I have had some serious debate, arguments and (believe or not) shouting matches over how to properly record I/O’s for Murphy Drips. Some nurses have a way of doing things and that is fine. However, one size never fits all, and you’ll see why shortly.
We can talk about Murphy Drip I/O until we are blue in the face, but here’s the only two things that matter; making sure the patient is comfortable and ideally having a positive balance (more out than what we put in). Here are the important boxes to check off when we do the I/O’s for our Murphy Drip patient.
- Bedside report
- Understand where the previous nurse left off
- Start over, unless we are 100% comfortable with what we receive in report, get a new sheet of printer paper and tape it somewhere close by, like the bathroom door.
- Nurse/tech huddle
- Documenting the I/O’s into the computer is the nurses responsibility. Not all the contents in the collection bag is urine output, the majority is the irrigation fluid
- Show our tech the I/O recording sheet we hung up, and have them write in the time and amount they’ve drained where you want it in the “Out” column
- If you don’t have a good report with the tech, or they are new, take total control over the I/O’s
- Mark the irrigation bags
- The first bag I hang is (1), then (2) and so on. This will help keep track of where we are during the shift
In the photo above we have our patient output draining into a Foley bag (A) with an attached urometer. We’ve taken bedside report and the nurse signing off shows us the I/O sheet (C) and says, “I hung a bag at 0900 and all the current output in the Foley bag belongs to your shift.”
- Mark the bags, the one that is running will be (1), the other bag that is clamped, (2)
- We return at 0950, bag (1) is almost empty (good timing!)
- Wait for bag (1) to finish, empty the urometer into the Folegy bag (Input of 2000cc)
- Clamp the line to bag (1), unclamp bag (2)
- With the “Murphy Drip Only” basin, drain and measure the output with a graduated cylinder (B)
- In this example we get 2100cc Output
- Bag (1) hung at 0900 has completed so we mark down 2L (or 2000cc/mL/whatever in the Input column
- We only emptied once for bag (1) so we only have one measurement (2100cc) to write in the output column
- Document: Output – Input = Urine output or 2100cc – 2000cc = 100cc Urine Output
- At my hospital we ‘adhoc’ in the Murphy Drip I/O instead of charting the standard “100cc Foley output” to indicate that we are irrigating the bladder. The computer does the math, we just need to put the numbers in the right place and note when the fluid was hung.
- Once I/O is recorded where it belongs, cross out that bag on your I/O sheet so it is not documented twice
- Take down empty bag (1), hang a new bag, label it (3)
- Assess the color of the output, remember we want a nice light watermelon pink
- Titrate accordingly
Writing this out, there are a lot of steps, but they are the same every time. It is a routine that is easy enough to pick up. So what happens if we do the math and we have a negative number for output?
First, don’t freak out. Assess the patient, if they look comfortable and the irrigation fluid is running in the drip chamber, they are fine for the moment. I almost always inherit a negative fluid balance from the previous shift when measuring my first bag. I don’t want to continue to see a negative fluid balance, but it almost always evens out over an eight hour shift. This risk is that we don’t want the patient’s bladder to explode or find out that the bladder has a fistula and we are draining bag after bag into their abdominal cavity.
Switching bags of irrigation fluid is not an exact science. The urometer used as mentioned above helps with accuracy. Over the course of the shift we want to find a positive fluid balance, preferably noting a urine output > 30cc an hour (240cc in an eight hour shift). Sometimes we go back and look at our I/O sheet and realize we added incorrectly, simple fix.
Again, assess the patient. If they aren’t in a coma, they will let you know when their bladder becomes full or distended, you shouldn’t even have to palpate it (don’t deeply palpate a full bladder). Note any changes/distention to their abdomen. If we do all these things and the balance is still negative or low, < 240cc for an eight hour shift, check the math, then notify the provider as appropriate. Make sure to tell them how the patient is responding to the irrigation.
- Because there’s an in/out to a catheter needed for a Murphy drip, they are large, and uncomfortable before we even start to talk about the bladder getting distended. Show mercy on them. Murphy patients will frequently get bladder spasms, also painful. Make sure you have a PRN for that situation.
- Murphy drip patients pain is usually remedied by manual irrigation or PRN anti-spasmodic
- It’s common for the color of the output to darken with ambulation, titrate accordingly.
- Sometimes we’ll struggle to run a 2 liter bag of irrigation fluid in an eight hour shift because the output looks so good (watermelon pink or even clear yellow), notify the provider, it’s almost ready to be completely clamped and trialed for discontinuation.
- These patients are actively bleeding. Monitor their hemoglobin and hematocrit, they occasionally need to be transfused with RBCs.
- If your patient is needing frequent manual irrigation or requires wide open irrigation and we have to change bags every 15 minutes, enlist the help of the charge nurse so we can see our other patients too.
- For I/O’s, if the drip is running fast you can measure more than one bag at a time. If you don’t have time to add up the output and document, just open another bag and move on. There will be more numbers to add because we’ve infused multiple bags.
- Make sure the drip doesn’t stop because the bags are empty.
- Develop your own system, as long as you can explain it to another nurse and keep accurate I/O, it’s fine.
- Some nurses prefer to add up all the input and output at the end of the shift. I prefer bag to bag so that I am aware of the fluid balance (hopefully positive) on a bag to bag basis and there is less risk of an addition error. I don’t want to get to the end of my shift and realize I’m negative 500cc.
- Share the experience with other nurses. I remember learning about the Murphy drip patient initially was not a comfortable experience. Half the battle is knowing what’s going on so the next time we run into one we can move forward with confidence and put the patient at ease.
- Don’t forget, every facility is going to have a protocol. Print it out and share.
- If you are around when the urologist is rounding, go in the room with them, help them with the patient and ask them questions to improve your practice.
Please drop me a comment if there are any questions. I hope you found this beneficial to your practice and I am always interested in your experiences.
Thanks for reading.