8/11/2014. Nutritional Management for Success - Hydration. Objectives

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1 Nutritional Management for Success - Hydration Objectives Discover the components of a comprehensive hydration program Estimate fluid needs for obese patients Discuss interventions to promote fluid intake Jeanne Carlson RD,LD Dehydration vs. fluid/electrolyte imbalance Dehydration is defined as a loss of body water that causes significant signs and symptoms, including physiological and/or functional decline from the individual's baseline. Dehydration is one form of fluid/electrolyte imbalance and may be caused by inadequate fluid intake and/or excessive fluid loss. A fluid/electrolyte imbalance is defined as an insufficiency or excess of either water or electrolytes (sodium and potassium) in certain body areas. Biochemical Signs of Dehydration* The AMDA guidelines committee translated its definition of dehydration into clinical terms. All three of the following elements must be present to label a patient clinically dehydrated: Suspicion of increased output and/or decreased input At least two physiological or functional signs or symptoms of dehydration (e.g., dizziness, dry mucous membranes, functional decline) Any of the following: BUN-creatinine ratio > 25:1 Orthostasis, or a decrease in systolic blood pressure = 20 mm Hg upon a change in position Pulse > 100 beats per minute or a pulse change of 10 to 20 beats per minute more than the patient's baseline pulse upon a change in position Elevated serum osmolarity above 295 mosmol gold standard Elevated serum sodium above mmol/l Elevated BUN/Creatinine ratio above Elevated Urine Specific Gravity above *Only diagnostic in the presence of clinical signs of dehydration 1

2 How Common is Dehydration? Dehydration is the most common fluid/electrolyte disorder of frail elders, and it is both under recognized and under treated. Per Mentes in 2006, the dehydration rate in nursing homes was 30-33% Early Dehydration Headache Fatigue Loss of appetite Flushed skin Heat intolerance Light-headedness Dry mouth or eyes Burning sensation in stomach Dark urine with strong odor Advanced Dehydration Difficulty swallowing Clumsiness Shriveled skin Sunken eyes Visual disturbances Painful urination Numb skin Muscle spasm Delirium Risk factors for Dehydration in the Elderly Decreased thirst response Aged kidneys decreased urine concentrating capacity, impaired excretion Decreased sensitivity to ADH Fear of incontinence Acute or chronic illnesses Decrease in total body water Increased need for feeding assistance Laxative, enema or diuretic use Difficulty swallowing Lack of access Consequences of Dehydration Hospital admission Functional decline and delirium Increased health care costs Urinary and respiratory infection Pressure ulcers Death Falls Constipation Medication toxicity 2

3 Dehydration and Tube Feeding Water is administered per physician order Amount administered varies by care giver Need clarification for before, between and medication administration. Need clarification for water flushes How are free fluids in formulas being calculated? Hydration Four Key Questions Where are we now? Where do we want to be? How do we get there? How do we get commitment from key individuals? Start Your Facility Assessment at the Door Starts at admission Receptionist HUC/HIM/ward clerk Nursing Dietary Rehab services Maintenance/housekeeping Social services Administration Research has shown that people who laugh together work better together. Interdisciplinary Approach to happy eaters The Basic Care Process Food Delivery Systems Review Assessment/recognition Diagnosis/cause identification Treatment/management Monitoring Meal delivery - Serving trays on carts delivered from the kitchen or steam tables in the dining room Choice vs. no-choice Menus Personal service 3 vs. 5 meals/day Culture change 3

4 Institutional Factors Staff attitudes and beliefs Staffing - Who s involved with meal delivery? All hands on deck Components of a Comprehensive Hydration Program 1. Educate staff and families on the warning signs for dehydration and on the action steps to prevent dehydration. 2. Estimate each resident s fluid needs upon initial, quarterly, annual and significant change assessments. Fluid needs increase by 6% per degree of fever over baseline temp. Components of Hydration Program (cont.) 3. Establish a facility standard for the minimum amount of fluid served on meal trays each day and assure that residents receive adequate assistance at mealtime. 4. Implement interventions 5. Monitor success 1. Educate staff and families on the warning signs for dehydration and on the action steps to prevent dehydration. Why Train? Training is not only the right thing to do; it can provide the basis for effective defenses to lawsuits and prevent deficient survey findings. It is tempting for employers with limited resources to provide only legally required training to employees Provide Written Information Comprehensive orientation and training programs give staff a sense of belonging and of status. It shows that your organization values them enough to make an investment in them, and helps to reinforce their commitment to your program. Food Item Container Size Individual creamer Ice cream/sherbet Juice (4 oz.. plastic cup) Milk carton (8 oz..) Soda (12 oz..) Popsicle (3 fluid oz..) Italian ice (6 oz..) Large glass (8 oz..) Approximate Amount cc Provided 15 ml 120 ml 120 ml 240 ml 360 ml 90 ml 180 ml 240 ml 4

