8/11/2014...8/11/2014 5 ©Pathway Health 2013 All fluids that a resident drinks are counted in Tell...

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©Pathway Health 2013

Nutritional Management for

Success - Hydration

Jeanne Carlson RD,LD ©Pathway Health 2013

• Discover the components of a comprehensive hydration program

• Estimate fluid needs for obese patients

• Discuss interventions to promote fluid intake

Objectives


• Dehydration is defined as a loss of body water that causes significant signs and symptoms, including physiological and/or functional decline from the individual's baseline. Dehydration is one form of

fluid/electrolyte imbalance and may be caused by inadequate fluid intake and/or excessive fluid loss.

• A fluid/electrolyte imbalance is defined as an insufficiency or excess of either water or electrolytes (sodium and potassium) in

certain body areas.

Dehydration vs. fluid/electrolyte imbalance



• Suspicion of increased output and/or decreased input

• At least two physiological or functional signs or symptoms of dehydration (e.g., dizziness, dry mucous membranes, functional decline)

• Any of the following:

– BUN-creatinine ratio > 25:1

– Orthostasis, or a decrease in systolic blood pressure = 20 mm Hg upon a change in position

– Pulse > 100 beats per minute or a pulse change of 10 to 20 beats per minute more than the patient's baseline pulse upon a change in position

The AMDA guidelines committee translated its definition of dehydration into clinical terms. All three of the following elements must be present to label a patient clinically dehydrated:


• Elevated serum osmolarity – above 295 mOsmol

– “gold standard”

• Elevated serum sodium – above 145-148 mmol/L

• Elevated BUN/Creatinine ratio – above 25-50

• Elevated Urine Specific Gravity – above 1.028

*Only diagnostic in the presence of clinical signs of dehydration

Biochemical Signs of Dehydration*

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©Pathway Health 2013 ©Pathway Health 2013

• Dehydration is the most common fluid/electrolyte

disorder of frail elders, and it is both under

recognized and under treated.

• Per Mentes in 2006, the dehydration rate in

nursing homes was 30-33%

How Common is Dehydration?


Headache

Fatigue

Loss of appetite

Flushed skin

Heat intolerance

Light-headedness

Dry mouth or eyes

Burning sensation in stomach

Dark urine with strong odor

Early Dehydration


Difficulty swallowing

Clumsiness

Shriveled skin

Sunken eyes

Visual disturbances

Painful urination

Numb skin

Muscle spasm

Delirium

Advanced Dehydration


– Decreased thirst response

– Aged kidneys – decreased urine concentrating capacity, impaired excretion

– Decreased sensitivity to ADH

– Fear of incontinence

– Acute or chronic illnesses

– Decrease in total body water

– Increased need for feeding assistance

– Laxative, enema or diuretic use

– Difficulty swallowing

– Lack of access

Risk factors for Dehydration in the Elderly


• Hospital admission

• Functional decline and delirium

• Increased health care costs

• Urinary and respiratory infection

• Pressure ulcers

• Death

• Falls

• Constipation

• Medication toxicity

Consequences of Dehydration

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• Water is administered per physician order

• Amount administered varies by care giver

• Need clarification for before, between and

medication administration.

• Need clarification for water flushes

• How are free fluids in

formulas being calculated?

Dehydration and Tube Feeding


Four Key Questions

• Where are we now?

• Where do we want to be?

• How do we get there?

• How do we get commitment from key individuals?

Hydration


Starts at admission

– Receptionist

– HUC/HIM/ward clerk

– Nursing

– Dietary

– Rehab services

– Maintenance/housekeeping

– Social services

– Administration

Interdisciplinary Approach to “happy eaters”

Start Your Facility Assessment at the Door


Research has shown that people who laugh together work better together.


• Assessment/recognition

• Diagnosis/cause identification

• Treatment/management

• Monitoring

The Basic Care Process


• Meal delivery - Serving trays on carts delivered from the kitchen or steam tables in the dining room

• Choice vs. no-choice

• Menus

• Personal service

• 3 vs. 5 meals/day

• Culture change

Food Delivery Systems Review

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Staff attitudes and beliefs

Staffing - Who’s involved with meal delivery?

– “All hands on deck”

Institutional Factors


• 1. Educate staff and families on the warning signs for dehydration and on the action steps to prevent dehydration.

