1. Keep strict record of intake and output. Teach client hours.Interventions with Dry skinDecreased skin turgorWea k ne s sChange in mental stateDry mucous membranesGoals/ObjectivesShort-term GoalClient will drink 125 mL of fl 2. Weigh client daily immediately on arising and following figood skin turgor; and immediate capillary refiLong-term GoalBy discharge from treatment, client will exhibit no signs or symptoms of dehydration (as evidenced by quantity of urinary output suffiv it a l sig n s w it h i n nor m a l l i m it s; moi st , pi n k mucou s membr a ne s; 3. Assess and document condition of skin turgor and any chang-information is required to promote client safety and plan weight is needed to plan nursing care for the client.importance of daily flvoiding. A lways use same scale, if possible. nursing care. cient to individual client; normal specifiSelected Rationales uid intake of 2000 to 3000 mL. uid each hour during waking Eating Disorders ll).An accurate daily c gravity; ●^ This rst^225
2 2506_Ch12_218-235.indd Sec1:225 506 Ch 12 218 - 235 .indd 7. Assess and document moistness and color of oral mucous 5. Monitor laboratory serum values, and notify physician of^ S^ 4. Discourage client from bathing every day if skin is very dry. 8. Encourage frequent oral care 6. Client should be observed for at least 1 hour following meals 9. Help client identify true feelings and fears that contribute ec 1 es in skin integrity. body flreducing discomfort from dry mouth, and to decrease bacte-rial count, minimizing risk of tissue infection.Hot water and soap are drying to the skin.to maladaptive eating behaviors. measure for evaluating adequate hydration.resolved if maladaptive behaviors are to be eliminated.regarding client hydration.signifimembranes. and may need to be accompanied to the bathroom if self-tive of malnutrition or dehydration.induced vomiting is suspected. : 225 cant alterations. uids and can precipitate flDry, pale mucous membranes may be indica-Condition of skin provides valuable data Laboratory data provide an objective to moisten mucous membranes, Vomiting causes active loss of uid volume defiEmotional issues must be cit. 1 10/1/10 9:36:00 AM 0 / 1 / 10 9 : 36 : 00 AM