Students must meet criteria of Critical Elements to safely perform the skill based on evidence-based practice. Score can be pass/fail, letter grade, or point assignment. Only acceptable score for Critical Elements is 100%
Critical Elements
Understanding of the importance and variations that can occur.
Provide accurate measurement.
Record all measurements in mL.
Maintain asepsis when obtaining measurements.
Procedure
Prior to Treatment: (Critical Thinking)
Assess patients need for intake and output recording.
Confirm order.
Gather appropriate supplies: measuring container and gloves.
Patient Interaction: (Safety)
Patient identifiers.
Provide privacy.
Explain procedure.
Procedure: (Patient Centered Care)
Intake
Apply gloves if touching patient tray.
Determine oral fluid intake.
Determine IV fluid intake.
Determine additional fluid intake.
Total input for shift/24 hours.
Output
Apply gloves.
Determine urine output – using measuring container if needed.
Determine drain output.
Determine additional fluid output.
Observe color, consistency of all fluid output.
Rinse all measuring devices after disposing body fluid.
Remove gloves.
Total input for shift/24 hours.
After Procedure (Patient Centered Care, Safety)
Provide appropriate nursing management for abnormal findings.
Documentation (Informatics, Communication)
Outcome of procedure.
Interventions used for nursing management of care.
Interventions for collaborative issues identified.