Download Nutritional Management for Success

8/11/2014
Nutritional
Management for
Success - Hydration
Objectives
• Discover the components of a
comprehensive hydration program
• Estimate fluid needs for obese patients
• Discuss interventions to promote fluid
intake
Jeanne Carlson RD,LD
©Pathway Health 2013
©Pathway Health 2013
Dehydration vs. fluid/electrolyte imbalance
• 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.
©Pathway Health 2013
©Pathway Health 2013
Biochemical Signs of Dehydration*
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:
•
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:
• Elevated serum osmolarity – above 295 mOsmol
– “gold standard”
• Elevated serum sodium – above 145-148 mmol/L
• Elevated BUN/Creatinine ratio – above 25-50
– 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
©Pathway Health 2013
• Elevated Urine Specific Gravity – above 1.028
*Only diagnostic in the presence of clinical signs of dehydration
©Pathway Health 2013
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How Common is Dehydration?
• 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%
©Pathway Health 2013
Early Dehydration
©Pathway Health 2013
Advanced 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
 Difficulty swallowing
 Clumsiness
 Shriveled skin
 Sunken eyes
 Visual disturbances
 Painful urination
 Numb skin
 Muscle spasm
 Delirium
©Pathway Health 2013
Risk factors for Dehydration in the Elderly
– 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
©Pathway Health 2013
Consequences of Dehydration
• Hospital admission
• Functional decline and delirium
• Increased health care costs
• Urinary and respiratory infection
• Pressure ulcers
– Increased need for feeding assistance
• Death
– Laxative, enema or diuretic use
• Falls
– Difficulty swallowing
• Constipation
– Lack of access
• Medication toxicity
©Pathway Health 2013
©Pathway Health 2013
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Dehydration and Tube Feeding
Hydration
• Water is administered per physician order
• Amount administered varies by care giver
Four Key Questions
• Need clarification for before, between and
medication administration.
•
Where are we now?
•
Where do we want to be?
• Need clarification for water flushes
•
How do we get there?
• How are free fluids in
•
How do we get commitment from key
individuals?
formulas being calculated?
©Pathway Health 2013
©Pathway Health 2013
Start Your Facility Assessment at the Door
Research has shown
that people who laugh
together work better
together.
Starts at admission
– Receptionist
– HUC/HIM/ward clerk
– Nursing
– Dietary
– Rehab services
– Maintenance/housekeeping
– Social services
– Administration
Interdisciplinary Approach to “happy eaters”
©Pathway Health 2013
The Basic Care Process
©Pathway Health 2013
Food Delivery Systems Review
• Assessment/recognition
• Meal delivery - Serving trays on carts
delivered from the kitchen or steam tables
in the dining room
• Diagnosis/cause identification
• Choice vs. no-choice
• Menus
• Treatment/management
• Personal service
• 3 vs. 5 meals/day
• Culture change
• Monitoring
©Pathway Health 2013
©Pathway Health 2013
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Components of a Comprehensive Hydration Program
Institutional Factors
Staff attitudes and beliefs
Staffing - Who’s involved with meal
delivery?
– “All hands on deck”
• 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.
©Pathway Health 2013
©Pathway Health 2013
Components of Hydration Program (cont.)
• 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
1. Educate staff and families on the warning
signs for dehydration and on the action steps
to prevent dehydration.
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
©Pathway Health 2013
©Pathway Health 2013
Provide Written Information
Food Item Container
Size
Approximate Amount cc
Provided
• Individual creamer
• 15 ml
• Ice cream/sherbet
“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.”
• Juice (4 oz.. plastic
cup)
• 120 ml
• 120 ml
• Milk carton (8 oz..)
• 240 ml
• Soda (12 oz..)
• 360 ml
• Popsicle (3 fluid
oz..)
• 90 ml
• 180 ml
• Italian ice (6 oz..)
• Large glass (8 oz..)
• 240 ml
©Pathway Health 2013
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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.
©Pathway Health 2013
©Pathway Health 2013
Train CNA’s to report the following:
• ½ cup (C) ice cream, frozen yogurt,
sorbet=100 mL
• Poor appetite
• ½ C sherbet=120 mL
• Refusal to take medications
• ½ C gelatin without fruit=110 mL
• New onset or worsening cognitive
impairment/ confusion/delirium
• ½ C gelatin with fruit=80 mL
• 1 freezer pop=120 mL
• 1 ice cube=10 mL
• Dysphagia
• Vomiting
• Not consuming all or almost all liquids
provided
• Diarrhea
• Fever
©Pathway Health 2013
Train LPN/RN 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
©Pathway Health 2013
• Vertigo
©Pathway Health 2013
Cont.
