Assessment S> O> The patient manifests: Dry and warm skin Good skin turgor Afebrile Acyanotic

anotic Pink palms and soles

Nursing Diagnosis >Risk for

Scientific Explanation

Planning Short term: After 4o of nursing interventions , Long term: After 3 days of nursing interventions

Intervention Establish rapport Take and record vital signs

Rationale To establish rapport To obtain baseline data

Expected Outcome Short term: After 4o of nursing interventions, Long term: After 3 days of nursing interventions,

Assess skin turgor and mucous membranes for signs of dehydration

Dry skin and mucous membranes are signs of dehydration

>V/S were taken as follows: T= 36 C HR= bpm RR= cpm

o

Encourage the patient to increase fluid intake

To replace fluid loss and prevent dehydration

Keep the pts bed free from clutter

To promote safety To promote awareness and prevent complications

>The patient may manifest:

Review medical regimen, therapy regimen and appropriate safety measure

with the SO