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Dehydration
Standardised care process
Objective
To promote evidence-based practice in the assessment and management of dehydration for older people who live in residential care settings.
Why the detection and
management of dehydration
is important
Dehydration is common in older people and can lead to constipation and increased risk of infections, falls and medication toxicity. Dehydration in older people is preventable. The risk of dehydration is increased in people living in aged care facilities (Mentes 2016).
Definitions
Body mass index (BMI): a weight-to-height ratio calculation that helps assess nutritional status. The BMI is calculated using the following formula:
BMI = weight in kilograms ÷ height in metres^2 (WHO 2012)
Dehydration: depletion of total body water caused by pathological loss of fluid, inadequate fluid intake or a combination of both (Mentes 2016, p. 112).
Team
Manager, registered nurses (RNs), enrolled nurses (ENs), personal care attendants (PCAs), leisure and lifestyle staff, general practitioner (GP), allied health professionals (such as a physiotherapist, occupational therapist and exercise physiologist), residents and/or family/carers.
Acknowledgement
This standardised care process (SCP) has been developed for public sector residential aged care services (PSRACS) by the Australian Centre for Evidence Based Care (ACEBAC) at La Trobe University through the Department of Health and Human Services Strengthening Care Outcomes for Residents with Evidence (SCORE) initiatives. This SCP is one of a series of priority risk areas reviewed based on the best available evidence in 2017.
Brief standardised care process
Recognition and assessment
- Identify residents at risk of dehydration.
- On admission and at any time if there is a change in the resident’s condition or symptoms of dehydration present, conduct a comprehensive assessment.
Interventions
If no dehydration is identified, implement and maintain strategies to prevent dehydration.
If dehydration is indicated by the assessment:
- Establish its severity and a treatment goal.
- Review daily intake, increasing oral fluids as tolerated.
- Document and monitor fluid intake and output review and revise prevention strategies currently in place.
- Monitor symptoms by repeating the above assessment.
- Refer to a GP if there is no improvement or symptoms are severe.
Referral
• GP
- Occupational therapist
- Speech pathologist
- Dietitian
- Pathologist
Evaluation and reassessment
- Monitor the resident until their symptoms are relieved.
- Monitor urine-specific gravity and colour.
- Continue preventative interventions.
- Monitor the resident’s functional ability.
- Monitor the resident for changes in their condition and/or symptoms of dehydration or over-hydration.
Resident involvement
- Involve the resident in identifying their preferred fluids and daily intake goal.
- Provide education regarding the importance of adequate fluid intake.
Staff knowledge and education
- Causes of dehydration in older people
- Maintaining adequate hydration
- Signs and symptoms of dehydration
- Fluid volumes of drinking utensils
Interventions
If no dehydration is identified, implement and maintain strategies to prevent dehydration:
- Calculate and document an individualised daily fluid intake goal (see the nomogram overleaf to determine the recommended water intake).
- Provide preferred fluids (but limit alcohol).
- Have fluid available at all times.
- Offer fluids regularly through the waking day (for example, every one and a half hours and during fluid rounds).
- Offer a variety of fluids over the day (for example, hot drinks, cold drinks, juice, milk, soups, icy poles). Caffeinated drinks can be included in the daily intake but not as the only source of fluid.
- Encourage the resident to drink small amounts throughout the day.
- Increase assistance as required and allocate adequate time to staff to facilitate this.
- Provide aids (for example, straws, ‘special’ cups), ensuring they are used at all times.
- Standardise the amount of fluid given with medications – for example, 180 mL per administration.
- Involve family to encourage fluid intake.
- Promote pleasurable and social opportunities for fluid intake (afternoon tea, non-alcoholic happy hour, drinks/ice-cream trolley).
- Prompt recognition and communication of symptoms of dehydration among staff.
If the assessment indicates dehydration:
- Establish its severity.
- Establish a treatment goal if the resident has reached the end-of-life phase.
- Review prevention strategies already in place.
- Review the daily intake goal, increasing oral fluids as tolerated.
