Phc Medicine Fluid Balance And Iv Therapy Form
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1
2PHC MEDICINE
FLUID BALANCE & IV THERAPY
Page: 1 of 2
Date from 0600
to 0600
Remember to weigh patient daily.
FLUID BALANCE
FLUID RESTRICTION:
ABDOMINAL GIRTH:
BR = Bathroom
INTAKE
OUTPUT
INC - Incontinent
Amount
Volume
TIME
IV Solution/Drug/Flow Rate
Initial
TIME
Oral
Initial
TIME Urine
Therapy
Start
Infused
TIME
IV
Oral
Total
TIME
Urine
Total
Init.
1800
+
+
=
1800
+
+
+
=
12 hour subtotals:
0600
0600
+
+
=
+
+
+
=
Combined total =
Combined total =
24-hour balance =
STANDARD VOLUMES
Soup bowls
180 mL
Styrofoam cup
180 mL
Pre-portioned juice/milk
114 mL
Popsicle
75 mL
Insulated mug
180 mL
Clear plastic water cup
420 mL
Pop cans
335 mL
Creamer
15 mL
Tetrapack juice/milk
235 mL
Dessert (ice cream/sherbet/jello)
120 mL
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