Terms and Definitions • Diaphoresis – excessive sweating • Graduate – a container marked with lines for measuring liquids • Milliliter (ml) – same as cubic centimeter (cc) • I&O (intake and output) – to measure and record all liquids ingested and expelled by the resident

Routes to Administer Fluids • Oral (PO) – into the mouth • Intravenous (IV) – into the vein • Nasogastric (NG) tube or gastrostomy (G) tube – into the stomach

Measurement of Fluid Intake and Output – Key Points • Average oral intake for an adult is 2,000 to 3,000 cc of fluid per day, which is approximately 2 to 3 quarts. Total body output should be about the same. Because the human body is 60% water, this liquid is absolutely essential to life. As a nurse assistant, one of your responsibilities is to make sure your residents have enough fluids. In order to help you meet your residents’ needs, you will learn what to observe and how to measure and record the intake and output of fluids for your residents. A normal, healthy person takes in 2,000 to 3,000 cc per day. We eliminate fluids as perspiration (450-1,050 cc/day), through breathing (250-500 cc/day), through feces (50-200 cc/day), and as urine (1,500 cc/day). Most adults need to consume an average of 600-800 cc of fluids during an 8-hour shift. Many residents sleep during the night shift so additional fluids must be consumed during the day and evening shifts.

Measurement of Fluid Intake and Output – Key Points • The physician or charge nurse may restrict or encourage fluid intake. It is the charge nurse’s responsibility to know what has been ordered and to communicate this information to the nurse assistant. • When “intake and output” (I&O) is ordered, accuracy is very important and the resident and his/her family should be informed of the procedure. • Keep paper and a pen at the resident’s bedside for each 8-hour shift to record I&O. • The nurse assistant generally check and records the resident’s liquid intake at mealtime and between meals. • Intake and output are totaled and recorded at the end of each shift and at the end of the 24-hour period (per facility policy).

Measurement of Fluid Intake and Output – Key Points • At mealtime, check resident’s tray before serving and after the resident has eaten to determine intake of liquids. Remember to include any foods that turn liquid if allowed to stand at room temperature. • To determine the amount that had been taken, measure water that is left before emptying the water pitcher. • Observe resident for signs of dehydration or edema. (See Unit IV, Lesson Plan 1, Nutrition.) Figure 3.1 – Graduated Urine Specimen Container • Measure urinary output accurately each time bedpan, urinal, specimen, drainage bag, or bedside commode are emptied, using an accurate graduate. (See Figure 3.1.)

Measurement of Fluid Intake and Output – Key Points • Measure and record any other body discharges such as vomitus and diarrhea. Mention diaphoresis on I&O record if resident perspires profusely. NOTE: If unable to measure accurately, estimate amount and record estimated amount on chart. • Measure fluids in a rigid container. Because catheter bags are not always accurate, drain into a graduate then observe and record output. Figure 3.2 – Reading a Transparent Graduate at Eye Level • When looking at a transparent graduate, read it at eye level. (See Figure 3.2.) • If the resident is incontinent, record the number of times on the I&O sheet.

Fluids That Must be Measured for Oral Intake • Water, coffee, tea, broth, ice chips, and gelatin • Juices and carbonated beverages (soda) • Ice cream, milk shakes, sherbet, milk, and cream (e.g., Half and Half)

Measurement Equivalents from Household to Cubic Centimeters (cc) • Various size containers are used in facilities. Nurse assistants must learn the fluid content of the containers used at the facility where they are employed. There are different types of graduate measures. Be sure to measure and record fluid intake and output correctly. (See Figure 3.3. NOTE: The soda can demonstrates a size comparison and is provided for reference.) • 1 ml = 1 cc • 1 tsp = 5 cc • 1Tbsp = 15 cc • 1 oz = 30 cc NOTE: Most water pitchers contain 1 quart, or 1,000 cc.

