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Acute Rehydration in Adults Emergency Medicine > Emergency medicine > Acute Rehydration in Adults

Care map

information

Provider and patient

resources

Updates to this care

map

Hauora Māori Pasifika POAC Provider

Resources

Clinical presentation

Caution

Assess dehydration

status

Severe dehydration Moderate dehydration Mild dehydration

Hospital admission

recommended

Consider further

investigations Trial oral fluids +/-

antiemetic

Consider trial oral

fluids and antiemetic

Discharge plan

GP Team Review (as

required)

If inadequate response Adequate response

or not appropriate,

commence IV fluids

GP Team review

GP Team review

Not improving Improving

Manage as per

specialist advice

Discharge plan

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1. Care map information

In Scope:

This pathway is specific to dehydration due to vomiting and/or diarrhoea. It aims to serve as a general guideline and support

aid in the assessment and management of mild to moderate dehydration. Severe dehydration is the result of large fluid losses

and may be complicated by electrolyte and acid base disturbances which require treatment and observation over a prolonged

period. Severe dehydration is not suitable for care under Primary Options for Acute Care (POAC) and admission to hospital is

recommended. However this pathway may also be used for nausea and vomiting in pregnancy resulting in mild to moderate

dehydration (see Nausea and Vomiting in Pregnancy pathway). Hyperemesis associated with severe dehydration is excluded - see

below.

Aims of the pathway include:

• improving clinical signs

• achieving adequate urine output

• recording fluid balance

• reducing fluid loss

• managing oral rehydration solution safely at home

Out of Scope:

Vomiting and/or diarrhoea are symptoms which may result from a wide range of diagnoses. A working diagnosis is important in the

management of subsequent dehydration. This guideline is not intended to replace the need for an accurate diagnosis and clinical

judgement. Patients with the following are excluded and admission to hospital should be considered:

• children <15 years - refer to Gastroenteritis in Children Pathway

• severe dehydration

• diabetes

• renal failure

• septicaemia

• shock resulting from blood loss

• unstable or acute heart failure

• cases of abdominal pain where there is not a clear diagnosis

• intracranial causes

• migraine - IV fluids are not indicated unless the patient is dehydrated and is not able to take oral fluids

• hyperemesis - contact the obstetric/gynaecology registrar for further advice

• incidence of hyperemesis gravidarum is around 0.3–1% of pregnancies [BPAC] [9]

• hyperemesis is characterised by the triad of [38]:

• body weight loss of more than 5% of pre-pregnancy weight

• dehydration

• electrolyte imbalance

• normally require hospital admission

Caution is also recommended for cases involving older adults, pre-existing heart failure, where symptoms have been prolonged or

involved overseas travel, where there is additional significant co-morbidity or where the social setting may impair management at

home.

2. Provider and patient resources

Provider resources:

• Adult fluid balance chart

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• oral rehydration - NZF

• metoclopramide - NZF

• prochlorperazine - NZF

• ondansetron - NZF

• POAC Transfer of Care/Handover form

Patient resources:

• Patient Information Brochure - Acute Adult Rehydration

2 Updates to this care map

3. Updates to this care map

Interim Update: June 2018

• Scope extended to include nausea and vomiting in pregnancy resulting in mild to moderate dehydration:

• for guidance for commencing IV fluids for this group of patients, refer to box ''If inadequate response or not appropriate,

commence IV fluids"

Interim Update: August 2017

• References to Recovery @ Home service changed to 'acute nursing support (DNS)'

First Publication Date: July 2016

This pathway has been updated in line with consideration to evidenced based guidelines.

4. Hauora Māori

Māori are a diverse people and whilst there is no single Māori identity, it is vital practitioners offer culturally appropriate care when

working with Māori Whānau. It is important for practitioners to have a baseline understanding of the issues surrounding Māori health.

