If you're familiar with I/Os, would love your feedback.

CCU BSN RN · Nov 2, 2016

Scenario:

- A patient is admitted for Congestive Heart Failure.

- The patient is identified as requiring fluid balance tracking.

- The patient is either ambulant or non-ambulant.

- They use any of the collection types (foley, urinal jug, or nun hats).

Beyond standard patient information (e.g. age), are there any questions or information you like to record prior to any fluid data?

This question makes no sense. I literally have no idea what type of information you are referring to here.

What is your current process to record I&Os for a patient? As step-by-step specific as possible would be ideal (e.g. "I walk into the hospital room, then..."; "I check every 2, 4, 6 hours"; "I record it on a tablet or I/Os fluid chart")

I round on my patients hourly. If they have a foley, I enter their hourly output with their vitals. If they have used their urinal, I empty that and record that. When I worked on the floor and had many patients, I would jot down their output. With 1-3 patients, however, I can remember it for 5 minutes until I sit down at my pod to chart my hourlies.

How satisfied are you with your current collection process? What are highlights? What are frustrations?

Satisfied. I like being in critical care where most patients have a foley, and where CNA/PCTs don't really enter I/Os. Working on the floor, it was really frustrating when a CNA and I would toilet the patient together, and then I wouldn't know if the 300 they put in the computer was from that time, or if the patient went to the bathroom another time with just the CNA. On the floor CNAs emptied foley bags, so if they forgot to put it in the computer and then left to go home, you have no idea how much your patient put out that shift. Incontinent patients are also a huge frustration here, because I have no way of measuring their output. You can put a condom catheter on a male, but you don't have that option with a female. Especially when a doctor will call and ask why they aren't getting strict I/Os when it is ordered, but also will not order a foley for their incontinent patient. You can't have it both ways.

- How often do you encounter the frustrations? (e.g. Every instance of collection?)
- Used to be daily when I worked on the floor, now rarely
- How do you currently solve for the frustrations?
- Ask the CNA to clarify what void they were charting about, explain to a doctor that 89 year old women who have pushed 6 children out of their lady parts will never be continent

[*]How many hours or minutes do you estimate you spend daily recording fluids for all your patients?

24 minutes in a 12 hour shift. 2 minutes an hour for hourly I/O. It would take longer if I had to chart them in a patient's room, because I would have to log into the computer and open the EMR in each individual room as opposed to doing it once at my pod and charting on all patients at once.

If fluid balance recording was automated and no longer consumes the daily amount above, what are some things you would likely focus on that you otherwise can't (e.g. Specific bedside care; paperwork)?

Spending time on the phone with tech support/IT/trying to fix the technology that was supposed to 'automate fluid balance recording'

Bonus

In your personal experience, are ambulant heart failure patients catheterized often?

No. Especially not if they are continent or male. Women cannot use a urinal in bed (I know they make female urinals, but come on.), bedpans overflow/tip/spill, it's easy to miss the hat in the toilet, no condom caths for women, so they're more likely to end up cathed, in my experience. If someone is so dyspneic, however, that getting onto a bedpan or ambulating to the bathroom causes them severe hypoxia/tachycardia (e.g. hemodynamic instability) they're getting a foley.

Is it valuable to know that a urination/output instance happened -- not the specific mL/cc volume? In other words, is knowing that a patient is urinating, regardless of amount, actionable or valuable in any way?

If I had the option of knowing they were urinating at regular intervals, or NOT knowing they were urinating at all- I would prefer to know that they were urinating. I do find that once people are past the initial CHF exacerbation and they're later on in their hospitalization, or they're here for something else but happen to also have CHF, they respond pretty predictably. They usually diurese a set amount from their daily lasix dose, and during other times of the day, people without retention issues usually void around the same amount. There are patients who void 50cc every 30 minutes, those who void 200-300cc when they void, and those who fill a urinal. I usually find that someone's regular bladder capacity doesn't vary by more than 100cc per void. So if I know the patient and am familiar with their treatment plan, how they respond, how much they generally void, there's definitely merit in a urine count. If the CNA tells me they voided twice, and they generally void 200cc, I know it's between 300 and 500 out. If they tell me someone who voids 50cc at a time voided twice, I know their output is around 100. It requires knowing your patients. If given the choice, I would always rather have the specific urine output. This is the real world, though, and I don't always get a specific output. Better to know they're voiding a good amount than not know anything. Also, regardless of output, as long as their breathing is improving/at baseline and they are being weighed daily and we're being cautious with IVF usage, I don't really care how much they're putting out. I care that my patient is clinically improving.

casdl · Nov 2, 2016

Thank you for the thorough response and taking time to share.

