Journal of Gerontological Nursing

Hydration Management Protocol

Janet C Mentes, PhD, RNCS, GNP

Abstract

Elderly residents of long-term care (LTC) facilities have ongoing problems with adequate oral hydration (ArmstrongEsther, Browne, Armstrong-Esther, & Sander, 1996; Kayser-Jones, Schell, Porter, Barbaccia, & Shaw, 1999; Mentes, Culp, Maas, & Rantz, 1999). Research has demonstrated that community-dwelling older adults consume a greater variety and larger amounts of fluids than those living in LTC facilities. The mean amount of fluid consumed by communitydwelling elderly individuals is 2,100 cc per day (Adams, 1988; de Castro, 1992), while the mean amount of fluid consumed by residents in LTC is 1,100 to 1,500 cc per day (Adams, 1988; Armstrong-Esther et al., 1996; Chidester & Spangler, 1997; Kayseret al., 1999; O'Neill, Duggan, & Davies, 1997). The prevalence of underhydration and dehydration in LTC residents is estimated at 33% (Colling, Owen, & McCreedy, 1994; Mentes et al, 1999).

The results of a chronically underhydrated state are acute confusion, dehydration, urinary and respiratory infections, and constipation, all of which could precipitate a preventable hospitalization (Palevsky, Bhagrath, & Greenberg, 1996) and place elderly individuals at increased risk for repeated hospitalizations (Gordon, An, Hayward, & Williams, 1998). In fact, this insidious state of chronic underhydration becomes a physiologic balancing act where the frail older adult becomes increasingly susceptible to small environmental or physiologic stressors that can precipitate dehydration and further health crises. The ramifications of chronic underhydration are further hidden by the fact that after an elderly individual is hospitalized for a stated health problem, such as pneumonia, the antecedent condition of underhydration or dehydration is obscured. Therefore, although the cost of hospitalizations for dehydration in 1996 exceeded $1 billion dollars (KayserJones et al, 1999), it is likely that this figure is much higher.

* Plan for at-risk individuals. For residents who are at risk of underhydration because of poor intake several strategies can be implemented based on unit preference, time, and staffing issues. Schedule fluid rounds midmorning and late afternoon where caregiver provides additional fluids (Spangler, Risley, & Bilyew, 1984). Plan "happy, hours" (Musson et al, 1990) or "tea time" (Mueller & Boisen, 1989) in the afternoon where residents can gather together for additional fluids, nourishment, and socialization. Modified fluid containers will be used based on resident's intake behaviors (e.g., ability to hold cup, to swallow) (Mueller & Boisen, 1989; Reedy, 1988). Offer a variety of fluids and encourage ongoing intake throughout the day. "Sip n' go" intervention can be used for residents who are reluctant to drink a standardized amount of fluid. For this intervention, anyone who enters a resident's room while that individual is awake, offers at least 2 ounces (60 mL) of water or other beverage of choice.

* Fluid regulation and documentation. Individuals who are cognitively intact and visually capable can be taught how to regulate their fluid intake by comparing the color of their urine to a standardized urine color chart (Armstrong et al., 1994). For those individuals who are cognitively impaired, caregivers can be taught how to use the color chart. Frequency of documentation of fluid intake will vary from setting to setting and is dependent on an individual's condition. However, in most settings, at least one accurate intake and output recording should be documented and include the amount of fluid consumed, intake pattern, difficulties with consumption, and urine specific gravity and color. Accurate calculation of intake requires knowledge of the volumes of containers used to serve fluids which should be posted in a prominent place on the care unit. A study by Burns (1992) suggested that nurses over- or underestimated the volumes of common vessels.

