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8/11/2014
1
©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
©Pathway Health 2013
• 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
©Pathway Health 2013
©Pathway Health 2013
• 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:
©Pathway Health 2013
• 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?
©Pathway Health 2013
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
©Pathway Health 2013
Difficulty swallowing
Clumsiness
Shriveled skin
Sunken eyes
Visual disturbances
Painful urination
Numb skin
Muscle spasm
Delirium
Advanced Dehydration
©Pathway Health 2013
– 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
©Pathway Health 2013
• 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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©Pathway Health 2013
• 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
©Pathway Health 2013
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
©Pathway Health 2013
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
©Pathway Health 2013
Research has shown that people who laugh together work better together.
©Pathway Health 2013
• Assessment/recognition
• Diagnosis/cause identification
• Treatment/management
• Monitoring
The Basic Care Process
©Pathway Health 2013
• 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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©Pathway Health 2013
Staff attitudes and beliefs
Staffing - Who’s involved with meal delivery?
– “All hands on deck”
Institutional Factors
©Pathway Health 2013
• 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
©Pathway Health 2013
• 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.)
©Pathway Health 2013
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.”
©Pathway Health 2013
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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©Pathway Health 2013
Tell me,
and I’ll forget.
Show me,
and I may not remember.
Involve me,
and I’ll understand.
– Native American Quote
©Pathway Health 2013
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.
©Pathway Health 2013
• 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
©Pathway Health 2013
• 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:
©Pathway Health 2013
• 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:
©Pathway Health 2013
• 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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©Pathway Health 2013
» Change in participation level
» Decrease in alertness
» Decline in fluid intake at activity functions
Train Activity and Rehab to report the following:
©Pathway Health 2013
» Observed changes in fluid or food intake
» Dining room observations
Train Dietary Staff to report:
©Pathway Health 2013
Encourage family members to let the nurse know when “Mom just isn’t acting right”
Family
©Pathway Health 2013
• 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
©Pathway Health 2013
• 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
©Pathway Health 2013
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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©Pathway Health 2013
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
©Pathway Health 2013
• 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
©Pathway Health 2013
Male
65 inches tall
248# , 112.6 kg
BMI 41.3
Case Study
©Pathway Health 2013
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
©Pathway Health 2013
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
©Pathway Health 2013
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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©Pathway Health 2013
• 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
©Pathway Health 2013
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
©Pathway Health 2013
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..
©Pathway Health 2013
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
©Pathway Health 2013
Calculate free water in the formula correctly.
Add enough free flush to meet calculated requirement.
Tube Feedings
©Pathway Health 2013
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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©Pathway Health 2013
– 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:
©Pathway Health 2013
• 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
©Pathway Health 2013
• 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
©Pathway Health 2013
• 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
©Pathway Health 2013
• 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
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©Pathway Health 2013
٭ 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:
©Pathway Health 2013
٭ 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:
©Pathway Health 2013
٭ 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:
©Pathway Health 2013
٭ Provide a large water cooler at each nursing station and replenish with fresh cool water daily. Make sure that cups are readily available.
Interventions
©Pathway Health 2013
٭ 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
©Pathway Health 2013
٭ 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:
©Pathway Health 2013
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
©Pathway Health 2013
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
©Pathway Health 2013
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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©Pathway Health 2013
Email: consult@pathwayhealth.com
Website: www.pathwayhealth.com
Phone: 877-777-5463
68
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