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OD UC E NUTRITION 411 The Importance of Adequate Hydration Nancy L. Kondracki, MS, RD, LDN; and Nancy Collins, PhD, RD, LD/N, FAPWCA dequate hydration is an essential requirement for wellA ness. This article addresses some of the ways hydration affects patient status and medical outcomes. The importance of hydration for wound prevention and treatment, in particular, will be discussed. Suggestions for ways to maintain hydration in a clinical setting are provided. Fluid losses such as those resulting from diarrhea, vomiting, fever, burns, or uncontrolled diabetes Fluid restriction due to chronic kidney disease or congestive heart failure Dementia, coma, or other decreased sensory function by which a patient may forget or be unable to drink Refusal of fluids Functional impairments such as restraints or aphasia that make drinking or communicating the need to drink difficult Inadequate fluid intake during intense exercise or hot, humid weather Excessive sweating Fluid losses due to evaporation from open pressure ulcers or wound drainage Dysphagia requiring thickened liquids Medications including diuretics, antihistamines, and antihypertensives Alcohol use Altitudes above 8,200 feet Acute illness Decreased thirst sensation associated with the normal aging process DO NO T RE PR The Importance of Water Water is the most abundant constituent of the body, accounting for approximately 72% of nonfat weight1 and 45% to 70% of total weight, depending on a person’s ratio of lean to fatty tissue.2 Water makes up nearly 75% of muscle and organs but only 20% to 30% of fat. Many metabolic reactions that occur in the body are dependent on water.2 Water also is critical to temperature regulation. Water transports nutrients including vitamins, minerals, and amino acids throughout the body; it is an important source of several nutrients including magnesium, calcium, and fluoride. Solutes within the body, both organic and inorganic, dissolve into water. Water is the basis for the osmotic pressure exerted across membranes that moves solutes into or out of cells and plays a major role in maintaining blood volume and fluid and electrolyte balance. Eighty percent of blood volume is water. Research suggests that aquaporins (hormonally regulated water channels in the collecting ducts of the kidneys) may play key roles in water transport functions, including fluid secretion from glands, neural signaling, and wound healing. More specifically, aquaglyceroporins are believed to be involved in skin hydration, cell proliferation, and fat metabolism via the regulation of glycerol content in various tissues.3 The body regulates body water by balancing thirst and renal output. The average adult loses 1 L to 2 L of fluid daily in urine and an additional liter through breath, sweat, and feces. Exercise depletes the body of water and electrolytes, especially in hot and humid environments. Adequate hydration reduces athletes’ risk of injury and helps them maximize their performance. Kidney stones may result from inadequate fluid intake or excessive sodium intake, among other factors. Patients subject to kidney stones are usually advised to increase their intake of water and other fluids (except tea) to decrease the Table 1. Risk factors for dehydration5,7-9 concentration of their urine. Three to four quarts of fluids per day are generally recommended for those with normal kidney function. In addition, epidemiological studies have shown that coffee and citrus (with the exception of grapefruit juice) decrease the incidence of kidney stones.4 Dehydration: Risk Factors and Consequences Insufficient fluid intake can quickly lead to dehydration, which increases susceptibility to urinary tract infections, dental disease, constipation, pneumonia, confusion, and pressure ulcers. The risk of falls also is increased with dehydration.5 Dehydration is associated with a decline in nutritional status in adults and often precedes unintentional weight loss, failure to thrive, and skin breakdown and compromises overall quality of life in the long-term care setting.6 While people typically Nancy L. Kondracki, MS, RD, LDN, is an independent contractor in Greensboro, NC, working to improve the health of area citizens and promoting registered dietitians as the premier source of nutrition information. Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at [email protected]. This article was not subject to the Ostomy Wound Management peer-review process. 