Intake and Output Monitoring and Weight Inaccuracies

[0.adamantite]

Hello, I am just posting to vent about one of my sticking points - Intake and Output Monitoring, and Daily Weights.

First of all, I am trying to decide between two schools of thought. My first instinct is to observe Intake and Output on all patients carefully, and on my internship unit this was the rule of thumb and they were VERY precise about it (similar type of floor to my current one). However, at my current facility Intake and Output monitoring is only done, for the most part, with a physician's order. (isn't this a nursing intervention/should be done with nursing judgement?)

I am finding that Intake and Output monitoring is being ordered on patients who appear to have no clinical reason to need it, as well as being left out on patients who obviously would need it.

I am then finding that compliance with Intake and Outputs is often very poor. I will note and Intake and Output monitoring on a patient, and see no urine output or oral/IV intake charted. There will be no hat in the patient's toilet. The patient will be upset or confused when I try to introduce these interventions. Sometimes I will leave a note to see if the Intake and Output is necessary if it doesn't seem so.

Even with a hat, PCA's and other staff who toilet my patients when I am busy often do not chart the urine output. I will always try to inform my patients that we are monitoring their urine output, and they will often help my reminding other caregivers to measure the urine in their hat.

Oral intake charting is always a gamble. Unless my patients are total assist with feeding, I often have no idea what they have consumed. I have tried to label cups with the date and CC's of fluid, but good-intention-ed people will refill the cups, or they will get tossed. Forget about dietary trays. If I even see my patient's tray, by the time I return it has been picked up or deposited in the return cart. The hospital trialed a method where dietary workers would chart fluid intake on the patient's board, but there was very little compliance. This is particularly difficult with patients on a fluid restriction.

Finally, I have found that IV pumps are not being cleared at the end of the shift. It is easy to calculate IVF intake, but this becomes complicated with titrated drips, or interruptions in IVF administration.

On a medical-surgical unit, I know that often exact numbers are not as important as in more critical care environments (where I&O's are often tallied hourly), but I know that physicians often base important decisions off of Intake and Output charted. And almost all of the time, it is grossly inaccurate.

Daily weights are similar. There are no standardized methods for zeroing the hospital bed. The bed is often zero'ed only once (usually on admission). I think the bed should be zero'd daily. Patients are often weighed with many extra blankets. Sometimes the weights are not done, or daily weights are ordered on patients who have no clinical reason for them. I have found on some occasions that patients have weight increases of 3-5lb that may or may not be accurate, but have no been addressed.

I believe this is a unit culture thing. I am wondering what your thoughts on the issues are, or what kinds of things I could do to help make I&O's more accurate. I would like to take up this project on my unit if possible.

[jadelpn, LPN, EMT-B]

I would take it on as a unit project, and see if you can get a good policy in place.

Daily weights are usually done first thing in the morning. Usually around the same time. If the patient can get up to a scale, great, if not, make sure everyone is familiar with the bed scales and how to use them. Often it is a frustrating process to try and make a bed scale work with a bed bound patient. So an inservice is always a good thing. And also how to convert pounds to KG's if the scale doesn't do that.

I's and O's are difficult to monitor on a patient who's intake is not nurse controlled. If they are on a fluid restriction, that needs to be monitored carefully. The trays need to be looked at as far as how much is on them. Even calorie count patients need to have this monitored. Again, with an inservice. And the dietician can help with that.

Output can be measured with a hat. Only with strict I&O patients. Which we need an order for as well. If we do not have a specific order, then a nurse can at least have a sense of I's and O's being quantity sufficient. It is important for a number of reasons, and it is the same thing as making sure your patient hasn't gone multiple days with no BM. We have a bowel protocol. There should be one for intake and output as well.

Inservices, protocol and a new policy. Most nurses have a general idea what needs to be done, you just have to get specific on the specifics and what to do if there's insufficency in either.

