A complete assessment addresses each of the following each visit, scaled to the patient's diagnosis and stability:
Hydration-status signs — moisture of the mucous membranes, skin turgor (noting its limited reliability in older adults), thirst, urine color and concentration, and capillary refill.
Fluid intake — adequacy relative to needs, or adherence to an ordered fluid restriction.
Output — urine frequency and amount, and other losses such as vomiting, diarrhea, wound drainage, or ostomy output.
The ordered fluid plan — a restriction (for heart failure or renal disease) or encouragement, and adherence.
Weight and the trend (measured with Vital Signs; volume meaning interpreted with Cardiovascular).
Signs of fluid overload — new edema, jugular venous distension, or crackles (assessed in Cardiovascular and Respiratory) — versus signs of deficit.
Risk factors — diuretics, advanced age, cognitive or functional limits on access to fluids, dysphagia, illness, and heat exposure.
Relevant laboratory values per order and any electrolyte-related symptoms.
