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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 1 8/11/2014 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 2 8/11/2014 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 3 8/11/2014 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 4 8/11/2014 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 5 8/11/2014 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 6 8/11/2014 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 7 8/11/2014 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 8 8/11/2014 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 9 8/11/2014 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 10 8/11/2014 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 11 8/11/2014 Email: [email protected] Website: www.pathwayhealth.com Phone: 877-777-5463 ©Pathway Health 2013 68 12