• Increased heart rate
• Lowered blood pressure
• Increased vein refill
time
• Internal bleeding
• Urinary tract infection
• Fluid restriction for any
reason
©Pathway Health 2013
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Train Activity and Rehab to report the following:
» Change in
participation level
Train Dietary Staff to report:
» Observed changes in fluid or food intake
» Dining room observations
» Decrease in
alertness
» Decline in fluid
intake at activity
functions
©Pathway Health 2013
Family
©Pathway Health 2013
Components of a Comprehensive Hydration Program
Encourage family
members to let the
nurse know when “Mom
just isn’t acting right”
• 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.
©Pathway Health 2013
Fluid Requirement
©Pathway Health 2013
Caron at al, 1997
• 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:
20 patients with CVA and Dysphagia to
thin liquids
Study:
– Control group: unrestricted thickened liquids
– Experimental group: thickened liquids and
access to water
(Kg body weight-20) X 15 +1500mL
©Pathway Health 2013
©Pathway Health 2013
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Results
Author’s Conclusions
Group
consumption
Fluid
• Dissatisfaction with thickened liquids
• Noncompliance with thickened liquids
Thickened liquids
1210 mL
Thickened liquids and water
liquid
855 mL thickened
463 mL water
• Potential dehydration
• Limited thickened fluid intake
• Complaints of dryness and thirst
• Conclusion: significant difference in
thickened liquid intake(p=0.03); water
intake was less than expected
• Nursing dependency to provide fluids and
encourage intake
©Pathway Health 2013
©Pathway Health 2013
Estimating Fluid Needs for Obese Patients
Case Study
Male
65 inches tall
248# , 112.6 kg
BMI 41.3
©Pathway Health 2013
Comparison of formulas
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©Pathway
apply
to fluid restrictions.
Health 2013
ADA Nutrition Care Manual
1. 100ml + 50ml + (15ml x 92.6) = 2889
Average healthy adult 30-35 ml/kg weight
2. (112.6 – 20) x 15 + 1500 = 2889
Adult 55-65
30 ml/kg weight
3. 112.6 x 30 = 3378 ml
Adult >65 years
25 ml/kg body weight
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
©Pathway Health 2013
©Pathway Health 2013
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Fluid Restriction
Initial Nutrition Assessment
• 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
 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
• I & O if needed
• MAR
• Tray card
• Care plan
• Nursing progress notes document weekly
©Pathway Health 2013
Initial Nutrition Assessment cont..
 Extent of cognitive impairment
 Medications
 Ability to
communicate
©Pathway Health 2013
Reassessment after Dx Dehydration or Change in Status
 Facilities are being tagged for lack of
reassessment
 Consider also the presence of progressive,
irreversible conditions such as dementia
and terminal illnesses
 Review care plan
 Serum sodium >147
 Re-assess fluid needs
 Hct >3x Hgb
 Consider the fluid content
in solids actually consumed
©Pathway Health 2013
Tube Feedings
©Pathway Health 2013
Example
 Calculate free water in the
formula correctly.
 Add enough free flush to
meet calculated
requirement.
©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
©Pathway Health 2013
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Consider the following items from the MDS in identifying
residents who are at risk for dehydration:
– 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.
Components of 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
©Pathway Health 2013
Typical Fluid Breakdown
• 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.
• 5. Monitor success
Typical Fluid Breakdown (cont.)
• 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.
©Pathway Health 2013
Between meal hydration pass for residents on
thickened liquids
©Pathway Health 2013
©Pathway Health 2013
Components of 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
©Pathway Health 2013
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Interventions:
Interventions:
‫ ٭‬Use 8oz cups to provide fluids
at each medication pass.
‫ ٭‬Implement a mealtime and between meals
fluid intake documentation system.
‫ ٭‬Start systemic fluid passes by
using a hydration cart at least
twice daily and offer a variety
of fluids.
‫ ٭‬Promote fluids with positive
encouragement by all staff with each visit
to the resident’s room.
‫ ٭‬Set up hydration stations in
the Rehabilitation and
Activities Departments.
‫ ٭‬Provide staff education on feeding skills
‫ ٭‬Address pain
‫ ٭‬Monitor weight
(Older people tolerate frequent
administration of fluid in smaller quantities
better than infrequent large quantities.)
©Pathway Health 2013
Interventions:
©Pathway Health 2013
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.
‫ ٭‬Provide a large water cooler at each
nursing station and replenish with fresh
cool water daily. Make sure that cups are
readily available.
©Pathway Health 2013
©Pathway Health 2013
Interventions:
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
©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
©Pathway Health 2013
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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
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
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
Skin
Routine
High Risk
Special treatment
Decubitis
Site:_______________
Contractures
Site:_______________
Wound
Site:_______________
Reposition_____________
_
Activities
PT
OT
ST
Escort needed
Comments:
Other:
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
Ph
ysi
cal
De
vic
es
NUTRITION RISK REVIEW TEAM








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
©Pathway Health 2013
• 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
©Pathway Health 2013
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Email: [email protected]
Website: www.pathwayhealth.com
Phone: 877-777-5463
©Pathway Health 2013
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