[0.adamantite]

You are right there, jadelpn. Many times I will be rushing to prepare a room for an admission and I go to zero the bedscale and lo and behold, it doesn't work. One time I switched out the bed only for the second bed to have a broken scale, too! The beds are also very picky about positioning and height in order for the scale to work. If the patient is ambulatory, I will often drag the 10 ton old battleship of a standing scale down 6 miles of hallway for the weight (a mild exaggeration).

Also, if the bed isn't zeroed before a bedbound patient arrives, or if they arrive on a bed, sometimes zeroing the bed is a physical impossibility if the patient can't be transferred off of the sleep surface, such as if a ceiling lift is unavailable.

[Bringonthenight]

Preach!!

This is one of my biggest annoyances! Nothing more frustrating then coming on shift, being told in report that the patient is on strict I + O yet that same nurse has recorded NOTHING all shift! Then the Drs round and it's you that gets yelled at!

Don't get me started on daily weights!

[SoldierNurse22, BSN, RN]

I had a doc try to yell at me for this one time. I charted I&Os religiously. Other nurses...not so much. It was of great importance on my ward as well as we had patients receiving chemotherapy that could alter their fluid balance.

A doc who was rounding at one point decided to yell at the nearest nurse for failing to perform duties (namely, me) and I calmly informed him that while he could feel free to check my I&O charting, it was an issue for the unit practice council that needed to be addressed. And you bet it was.

[nurseprnRN, BSN, RN]

I find that most people who are lackadaisical about any sort of monitoring (and fluid balance is a form of monitoring) lack the basic understanding of 1) what it's for, 2) why we care, 3) how to do it properly, and 4) how the physician and others use that information in formulating the plan of care.

In this case, you can't blame the CNAs, because they aren't held responsible for understanding all of that. But you can tell them the why and the how. People think that I&O is the critical measure, but it's not-- it's the daily weight that tells you the most about fluid retention/loss. This is because there are insensate losses which can be very significant, and sometimes very difficult or impossible to measure accurately. Think fluid losses in stool (liquid, soft, or formed), wound losses in dressings, incontinence, sweat (even the sweat you can't detect because it evaporates promptly), and the biggie, respiratory tree losses. If you go outside on a cold day and see the vapor escaping from your lungs in every exhalation, you can imagine how much is lost when you can't see it (it's more than a liter a day, 1kg, 2.2 lbs), and it's more if the patient is breathing unhumidified air or gas (nasal prongs, anyone?).

So it's time for a good (and mandatory) inservice on fluid balance and why we care. Don't even mention I&O and weights until the end, because people have already made the conscious or unconscious decision that it's just busywork. Before they can change that attitude, they need to know why their decision on monitoring fluid balance can make a real difference to the patient not just while he's in your care, but when he goes home.

Every daily weight in the morning, after voiding and before breakfast, is an opportunity to teach and reinforce the idea that the patient needs to do this himself, and to report a weight gain of 2-3 lbs (that's 1-1.5 L) immediately to his primary care. I hard a great presentation by an ER nurse specialist who realized that they were getting slammed with people in CHF on Wednesdays and wondered why. A little digging and she discovered they didn't know about monitoring their daily weights; after a weekend of being a little looser on their sodium and fluid restrictions, they were short of breath from the extra fluids load. But all the internal med docs' offices were booked full, so when they called the doc office they got told to go to the ER. Lather, rinse, repeat, ad infinitum.

So she got a grant and bought 100 bathroom scales, developed a patient teaching sheet in weighing and recording, inserviced the staff on how to teach this concept and give away the scales to CHF patients...and CHF admissions dropped like a shot. The docs took credit for it, but this, my friends, was nursing at its finest.

And it's all because everybody had to understand the concept of fluid balance and how to monitor it right.

One more thing: Edema isn't visible until there are about 10-20 liters extra on board. So don't rely on the presence of edema to be your "early warning system."