University of Colorado Hospital Nursing Practice Guideline

12
th
Floor Medicine/AC Unit! "ral Hydration Manage#ent
$elated Policies and Procedures!
Assessment of Adult Patients at Risk for Aspiration
Approved %y!
Acute Care of the Elderly Leadership Team
Acute Care of the Elderly Nurse Manager
Acute Care for the Elderly Service Medical irector
!eriatric Leadership Committee
N"C#E Committee
Nursing Practice !uidelines Su$committee
ffective! %&'(%)*
&escription! This guideline provides detailed information on hydration
management for the geriatric population+ "t identifies potential complications, risk
factors, ho- to assess for dehydration, and nursing interventions+ This guideline -as
developed to help nurses and nursing assistants provide geriatric sensitive care to prevent
dehydration+
Accounta%ility! The clinical nursing staff involved -ith the care of patients is
responsi$le for the management of the patient.s hydration status+
&efinitions!
ACP! Advanced Care Partner
'M(! /ody Mass "nde0
'UN! /lood 1rea Nitrogen
CNA! Certified Nursing Assistant
&ehydration! depletion of total $ody -ater of more than 23 due to pathologic fluid
losses, reduced -ater intake, or a com$ination of $oth+
H$! Electronic #ealth Record
()"! "ntake and 4utput
NP"! Nil Per 4s, nothing $y mouth
*'+! Total /ody 5ater accounts for a percent of an adult.s $ody -eight and consists of
intracellular and e0tracellular fluid compartments+
$N! Registered Nurse
Practice Guidelines!
A, Co#plications
)+ ehydration presents an increased risk for renal failure, decu$itus ulcers,
constipation, urinary tract infections, medication to0icity, deep vein
throm$osis, myocardial ischemia, respiratory infections, acute confusion,
diminished muscle strength, and falls+
', $is- Factors
)+ Age6related physiological changes
a+ ecrease in T/5, altered thirst sensation, effectiveness of
vasopressin, impaired kidney function 7conservation of -ater, urine
concentration8
(+ emographics
a+ Age 9 :; or female, /M" <() or =(&
2+ Medications
a+ >our or more medications, medications that increase fluid loss
7diuretics, la0ative8, sedating medications that decrease a$ility to
o$tain fluid, medications that dull the thirst response 7antipsychotics8
*+ Medical conditions
a+ Cognitive deficits 7such as, dementia, delirium, Al?heimer.s8,
depression, thrush or oral mucositis, infection, hyperglycemia, four or
more chronic conditions, malnutrition, history of dehydration, nausea
and vomiting, increased diaphoresis, prolonged NP4 status prior to
procedure or test
;+ >unction
a+ ependencies in eating and drinking, immo$ility, refusal to drink due
to concern a$out incontinence, s-allo-ing disorders, ill6fitting
dentures, poor dentation
C, Assess#ent
)+ Recommended tools
a+ ehydration Risk Appraisal Checklist
i+ This tool calculates risk for dehydration $y looking at personal
factors, health conditions, medications, oral intake $ehaviors,
and la$oratory indicators+ Risk level is determined $y the
num$er of characteristics that apply+
ii+ See Appendi0 )
$+ Types of hydration pro$lems and suggested strategies
i+ This ta$le identifies different oral hydration ha$its -ith a point
system and strategies to prevent dehydration+ There are four
main categories and under the main categories are
su$categories@ Can rink 7"ndependent, >orgets8, Can.t rink
7ysphagia, Physically ependent8, 5on.t rink 7Sipper,
>ears "ncontinence8 and End of Life+
ii+ See Appendi0 (
(+ #ealth history
a+ Assess patients medical history of disease that put patient at risk for
dehydration, num$er of prescription drugs, past history of dehydration
or repeated infections
2+ Physical
a+ Aital signs@ hypotension, orthostatic hypotension, tachycardia, fever,
-eak Bthready. pulse, increased respirations
$+ 5eight@ acute -eight loss
c+ Neurological@ altered mental status, speech difficulties, lethargy,
muscle -eakness
d+ Skin@ dry and tenting sternal skin turgor, increased capillary refill time,
cool peripheries
e+ Eyes, Mouth@ dry and pale mucous mem$ranes, decreased saliva,
longitudinal furro-s on tongue, sunken eyes
f+ !astrointestinal '!enitourinary@ vomiting, diarrhea, decreased urine
output, urine color, net "C4
*+ iagnostic
a+ La$s@ 5hen revie-ing la$s look for an increase in urine6specific
gravity, /1N, creatinine, hematocrit, serum sodium, /1N'creatinine
ratio, serum osmolality, and changes in electrolytes+
&, Nursing Care .trategies
)+ ocument
a+ "ntake and output as directed per order 7D:#, D*#, Strict, Accurate8
$+ "ntake
i+ Record patient.s intake in E#R+ Calculate fluid intake $y the
e0act volume of container+ Refer to nutrition room -here three
different cups have measured volume+ Record food intake $y
percentage eaten+
