Intake and Output Measurement

3/29/2021 Nursing Procedure
Nursing Procedures and Skills: Intake and output measurement Print Page
Introduction
Fluid intake and output must be monitored in patients who undergo surgery, receive IV therapy or
parenteral or enteral feedings, have fluid and electrolyte imbalances, or have nasogastric (NG) tubes
connected to drainage. Monitoring is also required in patients with burns, hemorrhage, vomiting,
diarrhea, edema, or kidney, liver, or heart disease. Intake and output assessment helps monitor a
patient's response to treatment, particularly when a patient is receiving treatment for dehydration or
heart failure.
Fluid intake includes oral fluids; IV fluids, medications, blood products, and flushes; tube feedings and
flushes; liquid medications; and other fluid instillations or irrigations (such as bladder irrigations). Fluid
output includes urine, liquid stool, vomitus, blood, and drainage from tubes (such as chest,
nephrostomy, or nasogastric tubes), ileostomies, suction devices, and wound and surgical drains. 1 2
About 100 mL of fluid or less is lost through the GI tract under normal conditions. Fluid is also lost
through the skin and lungs, but these insensible sources of fluid loss aren't measurable. 3
Intake and output measurement should be recorded in milliliters on a 24-hour intake and output
record. Recording can occur hourly or at the end of each shift, depending on the patient's condition
and the practitioner's order; most critical care units require hourly recording of intake and output.
Total intake and output should be calculated and recorded at the end of 24 hours as required by the
facility. To guide treatment and achieve optimal fluid balance, measurements and documentation must
be accurate. 4
Equipment
Calibrated measuring container(s)

Intake and output record
Gloves
Bedpan, urinal, commode, or urine collection hat
Labels
Optional: gown, mask with face shield or mask and goggles, emesis basin, medication cup or
syringe
Preparation of Equipment
Label the graduated container(s) with the patient's name.
Implementation
Gather and prepare the necessary equipment and supplies.
Perform hand hygiene. 5 6 7 8 9 10
Confirm the patient's identity using at least two patient identifiers. 11
Inform the patient and family (if appropriate) that you'll be measuring the patient's intake and
output. Explain the procedure according to their individual communication and learning needs to
https://lnareference.wkhpe.com/ref/view.do?key=f9688a1d1c6797eefbe2f71aeda01189f52c4f9b&nmn=openProcedure&procedureId=432&cssUrl=http… 1/6
increase their understanding, allay their fears, and enhance cooperation. 12 Instruct them to
keep track of the fluids that the patient consumes.
For a nonambulatory patient, provide a urinal, bedpan, or both as needed.
For an ambulatory patient, place a urine collection hat under the toilet seat or bedside commode
seat to collect urine for measurement.
Provide an emesis basin for a patient with nausea and vomiting. Instruct the patient to notify the
nurse of any output so the nurse can measure any vomitus.
Alert the staff of the need to measure and record the patient's intake and output using the
process identified in your facility.
Measuring intake
Record the type and volume of IV fluid infused.

Record the volume of oral fluids ingested. Include food that's a fluid at room temperature, such
as sherbet, ice cream, ice chips, and gelatin. Record ice chips at about one-half their volume.
If the patient requires enteral feedings, record the type and volume of the feedings and flush
solution.
Measure and record the type and volume of instillations and their method of administration, such
as bladder and NG tube irrigations.
Include the volume of medications in fluid or elixir form that are administered orally.
Measure and record the volume of medication given by the IV route, including preservative-free
normal saline solution flushes.
Measure and record the volume of medications given through an enteral tube, including flushes.
Measuring output