5 Tell me, and I ll forget. Show me, and I may not remember. Involve me, and I ll understand. Native American Quote What items should be counted as a fluid? All fluids that a resident drinks are counted in ml's. 1 oz.. = 30 ml 4 oz.. = 1/2 cup = 120 ml 6 oz.. = 3/4 cup = 180 ml 8 oz.. = 1 cup = 240 ml Other items that liquefy at room temperature also need to be included such as broth, ice cream, sherbet, gelatin, fruit ice, and popsicles. For dialysis diets, fruits and vegetables should be drained prior to being served. Train CNA s to report the following: ½ cup (C) ice cream, frozen yogurt, sorbet=100 ml ½ C sherbet=120 ml ½ C gelatin without fruit=110 ml ½ C gelatin with fruit=80 ml 1 freezer pop=120 ml 1 ice cube=10 ml Poor appetite Dysphagia Refusal to take medications New onset or worsening cognitive impairment/ confusion/delirium Vomiting Not consuming all or almost all liquids provided Diarrhea Fever Vertigo Train LPN/RN to report the following: Recent weight loss (5% in last 30 days or 10% in last 180 days) Starting a new a diuretic, digoxin or a medication associated with GI bleeding A new DX of terminal or irreversible, progressive, condition Cont. Increased heart rate Lowered blood pressure Increased vein refill time Internal bleeding Urinary tract infection Fluid restriction for any reason 5

6 Train Activity and Rehab to report the following: Train Dietary Staff to report:» Change in participation level» Decrease in alertness» Observed changes in fluid or food intake» Dining room observations» Decline in fluid intake at activity functions Family Encourage family members to let the nurse know when Mom just isn t acting right Components of a Comprehensive Hydration Program 1. Educate staff and families on the warning signs for dehydration and on the action steps to prevent dehydration. 2. Estimate each resident s fluid needs upon initial, quarterly, annual and significant change assessments. Fluid needs increase by 6% per degree of fever over baseline temp. Fluid Requirement 30 ml/kg body weight with a minimum of 1500 ml/day ml/kg body weight if severe CHF 1 ml/kcal energy consumed 100 ml/kg for first 10 kg, 50 ml/kg for next 10 kg, and 15 ml/kg for remaining kg. shortcut: (Kg body weight-20) X mL Caron at al, patients with CVA and Dysphagia to thin liquids Study: Control group: unrestricted thickened liquids Experimental group: thickened liquids and access to water 6

7 Results Author s Conclusions Group consumption Thickened liquids Thickened liquids and water liquid Fluid 1210 ml 855 ml thickened 463 ml water Conclusion: significant difference in thickened liquid intake(p=0.03); water intake was less than expected Dissatisfaction with thickened liquids Noncompliance with thickened liquids Potential dehydration Limited thickened fluid intake Complaints of dryness and thirst Nursing dependency to provide fluids and encourage intake Case Study Estimating Fluid Needs for Obese Patients Male 65 inches tall 248#, kg BMI 41.3 Actual body weight should be used for fluid estimates, not adjusted body weight. Formulas available: ml/kg for the first 10 kg, plus 50 ml/kg for the next 10 kg, plus 15 ml/kg for the remaining weight 2. Short cut = (kg body weight 20) x cc/kg body weight 4. 1cc/kcal intake L fluid/day ( at least 3.0 liters from beverages and the remainder from food) for men and 2.7 L/day ( at least 2.2 L from beverages and the remainder from food) for woman *Absolute minimal adult fluid needs: Urine output cc/day. Does not apply to fluid restrictions. Comparison of formulas ADA Nutrition Care Manual ml + 50ml + (15ml x 92.6) = ( ) x = x 30 = 3378 ml ml (assuming intake of 2400 kcal/d) ml (at least 3000 ml from beverages) Average healthy adult ml/kg weight Adult ml/kg weight Adult >65 years 25 ml/kg body weight Range from 2400 ml to 3700 ml 7

8 Fluid Restriction No water pitcher in room Inform Activities and Rehab of restriction Drain fruits, veg, soups No ice cream or sherbet unless specialty product Signage (disguised) in room I & O if needed MAR Tray card Care plan Nursing progress notes document weekly Initial Nutrition Assessment Determine the resident's need for assistance with eating and drinking. Record the resident's beverage preferences. Evaluate the resident's hydration status and risk of dehydration Ability to communicate Initial Nutrition Assessment cont.. Reassessment after Dx Dehydration or Change in Status Extent of cognitive impairment Medications Consider also the presence of progressive, irreversible conditions such as dementia and terminal illnesses Serum sodium >147 Hct >3x Hgb Facilities are being tagged for lack of reassessment Review care plan Re-assess fluid needs Consider the fluid content in solids actually consumed Tube Feedings Example Calculate free water in the formula correctly. Add enough free flush to meet calculated requirement. Resident receives 1600 ml of formula that is 85% free fluid = 1350 ml Calculated need is 1850 ml Then need 500 ml free warm water flush Look at timing of feedings allow time off for rehab and activities 8

