Assessment Subjective: Hindi ako masyadong nakaka inum ng tubig, kaya nanuyot ang balat ko.

Objective: -Dry skin -Chopped Lips -Restlessness V/S taken: Temp: 36.3C PR: 88bpm RR:17cpm BP:110/80mmhg

Diagnosis Deficient fluid volume may be related to active fluid loss (hemorrhage, vomiting, gastric intubation, diarrhea, burns, wounds, fistulas).

Inference Inadequate water intake, loss through vomiting, diarrhea, gastrointestinal obstruction, fever or sweating, hemorrhage, burns, third space fluid shifting.

Planning After 4 hours of nursing interventions, the Patient will 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.

Intervention Independent Monitor urinary output.

Weigh daily and compare with 4hour fluid balance. Evaluate clients ability to manage own hydration.

Ascertain clients beverage preferences, and set up a 24-hour schedule for fluid intake. Turn frequently, gently

Rationale Fluid replacement needs are based on correction of current deficits and ongoing losses. Measureme nt 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

Evaluation After 4 hours of nursing interventions, the Patient was 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

massage skin, and protect bony prominences.

Provide skin and mouth care.

mucous membranes are dry with decreased elasticity because of vasoconstriction and reduced intracellular water. Decreased cerebral tissue perfusion frequently results in changes in mentation.

Provide safety precautions.