Put on gloves and, as needed, other personal protective equipment to comply with standard
precautions. 13 14 15
As you measure output, assess its characteristics. Document your findings in the appropriate
section of the patient's medical record.
If the patient uses a bedpan or urine collection hat, pour urine from the device into a graduated
measuring container and record the volume in the intake and output record.
If the patient uses a urinal, measure the volume of urine using the markings on the side of the
urinal and record the volume in the intake and output record.
If the patient has a urinary drainage bag, open the clamp and allow the urine to empty into a
calibrated measuring container. A measuring container allows for a more accurate reading of
urinary output than using the markings on the side of the drainage bag. Don't touch the drainage
tube to the sides of the container to reduce the risk of introducing microorganisms into the
urinary drainage bag. 16 17 18 Close and secure the clamp after draining the urine. Record the
urinary output in the intake and output record.
Hospital-acquired condition alert: Keep in mind that the Centers for Medicare and Medicaid
Services considers catheter-associated urinary tract infection (CAUTI) as a hospital-acquired condition
because it can reasonably prevented using a variety of best practices. Make sure to follow evidence-
based CAUTI prevention practices—such as performing hand hygiene before and after any catheter
manipulation; maintaining a sterile, continuously closed drainage system; maintaining unobstructed
urine flow; regularly emptying the collection bag; replacing the catheter and drainage system using
sterile technique when breaks in sterile technique, disconnection, or leakage occurs; and discontinuing
the catheter as soon as it's no longer clinically indicated—when caring for a patient with an indwelling
urinary catheter to reduce the risk of CAUTI. 16 17 18 19 20 21
Measure and record the volume of liquid stool and vomitus in the intake and output record.
Empty drains into a graduated container and record the volume in the appropriate space in the
intake and output record. Label each drain, and record the volume from each separately to
identify the source of a change in volume. You may use a medication cup or syringe for accurate
measurement of volumes less than 30 mL.
For systems that don't get emptied, such as an NG suction container or chest tube drainage
system, mark the drainage height on the container, along with the date, the time, and your
initials, at the beginning of the shift. Record hourly or shift totals, as indicated, in the appropriate
location in the intake and output record.
Remove and discard your gloves and, if worn, any other personal protective equipment. 13 15
Document the procedure. 22 23 24 25
Special Considerations
Assess and record indicators of the patient's hydration status, such as vital signs, skin turgor,
jugular vein distention, heart sounds, breath sounds, daily weight, thirst, edema, pulses, and
mucous membranes. 22 Notify the practitioner of abnormal findings.
Keep in mind normal intake and output values for a healthy adult when evaluating the patient's
fluid status. 3
In addition to recording the volume of IV medication and liquid medication given orally or
through a feeding tube on the intake and output record, be sure to record these medications in
the medication administration record. 26
Patient Teaching
If the patient requires intake and output monitoring after discharge, teach the patient and family
members how to measure fluid intake and output, and ask for a return demonstration.
Documentation
If you're using a paper intake and output record, label the record with the patient's identifiers. Record
the total intake and output for each category of fluid for your shift. Total these categories, and provide
a shift total for intake and output. If the patient requires hourly intake and output assessment, record
these totals hourly and then total them at the end of the shift. At the end of 24 hours, calculate a daily
total. 22 Note that some electronic medical records automatically tally totals.
Include the findings from your physical assessment. In the patient's medical record, document the
characteristics of the patient's output. Record the name of the practitioner notified of abnormal
findings, the date and time of notification, prescribed interventions, nursing interventions, and the
patient's response to those interventions. Record teaching provided to the patient and family (if
applicable), their understanding of that teaching, and any need for follow-up teaching.
References
(Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)
1. Lyons, N., et al. (2015). Improving the recording of surgical drain output. BMJ OpenQuality, 4,
u209264-w3964.
2. Davies, H., et al. (2015). Effectiveness of daily fluid balance charting in comparison to the
measurement of body weight when used in guiding fluid therapy for critically ill adult patients: A
systematic review protocol. JBI Database of Systematic Reviews and Implementation
Reports, 13(3), 111–123. (Level I)
3. Stems, R. H. Maintenance and replacement fluid therapy in adults. (2019). In: UpToDate,
Emmett, M. (Ed.).
4. Leach, R. (2010). Fluid management on hospital medical wards. Clinical Medicine, 10, 611–615.
Accessed April 2020 via the Web at https://www.rcpjournals.org/content/clinmedicine/10/6/611
(Level VII)
5. The Joint Commission. (2020). Standard NPSG.07.01.01. Comprehensive accreditation manual
for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
6. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care
settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and
the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports,
51(RR-16), 1–45. Accessed April 2020 via the Web at
https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
7. World Health Organization. (2009). "WHO guidelines on hand hygiene in health care: First global
patient safety challenge, clean care is safer care" [Online]. Accessed April 2020 via the Web at
https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1
(Level IV)
8. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2019).
Condition of participation: Infection control. 42 C.F.R. § 482.42.
9. Accreditation Association for Hospitals and Health Systems. (2018). Standard 07.01.21.
Healthcare Facilities Accreditation Program: Accreditation requirements for acute care hospitals.
Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
10. DNV GL-Healthcare USA, Inc. (2019). IC.1.SR.1. NIAHO® accreditation requirements,
interpretive guidelines and surveyor guidance – revision 18.2. Milford, OH: DNV GL-Healthcare
USA, Inc. (Level VII)
12. The Joint Commission. (2020). Standard PC.02.01.21. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
13. Siegel, J. D., et al. (2007, revised 2019). "2007 guideline for isolation precautions: Preventing
transmission of infectious agents in healthcare settings" [Online]. Accessed April 2020 via the
Web at https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
15. Occupational Safety and Health Administration. (2012). "Bloodborne pathogens, standard
number 1910.1030" [Online]. Accessed April 2020 via the Web at
https://www.osha.gov/pls/oshaweb/owadisp.show_document?
p_id=10051&p_table=STANDARDS (Level VII)
17. Association of Professionals in Infection Control and Epidemiology (APIC). (2014). "APIC
implementation guide: Guide to preventing of catheter-associated urinary tract infections"
[Online]. Accessed April 2020 via the Web at https://apic.org/wp-
content/uploads/2019/02/APIC_CAUTI_IG_FIN_REVD0815.pdf (Level IV)
18. Lo, E., et al. (2014). SHEA/IDSA practice recommendation: Strategies to prevent catheter-
associated urinary tract infections in acute care hospitals: 2014 update. Infection Control and
Hospital Epidemiology, 35, 464–479. Accessed April 2020 via the Web at
http://www.jstor.org/stable/10.1086/675718 (Level I)
19. Healthcare Infection Control Practices Advisory Committee. (2010, revised 2019). "Guideline for
prevention of catheter-associated urinary tract infections 2009" [Online]. Accessed April 2020 via
the Web at https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf (Level I)
20. Jarrett, N., & Callaham, M. (2016). "Evidence-based guidelines for selected hospital-acquired
conditions: Final report" [Online]. Accessed April 2020 via the Web at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalAcqCond/Downloads/2016-HAC-Report.pdf
21. Agency for Healthcare Research and Quality, & U.S. Department of Health and Human Services.
(2015). "Toolkit for reducing catheter-associated urinary tract infections in hospital units:
Implementation guide" [Online]. Accessed April 2020 via the Web at
https://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/index.html
22. The Joint Commission. (2020). Standard RC.01.03.01. Comprehensive accreditation manual for
24. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2019).
Condition of participation: Medical record services. 42 C.F.R. § 482.24(b).
25. DNV GL-Healthcare USA, Inc. (2019). MR.2.SR.1. NIAHO® accreditation requirements,
interpretive guidelines and surveyor guidance – revision 18.2. Milford, OH: DNV GL-Healthcare
USA, Inc. (Level VII)
26. The Joint Commission. (2020). Standard RC.02.01.01. Comprehensive accreditation manual for
Additional References
Kearn, T. M. (2017). Fluid and electrolyte management across the age continuum. Nephrology
Nursing Journal, 44, 491–496.
Schneider, A. G., et al. (2012). Estimation of fluid status changes in critically ill patients: Fluid
balance chart or electronic bed weight? Journal of Critical Care, 27(6), 7–12. (Level V)
Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions

