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• Irritability temperature. .
• Diaphoresis
Encourage increase To replace fluid loss
fluid intake
Subjective: INDEPENDENT
Within 7 hours of nursing Within 7 hours of
Risk for Fluid
interventions, the patient Assessed skin turgor indicator of nursing
volume deficit dehydration
Objectives: will be able to maintain and moisture interventions, the
related to
adequate fluid volume at a patient maintained
increased decrease body
functional level through Monitored
• Oral Fluid metabolic rate fluids through adequate fluid
giving supplemental fluid as temperature
intake of secondary to perspiration and volume at a
ordered and increase oral increase
150 cc for inflammatory functional level as
fluid intake as evidenced by respiration.
the last 8 response evidenced by:
atleast additional 4 glasses
hours Monitored I & O to ensure a. taken
of water and continuous
• Weakness balance being accurate picture additional 5
TSB.
of fluid status glasses of
• Slightly dry aware of insensible
lips loses water
• Pallor TSB promotes b. SO continuous
Gave tepid sponge heat loss through TSB.
bath conduction and
evaporation
to maintain
Advised patient to hydration status
increase oral intake
COLLABORATIVE: