After reviewing the client’s intake and output record for the last eight hours, the nurse calculates the client’s current fluid balance as how many mL? (Enter numeric value only).
0730-8 oz of orange juice, hard boiled egg, and toast
0830-voided 150 ml
1200-1 cup of soup, tuna sandwich, and 1/2 cup of apple juice
1300 vomitus of 100 mL
1400 voided 250 mL and drank one 12 oz can of soft drink
The Correct Answer and Explanation is:
To calculate the client’s fluid balance, the nurse needs to consider both the intake and output of fluids over the specified period.
Step 1: Convert the Fluid Intake to Milliliters
- 0730 – 8 oz of orange juice
- 1 oz = 30 mL
- 8 oz × 30 mL/oz = 240 mL
- 1200 – 1 cup of soup
- 1 cup = 240 mL
- 1200 – 1/2 cup of apple juice
- 1 cup = 240 mL
- 1/2 cup = 120 mL
- 1400 – 12 oz can of soft drink
- 12 oz × 30 mL/oz = 360 mL
Now, sum up the total intake:
- Orange juice: 240 mL
- Soup: 240 mL
- Apple juice: 120 mL
- Soft drink: 360 mL
Total Intake = 960 mL
Step 2: Calculate the Fluid Output
- 0830 – Voided 150 mL
- 1300 – Vomitus 100 mL
- 1400 – Voided 250 mL
Now, sum up the total output:
- Urine (0830): 150 mL
- Vomitus (1300): 100 mL
- Urine (1400): 250 mL
Total Output = 500 mL
Step 3: Calculate the Fluid Balance
Fluid balance is calculated by subtracting the total output from the total intake:
Fluid Balance = Total Intake – Total Output
Fluid Balance = 960 mL – 500 mL = 460 mL
Final Answer:
The client’s current fluid balance is 460 mL.
Explanation:
The fluid balance is an important aspect of nursing care, particularly for clients who are at risk of fluid imbalances due to conditions such as dehydration, heart failure, or renal dysfunction. By carefully tracking both fluid intake (oral or intravenous) and output (urine, vomitus, etc.), nurses can assess whether a client is retaining fluids, losing too much, or maintaining a stable balance.
In this scenario, the nurse monitored the client’s fluid intake from beverages and food (since soup and juices contribute to fluid intake) and compared it against the fluid output, including urine and vomitus. The fluid balance calculation shows that the client has a positive balance of 460 mL, meaning they have retained more fluid than they have lost in the last eight hours. This positive balance might indicate normal hydration status or could suggest fluid retention depending on the client’s overall health condition. Regular monitoring is essential to ensure the client maintains an appropriate fluid balance to support bodily functions and prevent complications.