Ins and outs- what's the point?!

Nurses General Nursing

Published

I've talked to some fellow nurses lately getting opinions on the use of fluid balance charts in their specialty units. Everyone had different opinions.

The issue discussed was how fluid balance charts are so rarely properly filled out/ amounts are missed so the balance is never truly accurate; so they figure what good are they actually doing?

My ICU friends disagreed, obviously fluid balance is critical in ICU and with a 1:1 nurse to patient ratio plus IDC and ng/IV lines being able to get exact input and output, an accurate fluid balance is much more achievable.

One cardiologist I've worked with never ordered a fluid balance, believing a strict daily weight was the most accurate way to manage a CHF patient as he often found discrepancies in I+O charting- so he simply trialled working without them.

I know it depends on your specialty unit but I would love to hear everyone's opinions/stories and experiences (vents) with I + O charting.

Is this charting being properly performed where you work?

Do you believe fluid balance is critical where you work even when you have found discrepancies?

Do you think more education needs to be provided on the importance of recording an accurate fluid balance?

Thanks everyone

Specializes in Orthopedic, LTC, STR, Med-Surg, Tele.

Oh my gosh, this is one of my pet peeves. I'm not on a critical care unit, but we have "Intake and Output Monitoring" ordered and NO ONE DOES IT. I am always documenting my urine output and IV fluid intake, as well as what I see the patient drink, but it's VERY hit or miss. The previous shift RNs don't clear IV pumps (unless they are floated from a floor where that's actually taken seriously). And our docs don't care, so it's an uphill battle... no one cares really. So frustrating!

Specializes in Psych.

I think it depends on what type of unit you are on. Right now we have a psych patient on a fluid restriction. The pt is ambulatory and non-compliant. It is impossible to get an accurate recording on what she is taking in.

Specializes in Hospital Education Coordinator.

If a policy already exists that I&O's are to be done, then it is not education that is needed, but discipline. I am sure the nurse knows how.

Specializes in Critical Care.
Oh my gosh, this is one of my pet peeves. I'm not on a critical care unit, but we have "Intake and Output Monitoring" ordered and NO ONE DOES IT. I am always documenting my urine output and IV fluid intake, as well as what I see the patient drink, but it's VERY hit or miss. The previous shift RNs don't clear IV pumps (unless they are floated from a floor where that's actually taken seriously). And our docs don't care, so it's an uphill battle... no one cares really. So frustrating!

If nobody cares when are they being done in the first place?

Many patients need accurate I&O's, many don't. Rarely do my ICU patients not need accurate I&O's, but even then not all do. Failing to differentiate between the two results in half-$$$$ I&O's for everyone, particularly on floors where using accurate I&O's for clinical decision making is less common. Better assessment of who actually needs them done will help with compliance. Time is limited, and as a result aggressive prioritization is often required. Cutting out time that offers the patient no benefit isn't bad practice, it's good prioritization.

For our Onc/BMT patients are often on calorie counts as well as others have previously stated. Dietary needs to know exactly what has been consumed right down to how many salt packets and disposable butters they use, as this is also recorded as accurately as possible. I work nights, and most of the time people are not eating and drinking during this time, but you still must ask that patient how much liquid do you think they consumed or if they had any snacks in between the last time you have checked on them or done your rounds. Also, nurses are also required like us techs to maintain the I&Os as well whenever they see something. We know we cannot get an EXACT count of what they consume every second of the day, but we try to be as accurate as humanly possible. Sometimes as well, our patients may get up to use the bathroom and flush their output right down the toilet forgetting they needed their I&Os measured. At that time, we always try to remind them to use measuring equipment (hats, urinals, any type of measuring pitchers) so we can be as sure as possible on what they are consuming. Also, when you pour them a cup of water to drink or give them a pitcher of ice and are throwing that out to replace it or change the contents, OFTEN times the patient hasn't consumed what is actually missing. Make sure that you ASK that patient HOW MUCH have they had to drink and see if that matches up with the contents of their used cups, bedside trays etc. We also take daily weights which is usually almost ordered for every patient. This is also tricky depending on their weight, clinical weight, and what scale they were weighed on in a hospital. Bed scales and standing scales vary, sometimes depending on that particular patient's medications, they can gain or lose quite a few pounds in the hospital, so its crucial to make sure it is accurately taken. If you are ever in doubt about a bed scale weighing a patient properly, find someone to help you lift them out of their bed and reset the scale properly with the procedure/materials accounted for in the normal weight of the patient. And when in doubt, always use a standing scale.

