.HYD_NORMAL

Skilled hydration assessment: mucous membranes moist, turgor normal, no excess thirst; urine adequate/normal color; intake {adequate/within restriction}; weight stable; no overload or deficit signs; tolerating fluid plan. RN judgment applied to evaluate balance and distinguish deficit from overload given {dx}. Continued skilled monitoring indicated.

.HYD_ASSESS

Mucous membranes {moist/dry}; turgor {normal/poor}; thirst {y/n}; urine {color/amount}; cap refill {<3s/delayed}; edema {grade/none}; intake {amount} vs {plan}; output {amount}; balance {+/-}.

.HYD_ORTHO

Supine BP {###/##} HR {##}; standing {###/##} HR {##}; symptoms {reproduced/none}; drop {meets/does not meet} threshold — see Vital Signs.

.HYD_SKILL

Differentiated deficit vs overload; monitored I&O vs plan; reconciled with diuretic; {encouraged intake/reinforced restriction}; coordinated {labs/IV fluids}; mitigated access barrier.

.HYD_TEACH

Reviewed {fluid restriction/encouragement}, I&O tracking, and dehydration/overload signs with {pt/cg}; method {teach-back}; mastery {##}%.

.HYD_COORD

Provider notified at {time} re {dehydration/overload/losses}; reported {content}; order received {hold diuretic/labs/IV fluids}; reassessment {when}.

.HYD_SAFETY

Call for dizziness, dark/low urine, or new swelling and breathlessness; 911 for severe SOB with pink frothy sputum or fainting.

.HYD_NECESSITY

Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.