CNA SKill Measure the intake and output
As a nurse assistant it is necessary to explain to the patient why you have to measure the intake and output. You must measure and record all fluid intake in milliliter at scheduled times throughout the day. An ounce of liquid is equivalent to 30 millimeters (mm). All liquid consumed with and between meals must be measure. Measure the liquid at eye level and subtract it from the full serving.
Fluids in gelatin, ice cream, popsicles and ice chips must also be measured. A 100 mm of ice chips is equivalent to 50 mm of fluid. The nurse will be the one to measure and record fluid intake from liquid medications, fluids taken with medications, parenteral fluids, blood components, total parenteral nutrition and tube feedings if there is any.
Measure and record all fluid output. If a urine hat, commode, bedpan, specipan, or urinal has been used, tell the patient and family to call a Nurse Assistant, in this case you, to check and empty it once used.
Make sure to tell the patient not to put toilet paper in the specimen hat, bedpan or bedside commode.
For proper monitoring, instruct them to tell you about any of the following:
Other Output to Monitor
- Excessive perspiration
- Loose, watery stool
- Foley catheter drainage
- Wound or gastric tube drainage, if permitted.
Inform the patient that full catheter drainage or would or gastric tube drainage will also be measured if permitted by facility policy.
Write the patient’s name and bed number on a graduated container and use it only for that patient. IF a patient is using a urinal, you can measure the output directly on the urinal if it is marked. Otherwise, put on gloves and take measurements as necessary. Make sure to use appropriate containers only and note the drainage color and characteristics.
To obtain accurate measurements, put the container on a flat surface and look at the markings at eye level. When risk of splashing is present, make sure to wear a mask, eye protection and a gown according to facility policy.
If the patient has a catheter, note also the color and characteristics of the urine in the catheter tubing. If necessary you can get hourly measurements using a special device. Clean the drainage port according to facility policy and be sure that the port does not touch the side of the container. When allowed by the facility policy, measure other types output also. For patients with jacks and prat drain, measure the drainage with a measuring cup. If the patient has a larger drainage pouch, make sure to use a larger container like a 250mm graduated cup.
For a patient who has output using a naso-gastric tube, measure and record that too according to facility policy.
As a follow up care, get the total of the intake and output at the end of each shift and report it to the charge nurse. When output from a source other than voiding is recorded, take note of the source as well as the amount of output.