Hydration status examination

A hydration status examination is useful when assessing unwell patients and also when prescribing intravenous fluids.

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent

General inspection

• Patient: well/unwell, alert, breathless, fever, portals of infection/wounds/drains
• Around bed (if present, look at quantities of fluids going in/coming out)
  • In: IV fluids, NG feed, parenteral nutrition 
  • Out: catheter, stoma, NG tube, vomit bowl
  • Charts: observations, fluid balance, drug chart (e.g. for diuretics, infusions etc.)

Hands and arms

• Temperature (fever increases insensible losses)
• Pulse rate (tachycardia in dehydration)
• Blood pressure and postural drop (hypotension and postural drop in dehydration)

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Head and neck

• Eyes (sunken in dehydration)
• Oral mucus membranes (dry in dehydration)
• JVP (raised in overload; reduced/not visible in dehydration)
• Carotid pulse volume and character

Chest

• Sternum: capillary refill (>2 seconds in hypoperfusion), skin turgor (reduced in dehydration)
• Palpation: apex beat (may be displaced in LVF)
• Auscultation: heart (3^rd heart sound in overload), lung bases (pulmonary oedema in overload)

Abdomen

• Ascites

Legs

• Pedal oedema (overload)

To complete

• Thank patient 
• ‘To complete my hydration status assessment, I would take a full history, look at U&Es, observations, and the fluid balance chart.’ 
• Summarise and suggest further investigations, for example:
  • Serial weights
  • Catheterise and monitor urine output
  • U&Es
  • VBG and serum lactate

Test your knowledge

What are the major types of shock?

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In a patient who is clinically in decompensated right heart failure (fluid overload) but with an acute kidney injury, which condition are you concerned about and how would you manage them?

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What is ‘third spacing’ of fluid?

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