Figure 3.3 – Graduate Measures

Measurement Equivalents from Household to Cubic Centimeters (cc) • 1 cup (8 oz) = 240 cc If 1 oz = 30 cc then 8 oz = 240 cc Can be applied to any amount • Common container sizes Coffee/tea cup 6 oz, 180 cc, 180 ml Water pitcher 32 oz, 960 cc, 960 ml Styrofoam cup 6 oz, 180 cc, 180 ml Water/milk glass 8 oz, 240 cc, 240 ml Soup bowl 6 oz, 180 cc, 180 ml Jell-O, one serving 4 oz, 120 cc, 120 ml Ice chips 2 Tbsp, 30 cc, 30 ml Juice glass 4 oz, 120 cc, 120 ml

Frequent Fluids • Means taking in more than the usual number of drinks. Fluids should be offered at least every 2 hours. • Reasons why elderly may take less fluids: Diminished sense of thirst Fluids are not readily available or placed within reach Afraid of dribbling urine Afraid of having to get up and go to the bathroom at night Difficulty holding a glass, pouring liquid from pitcher, etc.

How to Administer Frequent Fluids • Place fluids within reach. • Offer small amounts frequently (at least every 2 hours). • Offer a variety of fluids. • Encourage foods with high fluid content (pudding, watermelon). • Offer favorite beverages. • Offer fluids at frequent intervals when resident is unable to obtain fluids by himself/herself. • If goal has been set, assist resident to reach it during time set. • Explain that dribbling sometimes results from infection or irritation. Therefore, more fluids are needed. • Check resident during night and assist to bathroom as needed; provide a night light.

Distribute Drinking Water • Ensure that fresh water is at the resident’s bedside at all times unless he/she is NPO. • Offer water at regular intervals and at meals. • Drinking glasses and pitchers are collected daily and sent to the dietary department where they are sanitized through a dishwashing process. Redistribute glasses and pitchers so that resident is not without water. • If the resident requires thickened liquids, do not refill the pitcher with water. (Follow facility policy for thickened liquids.) • If a resident requires a special cup, make sure it is at the bedside.

Conclusion This lesson has shown you the importance of fluids and has prepared you to identify those fluids that must be recorded as intake and output. You should now be ready to accurately identify and measure fluids.

Steps of Procedure for Distributing Drinking Water 1. Wash your hands. 2. Check with charge nurse to identify which residents are not allowed water. 3. Check care plan to identify which residents do not want or are not allowed ice. 4. Check to identify which residents require special cups or thickened liquids. 5. Collect pitchers, glasses, and trays from bedside of residents and place on cart or tray. Touch only bottom 2/3 portion of outside of glasses. 6. Take cart or tray of equipment to dietary department. 7. Obtain clean pitchers and glasses.

Steps of Procedure for Distributing Drinking Water 8. For residents allowed ice, fill pitchers 1/3 to 1/2 full with ice; use ice tongs or a large scoop to handle ice. Return tongs or scoop to OUTSIDE of ice machine or container. 9. Add water to fill pitchers. 10. Return pitchers, glasses, and trays promptly to residents’ bedside tables.

Steps of Procedure for Measuring Fluid Intake 1. Obtain a list of the most commonly used fluid containers in your facility. 2. Wash your hands. 3. Identify resident. 4. Explain to resident how he/she can assist by writing down the amount and kind of fluids taken (if resident is able to do so). 5. Have form available for recording intake and output.

Steps of Procedure for Measuring Fluid Intake 6. Measure and record all fluids consumed by the resident during your shift. a. Record intake after each meal before the tray is removed. b. Record other intake as it is consumed. c. Check the water pitcher for water consumed on your shift. 7. Wash your hands.

Steps of Procedure for Measuring Fluid Output 1. Wash your hands. 2. Put on gloves. 3. Identify the resident. 4. Explain or reinforce the reasons for accurate measurement of output. 5. Have form available for recording intake and output. 6. Obtain measuring device, specimen “hat,” or urinal (depending on type of drainage to be measured). 7. Measure and record fluid output (including urine, emesis, or liquid stool) on your shift. (Make sure to read the measuring device at eye level to ensure accuracy.)

Steps of Procedure for Measuring Fluid Output 8. Remove gloves and dispose of in a waste container per your facility policy. 9. Wash your hands.