ECAT paediatric assessment

Dehydration assessment

Published: December 2023 Printed on 20 May 2024

Weight loss is the best predictor of dehydration.
If available, document pre-illness weight.
Record current weight with minimal clothing or bare where appropriate.
Document detailed intake and output history in comparison to normal input and output.
Ensure observations are repeated regularly, as children can compensate well when dehydrated.
Symptoms of severe dehydration and/or shock are also present in sepsis.
If in doubt, switch to sepsis (suspected) protocol.

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	Mild dehydration	Moderate dehydration, signs mildly to moderately abnormal	Shock, signs markedly abnormal
	less than 5%	5–9%	10% and over
Conscious state	Alert and responsive	Lethargic, irritable	Reduced conscious state
Heart rate	Normal	Normal/mild tachycardia	Tachycardia
Breathing	Normal	Increased respiratory rate	Increased respiratory rate, deep acidotic breathing
Blood pressure	Normal	Normal	Hypotension
Skin colour	Normal	Normal	Pale or mottled
Extremities	Warm	Warm	Cold
Peripheral pulses	Normal	Normal	Weak
Eyes and fontanelle	Not sunken	Sunken	Deeply sunken
Mucous membranes	Moist	Dry	Dry
Skin turgor	Instant recoil	Mildly decreased	Decreased
Central capillary refill time	Normal	Prolonged	Markedly prolonged

Table reproduced, with permission, from: The Royal Children's Hospital Melbourne, Clinical Guidelines (Nursing): Neonatal Pain Assessment.