fluid balance assessment

Question 1

first steps

Answer 1

W ashes hands
I ntroduces oneself to patient and confirms identity of patient
P ermission obtained to perform examination
E xposes patient appropriately
R epositions patient at 45⁰
Q Are you in any pain?
Q Constitutional symptoms: fatigue, headaches, constipation, vomiting, thirst.

thirsty, d and v, dizzy when standing.

Question 2

inspection

Answer 2

General
Around the bed: Fluid restriction signs, Vomit Bowls, Drips,
Catheter bag

Patient
Body Habitus, Pallor (= sign of severe dehydration), Shortness of breath (= sign of over hydration), Orthopnoea, Sweating
P: at least 4 from the above list B: 2 from the above list

Question 3

palpation

Answer 3

Hands - Peripheral pulses and respiration rate
- Oedema
- Temperature (signs of peripheral cyanosis)
- Capillary refill (signs of peripheral cyanosis)
Mentions wishing to take BP

P: Mentions wanting to take standing and sitting BP to look for postural drop

Neck JVP (raised in over hydration, absent in dehydration)Carotid pulse (rate, rhythm, character,
volume)

Face - Sunken orbits, periorbital oedema
- Mucous membranes (eyes and mouth)

Chest - Assess skin turgor on chest (more accurate centrally)

• Palpate for apex beat, heaves or thrills
• Listen to heart sounds -3rd heart sound in RHF
• Listens to lung bases for fine inspiratory crackles

Abdomen (patient now flat)

• Look for sacral oedema
• Abdomen for ascites (shifting dullness)
• Ballot Kidneys – Looking for palpable kidneys

Legs - Pitting ankle oedema
- Thanks patient and closes consultation appropriately

Question 4

Completing the examination

Answer 4

8. SUMMARISE%
   – In(summary(this(paLent(is(hypovolaemic(/
   hypervolaemic(/(euvolaemic(

Fluid Balance and urine output
Weight chart
Observation chart

Offers to measure
FBCs, U&Es, LFTs
Extra Points (ask 1 only)

Causes of Dehydration? (Inadequate IV fluids, diarrhoea,
vomiting, burns, blood loss)

Causes of Over hydration? (Excess IV fluids, congestive heart failure, kidney failure, liver failure,
preeclampsia)

Question 5

Choosing an iv fluid

Answer 5

1. Before prescribing, assess the patient’s blood volume and general clinical condition (lying and
   standing pulse and blood pressure, hydration of the tongue and axilla, and JVP lying at 45o and flat).
2. Check the renal function and electrolytes.
3. If the patient has lost blood, transfuse.
4. In hypovolaemic shock – give colloid.
5. In metabolic acidosis – consider giving bicarbonate, but discuss with senior colleague.
6. Serum sodium very high or very low – consider giving hypo/hyper tonic saline, but not without
   senior supervision.
7. If none of the above, give an isotonic solution (5% dextrose, 0.9% saline, or dextrose saline).
8. If the patient is volume depleted, give saline. If euvolaemic, alternate dextrose and saline, or give
   dextrose saline.
9. Tailor the rate of fluid administration to the patient’s measured or expected urinary loss, allowing an
   extra volume of about 0.5L per 24h for “insensible” loss, and adjust this rate upwards or downwards to
   correct any abnormality of plasma potassium.
10. Give added potassium (eg. 20mmol/l), adjusted upwards or downwards to correct any abnormality
    of plasma potassium.
11. Watch the patient’s JVP, BP, arterial pulse, urine output, and U&Es to monitor effects of therapy.

Question 6

Major Causes of Dehydration

Answer 6

Major Causes of Dehydration? (Diarrhoea, vomitting, burns, blood loss)

Question 7

Major Causes of Overhydration

Answer 7

Major Causes of Overhydration? (Congestive heart failure, kidney failure, liver failure, preeclampsia)