• 2. Estimate each resident’s fluid needs upon initial, quarterly, annual and significant change assessments.

Fluid needs increase by 6% per degree of fever over baseline temp.

Components of a Comprehensive Hydration Program


• 3. Establish a facility standard for the minimum amount of fluid served on meal trays each day and assure that residents receive adequate assistance at mealtime.

• 4. Implement interventions

• 5. Monitor success

Components of Hydration Program (cont.)


Why Train?

Training is not only the right thing to do; it can provide the basis for effective defenses to lawsuits and prevent deficient survey findings.

It is tempting for employers with limited resources to provide only legally required training to employees

1. Educate staff and families on the warning signs for dehydration and on the action steps to prevent dehydration.

“Comprehensive orientation and training programs give staff a sense of belonging and of status. It shows that your organization values them enough to make an investment in them, and helps to reinforce their commitment to your program.”


Food Item Container

Size

• Individual creamer

• Ice cream/sherbet

• Juice (4 oz.. plastic cup)

• Milk carton (8 oz..)

• Soda (12 oz..)

• Popsicle (3 fluid oz..)

• Italian ice (6 oz..)

• Large glass (8 oz..)

Approximate Amount cc Provided

• 15 ml

• 120 ml

• 120 ml

• 240 ml

• 360 ml

• 90 ml

• 180 ml

• 240 ml

Provide Written Information

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Tell me,

and I’ll forget.

Show me,

and I may not remember.

Involve me,

and I’ll understand.

– Native American Quote


What items should be counted as a fluid?

All fluids that a resident drinks are counted in mL's.

• 1 oz.. = 30 mL

• 4 oz.. = 1/2 cup = 120 mL

• 6 oz.. = 3/4 cup = 180 mL

• 8 oz.. = 1 cup = 240 mL

• Other items that liquefy at room temperature also need to be included such as broth, ice cream, sherbet, gelatin, fruit ice, and popsicles. For dialysis diets, fruits and vegetables should be drained prior to being served.


• ½ cup (C) ice cream, frozen yogurt, sorbet=100 mL

• ½ C sherbet=120 mL

• ½ C gelatin without fruit=110 mL

• ½ C gelatin with fruit=80 mL

• 1 freezer pop=120 mL

• 1 ice cube=10 mL


• Poor appetite

• Dysphagia

• Refusal to take medications

• New onset or worsening cognitive impairment/ confusion/delirium

• Vomiting

• Not consuming all or almost all liquids provided

• Diarrhea

• Fever

• Vertigo

Train CNA’s to report the following:


• Recent weight loss (5% in last 30 days or 10% in last 180 days)

• Starting a new a diuretic, digoxin or a medication associated with GI bleeding

• A new DX of terminal or irreversible, progressive, condition

Train LPN/RN to report the following:


• Increased heart rate

• Lowered blood pressure

• Increased vein refill

time

• Internal bleeding

• Urinary tract infection

• Fluid restriction for any reason

Cont.

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» Change in participation level

» Decrease in alertness

» Decline in fluid intake at activity functions

Train Activity and Rehab to report the following:


» Observed changes in fluid or food intake

» Dining room observations

Train Dietary Staff to report:


Encourage family members to let the nurse know when “Mom just isn’t acting right”

Family


• 1. Educate staff and families on the warning signs for dehydration and on the action steps to prevent dehydration.

• 2. Estimate each resident’s fluid needs upon initial, quarterly, annual and significant change assessments.

• Fluid needs increase by 6% per degree of fever over baseline temp.

Components of a Comprehensive Hydration Program


• 30 mL/kg body weight with a minimum of 1500 mL/day

• 20-25 mL/kg body weight if severe CHF

• 1 mL/kcal energy consumed

• 100 mL/kg for first 10 kg, 50 mL/kg for next 10 kg, and 15 mL/kg for remaining kg.

shortcut:

(Kg body weight-20) X 15 +1500mL

Fluid Requirement


20 patients with CVA and Dysphagia to thin liquids

Study:

– Control group: unrestricted thickened liquids

– Experimental group: thickened liquids and access to water

Caron at al, 1997

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Group Fluid consumption

Thickened liquids 1210 mL

Thickened liquids and water 855 mL thickened liquid 463 mL water

• Conclusion: significant difference in thickened liquid intake(p=0.03); water intake was less than expected

Results


• Dissatisfaction with thickened liquids

• Noncompliance with thickened liquids

• Potential dehydration

• Limited thickened fluid intake

• Complaints of dryness and thirst

• Nursing dependency to provide fluids and encourage intake

Author’s Conclusions


Male

65 inches tall

248# , 112.6 kg

BMI 41.3

Case Study


Actual body weight should be used for fluid estimates, not adjusted body weight.