9 Consider the following items from the MDS in identifying residents who are at risk for dehydration: Components of Hydration Program Deteriorated cognitive status (section B); Deteriorated ADL status (section G); Failure to eat (section K); Health conditions such as diarrhea, fever or vomiting (sections H and J). Specific identification of dehydration as a problem is noted in section J. 3. Establish a facility standard for the minimum amount of fluid served on meal trays each day and assure that residents receive adequate assistance at mealtime. 4. Implement interventions 5. Monitor success Typical Fluid Breakdown Breakfast trays generally include 8 oz. milk, 6 oz. coffee, and 6 oz. juice for 600 ml. Lunch and Dinner meals usually provide another 4-8 oz. of milk, 6 oz. coffee, and 6-8 oz. of either water or juice at each meal for another ml/meal. Typical Fluid Breakdown (cont.) And then there is HS snack, which is often offered after residents have gone to bed. Another 8 oz. would bring the daily total to ml not including daytime snacks. Between meal hydration pass for residents on thickened liquids Components of Hydration Program 3. Establish a facility standard for the minimum amount of fluid served on meal trays each day and assure that residents receive adequate assistance at mealtime. 4. Implement interventions 5. Monitor success 9

10 Interventions: Use 8oz cups to provide fluids at each medication pass. Start systemic fluid passes by using a hydration cart at least twice daily and offer a variety of fluids. Set up hydration stations in the Rehabilitation and Activities Departments. Address pain Monitor weight Interventions: Implement a mealtime and between meals fluid intake documentation system. Promote fluids with positive encouragement by all staff with each visit to the resident s room. Provide staff education on feeding skills (Older people tolerate frequent administration of fluid in smaller quantities better than infrequent large quantities.) Interventions: Determine preferences of temperature and type of beverages for each resident. Establish a system for providing the RD and/or DTR with a copy of current hydration related laboratory values. The RD and/or DTR review the laboratory results, complete a timely assessment of the resident s hydration status and update the resident s hydration plan of care as needed. Interventions Provide a large water cooler at each nursing station and replenish with fresh cool water daily. Make sure that cups are readily available. Interventions Keeping a list of high-risk residents at strategic locations to remind others to monitor residents fluid intake. Consider placing a symbol, such as a drop of water, near the resident s bed as a sign for CNAs to encourage fluid intake. Flexible meal times Interventions: Implement quality assurance monitoring of the Comprehensive Hydration Program. Develop and maintain a comprehensive care plan that documents the resident s dehydration risk factors, estimated fluid needs and an individualized plan for meeting fluid needs. Place on nutrition risk list Encourage wet foods ice cream, soup, custard, yogurt, pureed fruit 10

11 Nursing ADL Worksheet Date Initiated: Date Last Revised: Eating Mobility Mental Status NUTRITION RISK REVIEW TEAM Grooming Vision Blind Glasses Poor Vision Hearing Deaf HOH Rt. Hearing Aid Left Hearing Aid Oral Care Independent Own teeth Assist Dentures Upper Lower No teeth Partial Plate Shave Independent Assist Bathing Bed bath Tub Shower Shampoo Minimal Assist Total Assist Diet: Independent Set up assist Partial assist Finger food Thicken liquids Supplement Type: Time: with meals midmorning mid afternoon bed time Fluids Restrict Encourage Intake Output Dining Room: Weight bearing status: Dexterity: R L Ambulate Independent 1 Assist 2 Assist Lift-Type: Cane Wheelchair Walker Paralysis Rt. Arm Rt. Leg Lt. Arm Lt. Leg Positioning Independent 1 assist 2 assist Q2 hours Hip precaution Transfer Independent Walker 1 assist Cane 2 assist W/C Alert Oriented Confused Forgetful Depressed Agitated Wanderer Dietary Manager &/or Registered Dietitian DNS &/or Lead/Charge Nurse Speech Pathologist Activities Director Social Services Restorative Nursing CNA/Weight Staff Other Important Contacts: MD, OT/PT, Pharmacist, Dentist Independent Dressing Self Care Assist Total Care Toileting Skin Activities Other: Toileting Schedule: Continent Routine High Risk PT OT Inc. Bladder Special treatment ST Facilities with active interdisciplinary nutrition care teams and a physician who appropriately makes referrals are less likely to have weight loss, dehydration and pressure sore development Hypodermoclysis (HDC), the subcutaneous infusion of fluids No single approach suffices for all situations and, in some cases, administration of fluids may be harmful. For example, a patient with progressive or acute heart failure with or without edema who may have intravascular volume depletion (reflected in an increase in the BUN/creatinine ratio) may need an increased dosage of diuretics, not more fluids. The physician must help to make such clinical decisions. Appendix Hydration Assessment 11

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