Republic of the Philippines TARLAC STATE UNIVERSITY COLLEGE OF NURSING Lucinda Campus, Brgy.

Ungot, Tarlac City Philippines 2300 Tel. No.: (045) 493- 1865 Fax: (045) 982-0110 website: www/tsu.edu.ph
Accredited Level 1 Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP) Inc

Performance Evaluation Checklist Measuring Intake and output

Name of Student: ________________________________________________________________ Year and Clinical Group: __________________________________________________________ School Year: __________________________ Term: ___First Sem ___Second Sem ___Summer Inclusive Dates of Clinical Rotation: ________________________________________________ Instructor: ______________________________________________________________________ Core Competency 2 1 0 I. SAFE AND QUALITY NURSING CARE
Assessment

1. Assess the clients risk factors for fluid overload 2. Determine if the client is receiving fluids or medications that would predispose her to fluid overload.
3. Assess the clients risk factors for fluid loss 4. Determine if the clients urine output is in excess of her fluid intake 5. Assess the clients ability to understand and cooperate with intake & output measurement. Planning /Expected Outcome 1. The clients fluid intke & output will be accurately measured and recorded. 2. The client will participate in the recording of fluid intake and output to the best of her ability. Implementation Intake 1. Wash hands 2. Explain rules of intake & output record 3. Measure all oral fluids in accord with agency policy Record all IVF as they are infused 4. Record time & amount of all fluid intake in nthe designated space on bedside form 5. Transfer 8 hour intake total fluid intake from bedside I&O record to graphic sheet or 24 hour I &O record on clients chart. 6. Record all forms of intake except blood and blood products in the appropriate column 7. Complete 24 hour intake record by adding all 8 hour total Output 8. Apply non sterile gloves and personal protective equipment (PPE) 9. Empty urinal ,bedpan or foley drainage bag into graduated container or commode hat.Other output may also be recorded ,including nasogastr4ic suction,suction bulb (eg. Jackson Pratt or hemovac ) 10. Remove gloves and wash hands. 11. record time and amount of output on bedside I &O record 12. Transfer 8 hour output totals to graphic sheet or 24 hour I &O record on the clients chart 13. Complete 24 hour output record by totaling all 8 hour totals. 14. Wash hands.

II.

MANAGEMENT OF RESOURCES, ENVIRONMENT AND EQUIPMENT 1. Prepares instruments and equipments needed. Intake & Output Record Chart

2. 3. 4. 5. 6. III. 1. 2. 3. 4. IV. 1.

Calibrated Drinking Glass Urine specimen collection bottle with calibration Drainage bag with calibration Maintain cleanliness during the procedure Observes proper measurement and time when reading and recording I&O in the record chart Uses supply diligently Performs after care of the materials and equipments used. Ensures proper waste management. HEALTH EDUCATION Teaches the client on basic preparation during the procedure. Explains the importance of checking & recording Intake & output to the client/relative Informs the client the benefit of proper checking & recording of I&O Respond to questions to clients and relatives regarding expectations LEGAL RESPONSIBILITY Secures informed consent (based on the hospital policy.)

2. Reports accurately and honestly the result of I & O to the attending Physician for proper treatment & management 3. In the procedure note the amount, color, presence of blood , odor and consistency of the urine and pattern of urination for proper reporting to the attending physician 4. Ensures proper identification of the client 5. Document all pertinent data correctly and completely. V. ETHICO-MORAL RESPONSIBILITY 1. Respect the religious, cultural and ethical practices of the client and family. 2. Promotes emotional security by supporting needs. 3. Ensures privacy and confidentiality VI. PERSONAL AND PROFESSIONAL DEVELOPMENT 1. Updates oneself with the latest trends and development in proper Intake & output recording & documentation. 2. Projects professional image of a nurse 3. Accepts criticism and recommendation VII. QUALITY IMPROVEMENT 1. Identifies deviation of practice from the standards and report to proper person in charge. 2. Participates in audit practices in Intake & Output recording & documentation 3. Recommends corrective and preventive measures for the identified deviation. VIII. RESEARCH 1. Identifies researchable problems related to In 2. Initiates research study on an identified researchable problems regarding Intake & Output recording & documentation 3. Participates as a member of a research team in the conduction of a research study. 4. Utilize findings of research studies in Intake & Output recording & documentation

IX. RECORD MANAGEMENT 1. Document accurately relevant data about the client. 2. Maintain an organized system of filling and keeping records of the client. X. COMMUNICATION 1. Utilizes appropriately all forms of communication verbal, non-verbal, electronic 2. Informs client/significant others of the progress of the procedure. 3. Listen attentively to clients and families queries and request. XI. COLLABORATION AND TREAM WORK 1. Functions effectively as a team member in any area. 2. Communicates any problems encountered during the procedure to other team members. 3. Establishes collaborative relationship with the members of the health team and family members. TOTAL SCORE:

Evaluated by:

_________________________________________ Signature over Printed Name Clinical Instructor

Performed by:

_________________________________________ Signature over Printed Name Student

Prepared by:

Maria Susan Z. Maglaqui, RN, MAN Clinical Instructor

Recommending Approval :

Lorna C. Gamis ,RN,MAN Chairwoman RLE Instructions

Approved :

Prof. Lucila O. Sunga ,RN,MPA ,MAN College Dean