Regarding the first question, I'm not familiar with all fluid tracking minutiae, so the goal is to gain visibility into any unknown areas -- e.g. questions about preference like "Does the patient have reservations about using a urinal jug? Have they had difficulty using them in the past?"; "Does the patient require assistance for each bathroom visit?".

"Beyond standard patient information (e.g. age), are there any questions or information you like to record prior to any fluid data?

This question makes no sense. I literally have no idea what type of information you are referring to here. "

AceOfHearts<3 · Nov 2, 2016

Beyond standard patient information (e.g. age), are there any questions or information you like to record prior to any fluid data?

No, everything is already in the electronic health record

What is your current process to record I&Os for a patient? As step-by-step specific as possible would be ideal (e.g. "I walk into the hospital room, then..."; "I check every 2, 4, 6 hours"; "I record it on a tablet or I/Os fluid chart")

I work on a very busy cardiac tele unit with 5 patients. If I help a patient to the toilet, bed side commode (great for getting accurate outputs since you don't worry about missing the hat), etc, then I record the amount. The aides are supposed to record their fluid intake, however if I refill a water cup I will record that.

How satisfied are you with your current collection process? What are highlights? What are frustrations?
- How often do you encounter the frustrations? (e.g. Every instance of collection?)
- How do you currently solve for the frustrations?

I'm not satisfied. Many times the info isn't accurately recorded. I had a patient last week with a foley strictly to monitor urine output. I went to check on it and empty it if needed and I knew it had already been emptied but nothing was recorded in the patient chart. I then was having to ask at the unit station who emptied it and how much was emptied so I could document it. It would have really caused issues if I hadn't tracked down that information,

How many hours or minutes do you estimate you spend daily recording fluids for all your patients?

I honestly have no idea.

If fluid balance recording was automated and no longer consumes the daily amount above, what are some things you would likely focus on that you otherwise can't (e.g. Specific bedside care; paperwork)?

You can tell how busy of a day I've had based on my charting. If I have time to keep up with my charting as the day goes it tends to be much more thorough and my POC notes are very detailed. If it's been a horrible day due to extremly needy and time consuming patients my charting is accurate, but not as thorough and I'm leaving late because I've had to stay late charting- I can't skimp on bedside care and not answer the three call bells that are ringing just because I have to document. Generally speaking though I think the biggest patient care item that gets missed due to not enough time and help is ambulating patients- so any extra time that can be saved on behalf of the nurses and aides would ideally go towards that on my unit.

Bonus

In your personal experience, are ambulant heart failure patients catheterized often?

The CDC has very clear guidlines on indwelling catheters and the reason for the insertion and continuation of use of them. At my facility if the patient does not meet any of their criteria it is a nurse driven protocol that we must remove that foley ASAP unless there is a clear reason not to documented by the provider or indicated by urology. Reasons include IV diuretics greater than every 6 hours, pt has an open wound on the buttocks/sacral area and is incontient, surgery within the last 24 hours, comfort/hospice care, creatinine greater than 1 above baseline or other kidney function concern. Those are the big ones- I might be missing one.

With that info the main reason a CHF patient might have a catheter is that they are on a lasix drip. I've had a male patient who was on a lasix drip that did not have a foley because he was able to use the urinal, but almost all of my other patients on a lasix drip have had a foley- it's pretty much protocol at my facility. The only other time I've had a patient on a lasix drip and no foley was when despite multiple tries by experienced staff we could not get one placed. It was a horrible shift too because the patient was totally incontient and not oriented. The MD was fine with no foley, but indicated we needed to accurately assess and document his weight.