Acute management of oral intake. Any resident who develops a fever, vomiting, diarrhea, or a…

Elderly residents of long-term care (LTC) facilities have ongoing problems with adequate oral hydration (ArmstrongEsther, Browne, Armstrong-Esther, & Sander, 1996; Kayser-Jones, Schell, Porter, Barbaccia, & Shaw, 1999; Mentes, Culp, Maas, & Rantz, 1999). Research has demonstrated that community-dwelling older adults consume a greater variety and larger amounts of fluids than those living in LTC facilities. The mean amount of fluid consumed by communitydwelling elderly individuals is 2,100 cc per day (Adams, 1988; de Castro, 1992), while the mean amount of fluid consumed by residents in LTC is 1,100 to 1,500 cc per day (Adams, 1988; Armstrong-Esther et al., 1996; Chidester & Spangler, 1997; Kayseret al., 1999; O'Neill, Duggan, & Davies, 1997). The prevalence of underhydration and dehydration in LTC residents is estimated at 33% (Colling, Owen, & McCreedy, 1994; Mentes et al, 1999).

The results of a chronically underhydrated state are acute confusion, dehydration, urinary and respiratory infections, and constipation, all of which could precipitate a preventable hospitalization (Palevsky, Bhagrath, & Greenberg, 1996) and place elderly individuals at increased risk for repeated hospitalizations (Gordon, An, Hayward, & Williams, 1998). In fact, this insidious state of chronic underhydration becomes a physiologic balancing act where the frail older adult becomes increasingly susceptible to small environmental or physiologic stressors that can precipitate dehydration and further health crises. The ramifications of chronic underhydration are further hidden by the fact that after an elderly individual is hospitalized for a stated health problem, such as pneumonia, the antecedent condition of underhydration or dehydration is obscured. Therefore, although the cost of hospitalizations for dehydration in 1996 exceeded $1 billion dollars (KayserJones et al, 1999), it is likely that this figure is much higher.

It is imperative for nurses to lead the way with the issue of oral hydration management for elderly individuals in LTC. With careful attention to assessment of fluid needs and appropriate supervision of certified nursing assistant (CNA) practice, adequate oral hydration can be established and maintained. The following protocol offers background information on individuals likely to be at risk for hydration management problems, assessment tips, and strategies for interventions. Although the complete protocol addresses both extremes of dehydration and overhydration, the review of this protocol will focus primarily on managing underhydration or dehydration.

PURPOSE

The purpose of this evidence-based protocol is to help health care providers in all settings determine adequate oral fluid intake for elderly individuals and to use strategies that will maintain hydration. Use of this protocol will help prevent dehydration and associated conditions, such as acute confusion and delirium (Foreman, 1989; O'Keeffe & Lavan, 1996; Seymour, Henschke, Cape, & Campbell, 1980), infections (Beaujean et al., 1997), and increased mortality (Warren et al., 1994); and overhydration. The focus of this protocol is to prevent dehydration or overhydration through careful assessment, identification of elderly individuals at risk for hydration problems, and implementation of individualized nursing interventions based on a risk profile. This protocol does not include interventions for acute or emergent rehydration of elderly individuals.

DEFINITIONS

Definition of Hydration Management

Hydration management is the promotion of adequate fluid balance that prevents complications resulting from abnormal or undesired fluid levels (See Fluid Management and Fluid Monitoring nursing interventions in McCloskey & Bulechek, 2000, pp. 348-349, 352).

Definitions of Associated Terms

Terms associated with dehydration are categorized in various ways according to:

* Sodium concentration (hypernatremic dehydration).

* Tonicity or active osmoles of the fluid (hypertonic dehydration).

* The fluid compartment affected (intracellular dehydration).

For the purposes of this document, tonicity will be used to categorize the hydration problem (Weinberg, Minaker, and the Council on Scientific Affairs, AMA, 1995).

Hypertonic dehydration. Hypertonic dehydration is a depletion in total body water content due to pathologic fluid losses, diminished water intake, or a combination of both (Gross et al., 1992). It results in hypernatremia in the extracellular fluid compartment, which draws water from the intracellular fluids. The water loss is shared by all body fluid compartments and relatively little reduction in extracellular fluids occurs. Thus, circulation is not compromised unless the loss is very large (Leaf, 1984; Mange et al., 1997). This is also known as intracellular dehydration or hypernatremic dehydration.

Hypotonic dehydration. Hypotonic dehydration is a depletion in both sodium and water with greater losses of sodium than water, resulting in extracellular fluid loss (Leaf, 1984; Mange et al., 1997; Silver, 1990). Causes of hypotonic dehydration include overuse of diuretics, chronic salt wasting renal disease, and decreased intake of both salt and water. Circulation is effected in hypotonic dehydration (Leaf, 1984; Silver, 1990). This is also known as extracellular fluid volume depletion.

