24hr Fluid Balance Chart for Children OF10176 May 2008.indd - ICID

First Name Hosp. No. Seek senior advice if urine output
24 Hour Fluid Balance Chart for Children
Surname
less than 0.5mls/kg/hr for 2 consecutive
hours or less than 1.0mls/
DoB Weight
kg/hr in an infant
Minimum expected urine output based on
Age Date
weight = mls/hr
Time Input Output
Total
Input
Total
Output
01.00
02.00
03.00
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
Total 12 hour fl uid balance +/-
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
24.00
Total 24 hour fl uid balance +/-
Nursing Intervention
OF10176

First Name Hosp. No. Seek senior advice if urine output
24 Hour Fluid Balance Chart for Children
Surname
less than 0.5mls/kg/hr for 2 consecutive
hours or less than 1.0mls/
DoB Weight
kg/hr in an infant
Minimum expected urine output based on
Age Date
weight = mls/hr
Time Input Output
Total
Input
Total
Output
01.00
02.00
03.00
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
Total 12 hour fl uid balance +/-
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
24.00
Total 24 hour fl uid balance +/-
Nursing Intervention