Dehydration

1. Dehydration By Julie Lesemann, RN IP

2. objectives • Define dehydration • Nursing home reform act of 1987 • Identification of dehydration • Risk factors • Contributing factors • Prevention of • Ongoing monitoring and collaboration with interdisciplinary team

3. Dehydration • Excessive loss of body water with consequent metabolic disruption • Symptoms : headache, decreased blood pressure (Orthostatic changes upon risking), vertigo, fainting, confusion, constipation, dry skin, thirst, decreased urinary output, dark urine, fatigue, dry mucous membranes, irritability, electrolyte imbalances • Eventual death can occur • Hypovolemic encompasses loss of body water, but also blood plasma loss • Malnutrition, dehydration of our patients / residents make up one of the largest, silent epidemics in our country today!!!

4. causes • Acute illness: influenza, diarrhea, vomiting, fever, sweating • Chronic conditions: renal failure, chf, metabolic imbalances i.e. Diabetes, hypernatremia, decreased senses as we age, etc. • Not consuming enough water : lack of the signal to drink in some conditions, hot weather, • Increased urination

5. The Nursing Home Reform Act of 1987 (NHRA) • Specifically addressed the prevention of both malnutrition and dehydration • Includes provisions for resident assessments, individualized care planning, physician oversight, standards for sufficient nurse staffing, provisions of quality of life, care and service • Why does this affect Dietary? • This law mandates that facilities must meet a residents nutrition and hydration needs

6. The effects of dehydration on patients • Increased infection rates (UTI’s, pneumonia) • Skin impairments: Pressure ulcers, decreased wound healing • Confusion which can lead to cognitive deficits, over medicating, behavior issues, safety issues such as falls resulting in potentially broken hips, etc. • Anemia • Longer hospitalizations • Depression • And the list goes on

7. Risk factors • We must be knowledgeable and recognize immediately who may be at a greater risk for dehydration • Chronic conditions or diagnoses- including depression, cognitive impairments i.e. Alzheimer’s, impaired oral hygiene/condition of teeth, dysphagia, chronic anemia, ascites, respiratory compromised patients (as no energy level), • Effects of medications

8. National average is 80% of all nursing home residents are cognitively impaired • Feeding assistance is required for a majority of elderly patients or residents • Oral health- many residents have ill fitting dentures, poor dentation • Swallowing disorders may prevent residents from appropriately consuming their meals. Potentially side effects of strokes, dementia, parkinsons, etc. • Medications contributing such as diurectics, digoxin, antibiotics, oral hypoglycemic meds i.e. metformin

9. Contributing factors • Staffing levels/ supervision at meals/ assistance provided is minimum • Nursing staff is assisting multiple residents therefore when a pt. requires more assist and time they are not given it. • Turnover rate in staff • Inadequate training regarding meals, snacks , nutritional knowledge and expectations (how many times do you see supplements not given?) • Decreased or inadequate monitoring of data/intakes • Poor environment in dining areas • Lack of monitoring and enforcement • Lack of adequate involvement of dieticians, speech pathology, physicians, nursing

10. environment • Environmental factors contribute greatly to how much a resident or patient consumes • Quiet/ calm area- most dining rooms in NH’s have multiple patients that have behaviors causing a disruptive environment. i.e. screaming, alarms going off • Timeliness of meal, presentation of meal • What’s your environment like? Think about that. • Can smaller groups be organized and adequately supervised? • Calming environment? • Homelike atmosphere- example of Memory care home

11. observations • Residents/patients playing with food • Spilling food • Distracting environment- others yelling, others taking food • No fluids offered (pt cannot drink on own) • Improper charting of meal intakes

12. Training of staff • Poor or no training of staff significantly increases the risk of dehydration • Education regarding cognitive impairments or disease processes and the impact on eating/drinking • Who is educating your staff? In dietary? In nursing? Essenital/ front line workers! • Review the education for new and annual employees • Work in conjunction with nursing managers to incorporate dehydration training, feeding, the “mealtime experience”, importance of snacks, supplements, etc. • Do they know what to report? Decreased appetite, dysphagia, weight loss, etc. • Follow up and monitoring

13. What can we do? • Train, providing opportunities to staff to increase their knowledge of dehydration, importance of proper hydration, • Monitor!!!!! QA/PI programs, audits, weekly reports • Be creative- work with nursing directors to increase staffing at meals: volunteers, meal aides, family members presence, non nursing personnel • Hold staff accountable • Work with interdisciplinary team members: pharmacy, nurse to monitor labs, meds,etc. • Create a homelike atmosphere: table cloths, colors of dishes, music, seating residents in chairs vs w/c’s, traffic patterns for serving as to not disrupt eating, placement of residents with behaviors

14. miscellaneous • Reminders at meetings • Increase offering fluids throughout the day • Warm weather emails sent out to all staff • Monthly educational emails from dietary • Example of our dehydration card

15. conclusion • Dehydration is common and can have serious if not fatal results • Our role is to prevent it!

16. “The Little Boy and the Old ManSaid the little boy, "Sometimes I drop my spoon."Said the old man, "I do that too."The little boy whispered, "I wet my pants."I do that too," laughed the little old man.Said the little boy, "I often cry."The old man nodded, "So do I."But worst of all," said the boy, "it seemsGrown-ups don't pay attention to me."And he felt the warmth of a wrinkled old hand.I know what you mean," said the little old man.” ― Shel Silverstein

17. Questions? • Thank you for all you do for our residents/ patients and clients!!!!

18. Resources • http://www.mayoclinic.com/health/dehydration/DS00561/DSECTION=treatments-and-drugs • www.cmwf.org