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Background

As an occupational therapist who works in acute care or inpatient rehab (ARU), you may hear the term “Strict I&O”, “Strict I/O”, or “Strict input and output”. Occupational therapists working in this setting should familiarize themselves with this term, its meaning, and implications for practice with consideration for OT and collaboratively on the interdisciplinary team.

Learning about I&O’s in general and more specifically, “Strict I&O” will help you become an OT who promote patient’s ADLs based on underlying medical and comorbid etiology in line with the team’s goals. This will help to prevent further medical complications, accurate record-keeping for nursing and medical staff (and not get you in trouble!), as well as promote successful outcomes through patient’s personal engagement and motivation with basic ADLs.

Implications

  • Fluid/electrolyte imbalance, e.g. sodium or plasma proteins
  • Potential risks for volume deficits
  • Fluid restriction (close monitoring of how much intake, often a certain volume per day or parts of the day)

Population & Conditions

  • You may see strict I & O in potentially any patient, especially an older adult or one with multiple comorbidities.
  • Renal, ESRD, Dialysis
  • Cardiac, CHF, Pulmonary edema
  • Critical and unstable
  • Patients on: diuretics or IV; wound irrigation, GI suctioning
  • Fever
  • Vomiting, Diarrhea
  • Polyuria
  • Excessive sweating (while likely not significant during an OT session, an important consideration for the patient’s who are especially diaphoretic)
  • Malnutrition, Poor intake

Definition

I & O – input and output.

Strict I & O – stresses the importance of recording and monitoring the intake and output.

Ice Cubes
Ice chips may count towards intake.

Input is the fluid that is consumed (tube feeding, IV, blood transfusions, beverages, ice chips, gelatin, ice cream/frozen treats, nutrition supplements). Pudding is usually not counted, depending on the source.

Output is fluid that leaves the body oftentimes through urine output. Also included: emesis, liquid stool, wound training, and suction. Collection methods include: commodes, bedpans, toilets, or similar containers. As an OT, “output” is not limited to what you find in foley catheter bags, and urinals – always look for spills/accidents, incontinence type of output in briefs/diapers, bed linens, clothing, etc. to account for additional volume loss.

Other output: typically more relevant for nurses who may also monitor the output of other fluids by (blood, post-surgical, infectious discharge, etc.) drainage as well – but this is beyond the scope of occupational therapists. Still, OT’s should monitor for output other than the usual routes for signs of bleeding or wounds for any abnormalities.

Strict I & O – MD Order

  • Usually this starts with a MD order from general/hospitalist, physiatrist, or specialist (e.g. cardiologist, nephrologist).
  • Can be easily overlooked on the order of therapy orders compared to weight bearing or other precautions since this may be communicated only in nursing orders/communication. If you have an awesome nurse, they may tell you to record the intake or measure the output.

Calculation and Recording

OT Role

  • OT’s will not need to calculate I & O – that’s the job of nurses. Phew!
  • OT’s will and should record intake and output and/or communicate with nursing their findings to help keep an accurate account of intake and output. This can be via debriefing with a nurse after a session, recording somewhere such as a patient’s communication board on the wall, or letting a CNA/care partner know (less recommended as this introduces a layer of potentially lost communication).
  • Always follow recommended swallow / dysphagia recommendations from other disciplines, e.g. SLP.
  • Considerations in OT Practice
    • “Strict I/O” on the patient’s communication board at beside or signage that may be posted at the head of bed or in the patient’s chart.
    • Cups or water pitchers that may be intentionally out of the patient’s reach.
    • Pay attention to how much volume the patient drinks. If you are being extra helpful and offering to refill pitchers, ice, etc. – let the RN know or record it.
    • If you help clear out the patient’s meal tray, remember to record intake as well!
    • Remember “Outside” fluids (e.g. from patient’s own belongings, a guest brought food, take-out, etc.) also count towards the intake.
    • Urine collection hats on commodes and toilets. Know what they look like and where to find them from the supply room if you need to grab one yourself in a pinch.
    • Incontinence on chux pads, soiled linens, clothes, etc.
    • You won’t need to worry about output found in foley catheter bags/boxes, suction canisters, external catheters (PureWick), etc.
    • Watch out for those automatic flushing toilets. Policy guidelines may technically prohibit modifying motion flushing sensors, e.g. covering them with tape. You’ll need to get “creative” and work around this either by preparing ahead of time with a hat.

Patient Education

  • Collaborate with the nursing staff.
  • Educate on fluid intake restriction and reason for restriction – I find that patient often does not understand why they are on fluid restriction which can lead to frustration, misunderstanding, poor patient outcomes, and compliance!
  • If the patient’s progress and become more independent and ambulatory to remember to use hats or other measuring devices before flushing the toilet or emptying output.
  • Educate caregivers, family members, visitors and stress the importance of strict I & O’s.

Conclusion

Depending on what unit you work on (I often encounter strict I & O’s in acute rehab more often than med surg), you may think that I & O and strict I & O is the responsibility of nursing. However, OT’s facilitate and promote function in I & O with ADLs through feeding/eating and toileting where I & O can occur naturally. It can also occur unintentionally such as incontinence or emesis. You’ll likely let the nurse know if your patient had emesis or incontinent, but may not be thinking about I & O through ADLs.

Overall, it is important to keep with the patient’s medical plan and following MD orders to ensure continuity of care and to let the medical team get an accurate representation of fluids both inside and outside the body. If you mess up and forget to record an I or O, don’t stress about it! Just let the nurse know what happened so that they can at least account for some gain/loss of volume from your OT session. As you become more experienced in these settings with patients who have strict I & O’s it will become more natural to you and your nurses will really appreciate the extra set of eyes and hands.