Intake Output

What is intake?

These are fluids taken IN the body. It can be via

various routes like the mouth, a tube, or
intravenous (IV).
What do you include for the liquids that are
consumed?

This includes anything that is liquid at room

temperature like:
 Juice
 Water
 Ice chips (NOTE: this melts to half its volume….if you give the patient 8
oz of ice chips RECORD 4 oz)
 Drinks (coffee, soft drinks, tea etc.)
 Milk
 Gelatin (Jell-O ®)
 Broths
 Ice cream
 Frozen treats: popsicles, sorbet
 Nutrition supplements like Ensure® or Boost
How about pudding or items similar to it like Daliya etc.?
Many times test questions will give you the
amount in ounces (oz), but we record intake
and output in milliliters (mL). To convert oz to
mL, simply multiply the amount of oz by 30.
Miscellaneous:

 Tube feedings (include free water)

 IV and central line fluids (TPN, lipids, blood products, medication

infusion)

 IV and central line flushes

 Irrigants (example: irrigating a catheter….calculate the amount of

irrigate delivered and subtract it from the total urine output…which
will equal the urine output)
What is output?

These are fluids that LEAVE the body. It can be via

various routes as well.

What’s included:

 Urine output (most of the output calculation)

 Emesis
 Liquid stool (ostomy or diarrhea)
 Wound draining (drains, tubes…example: chest tubes
etc.)
 Suction (gastric, respiratory)
 Not included but needs to be considered is:
insensible loss
This is from the skin and respiratory system. It
can’t be measured.
According the Mosby’s Medical Dictionary,
insensible loss is estimated to be 600 mL/day.
This varies depending on the patient’s activity
level, temperature etc. Therefore, you want to
take that in account when assessing if the
patient is at risk for fluid volume deficient OR
fluid volume overload.
 Interpreting Intake and Output

If the intake is less than output or if the output is

MORE than the intake….think DEHYDRATION! The
patient is losing too much fluids compared to what
they are taking in.

If the intake is more than output or if the output is

LESS than the intake….think that the patient may be
retaining fluid and is in FLUID OVERLOAD!

Example: Intake 4250 mL and Output 1210

mL…..patient is at risk for fluid volume overload.
 Calculate the patients INTAKE during
your 12-hour shift: (see below)?

8.00: Two pieces of toast, 2 cups of oatmeal, 8 oz yogurt, 12

oz orange juice, 2 oz corns
10.00: Two 8 oz of coffee w/ 2 oz of cream in each
11.00: 24 oz of ice chips
12.00: IV infusion of Zosyn 50 mL, 2 mL IV push Zofran and
10 cc saline IV flush
12.30: 01 House salad, 12 oz soda
14.00: One pack of red blood cells (250 mL)
15.00: 2 mL Morphine and 10 cc saline flush IV
17.15: 10 cc saline flush IV
16.00-19.00: Normal Saline IV 100 cc/hr
 Calculate the patient’s total urinary output for
the shift. The patient has continuous bladder
irrigation and a Foley catheter: (see below)?

0800-1000: 3 Liters of bladder irrigation

1000: emptied Foley catheter 3600 mL
1100: 1 Liter of bladder irrigation
1200: 2 Liters of bladder irrigation and emptied 3250 mL from Foley
catheter
1300: 1 Liter of bladder irrigation
1400: 1 Liter of bladder irrigation
1500: 1 Liter of bladder irrigation and emptied 3120 mL from Foley
Catheter
1600-1900: 3 Liters of bladder irrigation
1900: emptied 4200 mL from Foley catheter
 Calculate Intake Output
0800: 8 oz orange juice, 6 oz yogurt, slice of bread, 10 cc flush
1000: 8 oz coffee w/ 1 oz of cream
1200: 12 oz soda, Two 12 oz cherry seeds
3 oz chocolate pudding, 4 oz chicken broth
1300: 6 oz soda, 12 oz custard
1600: 8 oz ice chips
1400-1900: 50 cc/hr IV infusion
0700: 500 cc urine
1100: emesis 100 cc, ileostomy stool 350 cc
1200: wound vac drainage 200 cc
1300: 250 cc urine
1500: Drain 400 cc
1700: 350 cc urine
1730: 400 cc urine
1800: 350 cc urine
1830: ileostomy stool 400 cc
1845: 500 cc urine
ROUTES OF GAINS AND LOSSES

