FLUID BALANCE EXAMINATION

Question 1

How would you start any examination?

Answer 1

WIPER QQ
Wash hands
Introduce yourself
Ask permission
Expose the patient
Reposition the patient

Ask if they are in any pain or discomfort

Question 2

How exposed should the patient be for the fluid balance examination?

Answer 2

You will need to be able to see their arms, legs and abdomen.

Question 3

How should the patient be positioned for the fluid balance examination?

Answer 3

Lying down at 45 degrees

Question 4

Before inspection, what specific questions must you ask the patient at the beginning of a hydration assessment (or fluid balance examination)?

Answer 4

Have you had any diarrhoea or vomitting?

Do you feel dizzy on standing?

Question 5

On inspection from the end of the bed as part of the fluid balance exam, what sort of things might you be looking for?

Answer 5

Whether the patient looks comfortable/pale/sweaty
Breathless
Catheter
Obesity
Cachexia
NG tubes
IV lines
Stoma

Food or drink
BP cuff
Nil by mouth signs
Vomit bowels

Question 6

What are you looking for in the hands and arms of patient whose fluid balance you are assessing?

Answer 6

Temperature
Radial pulse character and rate - tachycardia in both dehydration and overload
Capillary refill time
Brachial pulse character and rate
Skin turgor - back of the hand

Question 7

Having inspected the patient’s hands and arms as part of the fluid balance examination, what would do you next?

Answer 7

Take a blood pressure, sitting and standing

Question 8

What would you look for in the face of someone whose hydration status you were assessing?

Answer 8

Conjunctival pallor
Sunken eye balls
Dry/wet mouth (remember to ask them to stick their tongue out)

Question 9

What would you look for in the neck of someone whose hydration status you were assessing?

Answer 9

JVP - remember to do hepatojugular reflex

Carotid pulse

Question 10

What should you ask the patient before you assess the JVP and hepatojugular reflex?

Answer 10

Ask patient to turn head to the left

Ask if they are in any pain in their tummy

Question 11

What would you look for on the chest of someone whose hydration status you were assessing?

Answer 11

Skin turgor

Central capillary refill time

Question 12

Having inspected the patient’s chest as part of a fluid balance examination, what would you do next?

Answer 12

Palpate apex beat

Percuss chest - remember to do the back as well

Question 13

Having percussed the chest as part of a fluid balance examination, what would you do next?

Answer 13

Auscultate the heart and chest

Question 14

What are you looking for when auscultating the heart as part of the fluid balance examination?

Answer 14

A third heart sound, which would be indicative of overload

Question 15

What are you looking for when auscultating the lungs as part of the fluid balance examination?

Answer 15

Crackles which could be a sign of pulmonary oedema, which could be a sign of overload

Question 16

Whilst you have patient sitting forwards to assess their lung bases, what must you remember to assess?

Answer 16

Sacral oedema

Question 17

Having auscultated the heart and lungs what would you look for as part of the fluid balance examination?

Answer 17

Ascites - recline the patient so they are lying flat

Ankle oedema

Question 18

What are the causes of overload?

Answer 18

Iatrogenic - IV fluid overload
Cardiac failure
Renal failure
Increased ADH secretion for any reason (siADH)

Question 19

How can the causes of dehydration be split?

Answer 19

Input

Output

Question 20

What are the causes of dehydration where reduced input is the key factor?

Answer 20

Often elderly people eat and drink less

Question 21

What are the causes of dehydration where increased output is the key factor?

Answer 21

Diabetes
Drugs (eg diuretics)
Diarrhoea
Vomitting
Fever - sweating
Iatrogenic - insufficient fluid replacement during surgery
Haemorrhage
Sepsis

Question 22

What are advised to do before approaching the patient to assess their hydration status?

Answer 22

Review the obs charts - looking specifically at BP, HR, urine output
Drugs charts - looking for any diuretics or nephrotoxic drugs and for any prescribed fluids
Review recent blood results - increased urea which is more than creatinine increase, increased albumin, increased haematocrit.

Question 23

How would you manage a patient who is found to be dehydrated following a fluid balance examination?

Answer 23

Fluid challenge - 250-500 ml of Hartmann's 
Work out why they are dehydrated
Increase oral intake of fluids
Add maintenance IV fluids if required
Adjust medication

Question 24

How would you manage a patient who is found to be overloaded following a fluid balance examination?

Answer 24

Nitrates
Diuretics
CPAP if breathlessness is severe
Work out why they are overloaded