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TRINITY VALLEY COMMUNITY COLLEGE

ASSOCIATE DEGREE NURSING


RNSG 1229
PROCEDURE GUIDE AND CHECK-OFF SHEET
MEASURING INTAKE AND OUTPUT
Monitoring intake and output (I & O) helps evaluate fluid and electrolyte status. Measurement of I & O
is usually advised when a fluid imbalance exists or the patient is at risk. Monitor I & O for any patient at
risk for or experiencing an actual fluid volume deficit or excess.
Delegation: This procedure may be delegated to unlicensed assistive personnel with proper training.
Assessment of the patients intake and output in identifying potential problems is retained by a nurse.

Procedure
1. The following equipment is
needed for this skill:
a. appropriate collection
devices (graduated
cylinder, medicine cup,
hat receptable)
b. gloves.
2. Monitor I & O in the following
situations:
a. fluid intake or urinary
output is less than normal
b. abnormal losses are
occurring
c. IV therapy is being
administered
d. patient has medical
problems that affect fluid or
electrolyte status
e. patient not physiologically
stable, such as after surgery
or trauma.
3. Intake measurements should
include:
a. oral fluids by mouth
(include foods that become
liquid at room temperature,
such as popsicles, etc.,
ice chips are recorded as
approximately half their
volume)
b. oral fluids by tube

Scientific Rationale

Helps maintain an ongoing evaluation


of a patients hydration status in order
to prevent imbalances.

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Procedure
c. IV fluids.
4. Output measurements should
include:
a. urine
b. liquid stool
c. vomitus
d. drainage from a tube (ex:
nasogastric tube, chest
tube)
e. wound drainage.
5. It may be necessary to compare
the weight of a clean product
that is used (linens, pad,
diapers) with the weight of the
soiled product. The difference
in grams is equal to the output
in milliliters.
6. Use the appropriate measurement device for the quantity
being measured, such as
medicine cup for amounts less
than 30 ml, or a graduated
cylinder to measure 100 ml to
1000 ml.
7. May teach the patient to assist
in keeping track of their own
intake and output if
appropriate.
8. Document I & O on an Intake
and Output Record in ml. The
total intake and output should
be calculated every 8 hours or
as ordered by the physician.
Note: Intake and output should
approximately equal.

Scientific Rationale

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When intake and output is critical,


weighing products may be necessary.

Ensures accurate I & O measurement.

Involves patient in their own care.

All data must be entered in patients


record. Comparing intake and output
helps identify any fluid volume
deficits or excesses.

N:ADN/Skills/RNSG 1229/ Measuring Intake and Output

Reviewed 04/10
Reviewed 04/11
Revised 06/11