Nursing Component Task
Nursing procedures & clinical learning

General Nursing (RGN)

RECORDING OF INTAKE AND OUTPUT

It is the process of measuring and noting the amount and type of fluids introduced into the body and excreted from the body over a 24-hour period. This procedure assists the nurse to maintain an accurate record of a patient's fluid balance. Fluid intake includes: 1. Oral fluids 2. Intravenous fluids 3. Nasopharyngeal fluids 4. Intragastric fluids Fluid output includes: Urine Vomitus Aspirates Diarrhoeal stool Sweat

Purpose

  • Assess the therapeutic effects of medication
  • Monitor fluid overload and dehydration

Indications

  • Patients requiring monitoring of fluid balance
  • Patients at risk of dehydration
  • Patients at risk of fluid overload
  • Patients receiving intravenous or other significant fluid therapy
  • Patients with conditions affecting fluid balance
  • Patients with significant fluid losses such as vomiting, diarrhoea or excessive drainage
  • Patients requiring accurate urine output monitoring

Equipment

  • A trolley containing the following:
  • Top shelf: Drinking cup (To measure fluid input)
  • Bottom Shelf
  • Urinal or bedpan
  • Measuring jug (To measure output)

Procedure steps

  • Establish rapport (Refer to steps)
  • Explain the importance of keeping the fluid balance chart to patient and relatives
  • Obtain fluid intake and output chart (manually or electronically) and confirm with patient's identity
  • Determine the types of fluid intake or output
  • Observe amount of fluids given to patient
  • Record the amount of oral and intravenous fluids prescribed at the intake column indicating the date and time
  • Add together the values for oral and parenteral fluids
  • Assist patient to void into a bedpan or urinal if possible, empty content into the measuring jug and note the volume OR if there is urine in a urine bag, empty content into the measuring jug and note the volume
  • Record other forms of output such as watery stools and vomitus at the output column indicating date, time and the amount
  • Record all measurements in milliliters
  • Add together all the values obtained for outputs
  • Total the intake and output at the end of every 24 hours
  • Find out amount of fluid retained by subtracting the values of fluid output from the intake
  • Perform hand hygiene
  • Inform the nurse in charge/doctor immediately if amount put out is greater than the amount taken in or when there is abnormally low output
  • Record findings in the appropriate recording software and observation chart
  • Dispose off used items and decontaminate trolley

Precautions

  • Confirm the patient's identity before recording intake or output
  • Use appropriately calibrated or graduated measuring equipment
  • Record all measurements accurately in milliliters
  • Record the date and time of each measurement
  • Measure urine, vomitus, drainage and other measurable fluid losses accurately
  • Use standard precautions when handling body fluids
  • Avoid contamination and spills during measurement
  • Report abnormally low output, excessive losses or significant changes in fluid balance promptly
  • Follow the prescribed monitoring frequency and facility fluid-balance policy
  • Document totals accurately at the required interval and at the end of the 24-hour period

Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.

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