ii+ ocument amount of intake volume upon completion of
container
iii+ "dentify patient.s a$ility to eat'drink and record in E#R for
feeding assistance under intake as either independent, moderate
assist, total assist, or )@) supervision+
c+ 4utput
i+ Continent'rains@ 1se hat in toilets or commode to accurately
measure outputE use cylinder to measure drain'foley output+
ii+ "ncontinent@ 1se prompted voiding to prevent incontinence+
>or incontinent episodes record in E#R as an occurrence+
iii+ Assess and document urine color, appearance and odor+
ocument stool assistance, appearance, color, amount, and
source+
(+ Communicate and educate
a+ Report to CNAs'ACPs patient.s feeding and drinking function and
needs, orders for "C4s freFuency, types of hydration pro$lems and
strategies+ Revie- CNA report sheet to ensure accurate "C4 status
$+ Reinforce need for oral care especially for patients -ith dysphagia and
NP4 status
c+ ocument intake of fluids upon completion of container
d+ Educate patients and families of current diet order, the importance of
hydration, the risk associated -ith increased age, and daily intake goal+
"nvolve family mem$ers'friends in encouraging the patient to drink
and eat+ Suggest the family mem$ers leave a list of $everages and
foods the patient likes to eat and drink if patient is una$le to do so+
e+ Contact doctor if patient.s diet order is NP4 to clarify -hen test is and
if it is necessary+
f+ 1sing the 1C# !eriatric Medicine Admission order set encourage
doctor include order Gminimum liFuids (;%mL P4 routine * times
dailyH
2+ "ncrease fluids
a+ "f no fluid restrictions are ordered on a patient, calculate recommended
daily fluid intake $y using recommended tool -hich is for older adults
-ho are hospitali?ed+
$+ Assess patient.s capacity for independent feeding@ conduct RN
$edside s-allo- screening, o$serve patient eating different types of
food and drinks using different modalities 7e+g+ stra-s, mugs, lids8+
c+ 1se modified fluid containers $ased on assessment of patient.s
capacity to hold cup and s-allo-+
d+ Assess need for change in diet consistency $ased upon patient.s
dentation, denture use, or patient.s preference
e+ Encourage fluid rich foods
f+ Suggest nutrition consult for patients needing supplements -ith or
$et-een meals or calorie count+
g+ "f appropriate for patient order room service -ith assistance so a
nutrition assistant can help patient order meals
h+ uring medication administration encourage patient to drink fluids+
i+ Make drinks availa$le+ o fluid rounds in mid6morning and late
afternoon to provide additional fluid in $et-een meals+ 4ffer a variety
of drinks+ Assess -hat patient prefers to drink and temperature+
Replenish and refresh drinks
I+ CNA fluid rounds at $eginning of shift 7%J2%, ):2%8 to remove and
record multiple or empty cups+ Replace -ith fresh -ater+
k+ Ensure patient is a$le to reach food and $everage
l+ "ncorporate s-allo-ing e0ercises if appropriate
m+ 1se visual reminders such as poster or note on patient -hite$oard to
encourage fluid intake
n+ Assess patients. diet and encourage GTea TimeH to increase fluid
intake+ 4n days that GTea TimeH is not offered provide patient -ith
options of $everages and snack in the afternoon+
Calculation
1//#l//-g for first 1/-g of 0eight
1/#l/-g for ne2t 1/-g of 0eight
11#l/-g for the re#aining 0eight
2a#ple
Patient weighting 73 kg
)%%ml')%kg6 )%%%
;%ml')%kg6 ;%%
);ml';2kg6 &K;
Calculated recommended daily fluid intakeL ((K;ml
Appendi2 1
&ehydration $is- Appraisal Chec-list
3 =:; years 3 /M" <() or =(&
3 >emale M/M"L -eight 7kg8'height 7m8
(
N
.ignificant Health Conditions/.ituations
3 ementia' Oscreen for cognitive impairment 3 Renal isease
3 epression' Oscreen for depression 3 Cardiac Arrhythmias
3 CAA 3 Malnutrition
3 ia$etes 3 #istory of dehydration
3 1rinary "ncontinence 3 #istory of repeated infections
3 MaIor Psychiatric isorders 3 9 * chronic health conditions
3 Aomiting 3 >ever
3 NP4 status 3 iarrhea
Medications
3 4* medications 3 iuretics
3 La0atives 3 Psychotropics@ Antipsychotics,
3 Steroids Antidepressants, An0iolytics
3 ACE inhi$itors
(nta-e 'ehaviors
3 ReFuires assistance to drink 3 Semi6dependent -ith feeding
3 #as difficulty s-allo-ing' Chokes 3 >luid intake of <);%%ml'day
3 Can drink independently $ut forgets 3 Spills
3 Poor eater 7eats <;%3 of food8 3 Receives tu$e feedings
3 Receiving "A fluid therapy 3 #olds food'fluid in mouth
3 rools 3 Spits out food'fluid
5a%oratory (ndicators
3 1rine specific gravity =)+%(% 3 Serum sodium =);%meF'L
3 1rine color dark yello- =* 3 Serum osmolality =2%%mmol'Pg
3 /1N'Creatinine = (%@) 3 #ematocrit = normal
ate of Assessment@ QQQQQQQQQQQQQQQQQQQQQQQQQQQ Assessor@QQQQQQQQQQQQQQQQQQQQQQ
(nstructions!
