptied 7-3 ua 1,050 ml from the urinary drainage bag. i ' True False . Total e (mL) 900 ! .‘ 5. The patient has a continuous bladder irrigation Intake and Outout Workshaet R0 infusing at 60 mL/hr from 8:00 a.m. to rake and DuTed Torkshee :(l 1] 2:00 p.m. At 3:00 p.m. the nurse emptied Shift Oral Urine | Emesis | Drainage | Other I' 1,000 mL from the urinary drainage bag. 7-3 uA hik True False catheter) =gl s g I “ Total B (mL) 640 il . CLINICAL REASONING 19-1 4 W% The nurse is caring for a patient who is on | & O. The patient refuses o drink the apple juice and cold water that is at the bedside. During the handoff report at 1500, the day nurse reports the patient’s oral intake for the shift was only 200 mL of a homemade tea brought in by a family 4 member. The patient’s physician has allowed the family to bring in the tea but wants the patient Al to drink four glasses (8 ounces each) of tea during the evening shift. How many mL will the nurse ask the patient to drink for the shiff? B Patients who are placed on intake and output require careful assessment and ongoing g monitoring to ensure that their daily fluid needs are met. Although the addition of a patient’s intake and output does not require complex calculations, the monitoring and . accurate documentation of the intake and output are an integral part of evaluating the CE hydration status of the patient.

CHAPTER NINETEEN m Calculating Intake and Output 439 12. For dinner, the patient drinks & oz of tea, 180 ml of broth, @ oz of soda, and eats two popsicles (3 ounces each). He drank 500 ml of water for the shift. The patient has @ continuous bladder irrigation infusing at 25 ml/ hr from 4:00 PM to 11:00 PM. At 11:00 PM, the nurse empties 725 ml from the urinary drainage bag. Use the | & O worksheet o record the patient's iniake and output for the 7 o 3 shif. Intake and Output Worksheet Shift Oral Urine Emesis | Drainage | Other 3-11 (uA catheter) Total (mL) 13. The patient has a confinuous tube feedings infusing at 75 mL/hr for the 2300 to 0700 shift. The nurse gives 100 mL of water after the administration of medications at 0200. Record the patient’s 8 hr intake on 1 & O worksheet for the 2300 to 0700 (11 to 7) shift. Intake and Output Worksheet Shift | Oral Tube Urine | Emesis | Other 11-7 (Feeding) Total (mL)

- Sy ] B3, S TR PR, o e 440 UNIT SEVEN = Intake and Output 14. For breakfast; the patient drank one 180 ml cup of coffee and a 4 oz glass of juice. For lunch, the patient ate 3 tsp of gelatin and drank 6 oz of tea. The patient voided 525 ml af 8:00 AM and 300 ml at 2:00 PM. The nurse emplied 35 ml of wound drainage for the shift. Record the tolal infake and oulput on the electronic record for the 0700 to 1500 (7 to 3) shift. Intake and Output Record : X} Name N.Patient Age 62 Gender F DOB 12-07-xx MR # 76321 Allergles NKDA Room 401 J . PRR=RsS s = - X e am T Y T Provider | C. Physici D ] 4-20-xx | { VProv de. ___ls_lc_:l_a_l_r}_i/L L Date _fizg‘xT = -’ : Intake Output ) v IVPB Urine | Emesis Wound 15. For breakfast, the patient drank 6 tsp of milk, 240 mL of coffee, and 3 ounces of juice. For lunch, the patient drank an 8 ounce container of milk and 550 mL of water during the shift. The patient has a continuous bladder irrigation infusing at 60 mL/hr from 10:00 AM to 15:00 PM. Al 1500, the nurse emptied 1,025 ml from the urinary drainage bag. Record the total intake and output on electronic record for the 0700 to 1500 (7 to 3) shift. Intake and Output Record _ Ed Name M.Patient Age 73 Gender M DOB 8-01-xx | MR # 98705 Allergies NKDA Room 316 e Provide: J.Physician,MD 'Date 3-18xx < Intake Output v IVPB Urine | Emesis Wound

