Nurses and HCAs play an important role in the hydration of clients.
A review of recent literature shows just how important this can be with much of the evidence reporting patients and clients are at a high risk, especially older adults.
A study by Miller (2017) suggests that dehydration is ‘frequently dismissed’ for people in nursing homes. Burns (2016) similarly connects dehydration to concerns for client safety.
Not only can this lead to long-term medical issues, with Lecko and Best (2013, cited in Burns 2016) reporting cases of pressure ulcers, falls, and UTIs being associated with dehydration, but dismissed dehydration may also diminish the person’s overall quality of life (Miller 2017).
‘Dehydration of as little as 2% loss of body weight results in impaired physiological responses and performance.’ (Nutrient Reference Values 2014).
Dehydration is not an issue confined to nursing homes, as it is also linked to hospital care (Burns 2016).
Chan et al. (2018) express that dehydration also significantly affects ‘care outcomes and postoperative recovery’. Interestingly, the retrospective documentary review found that there was a ‘high prevalence’ of older people being dehydrated at hospital admission. Female clients and people with swallowing difficulties may also be more likely to be connected to dehydration (Chan et al. 2018).
Nurses play an important role in the hydration of clients.
Nurses and carers can promote hydration by adequately screening clients for hydration (Miller 2017).
Hydration is also influenced by ‘physical, mental and behavioural factors’ that affect the ‘willingness’ and ability for people to remain hydrated (Miller 2017).
A non-modifiable risk factor for dehydration is older age (Burns 2016). Whilst it may not be possible to turn back time, nurses can use this information to modify their practice.
In nursing homes, it is recommended that nurses perform hourly checks on clients to ensure that they have access to and are assisted with hydration (Burns 2016). Chan et al. (2018) acknowledge that it is crucial for nurses to identify and treat dehydration early.
Signs of Dehydration
Some signs of dehydration may include:
- Increased thirst
- Altered mood
- Dry/cracked lips
- Nasal dryness
- The person may respond more slowly
(Better Health Channel 2014)
Burns (2016, p. 21) highlights that: ‘Signs of severe dehydration, which can result in a medical emergency, include (NHS Choices 2015):
- Weak/rapid pulse.
- Reduced consciousness.’
The systematic review by Hooper et al. (2015) found that:
‘There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water-loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated.’
Why Are Older Adults at Risk of Dehydration?
Due to the ageing process, older adults may not feel as thirsty. Some older people may have poor signalling and not recognise their thirst or dehydrated state (Better Health Channel 2014). This may therefore lead to dehydration or ‘water loss dehydration’. Hooper et al. (2015) explain that ‘water loss dehydration’ refers to the person not consuming enough fluids.
The Better Health Channel (2014) also identifies poor mobility as a risk factor for dehydration in the elderly. This highlights the need for nurses to complete regular, hourly rounds to check that clients have access to and assistance with drinking.
Other aspects that nurses may need to be aware of when nursing older clients is that medications (e.g. laxatives, diuretics) may place the person at risk of dehydration(Better Health Channel 2014). Also, the ageing process can lead to declining kidney function, which can place the older individual at further risk of dehydration.
Better Health Channel (2014) also reinforce that older people may experience dehydration related to chronic disease (e.g. diabetes, kidney disease) and hormonal changes.
Testing for Dehydration
Hooper et al.’s (2015) systematic review examined 67 different tests to evaluate whether any tests were able to satisfactorily tell if the person was hydrated or not.
Their study of older adults states that:
‘There was sufficient evidence to suggest that some tests should not be used to indicate dehydration. Tests that should not be used include dry mouth, feeling thirsty, heart rate, urine colour, and urine volume’
Nutrient Reference Values for Australia and New Zealand (2014) recommends that women aged over 70 years have 8 cups or 2.1L of fluids to drink in a day, and that males aged 70 years and over have 10 cups or 3.4L of fluids to drink per day.
This recommendation is an average, and evidently, factors such as very hot climates must be taken into account for the individual’s hydration needs (Nutrient Reference Values 2014).
For example, the following may lead to a person needing additional fluids to remain hydrated (Better Health Channel 2014): high protein diets, high fibre diets, vomiting, diarrhoea, sweating or exercise.
It is suggested that 75% of adult hydration is from oral fluids and 25% is from foods (Nutrient Reference Values 2014).
Obviously, healthcare professionals must be careful to follow the hydration needs of the individual such as fluid restrictions set by specialist doctors. It is thereby also essential to document fluid balance accurately.
One of the rare risks of consuming too much water can include hyponatraemia (Better Health Channel 2014). Hyponatraemia could potentially lead to blurred vision, coma, death, cramps, convulsions, or brain swelling (Better Health Channel 2014).
- Better Health Channel 2014, Water – a vital nutrient, State Government of Victoria, Melbourne, viewed 23 April 2018, https://www.betterhealth.vic.gov.au/health/healthyliving/water-a-vital-nutrient
- Burns, J 2016, ‘Patient safety and hydration in the care of older people’, Nursing Older People, vol. 28, no. 4, pp. 21-4, viewed 23 April 2018, https://www.ncbi.nlm.nih.gov/pubmed/27125939
- Chan, HYL, Cheng, A, Cheung, SSS, Pang, WW, Ma, WY, Mok, LC, Wong, WK & Lee, DTF 2018, ‘Association between dehydration on admission and postoperative complications in older persons undergoing orthopaedic surgery’, Journal of clinical nursing, viewed 23 April 2018, https://www.ncbi.nlm.nih.gov/pubmed/29493857
- Hooper, L, Abdelhamid, A, Attreed, NJ, Campbell, WW, Channell, AM, Chassagne, P, Culp, KR, Fletcher, SJ, Fortes, MB, Fuller, N, Gaspar, PM, Gilbert, DJ, Heathcote, AC, Kafri, MW, Kajii, F, Lindner, G, Mack, GW, Mentes, JC, Merlani, P, Needham, RA, Olde Rikkert, MGM, Perren, A, Powers, J, Ranson, SC, Ritz, P, Rowat, AM, Sjöstrand, F, Smit,h AC, Stookey, JJD, Stotts, NA, Thomas, DR, Vivanti, A, Wakefield, BJ, Waldréus, N, Walsh, NP, Ward, S, Potter, JF, Hunter, P 2015, ‘Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people’, Cochrane Database of Systematic Reviews 2015, no. 4, viewed 23 April 2018, http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD009647.pub2/full