The information on this form may $e collected from direct
o$servation, from chart revie-, or from MS information that has
$een collected+ Many of the items on this checklist have MS
identifiers ne0t to them reflecting that information from MS can $e
used to complete this checklist+ The total num$er of risk factors should
$e totaled+ The higher the num$er of risk factors checked, the higher
the risk for hydration pro$lems+ Please check all that apply+
Addressograph
References@
Mentes, R+C+ C The "o-a Aeterans Affairs Nursing Research Consortium 7(%%*8 Evidence-Based Practice Guideline: Hydration
management."o-a City, "A@ The 1niversity of "o-a !erontological Nursing "nterventions Research Center Research Translation
and issemination Core+
Mentes, R+C+ C The "o-a Aeterans Affairs Nursing Research Consortium+ 7(%%%8+ #ydration management+ Journal o
Gerontological !ursing" J6);+
(ndependent
7n L &8
l
Educate@
#o- much
l
1se
graduated
cup
l
Provide
preferred
$everages
Forgets
&8 n L 7
l
>reFuent
offers
l
>luid during
activities
l
Teatime'
happy
hours
l
/everage
cart
&ysphagic
7n L &8
l
S-allo-ing
e0ercises
l
>oods rich
in fluid,
smoothies
l
4ral care
l
Educate
family to
help
Physically
&ependent
7n L J8
l
Sports cup
-ith stra-
l
Physical
aids to
assist -ith
drinking
Fears
(ncontinence
7n L (8
l
Educate
a$out
maintaining
fluid intake
l
Pegels, urge
inhi$ition
l
Medication
as last resort
.ipper
7n L ;8
l
>reFuent
small
amounts
at each
contact
l
>luid -ith
activities
l
Provide
preferred
$everages
l
Resident
and family
preference
l
Advance
directive
*ypes of hydration pro%le#s
#an $rink
n L )*
%on&t $rink
n L &
#an&t $rink
n L )2
End o 'ie
n L )
Appendi2 2
$eferences!
Collins, M+, C Claros, E+ 7(%))8+ Recogni?ing the face of dehydration+ !ursing, ()7:8, (J62)+
L4E &
!odfrey, #+, Cloete, R+, ymond, E+, C Long, A+ 7(%)(8+ An e0ploration of the hydration care of
older people@ A Fualitative study+ *nternational Journal o !ursing +tudies, (,, )(%%6)())+ L4E
J
Mentes, R+, C Culp, P+ 7(%%28+ Reducing hydration6linked events in nursing home residents+
#linical !ursing -esearch, ).728, ()%6((;+ L4E 2
Mentes, R+, C Pang, S+ 7(%)28+ Evidence6$ased practice guideline@ #ydration management+
Journal o Gerontological !ursing, 3,7(8, ))6)K+ L4E &
Ru0ton, C+ 7(%)(8+ Promoting and maintaining healthy hydration in patients+ !ursing +tandards,
./72)8, ;%6;J+ L4E :
5otton, P+, Crannitch, P+, C Munt, R+ 7(%%:8+ Prevalence, risk factors and strategies to prevent
dehydration in older adults+ #ontem0orary !urse, 3)7)8, **6;J+ L4E :