Note from the American Medical Directors Association (AMDA) and the National Guideline Clearinghouse (NGC): The original full-text guideline provides an algorithm on "Dehydration and Fluid Maintenance" to be used in conjunction with the written text. Refer to the "Guideline Availability" field for information on obtaining the algorithm, as well as the full text of the guideline, which provides additional details.
Does the patient have risk factors or predisposing conditions for dehydration?
Assess the patient for risk factors and other indicators that may predispose to dehydration (see Tables 1 and 2, below).
|Table 1. Risk Factors for Dehydration
- Focal central nervous system lesions
- Hypodipsia of aging
- Medications (see Table 8 in the original guideline document)
|Decreased cognitive function
|Increased fluid losses
- Specialty air-flow mattresses
|Limitations in oral intake
- Fear of urinary incontinence
- Inadequate tube feeding volume
- Limited mobility
- Modified fluid consistency (thickened liquids)
- Need for feeding assistance
|Table 2. Potential Indicators Suggesting Increased Risk of or Need for Clinical Evaluation for Dehydration
- Acute illness
- Decrease in fluid intake (<75% of food or fluid consumed at meals)
- Dietary restrictions (e.g., thickened liquids)
- Excessive sweating, fever
- Medications (e.g., angiotensin-converting enzyme [ACE] inhibitors, diuretics, laxatives, lithium, phenytoin toxicity)
- Patient on nothing-by-mouth status (e.g., gastrointestinal preparation)
Signs and Symptoms
- Change in activities of daily living (ADLs)
- Change in mental status
- Decreased urine output
- Postural hypotension
- Weight loss (3–5 lb in short time)
Is the patient dehydrated?
Maintain a high level of suspicion for dehydration in the long-term care (LTC) setting.
- Medical History
- Body Weight
- Physical Examination
- Urine Color: Urine color is not a useful indicator of hydration status.
- Intake and Output Measurement: Intake and output measurement should be relied upon sparingly because the value of such monitoring is limited in the LTC setting.
The diagnosis of dehydration cannot be made on clinical grounds alone. Ultimately, the diagnosis is biochemical (established via laboratory tests). Because of potential complications, the diagnosis should be confirmed or excluded as quickly as possible.
Is a medical workup appropriate?
Patients should be categorized according to their level of risk for dehydration or fluid/electrolyte imbalance and given a workup appropriate to their risk level.
Perform appropriate laboratory evaluation.
If dehydration is suspected and a workup is indicated (or not limited by patient or family choice), at a minimum, obtain values for blood urea nitrogen (BUN), serum bicarbonate, creatinine, glucose, sodium, calcium, and potassium.
In addition, either directly measure or calculate serum osmolarity. This is a very sensitive measurement that rises in dehydration with a percentage body weight loss of as little as 1%. During dehydration caused by insufficient fluid intake, both plasma sodium and osmolarity are typically significantly elevated.
The BUN:Cr ratio should be used cautiously to assess hydration status.
Determine the causes of and factors contributing to dehydration.
If the patient is dehydrated, it is important to try to identify the underlying causes of the dehydration. These efforts should be continued until a cause is identified or it is determined either that a cause cannot be identified or that identifying a cause would not change the treatment or ultimate outcome.
Establish the severity of the patient's hydration status and summarize findings.
Using the information obtained in Steps 2 through 4, summarize the nature, severity, and causes of the patient's dehydration or risk for dehydration and assess the impact of this condition or risk on the patient's functioning and quality of life.
Establish treatment goals.
Treatment goals for the patient with dehydration may range from complete resolution of fluid/electrolyte imbalances to palliation.
Address dehydration and manage related issues.
When treatment is indicated, the key to correcting dehydration is to correct water and sodium deficits. The choice of therapy depends on the patient's clinical condition, including complications that influence the type and urgency of rehydration efforts.
- Subcutaneous Fluid Administration
- Intravenous Fluid Replacement
- General Support for Patients with Dehydration
Offer general support to all patients with dehydration. Such support may include administration of food and fluids, additional assistance as needed with activities of daily living (e.g., if dehydration has caused lethargy or delirium), and management of medical conditions that may be causing or complicating the patient's dehydration. The underlying cause or causes contributing to the dehydration should be identified.
Monitor the patient's overall condition and responses to intervention.
Ongoing monitoring of patients' fluid/electrolyte status should include frequent checking for signs and symptoms that may indicate dehydration (see Steps 1 and 2). Closely monitor the patient's general status (e.g., level of consciousness, vital signs) as well as specific organ systems (e.g., heart, lungs, kidneys, skin) that can be affected by dehydration or by rehydration efforts. Also monitor the patient's emotional responses to treatment. The frequency of monitoring will depend on the severity of the fluid/electrolyte imbalance, the patient's physical and mental function, and the route and rate of rehydration.
Improve the facility's approach to preventing and managing dehydration.
Prevention of Dehydration
Make reasonable efforts to try to prevent dehydration. A reasonable strategy is to combine individualized encouragement of fluids with efforts to address individual risk factors, to the extent possible, and individualized monitoring as indicated. The following strategies for preventing dehydration are based on expert consensus.
Strategies for Trying to Prevent Dehydration
- Communicate clinical changes effectively
- Emphasize the importance of hydration daily
- Encourage family involvement in increasing fluid intake
- Increase awareness of factors responsible for dehydration (e.g., fever, hot weather, diarrhea, vomiting)
- Increase early identification of acute illness
- Offer fluids regularly
- Provide preferred beverages
- Provide straws and cups that residents can use for drinking
- Report promptly decreased fluid intake and possible signs or symptoms of dehydration
- Try to manage urinary incontinence so that patients will be less likely to avoid fluids
- Use a hydration cart
- Use frozen juice bars
- Use swallowing exercises and use cues before administering thickened liquids