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CONSIDER: HYDRATION MANAGEMENT

Definitions

Dehydration: a decrease in total body water. Reflected in elevated BUN, altered serum sodium levels and osmolarity. These are three types:

  • Hypertonic dehydration
  • Hypotonic dehydration
  • Isotonic dehydration

Hydration management: promotion of adequate fluid balance that prevents complications resulting from abnormal or undesired fluid levels.

Hypertonic dehydration: depletion in total body water content due to pathologic fluid losses, diminished water intake, or a combination of both. It results in hypernatremia (>145mEq/L) 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.This is also known as intracellular dehydration or hypernatremic dehydration. (Mentes, p.3)

Hypotonic dehydration: depletion in both sodium and water with greater losses of sodium than water, resulting in extracellular fluid loss. 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. This is also known as extracellular fluid volume depletion. (Mentes, p.4)

Isotonic dehydration: a balanced depletion of water and sodium causing extracellular fluid loss. Causes of isotonic dehydration include: vomiting, diarrhea, and osmotic diuresis of glucose. Circulation is effected in isotonic dehydration. This is also known as isotonic fluid volume depletion. (Mentes, p.4)

Atypical Presentation

Dehydration may present in older adults as falls, confusion, change in level of consciousness, muscle weakness/change in functional status, or fatigue.

Common Symptoms of Dehydration

  • Change in mental status
  • Delayed capillary refill
  • Dry mucous membranes (lips) and skin, decreased saliva
  • Elevation in BUN (best measure), hematocrit, sodium
  • Fever or urinary tract infection
  • Hypotension with orthostatic changes
  • Lethargy
  • Lightheadedness
  • Muscle weakness (particularly upper body)
  • Nausea
  • Oliguria
  • Poor skin turgor over sternum
  • Postural hypotension and dizziness
  • Sunken eyes
  • Tongue dry; longitudinal furrows
  • Weight loss of 3-5% in less than 30 days or acute weight loss

Most Likely Causes of Dehydration: Assessment and Interventions
Presenting Symptoms/Causes Nursing Interventions
Increased demand for fluid resulting in dehydration
  • Hyperglycemia
  • Infection
    • Pneumonia/Influenza
    • UTI/urosepsis
    • Cellutis
  • Electrolyte imbalance
  • Check blood glucose
  • Check electrolytes, BUN, creatinine
  • Check stat urinalysis, culture and sensitivity
  • Check breath sounds, oxygen saturation, Chest xray
  • Inspect for signs of skin infection
Alterations in Cognition
  • Delirium - may be symptom and/or cause of dehydration; evaluate immediately
  • Dementia - can impair ability to recognize need to drink
  • Depression - may lack desire to drink
Medications
  • Diuretics
  • Sedating medications: narcotics, sedatives/hypnotics, sedating antidepressants, antihistamines, or antiemetics, antipsychotics--decreasing ability/desire for fluid intake
  • Alcohol abuse
  • Anabolic steroids
  • Evaluate medications as possible cause
  • Consider discontinuing or holding causative medicine
  • See Also consider: Medications
Increased output > intake
  • Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
  • Diarrhea, vomiting, NG tube to suction, constipation
  • Assess for likelihood of SIADH and check labs: electrolytes, BUN, creatinine, urine specific gravity, 24 hour urine
  • Assess for underlying cause of diarrhea or vomiting; consider discontinuing NG aspiration
Dysphagia
  • Due to new CVA, progressive dementia, delirium
  • Monitor for coughing or choking with swallowing (note with fluids, solids, or both)
  • Request speech therapy consultation to evaluate swallow
Other Causes to consider
  • Enteral feeding without adequate free water supplement
  • Drug toxicity
  • Functional decline/weakness
  • Access to fluids
  • Decreased thirst response (normal aging change)
  • Environmental causes such as heat waves resulting in heat stroke or heat exhaustion
  • Determine underlying cause(s)
  • Check drug levels as indicated, e.g. digoxin level
  • See Also consider Function
  • Provide fluids within reach, offer fluids on a schedule
  • Nutrition assessment for water supplementation with enteral feeding
General guidelines
  • Determine if patient can independently mange fluid needs, place on hydration schedule if not OR
  • Prepare for fluid replacement and additional diagnostic and therapeutic actions (check BUN, creatinine, electrolytes)
  • Monitor vital signs, check orthostatic blood pressure
  • Monitor intake and output
  • Institute fall precautions

References

  • Mentes, J. (2000). Hydration management protocol. Journal of Gerontological Nursing. 26, pp. 6-15.
  • Mezey et al. (2001). Dehydration. The Encyclopedia of elder care. Springer Publishing Company: New York.
  • American Medical Directors Association (AMDA). (2001). Dehydration and fluid maintenance. Columbia, MD: AMDA. Accessed July 7, 2004 at www.guideline.gov


    • Last updated - February 2005