11/13/24, 7\:05 PM Guide | Hydration assessment

Hydration assessment

Table of contents

Background

Being able to assess the hydration status of a patient is an important skill that you'll regularly use in clinical practice. It involves
assessment of whether a patient is hypovolaemic (dehydrated), euvolaemic or hypervolaemic (
ongoing clinical management.

Hypovolaemia vs hypervolaemia

Hypovolaemia refers to an overall de
vomiting, diarrhoea, haemorrhage, excessive diuretic therapy) and third space loss of
body but has shifted from the intravascular space to another compartment within the body).
Hypervolaemia refers to an excess of
common in the elderly and those with renal or cardiac failure. It can be caused by excessive
retention (e.g. heart failure, renal failure).
The quest to euvolaemia can be a di
clinical symptoms, signs and biochemical indicators. No single parameter or ‘gold standard’ con
hydration, and the clinician must contemplate a range of factors to fully appreciate whether the patient is hypovolaemic,
euvolaemic or hypervolaemic.

Patient factors to consider that may alter

Patient age\: elderly/very young patients are more prone to dehydration and elderly patients are generally more likely to have
cardiac failure and/or chronic renal disease.
Reasons for admission that can increase
Trauma
Febrile illness and sepsis
Burns
Surgical patients may need additional volume secondary to bleeding, drainage and third-space
Gastrointestinal losses (e.g. vomiting, diarrhoea)
Polyuria
Medical conditions that can a
Medications (e.g. diuretics can increase
Pertinent details in the patient's history\:
Bleeding from any source
Vomiting\: frequency, volume, presence of blood
Stools\: frequency, volume, presence of blood
Fever and diaphoresis
Urine output\: colour and volume
Pre-syncope/syncope
Presence of thirst
Eating and drinking status (e.g. oral
Symptoms of
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Is the patient on a

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adjust the head of the bed to a 45° angle and position the patient lying down.
Adequately expose the patient's chest for the examination (o
appropriate, inform patients they do not need to remove their bra). Exposure of the patient's lower legs is also helpful to assess
for peripheral oedema.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Clinical signs

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology\:
Cyanosis\: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to
hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Shortness of breath\: may indicate pulmonary oedema secondary to
Pallor\: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion
(e.g. hypovolaemia).
Malar
Oedema\: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites).

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Medical equipment\: such as an oxygen delivery device, intravenous
urinary catheter (note the volume/colour of urine).
Mobility aids\: items such as wheelchairs and walking aids give an indication of the patient's current mobility status.
Pillows\: patients with congestive heart failure typically su
As a result, they often use multiple pillows to prop themselves up.
Vital signs\: charts on which vital signs are recorded will give an indication of the patient's current clinical status and how
their physiological parameters have changed over time.
Fluid balance\:
patient appears
Daily weight chart\: provides an overview of the patient's weight allowing trends to be identi
Stool chart\: note the frequency and type of bowel motions (frequent diarrhoea results in signi
Medication chart\: note any medications which may impact
Fluid prescription chart\: note if the patient has received any intravenous

Surgical documentation (if the patient is post-op)\: check the estimated blood loss in the operating theatre and if any blood
or
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Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

Inspection

General observations
Inspect the hands and note your
Colour\: pallor suggests poor peripheral perfusion (e.g. congestive heart failure, hypovolaemia) and cyanosis may indicate
underlying hypoxaemia.
Leukonychia\: whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage liver disease, protein-losing
enteropathy). Hypoalbuminaemia can result in signi
Peripheral pallor [1]

Palpation

Temperature
Place the dorsal aspect of your hand onto the patient's to assess temperature\:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, hypovolaemia).
Capillary re
Measuring capillary re
Apply
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two
seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure)
and the need to assess central capillary re
Skin turgor
Assess skin turgor by gently pinching a fold of skin (this can be done on the back of the hand), holding for a few seconds and
then releasing the skin. Well hydrated skin should spring back to its previous position immediately, whereas dehydrated skin
will slowly return to normal (this is known as decreased skin turgor).
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Assess capillary re

Pulses and blood pressure

Radial pulse

Palpate the patient's radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
Calculating heart rate
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and
multiplying by 2 or measuring for 15 seconds and multiplying by 4. For irregular rhythms, you should measure the pulse
for a full 60 seconds to improve accuracy.
Normal and abnormal heart rates
In healthy adults, the pulse should be between 60-100 bpm.
A pulse \<60 bpm is known as bradycardia and has a wide range of aetiologies (e.g. healthy athletic individuals,
atrioventricular block, medications, sick sinus syndrome).
A pulse of >100 bpm is known as tachycardia and also has a wide range of aetiologies (e.g. anxiety, supraventricular
tachycardia, hypovolaemia, hyperthyroidism).
An irregular rhythm is most commonly caused by atrial
individuals and atrioventricular blocks.

