Fluid Balance / Intake and Output

Question 1

Routes of fluid intake

Answer 1

Oral fluids
Foods containing water
Food metabolism
IV, rectal irrigation

Question 2

Fluid is distributed between

Answer 2

Extracellular

Intracellular

Question 3

Routes of fluid output

Answer 3

Skin (sweat, tears)
Lungs (sputum, mucus)
GI (feces)
Kidney (urine)

Question 4

Healthy fluid intake and output

Answer 4

2200-2700 mL

Question 5

Healthy urine output

Answer 5

1200-1500 mL

Question 6

Healthy GI output

Answer 6

100-200 mL

Question 7

Risk factors for fluid imbalance

Answer 7

Infant
Older adult
Cardiovascular disease
Renal disease
Head injury
Respiratory illness
Burns
Recent surgery
Acute illness
GI output/drainage (NG suctioning)

Question 8

Fluid balance assessment

Answer 8

Environment
Dietary intake
Lifestyle
GI/GU output
Medications
Signs and symptoms

Question 9

Urine specific gravity measures

Answer 9

Concentration of particles in urine

Question 10

Urine specific gravity expected range

Answer 10

1.005-1.030

Question 11

Concentrated urine USP and cause

Answer 11

High specific gravity

Seen in dehydration, fluid volume deficit

Question 12

Dilute urine USP and cause

Answer 12

Low specific gravity

Seen in over hydration and fluid volume excess

Question 13

Fluid excess assessment findings

Answer 13

Skin: peripheral and dependent edema
CVS: hypertension, tachycardia, bounding pulses, JVD
GU: elevated UOP with dilute urine or low UOP
Neuro: change in LOC, cerebral edema
Weight gain

Question 14

Fluid deficit assessment findings

Answer 14

Weight loss
Neuro: sunken eyes, altered LOC, no tears, light-headed when sitting/standing
CVS: weak pulses, decrease cap refill, low BP, tachycardia, poor perfusion
HEENT: sticky, dry mucosa; cracked lips; no tears; decreased salivation
Resp: thick sputum
GI: constipation
GU: oliguria, auria, concentrated urine
Skin: hypothermia, dry, flushed, poor turgor, cold, clammy

Question 15

Fluid volume excess interventions

Answer 15

Strict I&O (hourly)
Daily weights
Mobilization of fluids (turn q 2 hr, ambulate, elevate lower extremities)
Fluid restrictions (24 hour limits, limit sodium)

Question 16

Interventions for PO intake

Answer 16

Encourage PO intake (small amounts of food more frequently, better food choice)
Fluid volume restriction (client teaching, develop a plan, fluid of choice, frequent mouth care)

Question 17

Interventions for fluid deficit

Answer 17

Monitor I&O's
Daily weights
Monitor vital signs
Fluid replacement (oral vs IV)
Skin care
Diet

Question 18

IV fluid resuscitation depends on

Answer 18

The assessed level of dehydration or fluid loss

Question 19

Acute vs emergent

Answer 19

Acute = pressing
Emergent = requiring immediate action

Question 20

Objective indicator of a client’s fluid status

Answer 20

Daily weights

Question 21

Consistency in daily weights

Answer 21

Same time
Same scale
Same clothes after voiding

Question 22

1 kg / 2.2 lb is equal to ____ in fluid loss

Answer 22

1 liter

Question 23

I&O documentation frequency

Answer 23

q 2 hours

Question 24

Strict I&O documentation frequency

Answer 24

q 1 hour

Question 25

Minimum adult output

Answer 25

30 mL/hr

Question 26

Minimum child output

Answer 26

1-2 mL/kg/hr

Question 27

I&O trends

Answer 27

Oral
Enteral feedings
IV fluids
Blood transfusions
Urine
Diarrhea
Emesis
Wounds
Drains