This knowledge can be actualised by (not in any order of priority):

• acknowledging Te Whare Tapa Wha (Māori model of health) when working with Māori Whānau

• asking Māori clients if they would like their Whānau or significant others to be involved in assessment and treatment

• asking Māori clients about any particular cultural beliefs they or their Whānau have that might impact on assessment and

treatment of the particular health issue (Cultural issues)

• consider the importance of Whānaungatanga (making meaningful connections) with their Māori client / Whānau

• knowledge of Whānau Ora, Te Ara Whānau Ora and referring to Whānau Ora Navigators where appropriate

• having a historical overview of legislation that has impacted on Māori well-being

For further information:

• Hauora Māori

• Central PHO Māori Health website

5. Pasifika

[refer to pasifika maternal co-ordinator]

Pacific Cultural Guidelines (Central PHO) 6MB file

Our Pasifika community:

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• is a diverse and dynamic population:

• more than 22 nations represented in New Zealand

• each with their own unique culture, language, history, and health status

• share many similarities which we have shared with you here in order to help you work with Pasifika patients more effectively

The main Pacific nations in New Zealand are:

• Samoa, Cook Islands, Fiji, Tonga, Niue, Tokelau and Tuvalu

Acknowledging The FonoFale Model (pasifika model of health) when working with Pasifika peoples and families.

Acknowledging general pacific guidelines when working with Pasifika peoples and families:

• Cultural protocols and greetings

• Building relationships with your pasifika patients

• Involving family support, involving religion, during assessments and in the hospital

• Home visits

• Contact information

Pasifika Health Service - Better Health for Pasifika Communities:

• the Pasifika Health Service is a service provided free of charge for:

• all Pasifika people living in Manawatu, Horowhenua, Tararua and Otaki who have long term conditions

• all Pasifika mothers and children aged 0-5 years

• an appointment can be made by the patient, doctor or nurse

• the Pasifika Health Service contact details are:

• Palmerston North Office - 06 354 9107

• Horowhenua Office - 06 367 6433

• Better Health for Pasifika Communities brochure

Additional resources:

• Ala Mo'ui - Pathways to Pacific Health and Wellbeing 2014-2018

• Primary care for pacific people: a pacific health systems approach

• Tupu Ola Moui: The Pacific Health Chart Book 2004

• Pacific Health resources

• List of local Māori/Pacific Health Providers

• Central PHO Pacific Health website

6. POAC Provider Resources

Adult fluid balance chart

Community Early Warning Score (EWS) forms (POAC sites will already have copy) - this is required for all patients observed under

POAC sites.

All patients commenced on either oral or IV rehydration are expected to have regular observations documenting progress

and the EWS is required as part of this process.

POAC Eligibility Criteria:

• primary provider MUST be registered with POAC to claim POAC services - for more information please contact 027 247 8106

• POAC eligibility criteria

POAC Provider Resources

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• Acute Rehydration Poster

• POAC Transfer of Care/Handover form

• POAC Referral Centres - Contact List (contains phone and fax numbers)

7. Clinical presentation

This pathway is specific to body fluid losses secondary to vomiting and/or diarrhoea. It aims to serve as a general guideline and

support aid in the assessment and management of mild to moderate dehydration. However, this pathway may also be used for

nausea and vomiting in pregnancy resulting in mild to moderate dehydration (see Nausea and Vomiting in Pregnancy pathway).

8. Caution

Caution should be observed:

• older adults

• pre-existing heart failure

• prolonged duration of symptoms

• significant co-morbidity

• features of evolving illness

• recent overseas travel

9. Assess dehydration status

Assessment should include consideration of duration of symptoms combined with prospective total daily losses:

• average 70kg person - normal daily losses range 2500-3000ml

• average vomit equal or greater than 200ml

• average diarrhoea equal or greater than 300ml

For POAC funding, clinical notes must give detail supporting the diagnosis and degree of dehydration.