• NURSING ALERT When fluid

• Kidneys balance is critical, all routes of
gain and all routes of loss must be
recorded and all volumes
• Skin compared. Organs of fluid loss
include the kidneys, skin, lungs,
and gastrointestinal (GI) tract.
• Lungs

• GI Tract
 Body Water
• In Adults – water makes up 45-60% of body weight.
• In infants – water makes up 75% of body weight.
• Body water gain(2500ml/day)
• Performed water- Ingested liquids & moist foods (2300ml/day).
• Metabolic water – (200ml/day)- Is produced in the body when electrolytes are
accepted by oxygen.
• Body water loss – 2500ml/day
• Kidney excrete – 1500ml/day
• Skin excrete – 400(evaporation)+200ml/day (sweat).
• Lungs excrete – 300ml/day.
• Gastrointestinal tract – 100ml/day.
 Fluid Balance

• Selectively permeable membranes separate body fluids

into distinct compartments. Fluids are in constant motion
from one compartment to another, the volume of fluid in
each compartment remains fairly stable.
• Osmosis – Is the primary method of water movement into
& out of body fluid compartments. The concentration of
solutes in the fluids determines the direction of water
movement
 Concentration of Solutions

• Electrolytes – Chemical compounds that dissociate in

solution and breakdown into separate particles (ions) are
known as electrolytes.
• Non-electrolytes – Chemical compounds that remain intact
in solution known as nonelectrolytes.
• A) positively charged ions – Cations e.g. sodium (Na+),
potassium (K+), calcium(Ca++) and magnesium (Mg++)
• B) negatively charged ions – Anions e.g. Chloride (Cl- )
Bicarbonate (HCO3 ) and phosphate (HPO4 ).
 Concentrations of electrolytes in Body
Fluids
• Sodium (Na+) – Most abundant extra cellular ion, Normal serum
Na+ concentration – 136-142mEq/liter.

• Chloride (Cl ) – Most prevalent extra cellular anions.Normal serum

chloride level – 95- 103mEq/l.

• Potassium (K+) – Most abundant cations in ICF. Normal level – 3.8

– 5.0mEq/liter.

• Bicarbonate (HCo3 ) – 2nd most prevalent extra cellular anions.

Normal level – 22-26mEq/liter in arterial blood & 19-24meq/liter
in venous blood.
 Concentrations of electrolytes in Body
Fluids

• Calcium – Most abundant mineral in the body. Normal value – 4.6

–5.5mEq/liter.

• Phosphate – Normal plasma concentration of ionized phosphate is

1.7 – 2.6 mEq/liter.

• Magnesium – Normal plasma Mg concentration is 1.3 – 2.1

mEq/liter.
 Alterations in fluid
&
electrolyte balances

• Fluid volume deficit : (dehydration) it is defined as loss of water/

electrolyte from extra cellular fluid.
• Proportional losses of water & electrolyte is known as isotonic
losses
• Disproportionate dehydration: hypotonic dehydration : electrolyte
loss is proportionately greater than loss of water.eg. Diabetes
insipidus
• Hypertonic dehydration : water loss is proportionately greater than
electrolyte loss
 Alterations in fluid
&
electrolyte balances

• Fluid volume excess : when water & solutes are gained in

proportionate amounts of extra cellular fluid, it is known as
extracellular fluid loss or over hydration
• Sign & symptoms:
-generalized edema
-wide spread accumulation of fluid in interstitial spaces
-coughing , dyspnea, weight gain, jugular vein engorgement
 ACID-BASE BALANCE

• A solution is acid or alkaline depends on the

concentration of hydrogen ions(H+). If the
concentration of H+ is increased, the solution
becomes more acidic, if the concentration is
decreased it becomes more alkaline.
• Acid-base balance of the body is maintained by
controlling the H+ concentration of body fluids
especially extra cellular fluid.
• Normal pH of ECF – 7.35 – 7.45 (.45mEq/l
- .035mEq/l).
 ACID-BASE BALANCE
• Homeostasis of pH is maintained by buffer systems, exhalation
of CO2, & kidney excretion of H+ & reabsorption of HCO3
• Buffer systems – Buffers act quickly to temporarily bind H+,
which removes the highly reactive, excess H+ from solution but
not from the body.
• Exhalation of CO2 – by increasing the rate of depth of
breathing, more CO2 can be exhaled. (hyperventilation). In
minutes, this reduces the level of carbonic acid (H2 CO3), which
raises blood pH.
• Kidney Excretion – The slowest mechanism, taking hrs or days,
but the only way to eliminate acids other than carbonic acid.
The kidney excrete H+ & reabsorb HCO3 .
 ACID-BASE IMBALANCES