Isotonic dehydration. Isotonic dehydration is a balanced depletion of water and sodium causing extracellular fluid loss. Causes of isotonic dehydration include: vomiting, diarrhea, and the osmotic diuresis of glucose. Circulation is effected in isotonic dehydration (Mange et al., 1997). This is also known as isotonic fluid volume depletion.

INDIVIDUALS AT RISK FOR DEHYDRATION

Elderly individuals are at increased risk for dehydration because of agerelated physiologic changes including:

* Altered thirst perception (Mack et al., 1994; Miescher & Fortney, 1989; Phillips, Bretherton, Johnston, & Gray, 1991; Phillips et al., 1984;).

* Reduced total body water (TBW) as a portion of body weight (Gross et al, 1992).

* Body composition changes (i.e., higher proportion of fat to muscle) (Metheny, 1996).

* Impaired renal conservation of water (Gross et al., 1992).

* Decreased effectiveness of vasopressin (Faull, Holmes & Baylis, 1993; Phillips, Johnston, & Gray, 1993).

* Increased prevalence of multiple chronic diseases (Weinberg et al., 1995).

Research based risk factors for dehydration in long-term care settings include:

* Older than 85 years of age (Lavisso-Mourey et al., 1988).

* Female gender (Gaspar, 1988; Lavisso-Mourey, Johnson, & Stolley, 1988; Mentes, 2000).

* Functionally semi-dependent (e.g., those individuals who are cognitively unaware of their needs yet have mobility, and those who are physically unable to meet their needs but who can express them) (Gaspar, 1988).

* Functionally independent (Gaspar, 1999; Mentes, 2000).

* Alzheimer's disease or other dementias (Albert, Nakra, Grossberg, & Caminal, 1989; Kayser-Jones et al., 1999).

Table

TABLE 1RELATIVE STRENGTH OF DIFFERENT SIGNS OF DEHYDRATION IN ELDERLY INDIVIDUALS

TABLE 1

RELATIVE STRENGTH OF DIFFERENT SIGNS OF DEHYDRATION IN ELDERLY INDIVIDUALS

* Four or more chronic conditions (Lavisso-Mourey et al., 1988).

* Bedridden (Lavisso-Mourey et al., 1988).

* More than four medications (Lavisso-Mourey et al., 1988).

* Fever (Pals et al., 1995).

* Decrease in activities of daily living (ADLs) (Pals et al, 1995).

* Few fluid ingestion opportunities (Gaspar, 1988).

* Poor oral intake (Weinberg et al., 1994).

* Communication difficulties (i.e., unable to speak English, aphasie) (Kayser-Jones et al., 1999).

Minimum Data Set (MDS)

Dehydration and fluid maintenance triggers for dehydration among residents of LTC facilities include (Omnibus Budget Reconciliation Act of 1987, 1990; Weinberg et al., 1995):

* Deterioration in cognitive status, skills, or abilities in past 90 days.

* Failure to eat or take medications.

* Urinary tract infection.

* Current diagnosis of dehydration (ICD-9 code 276-5).

* Diarrhea.

* Dizziness and vertigo.

* Fever.

* Internal bleeding.

* Vomiting.

* Weight loss (≥5% in past 30 days or 10% in past 180 days).

* Insufficient fluid intake (dehydrated).

* Did not consume all or almost all liquids provided during past 3 days.

* Leaves more than or equal to 25% food uneaten at most meals.

* Requirement for intravenous fluids.

Additional potential risk factors from the MDS include (Omnibus Budget Reconciliation Act of 1987, 1990; Weinberg & Minaker, 1995):

* Hand dexterity and body control problems.

* Use of diuretics.

* Abuse of laxatives.

* Uncontrolled diabetes mellitus.

* Swallowing problems.

* Purposeful restriction of fluids.

* Patient on enteral feedings.

* History of previous episodes of dehydration.

* Comprehension and communication problems.

