Accurate intake and output records help evaluate a patient's fluid and electrolyte balance, suggest various diagnoses, and influence the choice of fluid therapy. These records are mandatory for patients with burns, renal failure, electrolyte imbalance, recent surgical procedures, heart failure, or severe vomiting and diarrhea, and for patients receiving diuretics or corticosteroids. Intake and output records are also significant in monitoring patients with nasogastric (NG) tubes or drainage collection devices, and those receiving I.V. therapy.
Fluid intake comprises all fluid entering the patient's body, including beverages, fluids contained in solid foods taken by mouth, and foods that are liquid at room temperature, such as flavored gelatin, custard, ice cream, and some beverages. Additional intake includes GI instillations, bladder irrigations, and I.V. fluids.
Fluid output consists of all fluid that leaves the patient's body, including urine, loose stools, vomitus, aspirated fluid loss, and drainage from surgical drains, NG tubes, and chest tubes.
When recording fluid intake and output, enlist the patient's help if possible. Record amount in cubic centimeters (cc) or milliliters (ml). Measure; don't estimate. For a small child, weigh diapers if appropriate. Monitor intake and output during each shift, and notify the physician if amounts differ significantly over a 24-hour period. Document your findings in the appropriate location; describe any fluid restrictions and the patient's compliance.