Chapter 8 Implications of Abnormal Hydration Status ●

Educate nursing assistants on the importance of completing oral care.

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Remind older adults that hydration is important and that increasing fluid intake may actually decrease toileting needs. Urine will not be as con- centrated, thus decreasing the feeling of needing to use the toilet.

The amount of fluids needed is specific for each person and fluctuates as the older adult’s condition changes (eg, fever, wounds). These needs should be calculated by the RDN whenever conditions change as part of the overall assessment.

FACILITY PROCEDURES AND DOCUMENTATION

Dehydration in older adults is an issue of concern to those completing the Minimum Data Set (MDS), espe- cially MDS Coordinators. The Resident Assessment Instrument Manual (RAI Manual) states that the intent of J1550: Problem Conditions is to provide an opportu- nity for screening in the areas of fever, vomiting, fluid deficits/dehydration, and internal bleeding. The RAI Manual lists specific definitions that should be familiar to the RDN.

For those residents in nursing facilities who trigger dehydration, the MDS assessment process includes the completion of the Dehydration and Fluid Maintenance Care Area Assessments (CAAs). Information requested in the CAA is to be used to further assess care areas triggered from the MDS 3.0 resident assessment instru- ment. Changes were made in April 2012 in the Dehydration and Fluid Maintenance CAA, specifically within the areas of diseases and conditions that predis- pose the older adult to limitations in maintaining normal fluid intake and in the area of oral intake. Although the CAA is not a required assessment form, caregivers will still need to review indicators and supporting documentation and use critical thinking to draw conclusions. Documentation of a problem con- cerning the hydration of the older adult should include the description of the problem, causes, and contributing factors and risk factors related to the care area. The RDN must consider the implications that fluid intake deficits in older adults has on the facility’s annual survey. Dehydration has been at the forefront of survey compliance for a number of years, even becoming one of the sentinel events when the MDS 2.0 was initiated. “Numerous F-tags can be cited for not identifying dehy- dration and acting on it. These tags may be cited inde- pendently or in combination when facilities have not assessed the resident appropriately or on an ongoing basis.” With those states already under the Quality Indicator Survey (QIS) process, residents whose MDS has

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dehydration marked come into the survey process in Stage 2 for review, purely based on the MDS data. The care area pathway will be followed to make sure all com- ponents were done correctly—assessment, care planning, and provision of care (47).

Maintaining the hydration status of residents does not have to be that difficult. “Water is always the best source of hydration, but milk and juice are also com- posed mostly of water. Coffee, tea, or pop can contrib- ute but should not be the major portion of fluid intake. Many fruits and vegetables, such as watermelon and tomatoes, are 90% to 100% water by weight with all other foods providing 20% of total water intake” (47). Color-coded napkins have been used by some facil- ities as part of a system to maintain hydration, as has using a different type of pitcher from routine. Keeping water fresh is also a great way to increase hydration as long as the older adult is able to lift the pitcher when full. Many residents do not want water in their pitcher, so ask them if they would drink something else if it was in that bedside pitcher. Having fluids openly available in dens and living rooms of the facilities encourages older adults and their families as well as staff to offer fluids. “Out of sight out of mind,” so make sure fluids are readily in sight (47).

Ideas for successful programs are seldom complex. They are simple, homelike actions that focus on the older adult and what will work for that person. Asking residents for their input and preference may sound silly to many, but it is surprising how many older adults have not been given the opportunity to state what they would prefer. It is so easy to offer what has always been provided (47).

Having a strong interdisciplinary team, whether in the medical model of LTC or in the newly created neighborhood model, is the key to success. This group working with the family can identify changes in behav- iors and develop successful interventions with positive outcomes (47).

SUMMARY

In conclusion, when deprived of fluids over a period of time, older adults will not rehydrate to baseline levels as would younger adults. Effectively preventing, rec- ognizing, and managing dehydration in the older adult population, no matter the care setting, may be chal- lenging for many reasons. The diagnosis can be diffi- cult since no reliable physical signs and symptoms of dehydration exist. Risk for dehydration can also occur as a consequence of treating another problem or symptom, such as modifying fluid or diet consistency to manage dysphagia or treating hypertension or heart disease with diuretics. Disease processes at end of life may also undermine attempts to maintain fluid and