Research based factors that increase risk of hospitalization for dehydration include (Warren et al., 1994):

* Age. Individuals age 85 to 99 had six times the risk of individuals age 65 to 69.

* Race. Blacks were 1.5 to 2 times more likely than Whites.

* Gender. Within race, men were more likely than women, except for White men age 65 to 79.

* Admission from a nursing home (Palevsky, Bhagrath, & Greenberg, 1996).

Medical conditions associated with hospitalization for dehydration include (Warren et al., 1994):

* Respiratory illness (28.2%).

* Urinary tract infection (24.9%).

* Gastroenteritis (10.4%).

* Sepsis (7.1%).

* Frailty (20.3%).

* Cancer (15.7%).

* Diabetes (12.0%).

Literature-based risk factors for dehydration in acute and long-term care include (Boylan & Marbach, 1979; Irwin, 1987; Kositzke, 1990; Palevsky, Bhagrath, & Greenberg, 1996; Sansevero, 1997; Silver, 1990):

* Vomiting or diarrhea.

* Depression.

* Cognitive impairment.

* Self-imposed fluid restriction due to urinary incontinence.

* Tube feeding.

* Poor postoperative fluid management.

* Hot weather.

SCREENING CRITERIA

The following screening criteria indicate patients who are likely to benefit the most from use of this evidence-based protocol:

* All individuals older than 85 years of age.

* All institutionalized elderly individuals (Adams, 1988; ArmstrongEsther et al., 1996; Colling, Owen, & McCreedy,1994; Himmelstein, Jones, & Woolhandler, 1983).

* Individuals with recent weight loss of more than 5% of body weight.

* Individuals with feeding and eating difficulties.

* Individuals with a diagnosis of dementia.

* Febrile individuals.

DESCRIPTION OF INTERVENTION

The hydration management intervention is an individualized daily plan to promote adequate hydration based on risk factor identification derived from a comprehensive assessment. The intervention is divided into three phases:

* Initial assessment and risk identification phase.

* Hydration management phase.

* Evaluation phase.

Initial Assessment

Individualized assessment of elderly individuals is recommended and should include the following parameters:

Basic physiological measures. Basic physiological measures (Table 1) include (Eaton, Bannister, Mulley, & Connolly, 1994; Gross et al., 1992; Silver, 1990):

* Vital signs including temperature, pulse, respirations, orthostatic blood pressure.

* Weight (in kilograms).

* Height (in centimeters).

* Body mass index (BMI) Kg/cmp 2. A BMI less than 21 or greater than 27 puts an individual at risk for dehydration (Nutrition Screening Initiative, 1992).

* Review of systems or head-totoe assessment, including an assessment of the oral cavity, upper body strength, and speech (Gross et al, 1992).

Laboratory tests. Many laboratory tests (Armstrong et al., 1994; Metheny, 1996; Neelon, personal communication, 1998) can be helpful in assessing hydration status in elderly individuals (Table 2). It should be noted that the blood tests are better predictors of actual dehydration and the urine tests are better at predicting impending dehydration or those patients at risk for developing dehydration.

Table

TABLE 2APPROXIMATE RANGES OF LABORATORY TESTS FOR HYDRATION STATUS

TABLE 2

APPROXIMATE RANGES OF LABORATORY TESTS FOR HYDRATION STATUS

Hydration status. Hydration status includes:

* Urine specific gravity.

* Urine color.

* 24-hour fluid intake and urine output.

* Treatments (i.e., nothing-bymouth [NPO] status, enteral/tube feedings).

* Usual pattern of fluid intake (e.g., Do they consume most of their fluids during meals? At what time of the day do they consume the most fluids? What is the actual amount of fluid intake? What types of fluids are preferred?).

* Intake behaviors or problematic behaviors associated with fluid intake (e.g., choking, drooling, inability to hold a cup independently, or resistance to drinking caused by fear of incontinence).

Cognitive status. Cognitive status is determined using a standard mental status questionnaire such as the Mini Mental State Exam (MMSE) (Folstein, Folstein, & McHugh, 1975), Short Orientation Memory Concentration Test (Katzman, Brown, FuId, Peck, Schechter, & Schimmel, 1983), Short Portable Mental Status Test (SPMSQ) (Pfeiffer, 1975), the MDS Cognitive Performance Scale (Morris, et al., 1994), or the Cognitive Patterns section of the Resident Assessment Instrument (RAI) of the MDS (Morris, et al., 1990).