- Document and monitor the resident’s fluid intake and output.
- Refer to a GP to consider blood tests and withholding renal toxic, renally excreted or diuretic medicines.
- Monitor symptoms by repeating the above assessment, for example:
- daily if there is no or only marginal improvement in fluid intake
- in seven days if the daily intake goal is being achieved.
If severe symptoms are present or if mild symptoms do not improve:
- Refer to a GP for medical assessment, diagnosis (including underlying causes) and treatment.
- Implement a treatment plan as prescribed by the GP.
- In conjunction with the GP, review the resident’s daily fluid intake goal.
Referral
• GP
- Occupational therapist if available for advice regarding appropriate drinking aids
- Speech pathologist
- Dietitian
- Pathologist
Evaluation and reassessment
- Monitor the resident until their symptoms are relieved.
- Monitor urine-specific gravity and colour.
- Continue preventative interventions.
- Monitor the resident’s functional ability – for example, how much assistance the resident needs to access, pour and drink fluids.
- Monitor the resident for changes in their condition and/or symptoms of dehydration.
- Monitor the resident for symptoms of over- hydration – that is, unexplained weight gain, peripheral oedema, neck vein distension, shortness of breath.
Resident involvement
- Involve the resident to identify their preferred fluids and daily intake goal.
- Provide education regarding the importance of adequate fluid intake.
Staff knowledge and education
- Causes of dehydration in older people
- Maintaining adequate hydration
- Signs and symptoms of dehydration
- Fluid volumes of drinking utensils
To receive this publication in an accessible format phone 9096 6963,usingthe
elayService 1 3 36 77 if required,oremail<acqiu@dhhs.vic.gov.NationalR au>.
easuryPlace,Melbourne.uthorisedandpublishedbytheVictorianGovernment, 1 TrA tateofVictoria,DepartmentofHealthandHumanServices,March2018.(1802012)©S 78 - 0 - 7 311-6849-1(pdf))ISBN 9 vailablefromthedepartment’swebsiteat<www2.health.vic.gov.au/agAeing-and-residential-aged-aged-care/ standardised-care-processes>.ving-resident-care/e/safety-and-quality/improcar
Important note: This SCP is a general resource only and should not be relied upon as an exhaustive or determinative clinical decision-making tool. It is just one element of good clinical care decision making, which also takes into account resident/patient preferences and values. All decisions in relation to resident/ patient care should be made by appropriately qualified personnel in each case. To the extent allowed by law, the Department of Health and Human Services and the State of Victoria disclaim all liability for any loss or damage that arises from any use of this SCP.
Evidence base for this
standardised care process
American Medical Directors Association (AMDA) 2014, ‘Dehydration and fluid maintenance’, AMDA, Columbia.
Bunn D, Jimoh F, Wilsher HS, Hooper L 2015, ‘Increasing fluid intake and reducing dehydration risk in older people living in long-term care: a systematic review’, JAMDA , vol. 16, pp. 101–113.
Canadian Agency for Drugs and Technologies in Health 2014, ‘Prevention of dehydration in geriatric patients in long-term care: guidelines’, CADTH, Ottawa.
Department of Health 2012, Strengthening care outcomes for residents with evidence (SCORE) , Ageing and Aged Care Branch, Victorian Government, Melbourne.
Gaspar PM 2011, ‘Comparison of four standards for determining adequate water intake of nursing home residents’, Research and Theory for Nursing Practice: An International Journal , vol. 25, no 1, pp. 11–22.
Gupta A 2016, Oral hydration for the older person: evidence summaries , The Joanna Briggs Institute, Adelaide. Mentes JC 2016, ‘Managing oral hydration’, in: M Boltz, E Capezuti, T Fulmer, D Zwicker (eds) Evidence-based geriatric nursing protocols for best practice , 5th edition, Springer Publishing Company, New York. World Health Organization (WHO) 2012, ‘Global database on body mass index: BMI classification’, viewed 8 January 2018, <http://www.who.int/ nutrition/databases/bmi/en/>.
