1. ASSESSING AND MANAGING HYDRATION Chapter 24 Veronica Lambert & Doris O’Toole

2. Introduction This presentation will examine the signs and symptoms of dehydration, discuss methods of measuring fluid intake and output and suggest ways of managing dehydration. Part 1 – General Signs and Symptoms of Hydration Part 2 - Infant Hydration Assessment Part 3 – Potential Risk Factors for Developing Dehydration Part 4 – Practical Exercises Part 5 – Fluid Intake and Output: Requirements and Sources Part 6 – Weight Recording

3. PART 1: General Signs and Symptons of Hydration

4. General Signs and Symptoms Sunken eyes Dry mucous membranes Reduced urinary output Lethargy/sleepine ss Confusion Inelastic skin Increased temperature (underlying infection) Increased heart rate (reduced circulatory volume Low blood pressure (late sign)

5. PART 2: Infant Hydration Assessment

6. Infant Assessment FONTANELLE Examine the fontanelle by gently palpating the top of the infant’s head, observe/feel for a ‘dip’ or a depression in the skull. This may occur due to hypovolaemia (loss of fluid from vomiting and/or diarrrhoea).

7. HYPOTONIA Examine the infant’s muscle tone by observing the infant’s response to handling and positioning. The infant may appear ‘floppy’ (e.g. the limbs and the head) to hold as a result of fluid volume deficit/loss. Fluids (oral or I.V) are important to overcome this, as well as ensuring that a safe blood glucose level is maintained.

8. PART 3: Potential Risk Factors for Developing Dehydration

9. Q. Why do you think the following are considered risk factors? Age (infants, young children, elderly) Poor mobility Functional ability or level of dependence Medications e.g. diuretics Acute infections e.g. vomiting & diarrhoea Fear of incontinence Cognitive impairment e.g. dementia Visual impairment Mental status e.g. confused or depressed

10. Age INFANTS/SMALL CHILDREN  Increased risk due to greater surface area, increased rate of metabolism and immature kidney function. ELDERLY  Increased risk due to decrease in percentage of body water per body weight. This is due to loss of muscle mass, slower metabolism and reduced renal regulation.

11. Poor Mobility Elderly may find it difficult to reach for drinks. Poor dexterity e.g. opening bottles etc. Fear of falling due to poor mobility. Reduction of fluid intake due to fear of having to use the toilet frequently.

12. Functional Ability or Level of Dependence May require full assistance for feeding due to previous illness, i.e. have no control over functional ability (e.g. inability to use hands/grasp items due to illness (arthritis)). Elderly may feel embarrassed asking for assistance.

13. Medications ‘Diuretics’ are a type of medication administered to patients in a number of medical conditions (e.g. cardiac related conditions). Diuretics increase urinary output, therefore it is important that fluid intake is adequate to maintain normal fluid balance.

14. Acute Infections Gastroenteritis is a common acute infection (inflammation of the lining of the stomach) which can lead to fluid loss where the patient presents with vomiting and/or diarrhoea.

15. Fear of Incontinence Due to fear of incontinence, the elderly patient may avoid drinking an adequate volume of fluids. This may be related to a number of factors, including reduced mobility or as a result of disease (poor bladder muscle control).

16. Cognitive Impairment Particularly in elderly patients where s/he has an inability to recognise the importance of drinking adequate fluids. May not remember to drink unless prompted at intervals (e.g. patient presenting with dementia).

17. Visual Impairment Inability to see drinks available, or access drinks stored in difficult places (e.g. locker). Need to reinforce to patients where drinks are placed (e.g. bedside table). Use of appropriate equipment/utensils to assist with the above deficit.

18. Mental status Where the patient is confused, s/he needs to be reminded to maintain an appropriate level of fluid intake. Use utensils (e.g. cup/mug) that are familiar to the patient where possible to minimise confusion. Some patients who are depressed may not have interest/motivation to drink adequate fluids.

19. Normal Blood Glucose Range Age GroupBlood Glucose Range (mmols/l) Newborn > day old 2.8 – 5.0mmols/l Child3.3 – 5.5mmols/l Adult3.6 – 5.3mmols/l Note: Blood glucose range may vary in different healthcare settings

20. PART 4: Practical Exercises

21. Q. To help with recording volume of fluids, undertake the following exercises: 1.Measure out some water in a standard cup, glass and a disposable cup (if used) in your healthcare setting. Observe the volumes. 2.Examine some drainage bags, e.g. bile drainage bag, used in your healthcare setting to identify the measurement markings.

