Fluid Prescribing Flashcards
Inspection from end of bed
-RR and effort (use of accessory muscles)
=Pulmonary oedema/ metabolic acidosis secondary to renal failure
-Consciousness (ESRF)
-Pallor (anaemia)
-Oedema (nephrotic syndrome, ESRF)
-Obs, fluid balance, weight chart
=Cachexia (ESRF)
=Cushingoid appearance (high dose corticosteroids for renal transplant suppression or glomerulonephritis)
=Skin (yellow complexion, bruising, excoriation of pruritus, reduced skin turgor in fluid depletion)
-Medical equipment (Oxygen, catheter, nephrostomy drains, haemodialysis/peritoneal dialysis machines)
-Mobility aids
-Prescriptions
Hand assessment
-Peripheral cyanosis
-Pallor (anaemia)
-CRT <2
-Temp
-Skin turgor (Low= dehydration)
-Pulse (rate and rhythm)
-BP (erect and supine)
-Flapping tremor (uraemia)
-Tremor (immunosuppressive agents like ciclosporin and tacrolimus)
-Gouty tophi (CKD)
-Koilonychia (IDA)
-Leukonychia (hypoalbuminaemia in ESRF, nephrotic syndrome)
=Brown line pigmentation of nails
-Splinter haemorrhages (IE from dialysis catheter associated infection, sepsis, vasculitis, psoriatic nail change)
-Excoriation (Pruritis secondary to uraemia ESRF)
-Bruising (corticosteroid)
-Fistulas
Face and neck assessment
-45 degrees bed
-JVP (Conway cheat test)- press above clavicle/ hepatojugular reflex (elevated in fluid overload)
-Eyes: periorbital oedema (nephrotic), pallor
-Mouth: central cyanosis, dry mucous membranes
-Uraemic complexion (yellow skin caused by uraemia in advanced CKD)
-Hearing aid Alport syndrome
Torso
-Heart sounds: cardiac failure (gallop rhythm 3rd HS) fluid overload
-Apex beat, pericardial fraction rub?
-Lungs: fluid (fine inspiratory crep in oedema), percuss in both bases for stony dullness (pleural effusion in overload ESRF or nephrotic syndrome hypoalbuminaemia)
-Check sacral oedema
-Ascites: flat, percuss from midline to flank, shifting dullness, fluid thrill (nephrotic)
-Renal mass, local tenderness, bruits in renal vascular disease, rectal exam for prostate
Peripherals
-Ankle oedema
Scars relevant to renal pathology
-Rutherford-Morrison (‘hockey-stick’) scar: suggestive of a previous renal transplant.
-Bilateral iliac fossae scars: suggestive of a simultaneous pancreas-kidney transplant (for a patient with type 1 diabetes).
-Umbilical scar: suggestive of previous peritoneal dialysis catheter insertion.
-Flank scar: suggestive of a previous nephrectomy.
-Lipodystrophy marks: caused by repeated insulin injection in diabetic patients
Signs of renal transplant
Renal transplant patients frequently appear in OSCEs, as they are stable and have specific clinical signs:
Abdominal scar: right or left iliac fossa (Rutherford-Morrison scar)
Palpable mass underneath scar: this is the transplanted kidney
Signs of previous dialysis: AV fistula, peritoneal dialysis scar
If the transplanted kidney is working effectively, no other signs of end-stage renal disease will be present. However, you may find clues as to the underlying cause of their renal failure (e.g. large palpable native kidneys suggesting polycystic kidney disease).
Patients may have more than one transplanted kidney in their abdomen if they have undergone multiple transplants.
Causes of enlarged kidneys
Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.
A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.
Further assessments and investigations
Blood pressure measurement: if not already performed (do not perform on the side of an arteriovenous fistula).
Fundoscopy: to assess for evidence of retinopathy (e.g. diabetic, hypertensive).
Urinalysis: to screen for urinary tract infection and to assess for haematuria/proteinuria which is associated with glomerular disease.
24-hour urine collection: to assess various urinary compounds and assist in the calculation of protein-creatinine and/or albumin-creatinine ratio.
Urine culture: if a urinary tract infection is suspected.
U&Es: to assess renal function.
Bicarbonate: to assess for evidence of acidaemia.
Bone profile: to assess the levels of calcium, phosphate and PTH (to screen for secondary and tertiary hyperparathyroidism).
-Fundoscopy (hypertensive changes)
Fluid prescribing maintenance fluids
In the 2013 guidelines NICE recommend the following requirements for maintenance fluids:
25-30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50-100 g/day of glucose to limit starvation ketosis
So, for a 80kg patient, for a 24 hour period, this would translate to:
2 litres of water
80mmol potassium
When prescribing for routine maintenance alone, consider using 25-30 ml/kg/day sodium chloride 0.18% in 4% glucose with 27 mmol/l potassium on day 1 (there are other regimens to achieve this).
Fluid contraindications
0.9% saline
if large volumes are used there is an increased risk of hyperchloraemic metabolic acidosis
Hartmann’s
contains potassium and therefore should not be used in patients with hyperkalaemia
