INTAKE AND OUTPUT

One of the most basic methods of monitoring a client's health is measuring intake and output , commonly called I and O. By monitoring the amount of fluids a client takes in and comparing this to the amount of fluid a client puts out. The health care team can gain valuable insights into the client's general health as well as monitor specific disease conditions.

INTAKE
- all those fluids entering the client's body such as water, ice chips, juice, milk, coffee and ice cream. Artificial fluids include: parenteral, central lines, feeding tubes, irrigation and blood transfusion.

OUTPUT
- all fluid that leaves the client's body such as: urine, perspiration, exhalation, diarrhea, vomiting, drainage from all tubes and bleeding.

An accurate record of a client's fluid balance is an important nursing function.

Equipments:

- I & O form at bedside
- I & O graphic record in chart
- Pencil and paper
- Calibrated drinking glass
- Bedside pan, commode or urinal
- Calibrated container to measure outputs
- Weighing scale
- Non-sterile gloves
- Sign at bedside stating patient is for I & O monitoring

Ideal Daily fluid Intake and Output

Source/ AMOUNT/ Route/ AMOUNT
H2O consumed as fluid/ 1500ml/ urine/ 1400-1500ml
H2O present in food/ 750ml / insensible losses/ 350-400ml
H2O produced by oxidation/ 350ml / lungs/ 350-400ml
skin / 100ml
sweat/ 100-200ml
feces /
TOTAL/ 2600ml/ TOTAL/ 2300-2600ml

Purpose:
- helps evaluate client's fluid and electrolyte balance
- suggests various diagnosis
- influence the choice of fluid therapy
- document the client's ability to tolerate oral fluids
- recognize significant fluid losses

Mandatory for clients with burns, electrolyte imbalance, recent surgical procedure, severe vomiting or diarrhea, taking diuretics or corticosteroids, renal failure, congestive heart failure, NGT, drainage collection device and IV therapy.

Deviations:
Other sources of fluid loss and excessive losses from normal routes:
- drainage from catheter or tubes
- vomitus
- diarrhea
- diaphoresis
- hemorrhage
- ileostomy/ colostomy drainage
- excessive urine output

Average daily water requirement by age and weight:
AGE/ ml/ BODY WEIGHT ml/kg
3 days/ 250-350ml/80-100
1 year/ 1150-1300ml/ 120-135
2 years/ 1350-1500ml/ 115-125
4 years/ 1600-1800ml/100-110
10 years/ 2000-2500ml/70-85
14 years/ 2200-2700ml/ 50-60
18 years/ 2200-2700ml/40-60
adult /2400-2600ml/ 20-30

Nursing Intervention:
Intervention/ Rationale

1. Ideally intake and output should be monitored/ To obtain an accurate record
2. In critical situations, intake and output should be monitored on an hourly basis/ Urine output less than 500ml in 24 hours or less than 30cc/hour indicates renal failure
3. Daily weights are often done/ Indicate fluid retention or loss
4. Identify if patient undergone surgery or with medical problem / May affect fluid loss
5. Make sure you know the total amount and fluid sources once you delegate this task/ To get an accurate measurement
6. Record the type and amount of all fluids and describe the route at least every 8 hours
7. If irrigating a nasogastric or another tube or bladder, measure the amount instilled and subtract it from the total output/ To get exact amount
8. Keep toilet paper out of client urine output/ For an accurate measurement
9. Measure drainage in a calibrated container and observe it at eye level.

A significant change in a client's weight or a significant difference in a client's total intake and output should be reported immediately to the physician.

WEIGHT CHANGES
- mild dehydration- 2 to 5% loss
- moderate dehydration- 6 to 9% loss
- severe dehydration - 10 to 14% loss
- death- 20% loss

- mild volume overload- 2% gain
- moderate volume overload - 5% gain
- severe volume overload - 8% gain

Clinical Signs of Dehydration:
- dry skin and mucous membranes
- concentrated urine
- poor skin turger
- depressed periorbital space
- sunken fontanel
- dry conjunctiva
- cracked lips
- decreased saliva
- weak pulse

Client's signs of fluid excess:
- peripheral edema
- puffy eyelids
- sudden weight gain
- ascites
- rales in lungs
- blurred vision
- excessive salivation
- distended neck vein


UPDATE:
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NGT INSERTION

Thanks for visiting my site. I don't actually earn here so if you would like to help please feel free to do so. You can send it to Metrobank S/A No. 2348004756 . My account name is : Celso Balonzo. From the Philippines, Mabuhay and may God bless you always!

