Want to know more

HYDRATION MANAGEMENT
Nursing Standard of Practice Protocol: Oral Hydration Management

Janet C. Mentes, PhD, APRN, BC

Evidence-Based Content - Updated March 2008

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Goal

To minimize episodes of dehydration in older adults.

Back to top

 

Overview

Maintaining adequate fluid balance is an essential component of health across the life span; older adults are more vulnerable to shifts in water balance, both over-hydration and dehydration, because of age-related changes and increased likelihood that they have several medical conditions. Dehydration is the more frequently occurring problem.

Back to top

 

Background and Statement of Problem

A. Definitions

1. Hydration management is the promotion of adequate fluid balance that prevents complications resulting from abnormal or undesired fluid levels. (See Resources: Dochterman & Bulechek, 2004).

2. Dehydration is depletion in TBW 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 (Na > 145mE/L).

3. Volume depletion is the loss of both sodium and water with greater losses of sodium resulting in extracellular fluid loss and a reduction in intravascular volume, 1 also called hypotonic dehydration.

B. Etiologic factors associated with dehydration

1. Age-related changes in body composition with resulting decrease in TBW. 2

2. Decreasing renal function. 31

3. Lack of thirst. 4, 5, 6, 7, 8

C. Risk Factors

1. Individuals older than 85. 9, 10, 11

2. Individuals who are institutionalized. 12

3. Individuals with ADL dependencies, specifically feeding and eating. 16

4. Individuals with a diagnosis of dementia. 13, 14

5. Individuals with infections. 11

6. Individuals who have had prior episodes of dehydration. 12

Back to top

 

Parameters of Assessment

A. Health history

1. Specific disease states: dementia, congestive heart failure, chronic renal disease, malnutrition, and psychiatric disorders such as depression. 11, 13, 14

2. Presence of comorbidities: more than four chronic health conditions. 17

3. Prescription drugs: number and types. 17

4. Past history of dehydration, repeated infections. 12

B. Physical Assessments 15

1. Vital signs

2. Height and weight

3. BMI

4. Review of systems

5. Indicators of hydration

C. Laboratory Tests

1. Urine specific gravity. 34, 18

2. Urine color. 34, 18

3. BUN/creatinine ratio

4. Serum sodium

5. Serum osmolality

D. Individual fluid intake behaviors. 12

Back to top

 

Nursing-Care Strategies

A. Risk Identification 15

1. Identify acute situations: vomiting, diarrhea, or febrile episodes

2. Use a tool to evaluate risk: Dehydration Appraisal Checklist (see Resources)

B. Acute Hydration Management

1. Monitor input and output. 19

2. Provide additional fluids as tolerated. 19

3. Minimize fasting times for diagnostic and surgical procedures. 20

C. Ongoing Hydration Management

1. Calculate a daily fluid goal. 15

2. Compare current intake to fluid goal. 15

3. Provide fluids consistently throughout the day. 21, 22

4. Plan for at-risk individuals

a. Fluid rounds. 23

b. Provide two 8-oz. glasses of fluid, one in the morning and the other in the evening. 23

c. "Happy Hours" to promote increased intake. 24

d. "Tea time" to increase fluid intake. 25

e. Offer a variety of fluids throughout the day. 22

5. Fluid regulation and documentation

a. Teach able individuals to use a urine color chart to monitor hydration status. 26, 27, 34

b. Document a complete intake recording including hydration habits. 15

c. now volumes of fluid containers to accurately calculate fluid consumption. 28, 29

d. Maintenance of body hydration. 22, 23, 30

Back to top

 

Evaluation and Expected Outcomes

A. Decreased infections, especially urinary tract infections. 23, 30, 31

B. Improvement in urinary incontinence. 32

C. Normal urinary pH. 29

D. Decreased constipation. 23

E. Decreased acute confusion 33

Back to top

 

Follow-up Monitoring of Condition

A. Urine color chart monitoring in residents with better renal function. 18, 26, 27

B. Urine specific-gravity checks. 18, 26, 27

C. 24-hour intake recording. 2

Back to top

 

Relevant Practice Guidelines

A. Hydration-Management Evidence-Based Protocol See:
www.guideline.gov

Back to top

 

For Definition of Levels of Quantitative Evidence Click Here

 

Reprinted with permission from Springer Publishing Company. Tullman, D. F., Mion, L. C., Fletcher, K., & Foreman, M. D. (2008). Oral hydration management. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.). Evidence-based geriatric nursing protocols for best Practice (3rd ed.), (pp. 337-351). New York: Springer Publishing Company, Inc.

