The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [252]
To obtain value of urine in millilitres. E
6 If no scales available, use a jug with volume markings; pour urine into jug (using universal precautions), noting level of urine.
To measure urine volume. E
7 Once noted, dispose of urine appropriately.
To prevent contamination and/or cross-infection (Fraise and Bradley 2009, E).
8 Record value on fluid balance chart, adding this to the rest of the output values for the hour.
To determine fluid output for the hour (Sumnall 2007, E).
Postprocedure
9 Once all output has been determined, noted on chart and total hourly output calculated, subtract total output from total input.
To calculate hourly fluid balance (Levi 2005, E).
Procedure guideline 8.4 Fluid output: measuring output from drains
Essential equipment
Measuring jugs (with volume indicators)
Gloves, apron, goggles
Tape and pen
Preprocedure
Action Rationale
1 Determine sources of fluid output (see Table 8.2) and note them on the fluid balance chart.
To ensure all possibilities have been considered to ensure accurate (as possible) output determination (Scales and Pilsworth 2008, E).
Procedure
2 Explain to the patient that the output from the drains will be monitored hourly.
To inform the patient about current care and to ensure they are not alarmed by the frequent observations (Bryant 2007, E).
3 If the drain is drainable, empty contents into jug, noting volume; use universal precautions.
To determine volume of fluid drained and prevent cross-infection (Fraise and Bradley 2009, E).
4 If it is not possible to drain the fluid out of the bag, use a suitable pen and mark the level the fluid reaches each hour. Date and time each marking.
To determine drainage each hour. To ensure consistency in reading and to communicate to other members of the multidisciplinary team regarding drainage (Sumnall 2007, E).
5 Note volume/drainage on fluid balance chart.
To determine drainage each hour (Sumnall 2007, E).
6 Add this figure to the rest of the output values for the hour.
To determine accurate total fluid lost each hour (Sumnall 2007, E).
Postprocedure
7 Once all output has been determined, noted on chart and total hourly output calculated, subtract total output from total input.
To calculate hourly fluid balance (Levi 2005, E).
Procedure guideline 8.5 Fluid output: monitoring output from gastric outlets, nasogastric tubes, gastrostomy
Essential equipment
Urometer
Measuring jugs (with volume indicators)
Gloves, apron, goggles
Bile drainage bag/gastrostomy drainage bag
Preprocedure
Action Rationale
1 Determine sources of fluid output (see Table 8.2) and note them on the fluid balance chart.
To ensure all possibilities have been considered to ensure accurate (as possible) output determination (Scales and Pilsworth 2008, E).
Procedure
2 Explain to the patient that it is necessary to monitor drainage every hour.
To inform the patient of current care and interventions (Bryant 2007, E).
3 Ensure gastric outlet device has a drainage bag attached.
To collect any output for measurement. E
4 If instructed, leave the bag open to drain (this may differ depending on condition).
To enable drainage. E
5 Drain contents into marked jug every hour (if quantity allows), using universal precautions.
To determine volume and prevent cross-infection (Fraise and Bradley 2009, E).
6 Attach a urometer if output is high.
To ensure accurate reading and for ease of measuring. E
7 Note volume on fluid balance chart, adding this value to the rest of the output values for that 1 hour.
To enable determination of fluid balance (Sumnall 2007, E).
Postprocedure
8 Once all output has been determined, noted on chart and total hourly output calculated, subtract total output from total input.
To calculate hourly fluid balance (Levi 2005, E).
Procedure guideline 8.6 Fluid output: monitoring output from bowels
Essential equipment
Measuring jugs (with volume indicators)
Gloves, apron, goggles
Bedpan/commode
Scales
Rectal tube ‘Flexiseal’ (if required)
Preprocedure