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Assist in To maintain
suctioning clear and open
airway.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Fluid volume After 4 hours of
deficit r/t nursing intervention
Objective: the patient will
Dry lips maintain fluid
Warm skin volume at a
Tachycardia functional level as
Tachypnea evidenced by stable
vital signs.
V/S:
BP: 100/70
PR:184
RR:45
T: 38.0