Brachial pulse

Palpate the brachial pulse
Palpate the brachial pulse in their right arm, assessing volume and character\:
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1. Support the patient's right forearm with your left hand.
2. Position the patient so that their upper arm is abducted, their elbow is partially
3. With your right hand, palpate medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus.
Deeper palpation is required (compared to radial pulse palpation) due to the location of the brachial artery.
Types of pulse character
Normal
Slow-rising (associated with aortic stenosis)
Bounding (associated with aortic regurgitation and also CO 2
retention)
Thready (associated with intravascular hypovolaemia in conditions such as sepsis)

Blood pressure

Measure the blood pressure
Measure the patient's blood pressure in both arms (see our blood pressure guide for more details).
A comprehensive blood pressure assessment should also include lying and standing blood pressure.
Blood pressure abnormalities
Blood pressure abnormalities may include\:
Hypertension\: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal
to 150/90 mmHg if you're over 80 years old. Causes include essential hypertension, hypervolaemia and renal artery
stenosis.
Hypotension\: blood pressure of less than 90/60 mmHg. Causes include hypovolaemia, sepsis and antihypertensives.
Narrow pulse pressure\: less than 25 mmHg of di
include aortic stenosis, congestive heart failure and cardiac tamponade.
Wide pulse pressure\: more than 100 mmHg of di
include aortic regurgitation and aortic dissection.
Di
suggest aortic dissection.
Postural drop\: more than a 20mmHg decrease in systolic blood pressure when moving from sitting to standing.
Causes include hypovolaemia, autonomic dysfunction and antihypertensives.
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Palpate the radial pulse

Jugular venous pressure (JVP)

Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal
jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. The
presence of this continuous column of blood means that changes in right atrial pressure are re
atrial pressure results in distension of the IJV).
The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid,
making it di
sternocleidomastoid muscle).
Because of the inability to easily visualise the IJV, it's tempting to use the external jugular vein (EJV) as a proxy for assessment
of central venous pressure during clinical assessment. However, because the EJV typically branches at a right angle from the
subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous
pressure.
See our guide to jugular venous pressure (JVP) for more details.

Measure the JVP

1. Position the patient in a semi-recumbent position (at 45°).
2. Ask the patient to turn their head slightly to the left.
3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of
the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the
sternocleidomastoid. The IJV has a double waveform pulsation, which helps to di
carotid artery.
4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV
(in healthy individuals, this should be no greater than 3 cm).
Causes of a raised JVP
A raised JVP indicates the presence of venous hypertension/hypervolaemia. Cardiac causes of a raised JVP include\:
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Right-sided heart failure\: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of
right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
Tricuspid regurgitation\: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis\: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying
causes.
Observe the JVP

Face

Eyes

Inspect the eyes for signs relevant to the patient's
Sunken appearance\: associated with hypovolaemia.
Conjunctival pallor\: suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to
inspect the conjunctiva.

Mouth

Inspect the mouth for signs relevant to the patient's
Dry mucous membranes\: associated with hypovolaemia.
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Conjunctival pallor

Chest

Respiratory rate
Assess the patient’s respiratory rate for 30 seconds and then multiply by 2 to calculate the number of breaths per minute. An
increased respiratory rate (tachypnoea) may indicate pulmonary oedema secondary to hypervolaemia.
Central capillary re
If capillary re
Auscultate heart sounds
A systematic routine will ensure you remember all the steps whilst giving you several chances to listen to each valve area. Your
routine should avoid excess repetition whilst each step should ‘build’ upon the information gathered by the previous steps.
Ask the patient to lift their breast to allow auscultation of the appropriate area if relevant.
1. Palpate the carotid pulse to determine the
2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope whilst continuing to palpate the
carotid pulse\:
Mitral valve\: 5th intercostal space in the midclavicular line.
Tricuspid valve\: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve\: 2nd intercostal space at the left sternal edge.
Aortic valve\: 2nd intercostal space at the right sternal edge.
3. Repeat auscultation across the four valves with the bell of the stethoscope.
Abnormal heart sounds in hypervolaemia
A gallop rhythm (i.e. a third heart sound occurring after the normal 'lub' 'dub' heart sounds) may be noted in
hypervolaemia due to elevated atrial and ventricular
heart failure although it can also be present in healthy athletic individuals.
Auscultate the lungs
Auscultate the lung
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Coarse crackles are suggestive of pulmonary oedema.
Absent air entry and stony dullness on percussion are suggestive of an underlying pleural e
Assess respiratory rate

Abdomen

Inspection

Position the patient lying
Inspect the patient’s abdomen for signs suggestive of hypervolaemia\:
Abdominal distension\: can be caused by a wide range of pathology, but in the context of a hydration status assessment,
consider ascites.
Striae (stretch marks)\: caused by tearing during the rapid growth or overstretching of skin (e.g. ascites, intrabdominal
malignancy, Cushing’s syndrome, obesity, pregnancy).

Assess shifting dullness

Percussion can also be used to assess for the presence of ascites by identifying shifting dullness\:
1. Percuss from the umbilical region to the patient’s left
in the
2. Whilst keeping your
side (towards you for stability).
3. Keep the patient on their right side for 30 seconds and then repeat percussion over the same area.
4. If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).
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Inspect the abdomen

Oedema

Sacral oedema

Inspect and palpate the sacrum for evidence of pitting oedema.

Legs

Inspect and palpate the patient's ankles for evidence of pitting pedal oedema.
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