Specializes in Pedi.
Here's my thing... I'm all for I&Os. But I sure do wish that the residents would order them appropriately. Routine is just about adequate for everyone. Our specialties tend to be a little more lax in the strict I&O ordering, but man the residents want everyone on a cardiac monitor and want us to measure every drop of pee. Does the asthmatic who is taking good PO really need to pee in a urinal?

I guess I wonder sometimes.. what happened to good old assessment?

the only truly accurate I&Os on my floor are probably the bottle fed and diapered babies. We can weigh a diaper and measure formula. But a 15 year old will drink a half a soda here, four sips of water there, and half the time flushes the pee because they forget to pee in the hat. :sarcastic:

We over monitor SO MUCH, imo.... on all kinds of fronts! This is just one of them.

Pedi nurse here and I agree. Residents don't pay attention to what they're ordering, just click buttons and they have the elective admission for EEG monitoring ordered for strict I & O. When they order everyone for "strict I & O", including those who don't need it at all, people start to get very lax and then not do it on the patients who really need it.

They're important for SOME patients. It's like monitors and monitor fatigue. When they're frequently ordered on patients that don't need them, you become immune to them for the patients that do need them.

From doing clinical rotations in 4 different hospitals and now working on a Med/Surg unit, I could see that the ball is definitely dropped when it comes to recording I& O, and I also learned in nursing school that it is very difficult to get accurate I&Os and the most accurate way to measure fluid balance is with daily weights. Staff may not be measuring it every void, every drink, pts may not keep their urine to be measured, MANY pts are incontinent.... Technically every pt is I&Os, and I think everyone is aware of how difficult it is to follow through with, so that is why Drs order Strict I& O's, aka "seriously, keep accurate track of it", fluid restrictions, and have foleys inserted on incontinent pts when they really need to know their output. I always try to record voids when I empty urinals and bedpans, but I honestly don't worry too much about the I and O unless the pt has CHF and is getting lasix, has CBI going, fluid restriction, ARF, urinary retention etc.

I agree. "Strict" only has meaning insofar as it's relative to "routine". If everything is "strict", regardless of diagnosis or acuity, the concept slowly begins to become meaningless. Facilities need to have a clear distinction between routine and strict I and O's and doctors need to only order the strict when it's actually indicated, not just as part of their admit order routine. That's why routine and strict are two separate words.

That's a good point that when Drs order them on everyone the recording gets slack even when it comes to patients who actually need them.

Onc BMT

CHF

Renal pts

After foley has been removed

ICU pts

Ped patients

These seem to be the big groups that actually need a fluid balance recorded.

It's one of my biggest pet peeves when it doesn't get done I'm glad I'm not alone with that!

From doing clinical rotations in 4 different hospitals and now working on a Med/Surg unit, I could see that the ball is definitely dropped when it comes to recording I& O, and I also learned in nursing school that it is very difficult to get accurate I&Os and the most accurate way to measure fluid balance is with daily weights. Staff may not be measuring it every void, every drink, pts may not keep their urine to be measured, MANY pts are incontinent.... Technically every pt is I&Os, and I think everyone is aware of how difficult it is to follow through with, so that is why Drs order Strict I& O's, aka "seriously, keep accurate track of it", fluid restrictions, and have foleys inserted on incontinent pts when they really need to know their output. I always try to record voids when I empty urinals and bedpans, but I honestly don't worry too much about the I and O unless the pt has CHF and is getting lasix, has CBI going, fluid restriction, ARF, urinary retention etc.

The incontinent patients are another good point. Some nurses estimate where you really should be weighing the pad then subtracting the weight of a fresh pad.

And wet sheets are another story!

We do daily weights, same time, same scale.

There are so many diffferences in I&O recording, that it gets nuts. (75% of meal, QSCYU....) that the only thing that one knows for sure is how much IV fluid goes it. (and even then, unhooking for showering, etc. does happen as well) and what a foley puts out. And the BMx2 large/med/small....in all seriousness, we would have to be 1:1 with a patient to be accurate.

Maybe the answer is also daily labs and a U/A to measure specific gravity and lytes....

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