• Acidosis (Acidemia) – Is a systemic arterial blood pH

below 7.35. Its principal effect is depression of CNS.
Patient becomes disoriented & comatose.
• Alkalosis – Is a systemic arterial blood pH above 7.45. Its
principal effect is over excitability of the CNS –
Nervousness, muscle spasm & convulsion.
• Compensation – Is the physiological response to an acid-
base imbalance that attempts to normalize arterial
blood pH. It may be either complete, If pH indeed is
brought within the normal range, or partial if pH is still
lower than 7.35 or higher than 7.45.
 ACID-BASE IMBALANCES

• Respiratory Compensation – If a person has altered pH

due to metabolic causes, hyperventilation or
hypoventilation can help bring blood pH back to normal.
It occurs within minutes & reaches its maximum within
hrs.
• Metabolic Compensation – If a person has an altered pH
due to respiratory causes, renal mechanisms can help
compensate for the alteration.It may begin in minutes
but take days to reach maximum effectiveness.
 ACID-BASE IMBALANCES

• pCo2 (partial pressure of CO2) – (35-45mmHg) –

changes in pCO2 level causes respiratory acidosis &
respiratory alkalosis.

• HCO3 concentration- 22-26mEq/l in arterial blood –

changes leads to metabolic acidosis & metabolic
alkalosis.
 ACID-BASE IMBALANCES

• Respiratory Acidosis – Is elevation of pCO2 of arterial blood above

45mmHg.Inadequate exhalation of CO2 causes the blood pH to
drop. Any condition that decreases the movement of CO2 from the
blood to the alveoli of the lungs to the atmosphere causes a
buildup of CO2, H2CO3, & H+.
• Conditions include emphysema, pulmonary edema, injury to the
respiratory center, airway obstruction & disorders of muscles
involved in breathing.
• If the respiratory problem is not too severe, the kidney can help
raise by increasing their excretion of H+ & reabsorption of HCO3
(metabolic compensation).
 ACID-BASE IMBALANCES
• Respiratory Alkalosis – Arterial blood pCO2 falls below
35mm of Hg. Hyperventilation causes the pH to increase.
• Conditions include oxygen deficiency due to high altitude
or pulmonary disease, cerebrovascular accident, severe
anxiety & aspirin overdose.
• Metabolic Compensation may bring blood pH into normal
range, if kidneys decrease excretion of H+ HCo3.
• Treatment of respiratory alkalosis is aimed at increasing the level of
CO2 in the body.
• One simple measure is to have the person to breath into a paper
bag & then rebreathe for a short period of time.
 ACID-BASE IMBALANCES
• Metabolic Acidosis:- Blood HCO3 concentration drops below 22
mEq/liter.
• HCO3 < 22mEq/liter pH decreases acidic.
• Situations –
• severe diarrhea or renal dysfunction.(Actual loss of HCO3)
• Accumulation of an acid, as in ketosis.
• Failure of kidneys to excrete H+ from metabolism of dietary
proteins.
• Hyperventilation can help bring blood pH into normal range in mild
cases(respiratory compensation)
• Rx consists of intravenous solution of sodium bicarbonate &
correcting the cause of acidosis.
 ACID-BASE IMBALANCES
• Metabolic Alkalosis:- Blood HCO3 concentration is >26mEq/liter
leads to increased pH.
• Causes- Non respiratory loss of acid by the body.
• Excessive intake of alkaline drugs.
• Excessive vomiting of gastric contents leads to loss of hydrochloric
acid which causes metabolic alkalosis.
• Gastric suctioning, use of certain diuretics, endocrine disorders,
administration of alkali, severe dehydration.
• Respiratory compensation through hypoventilation.
• Treatment consist of fluid therapy to correct chloride, potassium
and other electrolyte deficiencies & correcting the cause of
alkalosis.
 DIAGNOSIS OF ACID-BASE
IMBALANCES
• By careful evaluation of three factors.
• Arterial blood pH, pCO2, concentration of HCO3 .
• These 3 blood chemistry values are examined in a four-step
sequence.
• Note – pH is high (alkalosis) or low(acidosis).
• See pCO2 or HCO3 – is out of normal range could be cause of the pH
change.
• If the cause is a change in pCO2, the problem is respiratory. If the
cause is a change in HCO3, the problem is metabolic.
• Now look at the value that doesn’t correspond with the observed pH change. If it
is within normal range- no compensation. If outside normal range- compensation
is occurring & partially correcting the pH.
 ARTERIAL BLOOD GASES
(Whole blood)