References

1. Mange, K., Matsuura, D., Cizman, B., Soto, H., Ziyadeh, F., Goldfarb, S., et al. (1997). Language guiding therapy: The case of dehydration versus volume depletion. Annals of Internal Medicine, 127, 848–853. Evidence Level: V: Literature Review

2. Metheny, N. (2000). Fluid and electrolyte balance. In Nursing Considerations (4th Ed., pp. 3–12, 24–26). St. Louis, MO: Lippincott, Williams, & Wilkins. Evidence Level VI: Expert Opinion.

3. Lindeman, R., Tobin, J., & Shock, N. (1985). Longitudinal studies on the rate of decline in renal function with age. Journal of the American Geriatrics Society, 33, 278–285. Evidence Level IV: Nonexperimental Study.

4. Kenney, W. L., & Chui, P. (2001). Influence of age on thirst and fluid intake. Medicine & Science in Sports and Exercise, 33, 1524–1532. Evidence Level V: Literature Review.

5. Mack, G., Weseman, C., Langhans, G., Scherzer, H., Gillen, C., & Nadel, E. (1994). Body fluid balance in dehydrated healthy older men: Thirst and renal osmoregulation. Journal of Applied Physiology, 76, 1615–1623. Evidence Level III: Quasi-experimental Study.

6. Miescher, E., & Fortney, S. (1989). Responses to dehydration and rehydration during heat exposure in young and older men. American Journal of Physiology, 257(26), R1050–R1056. Evidence Level III: Quasi-experimental Study.

7. Phillips, P., Rolls, B., Ledingham, J., Forsling, M., Morton, J., Crowe, M., et al. (1984). Reduced thirst after water deprivation in healthy elderly men. New England Journal of Medicine, 311, 753–759. Evidence Level III: Quasi-experimental Study.

8. Phillips, P., Bretherton, M., Johnston, C., & Gray, L. (1991). Reduced osmotic thirst in healthy elderly men. American Journal of Physiology, 261, R166-R171.

9. Ciccone, A., Allegra, J. R., Cochrane, D. G., Cody, R. P., & Roche, L. M. (1998). Age-related differences in diagnoses within the elderly population. American Journal of Emergency Medicine, 16, 43–48.Evidence Level IV: Nonexperimental Study.

10. Lavisso-Mourey, R., Johnson, J., & Stolley, P. (1988). Risk factors for dehydration among elderly nursing-home residents. Journal of the American Geriatrics Society, 36, 213–218. Evidence Level IV: Nonexperimental Study.

11. Warren, J., Bacon, E., Harris, T., McBean, A., Foley, D., & Phillips, C. (1994). The burden and outcomes associated with dehydration among U.S. elderly, 1991. American Journal of Public Health, 84, 1265–1269. Evidence Level IV: Nonexperimental Study.

12.Mentes, J. (2006). A typology of oral hydration problems exhibited by nursing-home residents. Journal of Gerontological Nursing, 23(1), 13–21. Evidence Level IV: Nonexperimental Study.

13. Albert, S., Nakra, B., Grossberg, G., & Caminal, E. (1989). Vasopressin response to dehydration in Alzheimer’s disease. Journal of the American Geriatrics Society, 37, 843–847. Evidence Level III: Quasi-experimental Study.

14. Albert, S., Nakra, B., Grossberg, G., & Caminal, E. (1993). Drinking behavior and vasopressin responses to hyperosmolality in Alzheimer’s disease. International Psychogeriatrics, 6, 79–86. Evidence Level III: Quasi-experimental Study.

15. Mentes, J. C., and The Iowa Veterans Affairs Nursing Research Consortium (2004). Evidence-based protocol: Hydration management. In M. G. Titler (Series Ed.), Series on evidence-based practice for older adults. Iowa City, IA: The University of Iowa College of Nursing Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core. Evidence Level I: Systematic Review.

16. Gaspar, P. (1999). Water intake of nursing-home residents. Journal of Gerontological Nursing, 25(4), 22–29. Evidence Level IV: Nonexperimental Study.

