Download The Importance of Adequate Hydration

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