ASSESSMENT SUBJECTIVE:

DIAGNOSIS Deficient fluid volume related to active fluid loss Limangarawnaakongnagtatae due to diarrhea at suka as verbalized by the patient.

OBJECTIVE: y y y y y Dry mucous membranes Cold, clammy skin Restlessness Poor skin turgor Slow capillary refill

PLANNING After 24 hours of nursing interventions, the Patient will maintain fluid volume at a functional level as evidenced by individually adequate urinary output and stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.

V/S taken as follows T: 36.3C P: 88 R: 17 BP: 110/ 80

INTERVENTION Independent y Monitor urinary output. y Weigh daily and compare with 24-hour fluid balance. y Evaluate clients ability to manage own hydration. y Ascertain clients beverage preferences, and set up a 24-hour schedule for fluid intake. y Turn frequently, gently massage skin, and protect bony prominences. y Provide skin and mouth care. y Provide safety precautions.

RATIONALE -Fluid replacement needs are based on correction of current deficits and ongoing losses. -Measurement provides useful data for comparison. -Impaired gag and swallow reflexes and change in level of consciousness are among the factors that affect clients ability to replace fluids orally. -Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement. -Tissues are susceptible to breakdown because of vasoconstriction and increased fragility. -Skin and mucous membranes are

EVALUATION After 24 hours of nursing interventions, the Patientwas able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.

Focus Hypovelimia

data SUBJECTIVE: Limangarawnaakongnagtatae at suka as verbalized by the patient. OBJECTIVE: y y y y y Dry mucous membranes Cold, clammy skin Restlessness Poor skin turgor Slow capillary refill

dry with decreased elasticity because of vasoconstriction and reduced intracellular water. -Decreased cerebral tissue perfusion frequently results in changes in mentation. -be present and action Response require correction. After 24 hours of nursing y Monitor urinary output. interventions, the Patientwas y Weigh daily and compare able to maintain fluid volume at with 24-hour fluid balance. a functional level as evidenced y Evaluate clients ability to by individually adequate manage own hydration. y Ascertain clients beverage urinary output with normal specific gravity, stable vital preferences, and set up a signs, moist mucous 24-hour schedule for fluid membranes, good skin turgor, intake. and prompt capillary refill. y Turn frequently, gently massage skin, and protect bony prominences. y Provide skin and mouth care. y Provide safety precautions.

FDAR-