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Module 2 : Clinical Assessment

 

 

Clinical examination of the patient

 

It is important to be able to recognise the fluid depleted as well as fluid overloaded patient. The picture below outlines what to look for when examining a patient in order to distinguish this.

 

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  Test Yourself !  
   
  Consider how these clinical observations would indicate dehydration and fluid overload. On a piece of paper divide up the page into two and jot down what you would expect to see in each clinical picture.

How did you do?
 

The table below summarises some of the clinical signs of dehydration and fluid overload.

 

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These signs of fluid deficit or overload may be very subtle until large volumes of fluid have been lost or gained. Often the first sign of fluid deficit is postural hypotension. Other methods of assessing hydration status include axillary moisture which has been observed to be a reliable sign in the elderly. 

These signs lack sensitivity and specificity, however in combination have greater weighting. 

It is important to closely monitor patients’ fluid balance to avoid the risk of acute kidney injury. The elderly are at particular risk and if goes unnoticed, permanent kidney damage can result. As a rule of thumb, the minimum acceptable urine output is 0.5-1.0 ml/kg/hr. Less than this, the patient has acute kidney injury (AKI).

 

  Test Yourself !  
   
  You suspect a patient may be becoming fluid depleted, which of the following should you preferentially carry out as an early indicator?

That's correct, well done!
 

Lying and standing blood pressure - Correct! A patient who drops their blood pressure rapidly on standing (postural or orthostatic hypotension) is a good early indicator of fluid depletion. Often the patient will complain of feeling dizzy and unsteady on their feet on rapid standing. With severe dehydration, postural hypotension may induce a temporary loss of consciousness on standing.

 

Assess skin turgor - Incorrect. This is generally a late sign of dehydration. In addition this can be an unreliable indicator of dehydration in older people as skin elasticity reduces with age. A good alternative to skin turgor is tongue turgor, as this is not age-dependent. In a well-hydrated individual, the tongue has one longitudinal furrow, but a person with depleted fluids will have additional furrows. X

 

Look for sunken, dry eyes - Incorrect. Again a late sign of dehydration. Sunken eyes may also result from starvation or wasting from disease.

 

Assess the JVP - Incorrect. Although the JVP is a good indicator of central venous pressure, often the internal jugular vein is very difficult to locate in patients and may only be obvious in grossly fluid overloaded patients. Studies have also shown there to be wide disagreement on JVP measurements between clinicians. With the patient lying at 45 degrees, the JVP is measured indirectly as the internal jugular filling level and should be no more than 3cm vertical distance from the manubriosternal joint (at the level of the second costal cartilages) to the highest level of jugular vein pulsation. If the internal jugular is difficult to locate, the external jugular may be used, although it is not preferred.

 

Distinguishing the jugular venous pulse from the carotid pulse, the jugular venous pulse is:

  • Not palpable
  • Occluded by pressure
  • Characterised by a double waveform
  • Varies with respiration - Decreased with inspiration
  • Varies with position – On standing the JVP appears lower in the neck
  • Enhanced by the hepatojugular reflux
  •  

    Sorry, that's incorrect!
     

    Lying and standing blood pressure - Correct! A patient who drops their blood pressure rapidly on standing (postural or orthostatic hypotension) is a good early indicator of fluid depletion. Often the patient will complain of feeling dizzy and unsteady on their feet on rapid standing. With severe dehydration, postural hypotension may induce a temporary loss of consciousness on standing.

     

     

    Assess skin turgor - Incorrect. This is generally a late sign of dehydration. In addition this can be an unreliable indicator of dehydration in older people as skin elasticity reduces with age. A good alternative to skin turgor is tongue turgor, as this is not age-dependent. In a well-hydrated individual, the tongue has one longitudinal furrow, but a person with depleted fluids will have additional furrows. X

     

    Look for sunken, dry eyes - Incorrect. Again a late sign of dehydration. Sunken eyes may also result from starvation or wasting from disease.

     

    Assess the JVP - Incorrect. Although the JVP is a good indicator of central venous pressure, often the internal jugular vein is very difficult to locate in patients and may only be obvious in grossly fluid overloaded patients. Studies have also shown there to be wide disagreement on JVP measurements between clinicians. With the patient lying at 45 degrees, the JVP is measured indirectly as the internal jugular filling level and should be no more than 3cm vertical distance from the manubriosternal joint (at the level of the second costal cartilages) to the highest level of jugular vein pulsation. If the internal jugular is difficult to locate, the external jugular may be used, although it is not preferred.

     

    Distinguishing the jugular venous pulse from the carotid pulse, the jugular venous pulse is:

  • Not palpable
  • Occluded by pressure
  • Characterised by a double waveform
  • Varies with respiration - Decreased with inspiration
  • Varies with position – On standing the JVP appears lower in the neck
  • Enhanced by the hepatojugular reflux
  •  

     

     

     

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