Is it valuable to know that a urination/output instance happened -- not the specific mL/cc volume? In other words, is knowing that a patient is urinating, regardless of amount, actionable or valuable in any way?

It can be, just depends on the situation. It's important to know if they aren't urinating, especially if they aren't alert and oriented.

casdl · Nov 3, 2016

This is fantastic. Thank you for the thoughtful response -- the foley information and hearing how your busy days change charting priorities was especially insightful.

NurseGirl525, ASN, RN · Nov 3, 2016

I work in ICU. I&Os are recorded hourly. Pt weight is huge, especially with CHF. I'm surprised you didn't put that. In a graduate program too.

Monitoring what our PTs take in and put on an hourly basis is important. Is it a pain? Yes. Is it important? Yes. If my pt gained 5kg overnight and only put out say 30ml an hour, do their lungs have crackles? Are they edemetous? What is the reason? What interventions should I try? So much goes into it.

As you are in a graduate program, have you never practiced, or is this a homework assignment?

color me confused.

casdl · Nov 3, 2016

Thanks for mentioning weights. Though my project partner is focusing on weights, I would appreciate your input while on the subject. How do you currently conduct the weighing? In other words, in your ICU, are they bed scales? Standing weights? If both (or another alternative) do you have a preference?

calivianya, BSN, RN · Nov 6, 2016

Most of my people are not eating or drinking and most have a foley, so my I/Os are pretty accurate. I record all tube feeds/IV intake every hour. I record urine output q2h. How often I check other drains/tubes depends on what's going on. If the patient is fresh out of surgery or just had a drain/chest tube placed, I will check it at least hourly if not more often for the first few hours. If the JP/accordion drain/chest tube/whatever is putting out a whole lot when they get to me and it's frank blood, I'm probably going to be emptying it at least every 5-10 minutes to decide if I need to call the physician or not.

A stable drain that has been putting out normal to small amounts I will empty q4h, unless it's putting out some really small amount per shift (less than 20mls or so), in which case I may just empty it before I leave in the morning. Rectal tube output and NGT/OGT output get recorded before I leave in the morning unless it's a lot. Ostomies I only empty when they're full, or at the end of my shift if they never fill up.

I eyeball all drains way more often than I actually empty them. I look at most drains/chest tubes/suction canisters q2h or so, but I don't take the time to empty and record them beyond the times I've already mentioned unless they're full.

If I have a CRRT running all of the rules change - I look at everything hourly. I don't mind because those patients are 1:1 anyway, so I have plenty of time. I usually spend 30-45 minutes on I/Os except for these patients, for whom the main priority of the whole shift is I/Os. I probably spend an hour and a half on I/Os for a CRRT.

I am satisfied with how I do I/Os generally. One frustration is when I have a patient who can drink and wants a pitcher of water. I hate pitchers. I feel like I don't know exactly how much a patient is drinking when they have a pitcher. Our pitchers don't have ml markings on the inside or anything, and I don't know how much they hold in the first place. I also get frustrated if I'm working somewhere that has a CNA and they are doing things with I/Os in my room. I also really get irked if I walk in a room and see that someone has brought my patient a drink, but I don't see new intake recorded. If someone brings my patient something I expect them to either tell me so I can chart it or chart it themselves.

I don't see how I/O could be automated. IV fluid intake sure - I just have to click the calculate option in the volume cell for that hour for the computer to calculate it for me, but that doesn't work for tube feeds, something like art line/CVP intake (I don't scan the pressure bag, just manually enter 5ml/hr) crushed meds in water, or whenever I flush a tube. I would be very suspicious of anything that could claim to automate I/Os.

Finding out a urine count is helpful. If a patient's BUN, creatinine, and BNP are normal, they're not on any critical drips, and they're not edematous, I don't really care that much how much they're urinating as long as they're actually doing it. Patients on critical drips or with acute kidney injury are going to get a foley if they're incontinent.

SunnyPupRN · Nov 9, 2016

Maybe the OP referred to something like night sweats, where some fluid can be lost but not measured?