Abnormal findings and what they may signal — each warrants Mode B focused documentation and, where parameters are met, intervention and notification:
Dry mucous membranes, poor turgor, excessive thirst, dark or concentrated or reduced urine, delayed capillary refill, tachycardia, or an orthostatic drop — suggesting dehydration.
Excessive fluid intake or nonadherence to an ordered restriction.
Signs of fluid overload — new or worsening edema, jugular venous distension, crackles, or a weight gain (interpreted with Cardiovascular).
Increased losses — vomiting, diarrhea, or high wound or ostomy output.
Electrolyte-related symptoms — weakness, cramping, confusion, or palpitations.
Reduced access to fluids from cognitive, functional, or swallowing limitations.
