Filamer Christian University

College of Nursing
Roxas City

Clinical Teaching Plan in MEDICAL WARD

Concept: FLUID INTAKE – INTAKE AND OUTPUT
I. Pre entry Competencies
Knowledge in
1. differentiating the difference between signs and symptoms
2. describing the anatomy and physiology of
a. Urinary system
b. Digestive system
c. Integumentary System
3. identifying the measuring instruments and equipments
4. correlating the importance of intake and output in giving patient’s
diagnosis

Skills in
5. taking the Vital signs
6. performing the Physical Assessment
7. conducting the communication process
8. computing mathematical problems

II. Medical Ward’s Orientation Activities of Students

A. Requirements
1. Clinical or Ward Class Notebook with an advanced notes in
a. Patient’s Bill of Rights
b. Vital signs concepts
c. Recording and Reporting
2. Charting Notebook (Grade 4 composition is preferred)
3. RLE Notebook for the Nursing Care Plans
4. Vital Signs Equipment
5. Complete set of ballpens
6. Pentel pens
7. Bandage Scissor
8. A bottled mineral water
9. Soap in a soap dish with white hand towel
10. Dictionary
11. MIMS or Drug Handbook
12. Books on Medical- Surgical Nursing or Fundamentals of Nursing (1 pc
each group)
13. Packed lunch
 B. Ward Endorsement
1. Physical set up
2. Ward Policies and Procedures
3. Organizational Set up
4. Be ready to be “on time” always
C. Clinical Lining and Nurses’ Rounds
1. Change of shift Report
2. Instructions and reminders on
a. routines and protocols
b. noting down the members of the health care team
c. readiness to be of service to patient’s needs
d. describing the level of competencies
3. Nurses’ rounds and Bedside endorsement
4. Team Leader’s Role and functions
D. Evaluative Techniques
Criteria for Evaluation
1. Ward Performance with Evaluation checklist 40%
i. Knowledge – 20%
ii. Skills – 50%
iii. Attitude – 30%
2. Exposure Test 30 %
3. RLE Notebook 20%
4. Readings 10%
Total – 100%

III. Objectives:
A. General Objectives: After 32 hours (one rotation) of Clinical Exposure, the
student will be able to acquire the necessary knowledge, skills and attitude in
performing a comprehensive nursing care in Medical Ward
B.
Objectives Teacher’s Activities Learner’s Method of
Activities Evaluation

Objectives:
 Describe what is meant by “fluid balance”
 Identify those items that should be calculated as fluid intake
 Compute intake accurately
 Compute output accurately
 List down ways in helping clients meet their fluid needs

A. FLUID BALANCE: FLUID INTAKE AND FLUID OUTPUT

The Nurse assists clients in maintaining normal fluid balance. Water is essential to
human life. Next to oxygen, water is the most important substance the body takes
in. A person can lose half of the body protein and almost half of the body weight
before death occurs. Yet, if an individual loses only about one-fifth of the total
body fluids, death usually results.

Through eating and admitting the average healthy adult will consume between 2
½ to 3 ½ quarts in 24 hours period . Fluid intake is the amount of fluid consumed
by mouth, through special feeding tubes or through the parenteral routes (into a
vein and under the skin).

The same average healthy adult will eliminate between 2 ½ and 3 ½ quarts in a 24
hours period. Fluid Output is the total amount of fluid eliminated from the body
through
1. the kidneys as urination, also referred to as voiding or passing water
(approximately 1 ½ quarts in 24 hours)
2. the skin through respiration and the lungs through respiration
(approximately 1 quart in 24 hours)
3. the intestinal tract where fluid is absorbed and discharged as part of the
feces or stool (less than 1 cup)
4. other ways such as emesis (vomiting), wound drainage, severe
perspiration, severe diarrhea, or hemorrhage (bleeding).

Fluid balance means that the individual eliminates about the same amount of
fluid that is taken in.

B. FLUID IMBALANCE
An imbalance of the body fluids occurs when fluid intake exceeds fluid output,
therefore fluid is retained by the body, leading to edema. Symptoms of edema and
fluid retention are:
1. swelling of feet, ankles, face, hands and fingers
2. weight gain
3. collection of fluid in abdomen and lungs
4. decreased urine output

Another type of imbalance exists if fluid intake is less than fluid output. This
results in a condition called Dehydration. Dehydration is one of the most
common medical problems of clients. Dehydration is due to not consuming
 enough liquids. Dependent clients maybe reluctant or unable to ask for water, or
may simply “forget”. Incontinent clients may stop drinking to reduce the chance
of having an “accident”.