Mild dehydration is often characterised by:

• mild thirst

• concentrated urine

Moderate dehydration is often characterised by:

• significant thirst

• oliguria

• sunken eyes

• dry mucous membranes

• weakness

• light headed

• postural hypotension (>20mmHg)

Severe dehydration is often characterised by:

• significant thirst

• tachycardia

• low pulse volume

• cool extremities

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• reduced skin turgor

• marked hypotension

• confusion

Ketones

For the purposes of this pathway, the presence of urinary ketones may provide some additional information to assess the degree of

dehydration of the patient.

The test is not intended to be used in isolation to assess patient’s degree of dehydration and should only be used as a part of the

information which contributes to the overall clinical assessment:

• Ketonuria : 0-1 + associated with mild dehydration

• 1-2 + mild to moderate dehydration

• 3+ and above severe dehydration

10. Moderate dehydration

Moderate dehydration is often characterised by:

• significant thirst • oliguria

• sunken eyes

• dry mucous membranes

• weakness

• light headed

• postural hypotension (>20mmHg)

These are the patients who may be considered suitable for the POAC pathway utilising either oral or IV fluid replacement.

11. Severe dehydration

Severe dehydration is the result of large fluid losses and may be complicated by electrolyte and acid base disturbances which

require treatment and observation over a prolonged period. Severe dehydration is often characterised by:

• significant thirst

• tachycardia

• low pulse volume

• cool extremities

• reduced skin turgor

• marked hypotension

• confusion

Severe dehydration is not suitable for care under POAC and admission to hospital is required. This is a clinical diagnosis however

the Early Warning Score (EWS) can aid this decision making process.

12. Mild dehydration

Mild dehydration is often characterised by:

• mild thirst

• concentrated urine

NB: may have no symptoms

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13. Consider further investigations

Investigations may not be necessary. Clinical judgement is recommended following the assessment of each case. If required, simple

tests which are easy to perform include:

• glucose - finger prick

• urine analysis - infection / ketones

• weight

• consider laboratory investigations - this may include electrolytes and creatinine - electrolyte disturbances and renal impairment

may result from excessive fluid losses and may be especially important in older patients

• faecal specimen

• pregnancy test

14. Hospital admission recommended

Contact the on-call Medical Registrar to arrange admission (06) 356 9169.

15. Trial oral fluids +/- antiemetic

For mild dehydration consider a trial of oral rehydration combined with an antiemetic (metoclopramide or prochlorperazine or

ondansetron). Treatment of hyperemesis in pregnancy is excluded from the scope of this pathway - contact the obstetric/

gynaecology registrar for further advice.

Aim for 3-4 litres over 24 hour period. Observation not required in clinic. POAC funding does not apply.

16. Consider trial oral fluids and antiemetic

For moderate dehydration consider a trial of oral rehydration combined with an antiemetic (metoclopramide or prochlorperazine or

ondansetron).

Specific oral fluid solution is at the clinician's discretion.

Observe in clinic for up to 60 minutes under POAC. Aim 3 - 4 litres of oral fluid over 24 hours.

Use adult fluid balance chart

17. Discharge plan

Consider the following discharge plan:

• able to manage oral fluids safely at home

• provide patient with contact/emergency numbers and instructions should their condition deteriorate or further symptoms

develop:

• patient information brochure

• GP Team to consider contacting patient the following day to check on progress (can be by telephone)

• consider referral to District Nursing Service for acute nursing support:

• new referrals into the District Nursing Service are only accepted between the hours of 9am - 5pm, 7 days per week

• call the District Nursing Service on (06) 350 8100 or 0800 001491 to refer a patient

• fax (06) 350 8102 through at least the following:

• relevant consultation notes

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• current medical history

• current medication

• advise of any altered health parameters requiring attention

• entry criteria checklist for acute nursing support (DNS):

• clinical oversight by GP/NP (including after hours arrangement made)

• patient has been assessed in the last three days by a GP/NP

• GP/NP has discussed with patient the need for further medical assessment if required

• patient clinically stable to be managed at home (baseline observations required)

• patient has consented to referral

• patient >16 years

19. If inadequate response or not appropriate, commence IV fluids

If inadequate response or not appropriate, commence intravenous therapy:

• commence intravenous fluids and antiemetic (metoclopramide or ondansetron).