22. 3. Fill a urinary drainage bag with some water and practice emptying the hourly urometer device on the urinary drainage bag (see chamber at front of the bag). 4. Can you estimate the volume when a child vomits on his/her clothing or on the floor? Spill some water on clothing/hospital sheet and observe the volume soaked, to assist you with your estimation 5. Identify the volume markings on an emesis bowl used in your healthcare setting.

23. Note: 1g of a wet nappy = 1ml of urine. 6. The weight of the wet nappy is subtracted from the weight of a dry nappy to determine how many millilitres of urine is voided. Now practise weighing an infant’s nappy on the nappy weighing scales. 7. The dry weight of the nappy is 30g. The wet nappy now weighs 72g. What is the weight of the output in the nappy (in millilitres).

24. PART 5: Fluid Intake and Output: Requirements and Sources

25. Infant/Neonate Age of neonate/infant Fluid Requirement (mls/kg/24hours) Newborn30mls/kg/day 2 Days60mls/kg/day 3 Days90mls/kg/day 4 Days120mls/kg/day 5 Days150mls/kg/day 1 week – 8 months 150mls/kg/day 9 – 12 months120mls/kg/day A Guide to Average Oral Fluid Requirements

26. Average Daily Fluid Requirements by Age and Weight AgeApproximate body weight mls/24hr 3days3.0kg250-300mls 1year9.5kgs1150- 1300mls 2years11.8kgs1350- 1500mls 6 years20kgs1800- 2000mls 10 years28.7kgs2000- 2500mls 14 years45kgs2200- 2700mls 18years54kgs2200- 2700mls

27. Under normal conditions, the average recommended volume of fluid intake for a healthy adult is approximately between 1,500 – 2,000mls daily. Adult

28. Sources of Fluid Intake Fluid (drinks) taken orally with and between meals Liquid foods e.g. soup, gelatine/jelly Tube feedings Water to flush tube feeds Liquid medications Intravenous (I.V.) infusion of fluids/medications

29. Sources of Fluid Output Urine (urinary catheter, bedpan, urinal, nappy) Stool / diarrhoea Vomit Naso-gastric (N/G) tube aspirations Stoma / fistulas Wound drainage e.g. chest, closed wound drainage

30. Average Daily Fluid Intake and Output in Adults Intake (ml)Output (ml) Oral fluid intake 1100 - 1500mls Solid food intake 700ml - 1000mls Metabolism 200ml - 300mls Urine 1200 - 1500mls Insensible losses Skin 500 – 600mls Lungs 300 – 400mls Faeces 100 - 200mls Total 2000 – 2800mlsTotal 2100 – 2700mls

31. PART 6: Weight Measurement

32. Weight Measurement Weight measurement provides a relatively accurate measurement of patient fluid status / changes Each Kilogram (Kg) of weight gained or lost is equivalent to 1 litre gained / lost

33. Do not leave the infant or older person (e.g. confused) unattended when undertaking the weighing process. Weigh patient at the same time each day, using the same scales. Older children/adults: weigh with light clothing and remove shoes. Double checking (2 persons) of the weight is policy in some healthcare settings (particularly with regards to children). Document weight in kilograms (kg) on the weight chart/observation sheet. Ensure the scales are in correct functioning order. The scales must be reading zero (0) before weighing. Procedure for Weight Measurement

34. INFANTS: Remove all clothing and nappy. Ensure any heavy tubing/equipment is not weighed on the scales. Document if the infant has a support splint (e.g. I.V. cannula splint) in place as this will add to the infant’s weight.

35. Patient/ relatives unable to recall intake of fluid/forgets their intake Other fluid intake e.g. I.V. fluids during theatre not accounted for on the fluid balance record Inappropriate use of measuring utensils Estimation rather than actual measuremen t Omission of items e.g. forgetting to add entries or a patient not recalling intake & output Mathematical errors Shift change errors e.g. in carrying forward from the previous shift Duplication of entries e.g. two people entering the same intake and output How can an error occur with fluid balance recording?