Functional health status/Activities of daily living. These are measured using a standard questionnaire such as the Katz ADL (Katz, Ford, Moskowitz, Jackson, &Jaffee, 1963), Functional Independence Measure (FIM) (Uniform Data System for Medical Rehabilitation, 1997), the Barthel Index (Mahoney & Barthel, 1965), or the ADL section from the RAI.

Mood status. A standard questionnaire, such as the Geriatric Depression Scale (GDS) (Yesavage & Brink, 1983), Cornell Scale for Depression in Dementia (Alexopoulos, Abrams, Young, & Shamoian, 1988), or the Mood section from RAI, is used to determine mood status.

Medical history. This includes:

Table

TABLE 3RISK APPRAISAL CHECKLIST*

TABLE 3

RISK APPRAISAL CHECKLIST*

* Specific disease states: dementia; congestive heart failure; chronic renal disease; malnutrition; and psychiatric disorders such as depression, schizophrenia, bipolar disorder.

* Presence of comorbidity (more than four chronic health conditions).

* History of dehydration or repeated infections.

Current medications. This includes the amount and types of prescription and over-the-counter drugs.

Risk Identification

Based on the assessment data, a risk appraisal for hydration problems is completed. Table 3 includes a copy of the Risk Appraisal Checklist (Mentes & Iowa-VA Nursing Research Consortium, 1998) referenced to MDS items. The more indicators present on the checklist, the greater the likelihood of underhydration or dehydration.

Table

TABLE 4FLUID BALANCE-DEHYDRATION

TABLE 4

FLUID BALANCE-DEHYDRATION

Hydration Management

Ongoing management of oral intake.

* Calculate a daily fluid goal (Figure 1). All residents will have an individualized fluid goal determined by a documented standard for daily fluid intake. There is preliminary evidence that the standard suggested by Skipper (1993) of 100 mL/kg for first 10 kg of weight, 50 ml/kg for next 10 kg, and 15 mL for remaining kg is preferred (Chidester & Spangler, 1997; Kayser-Jones et al., 1999).

Because this standard reflects fluid from all sources, to calculate a standard for fluids alone, 75% of the total calculated from the formula is used in this example. See the complete Hydration Management Protocol for other fluid calculation standards and formulas (Mentes & Iowa-VA Nursing Research Consortium, 1998)

* Compare resident's current intake to the amount calculated from applying the standard.

* Provide fluids consistently throughout the day. Fluid intake will be planned as 75% to 80% delivered at meals and 20% to 25% delivered during non-meal times (i.e., medication or nourishment rounds). Offer a variety of fluids based upon the individual's previous intake pattern (Zembrzuski, 1997). Alcoholic beverages, which exert a diuretic effect on the resident, should not be counted toward the fluid goal. Caffeinated beverages may be counted toward the fluid goal based on individual assessment, as there is preliminary evidence that in individuals who are regular users there are no untoward effects on fluid balance (Martof & Knox, 1997). A comparison of common oral fluids is included in the complete protocol. Fluid with medication administrations should be standardized to a prescribed amount (e.g., at least 180 mL [6 oz.] per administration time).

Figure 1. Sample fluid goal calculation for 70 kg individual.

Figure 1. Sample fluid goal calculation for 70 kg individual.

* Plan for at-risk individuals. For residents who are at risk of underhydration because of poor intake several strategies can be implemented based on unit preference, time, and staffing issues. Schedule fluid rounds midmorning and late afternoon where caregiver provides additional fluids (Spangler, Risley, & Bilyew, 1984). Plan "happy, hours" (Musson et al, 1990) or "tea time" (Mueller & Boisen, 1989) in the afternoon where residents can gather together for additional fluids, nourishment, and socialization. Modified fluid containers will be used based on resident's intake behaviors (e.g., ability to hold cup, to swallow) (Mueller & Boisen, 1989; Reedy, 1988). Offer a variety of fluids and encourage ongoing intake throughout the day. "Sip n' go" intervention can be used for residents who are reluctant to drink a standardized amount of fluid. For this intervention, anyone who enters a resident's room while that individual is awake, offers at least 2 ounces (60 mL) of water or other beverage of choice.

