1.  Dehydration in LTC Lisa Pezik, RN BScN Clinical Educator

2. Objectives  Define dehydration.  Assess the risk factors.  Discuss the signs and symptoms.  Review a treatment plan for dehydration.

3. Case Study: Jane  Jane is a 87 year old woman with dementia and congestive heart failure who has lived in LTC for 2 years.  She ambulates with her walker, but has recently developed a stage 3 pressure area on her heel. Staff put her to bed early last night to offload the pressure.  This morning Jane is difficult to arouse. When she does open her eyes, she simply stares off into space. Upon assessment, her blood pressure is 82/55 and her pulse 144.  The RN in charge can’t get ahold of Jane’s family; therefore, they follow the directive and send Jane to the hospital.

4. Statistics  48% of older adults in Emergency Departments have lab values indicative of dehydration.  31% of LTC residents are dehydrated.  Dehydration is present in up to 1/4 of older patients and those with dementia have higher risk.  If untreated, it has a 50% mortality risk. (J Gerontol Nurs 2006: 32(1); 13-19)

5. Dehydration  Loss of water from the body  Different from volume depletion  Blood loss  Imbalance in the body  Isotonic Dehydration  Excessive losses of sodium/water  Vomiting, diarrhea, sweat  Wounds  Inadequate intake  Can happen quickly  Hard to detect

6. Consequences  Constipation  Falls  Medication Toxicity  Urinary Tract and Respiratory Infections  Delirium  Renal failure  Delayed wound healing  Hyperthermia

7. Where Does Water Go?  Breathing 400 ml  Fluid is vaporized in the air.  Skin 400 ml  The air is dryer than our skin and the skin pulls moisture out.  Urine 500 ml  Feces 150 ml  In order to produce stool we need a bare minimum of 150 ml a day.

8. Question  If Jane drinks 600 ml and urinates 500 ml is she hydrated?

9. Risk Factors  What were Jane’s risk factors?  Age  Thirst is blunted  Kidney function declines  Medications  Polypharmacy  Kidney function and fluid balance  Hypotonic Dehydration  Sodium loss exceeds water  Diuretics and laxatives  Sedation and antipsychotics/antidepressants

10. Risk Factors  Cognitive and Functional Dependency  Remember to drink  Ability to get water  Dysphagia  Co-morbidities and Illness  CHF, CRF, Diabetes, Dementia  Hypertonic dehydration  Loss of more water than sodium  Fever induced with infections

11. Our Role  How do we encourage residents to drink and stay hydrated?

12. Sign Before A Symptom  Stop and Watch  Seems different than usual  Talks or communicates less  Overall needs more help  Pain- new or worse. Needs helps with activities  Ate less  No bowel movement in 3 days or diarrhea  Drank less  Weight change  Agitated or more nervous than usual  Tired, weak, confused, drowsy  Change in skin colour or condition  Help with walking, transferring, toileting more than usual

13. Signs and Symptoms  What were Jane’s symptoms?  General symptoms  Weakness  Confusion  Sunken eyeballs  Dry mouth and skin  Low BP, high pulse  Low and concentrated urine output

14. Diagnosis  Assessment for signs and symptoms  Blood Tests  Urea and Creatinine  Greater than or equal to 0.15  Elevated plasma sodium  Serum osmolality  Greater than 300  Urine Tests  Specific gravity

15. Treatment  H  Identify those at High Risk  Ensure adequate positioning  Toilet often  Mouth care  Vitals  2  Watch for 2 causes  Inadequate intake  Excessive loss  0  Offer fluids  Offer food high in water  Hypodermoclysis with isotonic/hypotonic solutions

16. Questions

17. References  Archibald, C. (2006) Promoting hydration in patients with dementia in health care settings. Nursing Standard, 20:44, 49-52.  Capezuti, E. et al. (2008). Evidence-Based Geriatric Nursing Protocols For Best Practice. Springer Publishing Company, New York.  Mentes, J. (2006) Oral Hydration in Older Adults. AJN, 106(6): 40- 49.  Mentes, J. (2006). A typology of oral hydration: Problems exhibited by frail nursing home residents. Journal of Gerontological Nursing, 32(1):13-19.