17. Lavisso-Mourey, R., Johnson, J., & Stolley, P. (1988). Risk factors for dehydration among elderly nursing home residents. Journal of the American Geriatrics Society,36, 213-218.

18. Wakefield, B., Mentes, J., Diggelmann, L., & Culp, K. (2002). Monitoring hydration status in elderly veterans. Western Journal of Nursing Research, 24, 132–142. Evidence Level IV: Nonexperimental Study.

19. Weinberg, A., Pals, J., Levesque, P., Beals, L., Cunningham, T., & Minaker, K. (1994). Dehydration and death during febrile episodes in the nursing home. Journal of the American Geriatrics Society, 42, 968–971. Evidence Level IV: Nonexperimental Study.

20. American Society of Anesthesiology Task Force on Preoperative Fasting (1999). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Anesthesiology, 90, 896–905. Level I: Systematic Review.

21. Ferry, M. (2005). Strategies for ensuring good hydration in the elderly. Nutrition Reviews, 63(6), S22–S29. Evidence Level V: Literature Review.

22. Simmons, S., Alessi, C., & Schnelle, J. (2001). An intervention to increase fluid intake in nursing home residents: Prompting and preference compliance. Journal of the American Geriatrics Society, 49, 926–933. Evidence Level II: Single Experimental Study.

23.Robinson, S., & Rosher, R. (2002). Can a beverage cart help improve hydration? Geriatric Nursing, 23, 208–211. Evidence Level IV: Nonexperimental Study.

24. Musson, N., Kincaid, J., Ryan, P., Glussman, B., Varone, L., Gamarra, N., et al. (1990). Nature, nurture, nutrition: Interdisciplinary programs to address the prevention of malnutrition and dehydration. Dysphagia, 5, 65–101. Evidence Level V: Program Evaluation.

25. Mueller, K., & Boisen, A. (1989). Keeping your patient’s water level up. RN, 52, 65–66, 68. Evidence Level V: Program Evaluation.

26. Armstrong, L., Herrera-Soto, J., Hacker, F., Kavouras, S., & Maresh, C. (1998). Urinary indices during dehydration, exercise, and rehydration. International Journal of Sport Nutrition, 8, 345–355. Evidence Level IV: Nonexperimental Study.

27. Armstrong, L., Maresh, C., Castellani, J., Bergeron, M., Kenefick, R., La Grasse, K., et al. (1994). Urinary indices of hydration status. International Journal of Sport Nutrition, 4, 265–279. Evidence Level IV: Nonexperimental Study.

28. Burns, D. (1992). Working up a thirst. Nursing Times, 88(62), 44–45. Evidence Level IV: Nonexperimental Study.

29. Hart, M., & Adamek, C. (1984). Do increased fluids decrease urinary stone formation? Geriatric Nursing, 5(6), 245–248. Evidence Level III: Quasi-experimental Study.

30. Mentes, J., & Culp, K. (2003). Reducing hydration-linked events in nursing-home residents. Clinical Nursing Research, 12,210–225. Evidence Level III: Quasi-experimental Study.

31. McConnell, J. (1984). Preventing urinary tract infections: Nursing measures alone reduced UTI in a nursing home. Geriatric Nursing, 5(8), 361–362. Level III: Quasi-experimental Study.

32. Spangler, P., Risley, T., & Bilyew, D. (1984). The management of dehydration and incontinence in nonambulatory geriatric patients. Journal of Applied Behavior Analysis, 17, 397–401. Evidence Level III: Quasi-experimental Study.

33. Mentes, J., Culp, K., Maas, M., & Rantz, M. (1999). Acute confusion indicators: Risk factors and prevalence. Using MDS data. Research in Nursing & Health 22, 95-105.

34. Mentes, J., Wakefield, B., & Culp, K. (2006). Use of a urine color chart to monitor hydration status in nursing-home residents. Biological Research for Nursing, 7, 197–203. Evidence Level IV: Nonexperimental Study.


Resources
McCloskey-Dochterman, J. C., & Bulechek, G. M. (Eds.) (2004). Nursing Interventions Classification (NIC) (4th ed., pp. 348–349, 352). St. Louis, MO: Mosby.. See both Fluid Management and Fluid Monitoring nursing interventions.

Dehydration Appraisal Checklist http://rgp.toronto.on.ca/
torontobestpractice/Dehydrationriskappraisalchecklist.pdf

Back to top

 

Last updated - March 2008