16 OSTOMY WOUND MANAGEMENT DECEMBER 2009 www.o-wm.com can live without food for weeks, death from dehydration can occur in as little as 3 to 4 Thirst days. Severe dehydraDry mucous membranes Dry skin tion requires immediCracked lips ate medical treatment. Dry mouth or tongue Risk factors for dePoor skin turgor hydration include imDrowsiness mobility, incontinence, Concentrated, dark-colored urine inadequate nutrition Decreased urine volume and hydration, sensory Headache deficits, comorbid conMuscle weakness ditions, and circulatory Dizziness or lightheadedness problems. Table 1 lists Reduced tearing additional risk factors Diminished sweating Fever for dehydration. Older Low blood pressure adults and people with Rapid heartbeat chronic illnesses are Unplanned weight loss most at risk for dehyAbnormal lab values dration. Dehydration causes skin to become fragile and prone to breakTable 3. Laboratory down, decreases the circulattests for the evaluation ing blood volume, and reduces of hydration status6 peripheral blood flow, impairing the delivery of nutrients Test Name and oxygen to wounds. Length of stay, acute care Albumin readmission, and mortality Blood urea nitrogen (BUN) Chloride are increased in dehydrated Hematocrit hospitalized older adults.8 Hemoglobin Pressure ulcers, a sequelae of Potassium dehydration, are occurring Serum osmolality with increasing prevalence in Serum sodium Transferrin hospitalized patients; an estiUrine osmolality mated 2.5 million patients Urine specific gravity develop pressure ulcers in Urine sodium acute care settings, accounting for $11 billion annually in For more complete information on healthcare costs. Consehydration-related quently, the Institute for laboratory tests, please Healthcare Improvement has see the online version named the prevention of of this article at pressure ulcers one if its 12 www.o-wm.com interventions in the 5 Million Lives Campaign.10 Long-term care guidance manuals specify that facilities, “must provide each resident with sufficient fluid intake to maintain proper hydration and health,” and regulations outline guidelines for the prevention of dehydration.9 In addition, the Nutrition Screening Initiative8 has developed a single-page tool to help identify those at risk for nutrition-related conditions, including dehydration. The high prevalence of dehydration and pressure ulcers was highlighted by the Centers for Medicare and Medicaid Services’ Nursing Home Oversight and Monitoring Program.11 This program increased Certified Nursing Assistant (CNA) awareness and likelihood of reporting nutrition and hydration problems. It also assisted dietary managers, registered dietitians, and directors of nursing with incorporating nutrition and hydration best practices into dining programs. Assessing Fluid Needs Early assessment of risk factors is critical to preventing dehydration. Several validated tools exist for screening for nutrition and hydration status. The Minimum Data Set (MDS) and Resident Assessment Protocols (RAPs) governed by the Nursing Home Reform Act of 1987 address both nutrition and hydration. Fluid needs should be assessed based on the summation of physical examination, review of relevant laboratory results, and fluid intake/output documentation, as well as individualized assessment considering medical history, reported symptoms, medications, and weight/weight changes. The clinical signs of insufficient fluid intake are outlined in Table 2. Laboratory values used in the assessment of hydration status are shown in Table 3. Periodic reassessment of hydration status by an interdisciplinary team that includes physicians, nurses, dietitians, speech pathologists, dentists, administrative personnel, and CNAs is recommended.8 The average adult needs 30 to 40 mL/kg body weight in fluid intake daily. Alternately, fluid needs may be estimated as 1.0 to 1.5 mL/kcal expended daily, including calories expended through both metabolism and physical activity.14 The minimum daily fluid intake is 1,500 mL. This does not apply to patients with renal or cardiac stress that require reduced fluid intakes. Patients with pressure ulcers require at least 30 to 33 mL/kg/day, with additional fluids to compensate for incidental losses including wound exudates, fever, vomiting, or diarrhea.12 Patients who use air-fluidized beds (usually those with multiple mid-body Stage III or Stage IV ulcers or those who have not improved with the use of low-air-loss mattresses) require an additional 10 to 15 mL/kg body weight.15,16 DO NO T RE PR Table 2. Clinical signs of insufficient fluid intake7,10,12 OD UC E NUTRITION 411 18 OSTOMY WOUND MANAGEMENT DECEMBER 2009 Fluid Sources Foods are responsible for about 20% of the fluids consumed by most people. For example, fruits and vegetables are often more than 90% water by weight. Suggestions for improving fluid intake are provided in Table 4. The total daily fluid intake recommended by the Institute of Medicine (IOM) is approximately 11½ cups for women and 16 cups for men17; however, available research has not yet adequately determined fluid needs in many populations.18 Although the majority of fluids are ingested as beverages, beverage content can vary widely. This feature can be used to one’s benefit in the clinical setting. For example, www.o-wm.com Table 4. Tips for maintaining adequate hydration19 References 1. Hydration and your health. Caribbean Food and Nutrition Institute. Nyam News. 2007;1:2. 2. Manore M, Thompson J. Sport Nutrition for Health and Performance. Champaign, IL: Human Kinetics;2000:217–243. 3. Verkman AS. Aquaporins: translating bench research to human disease. J Exp Biol. 2009;212(11):1707–1715. 4. Schardt D. Skipping stones: how to avoid kidney stones. Nutrition Action Healthletter, Center for Science in the Public Interest. Washington, DC. 2009;January/February. 