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ASSESSMENT Subjective: Nauuuhaw pa po ako as verbalized by the patient.

Objective: >Dry and chapped lips >dry mucous membranes (mouth), >complaints of thirst >decreased skin turgor >Slight irritability due to thirst >increase BP 110/80 V/S taken: T: 37.30C P: 119 R: 24 BP: 110/80

DIAGNOSIS Skin Integrity due to limited fluid intake as resolution to edema in treatment of Acute Glumerular Nephritis Fluid volume deficit related to inadequate intake of fluids

INFERENCE The patient is experiencing thirst as resolution for the edema as a complication of Acute Glumerular Nephritis. Fluid Restriction is necessary to resolve the complications of edema. Patients with fluid volume deficit are more at risk to skin breakdown.

PLANNING After 8hours of nursing interventions, the patients discomfort will be decreased and will demonstrate use of relaxation skills and other methods to promote comfort. The patient to maintain fluid volume at a functional level as indicated by moist mucous membranes, good skin turgor, adequate urinary output and no discomfort in defecation and regular bowel movement.

INTERVENTION Independent: Monitor vital signs

RATIONALE > Knowledge of vital signs allows physicians to understand patients physiologic status and is helpful in determining appropriate goals. >This could give further information on the patients water retention problem >To promote comfort to patient on a humid and hot day, to lessen sweating > These are diversional activities to redirect attention from being thirsty >To promote hygiene and prevents drying of skin >To prevent further dryness and skin breakdown > To lessen friction on dry skin , to prevent skin breakdown

EVALUATION On the second day of duty, the patient has improved hydration manifested by lesser chapping of lips and lesser drying of the mouth. The patient can cope with the limited of fluid intake by lessening activities which could make her thirsty and sweat. The patient is doing diversional activities to redirect her attention from being thirsty.

Monitor weight gain and loss Assess edematous

Advise patient to wear light clothing Advise patient to lessen activity Suggest sleep or do light reading as diversional activity Bathing every other day, sponge bath only on intervals Apply wet cotton balls on dry and chapped lips Straighten wrinkled linens to lessen friction on dry skin

Dehydration is a condition when output of body fluids exceeds fluid intake. In early dehydration, fluid loss is from both intracellular and extracellular compartments. In chronic dehydration, fluid loss is predominantly cellular. Fluid loss may result in shock, acidosis or alkalosis, kidney and brain damage in children; death occurs much more quickly than in the adult patients.

Dependent: Administer diuretics and antibiotics as ordered by Physician

This is resolution for the complications of edema