• normal saline 500ml - 1000ml over 60 minutes (18-20g angiocath)

• review hydration status utilising observation chart and community Early Warning Score (EWS)

• LIMIT - 1000ml per consultation - if further fluid replacement is required this should be discussed with the ED consultant prior to continuing treatment

Considerations in pregnancy:

• NB: pregnant women may require larger fluid volumes provided there are no other significant medical problems e.g. renal or

heart failure - 1000ml - 2000ml may be required:

• PNH protocol is to give 1000ml stat and then 1000ml over one hour

• consider taking blood to check serum electrolytes and creatinine if prolonged history of nausea and vomiting

• if inadequate response after 2000ml, discuss with on-call Obstetrics Registrar (06) 356 9169

Caution should be observed in the following groups and consideration given to a slower rate of infusion and reduced

volume with more frequent reassessment of rehydration status:

• older adults

• pre-existing heart failure

• prolonged duration of symptoms

• significant co-morbidity

• features of evolving illness

• recent overseas travel

Use adult fluid balance chart

20. Adequate response

The patient should be reviewed frequently throughout the period with assessment of hydration status to guide ongoing fluid

requirements - utilise EWS observation and fluid balance chart. The patient should be observed for a minimum of 60 minutes.

Watch for:

• inadequate response (ongoing diarrhoea and/or vomiting)

• persisting fluid losses

• ketosis

• deterioration of symptoms

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• signs of evolving illness

For non-POAC sites who may not have access to EWS charts, regular documented observation is still required showing clinical

progress.

21. GP Team review

Discharge plan:

• able to manage oral fluids safely at home

• provide patient with contact/emergency numbers and instructions should their condition deteriorate or further symptoms

develop (patient information brochure)

• review current medications, adjust as required and arrange appropriate follow-up

• GP Team to make contact with patient the following day to check on progress (can be by telephone)

• consider referral to District Nursing Service (DNS) for acute nursing support:

• new referrals into the DNS are only accepted between the hours of 9am - 5pm, 7 days per week

• call the DNS on (06) 350 8100 or 0800 001491 to refer a patient

• fax (06) 350 8102 through at least the following:

• relevant consultation notes

• current medical history

• current medication

• advise of any altered health parameters requiring attention

• entry criteria checklist for acute nursing support (DNS):

• clinical oversight by GP/NP (including after hours arrangement made)

• patient has been assessed in the last three days by a GP/NP

• GP/NP has discussed with patient the need for further medical assessment if required

• patient clinically stable to be managed at home (baseline observations required)

• patient has consented to referral

• patient >16 years

22. GP Team review

The patient should be reviewed frequently throughout the infusion period with assessment of hydration status to guide ongoing fluid

requirements - utilise EWS observation and fluid balance chart. The patient should be observed for a minimum of 60 minutes.

Watch for:

• fluid overload

• inadequate response (ongoing diarrhoea and/or vomiting)

• persisting fluid losses

• ketosis

• deterioration of symptoms

• signs of evolving illness

For non-POAC sites who may not have access to EWS charts, regular documented observation is still required showing clinical

progress.

23. Not improving Seek specialist advice if patient not improving. Please contact ED or relevant specialty registrar (06) 356 9169.

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24. Improving Improving:

• able to manage oral fluids safely at home

25. Discharge plan Discharge plan:

• provide patient with contact/emergency numbers and instructions should their condition deteriorate or further symptoms

develop:

• patient information brochure

• review current medications, adjust as required and arrange appropriate follow-up

• GP Team to make contact with patient the following day to check on progress (can be by telephone)

• consider referral to District Nursing Service (DNS) for acute nursing support:

• new referrals into the DNS are only accepted between the hours of 9am - 5pm, 7 days per week

• call the DNS on (06) 350 8100 or 0800 001491 to refer a patient

• fax (06) 350 8102 through at least the following:

• relevant consultation notes • current medical history

• current medication

• advise of any altered health parameters requiring attention

• entry criteria checklist for DNS:

• clinical oversight by GP/NP (including after hours arrangement made)

• patient has been assessed in the last three days by a GP/NP

• GP/NP has discussed with patient the need for further medical assessment if required

• patient clinically stable to be managed at home (baseline observations required)

• patient has consented to referral

• patient >16 years

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Acute Adult Rehydration

Provenance Certificate

Overview

Overview | Editorial methodology | References | Contributors | Disclaimers

This document describes the provenance of MidCentral District Health Board’s Acute Adult Rehydration pathway.

This localised pathway was last updated in July 2016.

One feature of the “Better, Sooner, More Convenient” (BSMC) Business Case, accepted by the Ministry of Health in 2010, was the development of 33 collaborative clinical pathways (CCP).

The purpose of implementing the CCP Programme in our DHB is to:

• Help meet the Better Sooner More Convenient Business Case aspirational targets, particularly the following:

o Reduce presentations to the Emergency Department (ED) by 30%

o Reduce avoidable hospital admissions to Medical Wards and Assessment Treatment and Rehabilitation for over-65-year-olds by 20%

o Reduce poly-pharmacy in the over-65-year-olds by 10%

• Implement a tool to assist in planning and development of health services across the district, using evidence-based clinical pathways.

• Provide front line clinicians and other key stakeholders with a rapidly accessible check of best practice;

• Enhance partnership processes between primary and secondary health care services across the DHB.

To cite this pathway, use the following format:

Map of Medicine. Medicine. MidCentral District View. Palmerston North: Map of Medicine; 2014 (Issue 1).

Editorial methodology

This care map was based on high-quality information and known Best Practice guidelines from New

Zealand and around the world including Map of medicine editorial methodology. It has been checked by

individuals with front-line clinical experience (see Contributors section of this document).

Map of Medicine pathways are constantly updated in response to new evidence. Continuous evidence

searching means that pathways can be updated rapidly in response to any change in the information

landscape. Indexed and grey literature is monitored for new evidence, and feedback is collected from

users year-round. The information is triaged so that important changes to the information landscape are

incorporated into the pathways through the quarterly publication cycle.

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References

This care map has been developed according to the Map of Medicine editorial methodology. The content of this care map is based on high-quality guidelines and practice-based knowledge provided by contributors with front-line clinical experience. This localised version of the evidence-based, practice- informed care map has been peer-reviewed by stakeholder groups and the CCP Programme Clinical Lead.

Contributors

MidCentral DHB’s Collaborative Clinical Pathway editors and facilitators worked with clinical stakeholders such as front-line clinicians and pharmacists to gather practice-based knowledge for its care maps.

The following individuals have contributed to this care map:

• Dr David Prisk, ED Consultant, MidCentral DHB (Secondary Care Clinical Lead)

• Dr Wayne Hayter, Medical Director, Radius, The Palms (Primary Care Clinical Lead)

• Dr Paul Cooper, Medical Director & Clinical Director Acute Care, Central PHO

• Jenni Olivier, Nurse Co-ordinator, City Doctors Ltd

• Leanne Bell, Clinical Nurse Specialist Lead, Acute Care, MidCentral DHB

• Jess Long, Project Director, Collaborative Clinical Pathways Programme (Editor)

Disclaimers

Clinical Board Central PHO, MidCentral DHB

It is not the function of the Clinical Board Central PHO, MidCentral DHB to substitute for the role of the

clinician, but to support the clinician in enabling access to know-how and knowledge. Users of the Map

of Medicine are therefore urged to use their own professional judgement to ensure that the patient

receives the best possible care. Whilst reasonable efforts have been made to ensure the accuracy of

the information on this online clinical knowledge resource, we cannot guarantee its correctness and

completeness. The information on the Map of Medicine is subject to change and we cannot guarantee

that it is up-to-date.

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