Eliminating too much fluid also causes dehydration. Examples are vomiting,
bleeding, perspiring profusely , or losing through diarrhea or wound drainage .
The symptoms of dehydration are:
1. thirst
2. decrease urine output
3. dry-looking non-elastic skin tone
4. parched or cracked lips and tongue

Dehydration affects all systems of the body: it is a life-threatening problem.

Although the physicians will treatment for the cause of dehydration, nurses play a
vital role in helping clients their fluid needs, Nurses do this by:
1. keeping fresh water within the client’s reach at all times
2. Offering fluids and reminding clients to consume fluids. A good habit to
follow is to offer clients fluids each time you enter the room, unless there us a
fluid restriction ordered.
3. Proving encouragement to the clients to the clients so that all fluids served
with meals or as between-meal nourishments are consumed. Menus are
planned to provide the client with a substantial portion of their fluid intake.

Each facility has established policies and procedures for the passing of fresh
water. This is usually done each shift so that there is a constant supply of fresh
drinking water available to clients. In some facilities each water pitcher is
takes to a clean area and filled with ice and fresh water. Nurses need to follow
the policies and procedures established in their facility.

C. UNDERSTANDING FLUID INTAKE AND OUT PUT

In order to determine the client’s intake , you must measure and record everything
a client consumes by mouth that is fluid- water, milk, coffee, tea, soups, etc. Food
items that become liquid at room temperature also must be included—gelatin and
ice cream. Although solid foods contain some liquid, most of the fluid intake
comes from what a person drinks in the form of liquids.

To determine the client’s fluid output, you must measure and record all urinary
output and vomitus and report hemorrhage, excessive wound drainage and
excessive respiration.

You will measure urinary output of the client with an indwelling catheter by
emptying and measuring the contents of the urinary drainage bag. If the client is
incontinent, you will not be able to collect or measure urine output. It is important
to record on the intake and output record the number of time the client is
incontinent each shift.
 If vomiting, hemorrhage, excessive wound drainage, or excessive perspiration
occur, notify your Staff Nurse or the doctor at once. The Doctor will help you
estimate the amount of fluid lost and will take other corrective actions. Never
discard vomitus or drainage before the Staff Nurse/Doctor (ROD) comes. When a
fluid imbalance is suspected, you may be instructed to measure and record the
client’s fluid intake and output. Be sure to follow the specific procedures on fluid
in your facility.

Measuring and recording fluid intake and output are very important. Many times
the client will use the date recorded on the Intake and Output Record to determine
what medications or treatment the clients needs.

The time of the Nurse to record fluid intake is when the client consumes it. Fluid
output should be recorded when urination, vomiting etc. occurs. Do not try to
remember--- this is not the time for guess work. Most facilities total the client’s
intake and output at the end of each shift. The 24 hour total is generally calculated
and recorded on the PM shift (3-11 shift)

D. USING THE METRIC SYSTEM

The most commonly system of measurement in all hospital is the metric system.
Fluids are measured in the “cc” or cubic centimeters. A cubic centimeter is simply
a square block with each edge of the block one centimeter long. If the block is
filled with water, there would be one cubic centimeter (1 cc.) of water inside the
block.

The conversion chart with equipment metric measurement

cc.- cubic centimeter 30 cc.= 1 oz.
ml.- milliliter 60 cc. = 2 oz.
oz.- ounce 90 cc. = 3 oz.
1 cc= 1 ml 500 cc= 1 pint
½ teaspoon- 1 1000 cc = 1 quart
1 teaspoon 4,000 cc. = 1 galloon

E. GUIDELINES FOR MEASURING FLUID INTAKE

1. Obtain a list of the most commonly used fluid containers in your facility
and along with a listing of how many ounces or cc it will hold. If this is
not available, you will need to measure the amount of liquid each
container holds and make a list for yourself.
2. Obtain the forms used for recording intake and output in your facility.
3. Measure and record all fluids consumed by the client during your shift
duty. (Calculate the differences between the full amount of the container
and the amount left in the container). Observe and record fluids consumed
from the client’s food trays, water pitchers and between meals snacks.
4. Convert (change) amounts such as ½ bowl of soup, ½ glass of juice, or ¼
cup of coffee into cubic centimeters for recording. For example: Mrs.
Diaz’s water pitcher contained 1 quart (liter) which equals 1000 cc. At the
 end of the shift, she stated “I drank all but what is left?” You would
measure what remained (in this case 250 cc) and subtract the differences:
1000 cc – 250 cc= 750 cc.
5. Record intake after each meal, before tray is measured. Record other
intake as it is consumed. Note: Intravenous fluid infused, blood transfused,
milk formula (MF) for babies, and gastric gavage (feeding for NGT)
should also be included in rendering for the intake.