5. Grandjean A. Hydration: more than just water. The Beverage Institute for Health & Wellness. Available at: www.thebeverageinstitute.org/healthcare_professionals/hydration_qa.shtml. Accessed November 9, 2009. 6. Litchford MD. Common Denominators of Declining Nutritional Status. Greensboro, NC: CASE Software & Books;2005:10. 7. Dehydration. The Mayo Foundation for Medical Education and Research. 2009. Available at: www.mayoclinic.com/health/dehydration/DS00561. Accessed November 12, 2009. 8. Burger SG, Kayser-Jones J, Prince Bell J. Malnutrition and dehydration in nursing homes: key issues in prevention and treatment. The National Citizens’ Coalition for Nursing Home Reform. The Commonwealth Fund, Pub. #386. June 2002. 9. State operations manual. Rev. 52, 2009. Appendix PP: Guidance to surveyors for long-term care facilities. Available at: www.cms.hhs.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed November 9, 2009. 10. Institute for Healthcare Improvement: Relieve the pressure and reduce harm. 2007. Available at: www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureandReduceHarm.ht m. Accessed October 10, 2009. 11. Pelovitz SA. Training request for CMS’s nutrition/hydration awareness campaign. [letter]. Ref: S&C-02-03. Department of Health & Human Services. Centers for Medicare & Medicaid Services. Baltimore, MD. October, 2001. Available at: www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter02-03.pdf. Accessed November 9, 2009. 12. Dorner B. Clinical questions: fluids/hydration. Available at: www.beckydorner.com/clinicalquestions. Accessed November 1, 2009. 13. National Kidney Foundation. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease, 4th Edition. 2009. Available at: www.kidney.org. Accessed November 21, 2009. 14. The American Dietetic Association. What is the current recommendation for vitamin and mineral supplementation for pressure ulcers? Available to subscribers at: www.eatright.org/cps/rde/xchg/ada/hs.xsl/nutrition_19365_ENU_HTML.htm. Accessed November 9, 2009. 15. The Arkansas Foundation for Medical Care, American Medical Directors Association. It’s time to take the pressure off! Available at: www.afmc.org/documents/quality_improve/qi_tools/pressure_ulcer/PUbooklet.pdf. Accessed November 9, 2009. 16. Todorovic V. Food and wounds: nutritional factors in wound formation and healing. Br J Community Nurs. 2002;7(9):43–54. 17. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. National Academy of Sciences. Institute of Medicine. Food and Nutrition Board; 2004. Available at: www.fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level= 4&tax_subject=256&topic_id=1342&level3_id=5141&level4_id=105092. Accessed November 21, 2009. 18. Wipke-Tevis DD, Williams DA. Effect of oral hydration on skin microcirculation in healthy young and midlife and older adults. Wound Rep Reg. 2007;15:174–185. 19. Ord H. Nutritional support for patients with infected wounds. Br J Nurs. 2007:16(21):1346–1352. PR Carry a water bottle or keep water available regularly (eg, at bedside, desk) Sip water often, regardless of thirst Add a small amount of lemon juice or other fruit juice to water if plain water is unpalatable Serve beverages chilled to improve taste Offer fluids between meals Offer a variety of beverages Provide a beverage cart service Be aware of any medications taken that may cause water loss Assist debilitated patients with opening beverage containers and drinking Adjust the positioning of beverages, if necessary, to improve accessibility Serve “solid” forms of liquids such as popsicles, ice-chips, gelatin, and puddings for snacks Monitor hydration status and offer water (if appropriate) each time a patient is repositioned Increase med-pass volumes OD UC E NUTRITION 411 NO T RE malnourished patients can be given nutrient-dense supplements in addition to meals; whereas, persons who would benefit from weight loss or weight maintenance could be given calorie-free plain water most often. A large number of specialized nutrient-added waters and juices have recently become available in stores but few have any evidence to support their use. The belief that caffeinated beverages such as coffee and tea have a dehydrating effect has been shown to be false.5 Community-dwelling older adults frequently experience a mild decrease in subcutaneous blood flow as the result of inadequate hydration. Decreased plasma volume associated with dehydration impairs skin blood flow, restricting the delivery of nutrients to the organ. This impairment can slow wound healing and increase infection. Supplemental oral hydration (500 mL water) has been shown to improve skin microcirculation in the short term.18 DO Conclusion Maintaining a state of euhydration can prevent numerous health problems. Improved understanding of skin physiology is providing hope for better methods of preventing and treating issues related to hydration. In the patient care setting, prompt and regular reassessment of dehydration risk factors by a multidisciplinary team of healthcare professionals is the first and most important step toward improving long-term health. ■ 20 OSTOMY WOUND MANAGEMENT DECEMBER 2009 Coming in January: Nutrition Product News www.o-wm.com