Formulas available:

1. 100 ml/kg for the first 10 kg, plus 50 ml/kg for the next 10 kg, plus 15 ml/kg for the remaining weight

2. Short cut = (kg body weight – 20) x 15 + 1500

3. 30cc/kg body weight

4. 1cc/kcal intake

5. 3.7 L fluid/day ( at least 3.0 liters from beverages and the remainder from food) for men and 2.7 L/day ( at least 2.2 L from beverages and the remainder from food) for woman

*Absolute minimal adult fluid needs: Urine output + 500 cc/day. Does not apply to fluid restrictions.

Estimating Fluid Needs for Obese Patients


1. 100ml + 50ml + (15ml x 92.6) = 2889

2. (112.6 – 20) x 15 + 1500 = 2889

3. 112.6 x 30 = 3378 ml

4. 2400 ml (assuming intake of 2400 kcal/d)

5. 3700 ml (at least 3000 ml from beverages)

Range from 2400 ml to 3700 ml

Comparison of formulas


Average healthy adult 30-35 ml/kg weight

Adult 55-65 30 ml/kg weight

Adult >65 years 25 ml/kg body weight

ADA Nutrition Care Manual

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• No water pitcher in room

• Inform Activities and Rehab of restriction

• Drain fruits, veg, soups

• No ice cream or sherbet unless specialty product

• Signage (disguised) in room

• I & O if needed

• MAR

• Tray card

• Care plan

• Nursing progress notes document weekly

Fluid Restriction


Determine the resident's need for assistance with eating and drinking.

Record the resident's beverage preferences.

Evaluate the resident's hydration status and risk of dehydration

Ability to communicate

Initial Nutrition Assessment


Extent of cognitive impairment

Medications

Consider also the presence of progressive,

irreversible conditions such as dementia and terminal illnesses

Serum sodium >147

Hct >3x Hgb

Initial Nutrition Assessment cont..


Facilities are being tagged for lack of reassessment

Review care plan

Re-assess fluid needs

Consider the fluid content

in solids actually consumed

Reassessment after Dx Dehydration or Change in Status


Calculate free water in the formula correctly.

Add enough free flush to meet calculated requirement.

Tube Feedings


Resident receives 1600 ml of formula that is 85% free fluid = 1350 ml

Calculated need is 1850 ml

Then need 500 ml free warm water flush

Look at timing of feedings – allow time off for rehab and activities

Example

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– Deteriorated cognitive status (section B);

– Deteriorated ADL status (section G);

– Failure to eat (section K);

– Health conditions such as diarrhea, fever or vomiting (sections H and J).

– Specific identification of dehydration as a problem is noted in section J.

Consider the following items from the MDS in identifying residents who are at risk for dehydration:



• 4. Implement interventions

• 5. Monitor success

Components of Hydration Program


• Breakfast trays generally include 8 oz. milk, 6 oz. coffee, and 6 oz. juice for 600 ml.

• Lunch and Dinner meals usually provide another 4-8 oz. of milk, 6 oz. coffee, and 6-8 oz. of either water or juice at each meal for another 480-660 ml/meal.

Typical Fluid Breakdown


• And then there is HS snack, which is often offered after residents have gone to bed.

• Another 8 oz. would bring the daily total to 1800-2160 ml not including daytime

snacks.

Typical Fluid Breakdown (cont.)

Between meal hydration pass for residents on thickened liquids



• 4. Implement interventions • 5. Monitor success

Components of Hydration Program

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٭ Use 8oz cups to provide fluids at each medication pass.

٭ Start systemic fluid passes by using a hydration cart at least twice daily and offer a variety of fluids.

٭ Set up hydration stations in the Rehabilitation and Activities Departments.

٭ Address pain

٭ Monitor weight

Interventions:


٭ Implement a mealtime and between meals fluid intake documentation system.