F. MEASURING URINARY OUTPUT

It is not possible o accurately measure the amount of fluid eliminated through the
intestinal tract, the respiratory tract, or the skin. Therefore, the urinary output is
the most reliable measurement of fluid output.

Procedure:
1. Assemble your equipment in the Client’s Bathroom, depending on the
client’s preference.
a. Bed pan and fracture pan – containers used to collect urine from non
ambulatory clients or clients on MIO.
b. Urinal – containers used to collect urine from non ambulatory male
clients or clients on MIO
c. Specimen hat – container which when placed anteriorly in the toilet,
underneath the seat, collects urine for measurement or study.
d. Calibrated Measuring Device (sometimes IVF bottle) – device which
makes possible the recording of an accurate urine output.
2. Pour the urine into the calibrated measuring device.
3. Place the calibrated measuring device on a flat surface at eye level and
read the amount of urine.
4. Observe the urine for any abnormalities (ex. Blood, dark color, large
amount of mucus or sediments, or changes in characteristics or odor).
Report any abnormalities to your Staff Nurse or ROD before discarding
the urine.
5. Discard the normal urine in the toilet.
6. Rinse the measuring device bed pan or urinal and return to their proper
place. Note: A Bedside Commode has a container from under the
commode seat which will be emptied as well.
7. Wash your hands,
8. Record the amount of urine (in cc.) on the Intake and Output Record.
Record the time of each entry.

G. EMPTYING THE URINARY DRAINAGE BAG

 Related Device
1. Small urine collection bag is well suited for ambulatory clients; maybe
easily emptied in the toilet, easily concealed in pants or a skirt
2. Large urine collection bag – generally emptied once each eight- hour shift;
provides an approximate measure of urine.
 3. Large urine collection bag with accurately calibrated small chamber for
determining precise hourly urine outputs. The built-in calibrated
measuring chamber is called urinometer.
4. 2 way and 3 way foley catheter – for continuous bladder irrigation.
5. 3000 cc bag or irrigation for continuous bladder irrigation

 Procedure
1. Assemble your equipment
a. calibrated measuring device or measuring cup
b. bed pan or urinal
2. Wash your hands.
3. Carefully open the drain outlet from the urinary drainage bag, making sure
the drain outlet does not touch the container or the floor.
4. Allow the bag to drain completely and re-attach the drainage outlet
securely to the drainage bag.
5. Pour the urine from the bedpan or urinal into the measuring cup or pour
directly the urine to the measuring cup.
6. Place the measuring cup or device on a flat surface at eye level and
determine the amount of urine in the calibrated graduate.
7. Discard the urine into the toilet.
8. Rinse easily every device used and return to their proper places.
9. Wash your hands.
10. Report the amount of urine in cc and time collected on the Intake and
Output Record.
11. Report the unusual observations to your Staff Nurse then to the ROD.

H. RESTRICTING FLUID INTAKE

There are times when it is necessary for the Physician to order fluids restricted.
Clients who have Congestive heart Failure or Kidney Disease may need to have
their fluid intake restricted. Clients on Kidney Dialysis (the use of a machine that
performs the basic functions of the Kidney) almost always require some type of
fluid restriction. The client’s order may read “ give no more than 1500 cc in 24
hours”. It is always important to explain the reasons for fluid restrictions to the
client and family. They should never believe that the restriction is a punishment.
Follow the instructions of your Staff Nurse and measure all fluids accurately. If
fluid restriction are not allowed, the client may not suffer severe consequence. If
the client is uncooperative, ask your Staff Nurse for assistance.

There are some occasions when a physician will order a client to be NPO
(consume nothing by mouth). NPO is taken from the Latin word, NILS PER OS,
which means “nothing by mouth”. This is usually ordered prior to surgical or
laboratory procedures. The NPO client may not eat or drink anything at all- not
even water. For example, the Physician’s order might say “NPO till lab work done
in AM”. After the Lab work has been drawn, they are allowed to have their
normal intake. Since clients who are on NPO may become irritable, explain why
the order is necessary.
 I. URINE SPECIMEN COLLECTED TO BE INCLUDED IN MIO (Measure
Intake and Output) DOCUMENTATION
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