5. • Assess VS
– Check BP lying, sitting, standing
– Note changes
• Assess current urine output and recent
I&O
• Make sure patient is comfortable and
safe
• Notify physician
6. • Document the following:
– Patient’s status
– Phone call to physician or NP
– Physician or NP response
8. Assess:
• VS including temperature
• Skin for
color, moistness, temperature, integrity
• Mucous membranes
• LOC and orientation
• For patent IV access
10. • Administer or oral IVF
• Closely monitor I&O
• Monitor urine output for adequate
hourly rate
• Assess electrolytes, BUN, creatinine
• Maintain safe environment
• Provide oral care
• Chart patient status and convey to
physician or NP
15. Signs and Symptoms of Progressive
Dehydration
Moderate
Symptom/sign Mild Dehydration Severe Dehydration
Dehydration
LOC Alert Lethargic Obtunded
Capillary refill 2 sec 2-4 sec >4 sec, cool limbs
Mucous membranes Normal Dry Parched, cracked
HR Slight increase Increased Very increased
Increased and
RR Normal Increased
hyperpnea
BP Normal Normal but orthostasis Decreased
Pulse Normal Thready Faint or impalpable
Skin turgor Normal Slow Tenting
Urine output Decreased Oliguria Oliguria/anuria