pH : 7.35 – 7.45
PaCO2 : 35 – 45mmHg
PaO2 : 80 –100mgHg.
HCO3 : 22 – 26mEq/l (Bicarbonate)
BE base excess : +2 to –2 mEq/l
Description:- ABG are utilized to assess acid-base
imbalances caused by metabolic acidosis or metabolic
alkalosis or respiratory acidosis or respiratory imbalances.
Acid-base pH PaCO2 HCO3 BE
Imbalances

Respiratory .
Acidosis Normal Normal

Respiratory
Alkalosis Normal Normal

Metabolic
Acidosis Normal

Metabolic
Alkalosis
Normal
 MEDICATIONS

That affect pH levels:-

• - Narcotics, Barbiturates, Ammonium chloride,
Acetazolamide.

• - Sodium bicarbonate, Antacids, Steroids,

salicylate overdose or diuretics.
 Identification of Acid-Base Status
• Acid – donates hydrogen ions.
• Base – accepts hydrogen ions.
• Check pH – first step:
• pH <7.35 – Acidosis (increase H+ in the blood).
• pH >7.45 – Alkalosis (decrease H+ in the blood)
• Buffer – Is a weak acid or a weak base that transfers hydrogen ions
between solution to maintain Acid-base balance.
• Check PCO2 (2nd step): indicator of respiratory buffering.
• PCO2 <35mmHg – alkalosis
• PCO2 >45mmHg – acidosis.
• E.g. pH < 7.35 + pCO2 >45mmHg – Resp. Acidosis.
• pH >7.45+ PCO2 <35mmHg – Resp. Alkalosis.
 Identification of Acid-Base Status
• Check HCO3 (3rd Step): indicator of metabolic buffering.
• HCO3 <22mEq/l – Acidosis.
• HCO3 >26mEq/l – Alkalosis.
• pH <7.35+HCO3 <22mEq/l – Met. Acidosis.
• pH >7.45+HCO3 >26mEq/l – Met. Alkalosis
• After interpreting the pH value determine whether the
respiratory or metabolic buffering component matches the acid-
base component.
• E.g. – pH –7.2, pCO2-50mmHg, HCO3 – 24mEq/l
• E.g. – pH –7.55, pCo2 –38mmHg, HCO3 – 30mEq/l
 COMPENSATION
Acid-Base Arterial Blood gas Analysis
Compensation
Normal Normal pH, normal PCO2 &
normal HCO3
Uncompensated Abnormal pH, abnormal PCO2
or abnormal HCO3
Partially Compensated Abnormal pH, abnormal PCO2
or HCO3.
pH condition (acidosis or
alkalosis matches either PCO2
or HCO3 but not both.
Compensated Normal pH, abnormal pCO2 or
abnormal HCO3
 Example of a Patient
The patient is in the ICU because he
suffered a severe myocardial infarction
3 days ago. Make a diagnosis & decide
whether or not compensation is
occurring. The lab reports the following
values from an arterial blood sample
pH-7.30, HCO3 -20mEq/l, pCO2-
32mmHg.
• 1) pH – 7.30 indicates slight acidosis.
• 2) HCO3 is <normal (20mEq/l) – cause metabolic.
• 3) pCO2 is <normal (32mmHg), so hyperventilation is
providing some compensation.
• Diagnosis: partially compensated metabolic acidosis.
• Possible cause is kidney damage that resulted from loss of
blood flow during heart attack.
 FLUID REGULATION
Fluid Volume Imbalances
Volume Deficit Volume Overload
Asses Temp. increases,Rapid & weak No change in temperature, pulse
sment pulse, Respirations increase, increases slightly & is bounding,
poor skin turgor – skin cool, Respirations increase, shortness of
moist, Hypotension, Emaciation, breath, Dyspnea, rales (crackles),
weight loss, Dry eye sockets, Peripheral edema – bloated
mouth & mucous membranes, appearance, hypertension,May
Anxiety, apprehension, have muffled heart sounds, Jugular
exhaustion, Urine specific gravity vein distension, Urine specific
>1.030, Decreased urine output, gravity <1.010, Apprehension,
Increased hematocrit, Increased venous pressure,
Headache,lethargy, confusion, Decreased hematocrit & BUN.
disorientation.
 FLUID REGULATION
Fluid Volume Imbalances
Volume Deficit Volume Overload
Analy Isotonic Loss, vomiting, Isotonic gain, increase in the
sis diarrhea, GI suction, Sweating, interstitial compartment,
Decreased intake intravascular compartment, or both,
CHF, Renal failure, Cirrhosis of the
liver, Excessive ingestion of
sodium, excessive or too rapid
intravenous infusion.