The following leveling system is from Evidence-Based Practice in Nursing and Healthcare: A Guide to
Best Practice (2nd ed.) by Bernadette Mazurek Melnyk and Ellen Fineout-Overholt.
Level I: Evidence from a systematic review or meta-analysis of all relevant randomized
controlled trials (RCTs)
Level II: Evidence obtained from well-designed RCTs

Level III: Evidence obtained from well-designed controlled trials without randomization
Level IV: Evidence from well-designed case-control and cohort studies
Level V: Evidence from systematic reviews of descriptive and qualitative studies
Level VI: Evidence from single descriptive or qualitative studies
Level VII: Evidence from the opinion of authorities and/or reports of expert committees
Modified from Guyatt, G. & Rennie, D. (2002). Users' Guides to the Medical Literature. Chicago, IL: American
Medical Association; Harris, R.P., Hefland, M., Woolf, S.H., Lohr, K.N., Mulrow, C.D., Teutsch, S.M., et al. (2001).
Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. American Journal of
Preventive Medicine, 20, 21-35.

Intake and Output Measurement

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Intake and Output Measurement

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3/29/2021 Nursing Procedure

Calibrated measuring container(s)

Label the graduated container(s) with the patient's name.

Record the type and volume of IV fluid infused.

Perform hand hygiene. 5 6 7 8 9 10

Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions

Level II: Evidence obtained from well-designed RCTs

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