Assess the client’s risk factors for fluid overload.
Assess if client is receiving fluids or medications that would predispose her to fluid overload.
Assess the client’s risk factor for fluid loss.
Determine if the client’s urine output is in excess of her fluid intake.
Assess the client’s ability to understand and cooperate with intake and output measurement.
Greet and identify patient.
Explain rules of intake and output (I&O) record.
Measure all oral fluids in accord with agency policy. Record all IV fluids as they are infused.
Apply non-sterile gloves.
Empty urinal, bedpan, or Foley drainage bag into graduated container. Other output may also be recorded, including nasogastric suction, suction bulb (e.g. Jackson-Pratt or Hemovac), or chest tubes. Refer to agancy policy.
Remove gloves and wash hands.
Record time and amount of output on bedside I&O record.
Transfer 8-hour total fluid intake from bedside I&O record to graphic sheet or 24-hour I&O record on client’s chart.
Record all forms of intake, except blood and blood products, in the appropriate column.
Complete 24-hour intake record by adding all 8-hour totals.
ADMINISTERING BLOOD TRANSFUSION Verify the written order for the transfusion. Greet and identify the patient. Explain the procedure to the client. Start I.V. if necessary. Have the client sign consent forms. Obtain baseline......
Nasoenteric-Decompression Tube Care Is inserted by a physician or nurse practitioner nasally and advanced beyond the stomach into the intestinal tract. The patient requires encouragement and support while the tube is in place.......
Continuous Bladder Irrigation Continuous bladder irrigation is a procedure usually required for two common reasons. One is that it is done in order to decrease the chances of the formation of blood clots......
Colostomy Care Colostomy is the opening of some portion of the colon onto the abdominal face Reasons for Performing a Colostomy When feces cannot progress naturally from the colon to the anus......