INTAKE AND OUTPUT SHEET1oz=30ccJELLO-150CC JUICE CUP- 120CC ICE CREAM-120CC STYROFOAM CUP- 200CCSOUP-220CC PLASTIC CUP-180CC COFFEE/TEA-220CCSODA-240CCMILK-240CC

0700-1500 SHIFT PO IV URINE N/G STOOL

0700

0800

0900

1000

1100

1200

1300

1400

1500

TOTAL TOTAL

SHIFT TOTAL SHIFT TOTAL

INTAKE AND OUTPUT SHEET1oz=30ccJELLO-150CC JUICE CUP- 120CC ICE CREAM-120CC STYROFOAM CUP- 200CCSOUP-220CC PLASTIC CUP-180CC COFFEE/TEA-220CCSODA-240CCMILK-240CC

1500-2300 SHIFT PO IV URINE N/G STOOL

0700

0800

0900

1000

1100

1200

1300

1400

1500

TOTAL TOTAL

SHIFT TOTAL SHIFT TOTAL

INTAKE AND OUTPUT SHEET1oz=30ccJELLO-150CC JUICE CUP- 120CC ICE CREAM-120CC STYROFOAM CUP- 200CCSOUP-220CC PLASTIC CUP-180CC COFFEE/TEA-220CCSODA-240CCMILK-240CC

2300-0700 SHIFT PO IV URINE N/G STOOL

0700

0800

0900

1000

1100

1200

1300

1400

1500

TOTAL TOTAL

SHIFT TOTAL SHIFT TOTAL

Mr. Jones has been admitted to Concorde Career Hospital with a Diagnosis of Congested Heart Failure. He has been placed on Strict Intake and Output (I & O). INTAKE OUTPUT

TIME ROUTE AMOUNT/SOLUTION URINE

0700 PO WATER 8 OZ 150cc

0800 PO COFFEE 1 CUP 325cc

0900 PO OJ 8 OZ 150cc

1100 IV D5W 100ML

1200 PO TEA 8 OZ 100cc WATER 10OZ SOUP 1 BOWL 1300 PO GINGER ALE 8OZ JELLO 1400 IV D5W 100ML 200cc

1500 PO WATER 8OZ

1600 PO APPLE JUICE 8OZ 500cc

1700 PO COFFEE 1 CUP

1900 IV D5W 100ML 150cc

2100 PO JELLO

2200 PO WATER 12OZ 200cc

0000 PO WATER 8OZ 75cc

0200 PO WATER 6OZ 0600 PO APPLE JUICE 4 OZ 300cc

MEAL INTAKE GUIDELINES 0 % refused meal completely or consumed only 1 or 2 bites of each item Refused 25% approximately 25% of entrée or 50% of one item eaten Poor 50% approximately ½ of food is eaten – 50% of entrée, vegetable, starch & Fair dessert consumed 75% almost all of the meal is consumed but a significant amount of 1 or more Good items is left– Ex. 25% of entrée or 75% of vegetable is not eaten. 100% Entire meal is consumed except for a minimal amount of food – ex. Less All than 25% of vegetable or dessert left Instructions: You are assigned to feed your patient either applesauce, pudding, yogurt, or jello. Record food intake as a percentage (&) of food eaten Record: X- next to the % category that best matches the resident’s intake R- if the resident refuses to eat SNACK MARK “X” NEXT TO

% OF FOOD INTAKE

75-100% 50-75% 25-50%

% EATEN

0-25%

TYPE/FOOD EATEN_______________ SIGNATURE:

NAME______________________________________________________ CONVERT THE FOLLOWING OUNCES TO CUBIC CENTIMETERS AND VICE VERSA KEY: 1 OUNCE (oz) = 30 cubic centimeters 1 milliliter (ML)= 1 cubic centimeter (CC)

1. 10oz=___________cc 11. 45cc=__________oz

2. 16oz=___________cc 12. 150cc=_________oz

3. 4oz= ___________cc 13. 75cc=__________oz

4. 5oz=____________cc 14. 30cc=__________oz

5. 100oz=__________cc 15. 900cc=_________oz

6. 25oz=___________cc 16. 180cc=_________oz

7. 150oz=__________cc 17. 210cc=_________oz

8. 20oz=___________cc 18. 300cc=_________oz

9. 125oz=__________cc 19. 450cc=_________oz

10. 45oz=__________cc 20. 90cc=__________oz