Plan/ Force fluids, Provide isotonic IV Administer diuretics, Restrict fluids,

Imple fluids: lactated ringer’s or 0.9% Sodium-restricted diet –average
menta Nacl, I/O hourly, Daily weights daily diet 6-15mg Na+), Daily
tion (1literfluid=1 kg or 2.2lb), weight, Assess breath sounds,
Monitor vital signs, Check Skin check feet/ankle/sacral region for
turgor, Assess urine specific edema.
gravity. Semi-fowler’s position if dyspneic.
• Diagnostics – CVP (right atrial pressure).
• Purpose – measurement of effective blood volume &
efficiency of cardiac pumping of the right side of the
heart; measures pressure in superior vena ceva.
• Indicates ability of right side of heart to manage a fluid
load.
• Guide to fluid replacement.
• Equipment:-
• Central line threaded into right atrium.
• Water manometer with three-way stopcock.
• IV fluids.
Procedure:-
• Patient has catheter in jugular, subclavian or median cubital
vein.
• Attach manometer to a 3-way stopcock than also connects IV
to central catheter inserted into jugular, subclavian, or
median cubital vein.
• Zero on manometer placed at the level of the right atrium at
midaxillary line.
• Measured with patient flat in bed.
• Stopcock opened to the manometer, which allows for fitting
with IV fluid to level of 18-20 cm.
• Stopcock turned to allow for fluid in manometer to flow to
patient.
• Level of fluid fluctuates with respirations.
Procedure:-
8. When level stabilizes, reading is taken at highest level of fluctuations.
9. Return stopcock to proper position & adjust IV flow rate.
10. Normal reading 2-14 cm H2O
a. Elevated - >14 hypervolemia or poor cardiac contractility.
b. Lowered - <2 hypovolemia.
11. Potential complications:- Pneumothorax, Air embolism, Infection at
insertion site.
12. Nsg. Management:-
c. Dry, sterile dressing
d. Change dressing, IV fluid bag, manometer & tubing every 24 hrs.
e. Instruct patient to hold breath ( Valsalva maneuver) when tubing
changed to prevent air embolism.
f. Check & secure all connections.
 Definition of Terms
• Tonicity:-Concentration of a substance dissolved in water.
• Isotonic Fluids:- same concentration as body fluids.
• Hypertonic solution:- solute concentration greater than that of
body fluids.
• Hypotonic solution:- Solute concentration less than that of body
fluids.
• ECF:- extracellular fluid.
• Intake refers to all possible avenues of intake e.g. oral fluids,
food, IV fluids, gavage feedings, irrigations.
• Output refers to all possible avenues of output, e.g. insensible
losses, urine, diarrhea, vomitus, sweat, blood & any drainage.
 Intravenous Fluids
Type of Fluid IV Fluid

Isotonic 0.9% Nacl

Ringer’s solution
Lactated Ringer’s
5% dextrose in water

Hypotonic 0.45% Nacl

Hypertonic 10-15% dextrose in water
3.0% Nacl
Sodium Bicarbonate 5%
5% dextrose in lactated ringer’s solution
• Nsg.Considerations for IVs;-
• Main Purpose- to maintain or restore fluid & electrolyte balance.
• Secondary purpose – to provide a route for medication, nutrition, &
blood components.
• Type,amount & sterility of fluid must be carefully checked.
• Macrodrip - delivers 10,12, or 15 drops/ml; should be used if rapid
administration is needed.
• Microdrip – deliver 60drops/ml; should be used when fluid volume
needs to be smaller or more controlled, e.g. pt’s with compromised
renal or cardiac status.
• Maintain sterile technique.
• Monitor rate of flow; set IV pump properly.
• Assess for infiltration- cool skin, swelling, pain.
• Assess for phlebitis – redness, pain, heat,swelling.
• Change tubing every 72hr, change bottle every 24hr.