Answer Key 531 APPLY LEARNED KNOWLEDGE 19.2 (P. 428) 6. 1. Incorrect. Answer: 60 ml (Use the melric equivalent: 1 ths = 15 ml) Name R. Patient pge 87 MR #899326 Room_108-A 2. Incorrect. Answer: 120 ml (Remember that ice chips Intake and Output Worksheet melt fo one-half their orlgma/ volume.| Shift Oral Urine | Emesis | Drainage | Other 3. Correct 7-3 180 4, Correct 435 5. Incorrect. Answer: 480 ml (The nurse gave the patient two feedings of 240 ml each.) APPLY LEARNED KNOWLEDGE 19.3 (P. 431) 1. False. The output has been recorded in the wrong cafegories. Total 2. True (mL) 615 3. True 4, False. The gastric fube drainage is listed as emesis 7. instead of gastric drainage. Nome, Q. Palient Age 59 MR #385248 Room 222 5. True Intake and Output Worksheet r APPLY LEARNED KNOWLEDGE 19.4 (P 435) Shift Oral Urine Emesis | Drainage | Other 1. True 7-3 325 200 2. False. The actual urine output is 535 ml. The amount £ recorded is the amount of irrigant not the amount of urine. (775 ml — 240 mlL = 535 ml) 3. True i 4. False. The actual urine output is 750 mb. Normal g Saline irrigation infused for 6 hours (7:00 a.m. ! to 10:00 a.m. and again from 12:00 p.m. to ol i 3:00 p.m.) at 50 mL/hr = 300 ml of irrigant. (mL) 500 200 ! (1050 mL — 300 mL = 750 ml) 5. True 8. Name A. Patient Age 34 MR #552681 Room_ 541 CLINICAL REASONING 19.1 (P. 436) i The nurse will have the patient iake 960 ml of tea for the Infake,dndiGMpUtWerSHEE! evening shiff. Shift Oral Urine | Emesis | Drainage | Other | DEVELOPING COMPETENCY (P. 437) 3711 g (i) 175 250 ' 1. 540 ml 2. 420 ml (lce chips melt to one-half the starting amount.) 3. 1,020 mL | 4. 800 ml | 5. 650 ml o (mL) 475 250

532 Answer Key 9. 675 ml 14. 10. 800 ml Intake and Output Record %] 11. Name N.Patient Age 62 Gender F DOB 12-07-xx Name M. Pattent Age 18 MR # 75412 Room 125 MR # 76321 , Allergies NKDA Room 401 Provider = C. Physician, MD Date 4-20-xx <= =i Intake and Output Worksheet e e e o U Errpe—s=p _ Shift Oral Urine | Emesis | Drainage | Other Intake Output 7-3 180 295 (Wound) Oral v IVPB Urine | Emesis | Wound 240 150 = e 120 495 r 825 35 240 T I - i 180 | ‘ | I 15. Intake and Output Record (%] otal N i A Gender M DOB (mL) 960 375 30 ame M. Patient ge 73 Gender 8-01-xx MR # 98705 Allergies NKDA Room 316 12. Provider J F_’pyf_lglag Mb_i-_.‘ _' Date _3;1i—x_x__ <= = Name_S. Patient Age 55 MR #25610 Room 131-B Intake Output Intake and Output Worksheet v IVPB | Urine | Emesis | UA Catheter Shift Oral Urine | Emesis | Drainage | Other B ‘ N 72_5 7-3 180 | (catheter) - ; —— T ’ 180 i , f 270, —— — -— 180 500 Total (mL) 1310 550 13. Intake and Output Worksheet Shift Oral Tube Urine | Emesis | Other 11-7 (feeding) 600 (H20) 100 Total (mL) 700