٭ Promote fluids with positive encouragement by all staff with each visit

to the resident’s room.

٭ Provide staff education on feeding skills

(Older people tolerate frequent administration of fluid in smaller quantities better than infrequent large quantities.)

Interventions:


٭ Determine preferences of temperature and type of beverages for each resident.

٭ Establish a system for providing the RD and/or DTR with a copy of current hydration related laboratory values. The RD and/or DTR review the laboratory results, complete a timely assessment of the resident’s hydration status and update the resident’s hydration plan of care

as needed.

Interventions:


٭ Provide a large water cooler at each nursing station and replenish with fresh cool water daily. Make sure that cups are readily available.

Interventions


٭ Keeping a list of high-risk residents at strategic locations to remind others to monitor residents’ fluid intake.

٭ Consider placing a symbol, such as a

drop of water, near the resident’s bed as a sign for CNAs to encourage fluid intake.

٭ Flexible meal times

Interventions


٭ Implement quality assurance monitoring of the Comprehensive Hydration Program.

٭ Develop and maintain a comprehensive care plan that documents the resident’s dehydration risk factors, estimated fluid needs and an individualized plan for meeting fluid needs.

٭ Place on nutrition risk list

٭ Encourage “wet” foods – ice cream, soup, custard, yogurt, pureed fruit

Interventions:

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Nursing ADL Worksheet

Date Initiated: ____________ Date Last Revised: ____________

Grooming

Vision

Blind Glasses

Poor Vision

Hearing

Deaf HOH

Rt. Hearing Aid

Left Hearing Aid

Oral Care

Independent

Own teeth

Assist

Dentures

Upper Lower

No teeth

Partial Plate

Shave

Independent

Assist

Bathing

Bed bath Tub

Shower

Shampoo

Minimal Assist

Total Assist

Independent

Dressing

Self Care Assist

Total Care

Eating

Diet: _______________

Independent

Set up assist

Partial assist

Finger food

Thicken liquids

_______________

Supplement

Type: ______________

Time:

with meals

midmorning

mid afternoon

bed time

Fluids

Restrict

Encourage

Intake

Output

Dining Room: ___________

Mobility

Weight bearing status: ____

________________________

Dexterity: R L

Ambulate

Independent

1 Assist

2 Assist

Lift-Type: ___________

Cane

Wheelchair

Walker

Paralysis

Rt. Arm Rt. Leg

Lt. Arm Lt. Leg

Positioning

Independent

1 assist

2 assist

Q2 hours

Hip precaution

Transfer

Independent Walker

1 assist Cane

2 assist W/C

Mental Status

Alert

Oriented

Confused

Forgetful

Depressed

Agitated

Wanderer

Ph

ysi

cal

De

vic

es

Toileting

Toileting Schedule: _______

Continent

Inc. Bladder

Inc. Bowel

Bladder retraining

Bowel retraining

Disp. Brief: Size ______

Catheter care Q shift

Record BM Q shift

I & O

Skin

Routine

High Risk

Special treatment

Decubitis

Site:_______________

Contractures

Site:_______________

Wound

Site:_______________

Reposition_____________

_

Activities

PT

OT

ST

Escort needed

Comments:

Other:


Dietary Manager &/or Registered Dietitian

DNS &/or Lead/Charge Nurse

Speech Pathologist

Activities Director

Social Services

Restorative Nursing

CNA/Weight Staff

Other Important Contacts: MD, OT/PT, Pharmacist, Dentist

NUTRITION RISK REVIEW TEAM


Facilities with active interdisciplinary nutrition care teams and a physician who appropriately makes referrals are less likely to have weight loss, dehydration and pressure sore development

• Hypodermoclysis (HDC), the subcutaneous infusion of fluids


No single approach suffices for all situations and, in some cases, administration of fluids may be harmful. For example, a patient with progressive or acute heart failure with or without edema who may have intravascular volume depletion (reflected in an increase in the BUN/creatinine ratio) may need an increased dosage of diuretics, not more fluids. The physician must help to make such clinical decisions.

Hydration Assessment

• Appendix

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Email: [email protected]

Website: www.pathwayhealth.com

Phone: 877-777-5463

68

mailto:[email protected]

http://www.pathwayhealth.com/

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