* Fluid regulation and documentation. Individuals who are cognitively intact and visually capable can be taught how to regulate their fluid intake by comparing the color of their urine to a standardized urine color chart (Armstrong et al., 1994). For those individuals who are cognitively impaired, caregivers can be taught how to use the color chart. Frequency of documentation of fluid intake will vary from setting to setting and is dependent on an individual's condition. However, in most settings, at least one accurate intake and output recording should be documented and include the amount of fluid consumed, intake pattern, difficulties with consumption, and urine specific gravity and color. Accurate calculation of intake requires knowledge of the volumes of containers used to serve fluids which should be posted in a prominent place on the care unit. A study by Burns (1992) suggested that nurses over- or underestimated the volumes of common vessels.

Acute management of oral intake. Any resident who develops a fever, vomiting, diarrhea, or a non-febrile infection should be closely monitored by implementing intake and output records and provision of additional fluids as tolerated (Weinberg et al, 1994). Individuals who are required to be NPO for diagnostic tests should be given special consideration to shorten the time that they must be NPO and should be provided with adequate amounts of fluids and food when they have completed their tests.

EVALUATION OF PROCESS OUTCOMES

Adherence to the hydration management guideline must be monitored. The frequency of monitoring may be determined by the health care setting. The following parameters should be included in any adherence evaluation:

* Urine color monitoring consistently checked at the same time of day to make the most valid comparison (Armstrong et ah, 1994, 1998). Cutoff values of urine color indicative of impending dehydration based on Armstrong's chart are currently being researched. The urine color chart is available from: Lawrence Armstrong, Ph.D., University of Connecticut, 2095 Hillside Road, Box U-IlO, Storrs, CT 06269-1110.

* Urine specific gravity evaluation consistently checked at the same time of day to make the most valid comparison (Armstrong et al., 1994, 1998).

* Twenty-four-hour intake recording (output recording may be added; however in settings where individuals are incontinent of urine, an intake recording should suffice).

Deviations from the guideline should be discussed with the individual's primary nurse. Updated plans to manage hydration status will be implemented.

EVALUATION OF PATIENT OUTCOMES

To evaluate the use of this protocol among patients at risk for hydration management problems, specific resident outcomes relevant to hydration management should be evaluated on a regular basis according to resident need or institutional policies.

OUTCOME FACTORS

Outcomes of adequate hydration reported in the literature include:

* Maintenance of body hydration.

* Decreased infections, especially urinary tract infections (McConnell, 1984; Mentes, 2000).

* Improvement in urinary incontinence (Spangler et al., 1984).

* Lowered urinary pH (Hart & Adamek, 1984).

* Decreased constipation (Hert & Huseboe, 1998; Sheehy & Hall, 1998).

* Decreased acute confusion (Mentes & Buckwalter, 1997; Mentes et al., 1999).

The use of an outcome monitoring system such as the Nursing Outcomes Classification (NOC) can also help in the evaluation of resident outcomes. Table 4 lists critical indicators adapted to evaluate improvement in underhydration and dehydration using the Fluid Balance Outcome Scale from NOC (Johnson, Maas, & Moorhead, 2000).

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  • Key:
  • (R) = Research
  • (L) = Literature
  • (N) = National Guideline
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  • Wooten, M., & Liebman, B. (1998). Ten steps to a healthy 1998. Nutrition Action Health Letter, 25(1), I1 6-9. (L)

TABLE 1

RELATIVE STRENGTH OF DIFFERENT SIGNS OF DEHYDRATION IN ELDERLY INDIVIDUALS

TABLE 2

APPROXIMATE RANGES OF LABORATORY TESTS FOR HYDRATION STATUS

TABLE 3

RISK APPRAISAL CHECKLIST*

TABLE 4

FLUID BALANCE-DEHYDRATION

10.3928/0098-9134-20001001-04

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