NGT INSERTION- basically an insertion of a nasogastric tube to the nasoesophageal tract to the stomach

Purpose:
- to provide nutrition and medication - gavage
- to gain access to the stomach and its contents- lavage
- to decompress the stomach

Contraindications:
- basal skull fracture
- esophageal strictures
- fistulae
- nasal fractures/ nose bleeds
- patients who have recent esophageal surgery
- esophageal varices

Getting started:
- check doctor's order
- introduce yourself to the patient and explain the procedure
- get consent and let her/him sign the consent form. Remember to make a full clinical assessment of the patient prior to carrying out the procedure.

Materials needed:
- sterile gloves
- hypoallergenic tape
- 5O ml asepto syringe
- stethoscope
- water-soluble lubricant
- nasogastric tubing

Patient's position:
- sit the patient in a semi-recumbent position
- examine the nasal passages for any deformity/obstruction in order to determine the best side for insertion

Determine the length to be inserted:
-Place the tip of the tube against the epigastrium

Measure length to be inserted:
- passing the tube behind the ear, over the top of the ear and to the tip of the nostril

Mark the NGT:
- mark the NGT with an indelible marker

Lubricate the NGT:
- lubricate the tip of nasogastric tube with a water based lubricant or just water depending on local policy

Lubricate the nasal meatus:
- apply gel or water to the nasal meatus that you have selected to insert the nasogastric tube in

Insertion of the NGT:
- insert the nasogastric tube into the nasal meatus
- advance forward in a calm manner

Things to remember:
- if obstruction is encountered, withdraw slightly then advance the tube at a slightly- different angle. Gentle rotation of the tube can be helpful.
- if the patient can cooperate, instruct him that when the tip of the tube is felt in the throat; he should swallow, tilting the chin downward slightly at the same time. Swallowing enhances the passage of tube into the esophagus.
- never force the NGT. Withdraw the tube immediately if the patient demonstrates any signs of respiratory distress.

Continuing insertion:
- continue to pass the tube until you reach the part with the marking
- secure the nasogastric tube with tape to the cheek.Then proceed to checking of placement.

Checking the placement using "swoosh" method
- the swoosh method is done with the use of syringe. You push a small volume of air down the NGT while listening for the bubbling sound in the epigastric area by a stethoscope.

Checking the placement of NGT using pH paper:
- another method for checking the placement of a nasogastric tube is by aspirating a sample with a 5O ml catheter tip syringe. Test the pH of the aspirate with appropriate pH paper. Gastric contents should have a pH below 4.

Checking the placement of the NGT always take place :
- after initial insertion
- before administering each feed
- before giving medication via the NGT
- following any episode of vomiting or coughing
- if you suspect the nasogastric tube has moved like loose tape or the tube appears longer

Caution:
- if there is any query or doubt about the position of the NGT no feeding or administration of medication should take place

Checking placement using X-ray:
- the most accurate method for confirming the correct placement of NGT is radiography. An x-ray is not required routinely to confirm correct placement. If it is not possible to use swoosh method or to obtain an aspirate or if the pH of the gastric content is above 4 an x-ray is required. If you are unable to see the NGT tip clearly below the diaphragm, do not allow the NGT to be used until the x-ray has been reviewed by an experienced doctor.

Secure the NGT:
- anchor the tube securely to the nose and cheek keeping it out of the patient's field of vision
- correctly dispose of clinical waste and wash your hands

Documentation:
-date and time of procedure
- indication for insertion
- type of tube used
- distance tube inserted if appropriate
- the nature of the aspirate
- method used to check location of the tube insertion
- any procedural comments