Fluid balance

WIPER PS Examine in sequence do the following 1. Inspect the patient from the end of the bed 2. Note anything around the bed 3. Has the patient got a catheter? 4. Look at and feel the hands 5. Cap Refill 6. Hands warm and well perfused? Whats this patients temperature 7. Pulse Heart rate Character of pulse Is patient well or unwell? Note any drip lines/vomit bowls/

8. Ask for Blood pressure mention that would like to do standing and lying comparison 9. Look at face 10. Examine mucous membranes 11. Assess JVP 12. Check skin turgor 13. Listen to heart for flow murmurs 14. Listen to lung bases 15. Examine abdomen 16. Hepatomegaly 17. Look at catheter bag/urine specimen 18. Peripheral oedema Ask patient about 1. 2. 3. 4. Headache Constipation Thirst Tiredness what colour is the urine? Sacral and Lower Limb Swelling distressed/pain? Are they dry?

Complete Examination by doing following 1. Examine any system requiring specific attention e.g. CVS or Abdo 2. Review observation charts/complete assessment 3. Examine/investigate urine i. Specific gravity ii. Osmolality 4. Look at fluid balance charts 5. Weight patient Especially if on dialysis or in fluid overload 6. Review notes and biochemistry i. Electrolyte balance ii. Renal function

FLUID BALANCE
THIS EXAMINATION CONCERNS 2 SITUATIONS Hypovolaemia Fluid Depletion Hypervolaemia Hypoproteinaemia, Fluid overload WIPER Wash hands, Introduce, Permission and Pain Expose Waist up Reposition 45o 1. Inspection Inspect the patient from the end of the bed Are they well or unwell? Look around the bed Cannulae/Central Lines/I.V. Fluids Check which fluids are running Kidney dishes vomiting Catheter? NG tube/PEG Drains Evidence of burns or other wounds (e.g. surgical) Nil by mouth signs 2. Hands Capillary refill+ Peripheral Cyanosis Peripheral shut down Radial Pulse rate Taccycardic, (failure and hypovol) Thready Pulse in sev. Hypovol. Quickly observe if tachypnoeic In extremis: Hypovolaemia, Heart failure, Cor Pulmonale DO LYING AND STANDING Blood Pressure 3. Face Mucous Membranes Dry tongue and lips (NB relatively inconstant sign) Tongue offer to do Temperature Sunken features 4. Neck JVP Raised in overload/May be in hypovolaemia 5. Chest Skin turgor Assess skin turgor on anterior chest wall or neck Gently pinch a piece of skin for a few seconds and release Examine heart Listen to Lungs Cardiac asthma Wheeze (failure), bibasal insp. crackles 6. Abdomen Any intra-abdominal surgery has risk of bowel ileus 24-48hours pt. has up to 8L/day 3rd space loss Inspect abdomen for swelling 3rd space losses may be a cause of intravascular hypovolaemia Inspect stoma +++ risk of fluid loss if high output (e.g. Ileostomy) Inspect catheter Functioning properly, draining, check with fluid charts Listen for bowel sounds absent in Ileus Concentration of urine 7. Legs Check for peripheral oedema Sacral and Limb Check peripheral pulses, Dorsalis pedis and Posterior tibial Periph shutdown 8. Special Tests Review fluid charts for patient Complete vital signs assessment Weight Patient Review Renal function and haematocrit

Write up fluids/Diuretics Also HR Mucous membranes Bp Urine Turgor JVP