Dehydration in Nursing Homes

Dehydration means that the body is losing more fluid than it is taking in and is the most common fluid problem in older people. The diagnosis of dehydration is based on signs, symptoms, and lab values. If a diagnosis of dehydration is missed, deadly electrolyte imbalances, seizures, kidney, brain and other organ failure, and even death may result. Dehydration also increases medication concentrations in the bloodstream and the risk for side effects and drug toxicity.

Why are elders at such risk for dehydration?

  • Decreased content of body water
  • Decreased thirst response
  • Normal kidney changes
  • Trouble swallowing

What are some other risk factors for dehydration?

  • Fever
  • Infection
  • Poor dietary intake (food is up to 80% fluid)
  • Lack of available fluid
  • Impaired physical or mental ability to consume fluid without assistance
  • Warm environmental temperature
  • Depression
  • Confused mental state
  • Stomach or intestinal disorders such as nausea, vomiting, and diarrhea
  • Increased urine output
  • Excessive activity
  • Excessive perspiration
  • Excessive wound drainage
  • Medications that cause fluid loss (diuretics “water pills”)
  • Highly concentrated tube feedings
  • Uncontrolled diabetes
  • Shortness of breath
  • Enemas/irrigation

Those at highest risk for dehydration are female, bedridden, have an acute illness (ex. urinary tract infection), are over age 85, on 4 or more medications, and have more than 4 chronic illnesses.

What are some signs and symptoms of dehydration?

  • Sunken cheeks
  • Sunken eyeballs
  • Dry, brown tongue
  • Dry mouth
  • Dry, inelastic skin
  • Weight loss
  • Increased drop in blood pressure when changing positions (increases the risk for falls)
  • Low blood pressure
  • Increased pulse
  • Elevated temperature
  • Weakness, particularly in the upper body
  • Mental confusion
  • Concentrated, dark urine
  • Constipation and fecal impaction
  • Nausea
  • Decreased appetite
  • Thirst
  • Flushed skin
  • Headache
  • Dizziness

What are some laboratory values that suggest dehydration?

  • Elevated blood urea nitrogen
  • Low potassium
  • High sodium
  • Elevated serum creatinine

How much fluid do you need to prevent dehydration?

The elderly need one ounce (30 ml) of fluid per kilogram (about half an ounce per pound) of body weight per day. For example, a 150-pound person needs 75 ounces of fluid every day.

What should the nursing home be doing to prevent dehydration?

  • Identify those at risk for dehydration and monitor them carefully.
  • Monitor intake and output measurements in those who are determined to be at especially high risk (this does not require a doctor’s order). If output is noted to be greater than intake, then the risk of dehydration is higher.
  • Develop a specific plan of care to address dehydration.
  • Note that output may include not only urine, but wound drainage, vomitus, and liquid stools.
  • Determine what fluids the resident likes and will consume most readily, and attempt to provide these items.
  • Promptly obtain laboratory tests ordered by the physician if signs of dehydration are noted. If abnormal, the standard of care calls for the nurse to make phone contact with the physician.
  • Encourage residents to drink at each interaction.

Who should have intake and output monitoring completed to assess hydration status?

  • Residents receiving tube feedings
  • Residents with catheters
  • Residents with physician orders for fluid restrictions or orders to force (encourage) fluids
  • Residents who are known to be dehydrated or who are at risk for dehydration
  • Residents receiving intravenous fluids

Resources

Medline Plus
National Citizens’ Coalition for Nursing Home Reform
National Citizens' Coalition for Nursing Home Reform