The grades for the strength of evidence (A-D) are provided at the end of the "Major Recommendations" field.
The hydration management intervention is an individualized daily plan to promote adequate hydration based on risk factor identification that is 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 (see Appendix A.1 in the original guideline document for an example of an assessment form that can be used):
- Basic physiological measures:
- Vital signs including temperature, pulse, respirations, orthostatic blood pressure
- weight
- height
- Body mass index (BMI) kg/m2
- Mucus membrane assessment
- Hydration status including:
- urine specific gravity
- urine color
- 24-hour intake/output
- usual pattern of fluid intake
- intake behaviors
- treatments (e.g., NPO [nothing by mouth] status or tube feedings)
- Cognitive status using a standard mental status questionnaire such as the Mini Mental State Exam (MMSE)
- Functional health status using a standard questionnaire such as the Katz Activities of Daily Living (ADL) scale, Functional Independence Measure (FIM), or functional status items from the Minimum Data Set (MDS) for long-term care
- Mood status using a standard questionnaire such as the Geriatric Depression Scale (GDS)
- Medical history including:
- Diagnoses
- Current medical condition
- History of over- or dehydration
- Current medications
Risk Identification
Based on the assessment data, a risk appraisal for hydration problems is completed using the Dehydration Risk Appraisal Checklist (see Appendix A.2 in the original guideline document).
Risk of Underhydration
The more of the following indicators that are present, the greater the likelihood of dehydration:
- Acute situations: vomiting, diarrhea, and/or febrile episodes (i.e., deviation from baseline temperature, repeated NPO status)
- Diagnosis of:
- Alzheimer's or other dementia
- Major psychiatric disorders: depression
- Cerebral vascular accident (CVA)
- Repeated infections
- Diabetes
- Malnutrition
- Urinary incontinence
- History of dehydration
- >4 chronic conditions
- Cardiac arrhythmias
- Medications:
- Diuretics
- Psychotropics: antipsychotics, antidepressants, and anxiolytics
- Laxatives
- >4 medications
- Steroids
- Angiotensin-converting enzyme (ACE) inhibitors
- Age >85 years
- Chronic cognitive impairment
- Functional status: independent, semidependent with feeding
- Inadequate nutritional status including the use of hyperosmolar or high protein enteral feedings
After risk appraisal is conducted, those individuals at risk for dehydration should have their trays marked with a blue flag to indicate to caregivers that they should finish 75 to 100% of their food and fluids.
Hydration Management
Managing fluid intake for optimal fluid balance consists of 1) acute management of oral intake, and 2) ongoing management of oral intake.
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. Evidence Grade = C). 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. For many procedures a 2 hour fluid fast is recommended (American Society of Anesthesiology, 1999. Evidence Grade = D).
Any resident who develops unexplained weight gain, pedal edema, neck vein distension, or shortness of breath should be closely monitored for overhydration. Fluids should be temporarily restricted, and the resident’s primary care provider notified.
Ongoing Management of Oral Intake
Ongoing management of oral intake consists of the following five components:
- Calculate a daily fluid goal.
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 (1998) 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).
Since this standard reflects fluid from all sources, to calculate a standard for fluids alone, 75% of the total calculated from the formula can be used. See the original guideline document for other standards.
- Compare resident's current intake to the amount calculated from applying the standard.
- Provide fluids consistently throughout the day.
- Plan fluid intake as follows: 75 to 80% delivered at meals, 20 to 25% delivered during non-meal times, such as medication times and planned nourishment times.
- Offer a variety of fluids, keeping in mind the individual's previous intake pattern (Zembrzuski, 1997. Evidence Grade = D). 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 effect on fluid balance (Martof & Knox, 1997. Evidence Grade = C) (See Appendix B in the original guideline document for Comparisons of Common Oral Fluids).
- Fluid with medication administrations should be standardized to a prescribed amount (e.g., 180 mL [6 oz] per administration time).
- Plan for at risk individuals
For residents who are at risk of underhydration because of poor intake, the following strategies can be implemented based on unit preference, time, and staffing issues:
- Fluid rounds mid-morning and late afternoon, where caregiver provides additional fluids (Spangler, Risley, & Bilyew, 1984. Evidence Grade = B).
- Provide 2 8-oz glasses of fluid in AM and PM (Robinson & Rosher, 2002. Evidence Grade = B).
- "Happy Hours" in the afternoon, where residents can gather together for additional fluids and socialization (Musson et al., 1990. Evidence Grade = C)
- "Tea Time" in the afternoon, where residents come together for fluids, nourishment, and socialization (Mueller & Boisin, 1989. Evidence Grade = D)
- Use of modified fluid containers based on resident's intake behaviors (e.g., ability to hold cup, to swallow) (Mueller & Boisin, 1989; Reedy, 1988. Evidence Grade = D)
- Offer a variety of fluids and encourage ongoing intake throughout the day for cognitively impaired residents. Offer fluids that residents prefer (Simmons, Alessi, & Schenelle , 2001. Evidence Grade = B).
- Fluid regulation and documentation
- Individuals who are cognitively intact and visually capable can be taught how to regulate their intake through the use of a color chart to compare to the color of their urine (Armstrong et al., 1994, 1998. Evidence Grade = B). For those 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 should include: the amount of fluid consumed, intake pattern, difficulties with consumption, and a 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, as a study by Burns (1992. Evidence Grade = C) suggested that nurses over- or underestimated the volumes of common vessels.
Evaluation
Adherence to the hydration management guideline can be monitored by (frequency of monitoring to be determined by setting):
- urine specific gravity checks, preferably a morning specimen (Armstrong et al., 1994, 1998. Evidence Grade = B; Wakefield et al., 2002. Evidence Grade = C). A value greater than or equal to 1.020 implies an underhydrated state and requires further monitoring (Mentes, 2000; Kavouras, 2002. Evidence Grade = C).
- urine color chart monitoring, preferably a morning specimen (Armstrong et al., 1994, 1998; Wakefield et al., 2002. Evidence Grade = B)
- 24-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, and updated plans to manage hydration status will be implemented.
Definitions:
Rating Scheme for Strength of Evidence
A = Evidence from well-designed meta-analysis
B = Evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action (e.g., assessment, intervention or treatment)
C = Evidence from observational studies (e.g., correlational descriptive studies) or controlled trials with inconsistent results
D = Evidence from expert opinion or multiple case reports
