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INTAKE AND OUTPUT
MEASUREMENT AND RECORDING OF ALL FLUID INTAKE AND OUTPUT (180) DURING A 24-HOUR PERIOD.
ORAL FLUIDS
Water, milk, juice, soft drinks, coee, tea, cream, soup, and any other beverages balance
2 cubes
1/4 cup
4 cubes
1/2 cup
6 cubes
3/4 cup
8 cubes
1 cup
TUBE FEEDING
Include volume used for ushing before and after medication administration, intermittent feedings, residual checks, or any water any water given via feeding tube
PARENTERAL FLUIDS
the exact amount of IV uid administered must be recorded
IV MEDICATIONS
IV meds that are administered as an intermittent or continuous infusion must be included
CATHETER OR TUBE IRRIGANTS
Fluids used to irrigate urinary catheters, NGT tubes, and intestinal tubes must be recorded if not immediately withdrawn part of the irrigation
Vomitus and liquid feces
the amount and type of uid and the time need to be specied PAGE 1 MCN W/PROBLEMS RLE | PRELIMS | Transcripted by:
Tube draining balance
Includes gastric or intestinal drainage
Wound and stula drainage
Drainage may be recorded by documenting the type and number of dressing or linen saturated with drainage or by measuring the exact amount of drainage collected in a vacuum or gravity drainage system
EQUIPMENT for IO:
● Intake and output sheet
● Calibrated cup or glass
● Graduated container for output
● Bedpan
● Working Gloves
FDAR
It is a method of organizing health information in an individual's record.
FDAR Acronym
Focus, Data, Action, Response
ADVANTAGES of FDAR:
- Provides documentation of comprehensive care
● Problem solving approach
● Improves continuity of care
● Easy to audit
● Reinforces application of the nursing process.
● Requires continual evaluation revision of the plan of care
Three columns are usually used in focus charting for documentation:
○ Date and Time
○ FOCUS
○ Progress notes
DAR (Third column):
○ D-Data
○ A-Approach
○ R-Response