Review each scenario. Answer the I&O related questions. There are 20 questions, each is worth 5 points.
Mr. Juan Garcia is a 60-year-old male presents to the clinic with a diagnosis of congestive heart failure. He has experienced increased fatigue and shortness of breath on exertion over the last
week. He has peripheral swelling of 4+ edema to the lower extremities. He has had a decreased appetite with a weight gain of 10 lbs over the last 2 months.
The health care provider has admitted the patient to the telemetry floor with the following orders:
Today Admit to telemetry: DX: Congestive Heart Failure
0945 Tele monitoring
VS q 4 hr
O2 2LNC titrate to keep O2 sats > 92%
Diet: Oral Fluid Restrict 17oomL /24 hours; low sodium diet
Saline lock IV
Place foley to gravity
Strict I & O
BNP,CMP, BMP, PT, PTT, INR in am tomorrow
Cxr in am tomorrow
ECG Now (done in ER)
2 D Echocardiogram (done in ER)
Lasix 40mg IV BID
Altace 5 mg PO daily
Coreg 3.125mg PO BID (hold for SBP < 90)
Coumadin 2.5 mg PO daily
Tylenol 625 mg PO prn temp >100 degrees F
John Marshall, MD Today @ 0730
MR # 06992
DOB: 8/23/1949 Physician: Dr. Marshal
Admit date: Yesterday
1. What is the difference between strict I&O and fluid restrict?
2. How will the 1700mL fluid restrict be divided over the 24 hour period in three 8 hour shifts?
Scenario 1 Continued:
In the last 8 hour shift (7a-3p), for breakfast Mr. Garcia had toast with 1 packet of jam and 4oz of orange juice. At 0900 the nurse administered 40mg of Lasix that came in a 40mg/4mL vial (4mL
total) with a 10mL saline flush. He consumed his am medications with 45mL of water. At 1100 the CNA recorded 1500mL from the Foley catheter. For lunch Mr. Garcia had a 50mL of water and ½
cup of sugar-free jello with his meal. At 1230, Mr Garcia had a solid well-formed bowel movement. At 1300, the nurse administered Tylenol as ordered for a temp of 100.2 degrees F with 40mL of
water. At 1500 the CNA recorded 475 mL from the Foley catheter.
3. What is the intake for the 8 hour shift?
4. What is the output for the 8 hour shift?
5. Is the intake within the 1700mL fluid restrict for the first 8 hour shift?
6. What is the fluid balance for the 8 hour shift? (Is it positive or negative? And by how much?)
7. What is the cause of the imbalance and in your nursing judgment is it an expected outcome, why?
Mr. B was admitted for a second bowel resection surgery three days ago. He also has a Foley catheter. He has an IV of LR running at 125 mL/hr and is on a clear liquid diet. In the last 12 hour
shift (7a-7p), for breakfast Mr. B consumed 3 ½ oz of water with toast and eggs. He consumed 50mL with his morning medications. At 1100 the CNA records 435 mL from the Foley. At lunch Mr. B
had 1 cup of soup and 1 cup of jello. At 1500 the CNA records 375 mL from the Foley. At 1630 the nurse uses 350mL of sterile water to clean and empty the colostomy pouch. A total of 525mL is
measured. Mr. B’s diet was advanced to full liquids for the evening meal. He consumes 4oz of milk with 1 cup of cream soup and a saltine cracker. At 1900 the CNA records 380mL from the Foley.
8. What is the intake for the 12 hour shift?
9. How do you obtain actual colostomy output in relation to the volume of sterile water used to clean the colostomy into the intake and output?
10. What is the output for the 12 hour shift?
11. What is the fluid balance for the 12 hour shift (Include sign and volume)?
12. In your nursing judgment is the fluid balance appropriate, why?
13. What are some expected assessment findings with this fluid balance?
14. What is the appropriate nursing intervention?
15. What is wrong with Mr. B’s evening meal?
Mrs N is one day post-op mastectomy. She has a Jackson Pratt drain to the affected side. She is on a clear liquid diet. She has an IV of LR running at 75 mL/hr. In the last 12 hour shift (7a-7p),
for breakfast, Mrs N consumed 5 oz of coffee and 1 cup of clear broth. Mrs N voided 575mL in the bedside commode hat. At 0900 Mrs N. consumed 150mL with her morning medications. At 1130
the CNA assisted Mrs N to the bedside commode for a void of 500mL. For lunch Mrs N consumed 4 oz of milk with her clear broth. She only consumed 1/3 cup of the soup. At 1430 Mrs N voided
580mL clear yellow urine in the bedside commode hat. For dinner Mrs N consumed 1 ½ cups of jello and ¾ cups of clear broth. At 1640 Mrs N voids 360mL. At 1815 the nurse empties 150mL of
serosangeunous fluid from the JP drain and re-sets the drain.
16. What is the intake for the 12 hour shift?
17. What is the output for the 12 hour shift?
18. What is the fluid balance for the 12 hour shift (Include sign and volume)?
19. In your nursing judgment is the fluid balance appropriate; why?
20. What is wrong with Mrs N’s noon meal?
Define or describe serosanguenous fluid.
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