Dehydration is the loss of at least 1% of body weight as a result of fluid loss. Dehydration is a much greaterproblem than malnutrition in long-term care, and its symptoms are often atypical and easily mistaken for otherillnesses of delirium.Add the following appropriate nursing interventions to the plan of care pending more specific dietitianrecommendations: Provide extra fluid with meals, including juice, soup, ice cream and sherbet, gelatin, water on trays. Serve beverages at activities. All staff should encourage at least 60 ml of fluid of the resident’s choice upon entering each resident’s room. Encourage the resident to consume at least 180 ml with medications. Residents who limit water intake may accept sugar-free juices during medication pass. Offer Popsicles between meals. Pass juice or fluid cart at least twice a day. Record accurate I & O. Cumulate each shift. Evaluate daily compared with resident’s minimum fluid requirements.Differential diagnosisIn humans, dehydration can be caused by a wide range of diseasesand states that impair water homeostasis in the body. These include: External or stress-related causes Prolonged physical activity with sweating without consuming adequate water, especially in a hot and/or dry environment Prolonged exposure to dry air, e.g., in high-flying airplanes (5%– 12% relative humidity) Blood loss or hypotension due to physical trauma Diarrhea Hyperthermia Shock (hypovolemic) Vomiting Burns Lacrimation Use of methamphetamine, amphetamine, caffeine and other stimulants
Excessive consumption of alcoholic beverages Infectious diseases Cholera Gastroenteritis Shigellosis Yellow fever Malnutrition Electrolyte disturbance Hypernatremia (also caused by dehydration) Hyponatremia, especially from restricted salt diets Fasting Recent rapid weight loss may reflect progressive depletion of fluid volume (the loss of 1 L of fluid results in a weight loss of 1 kg (2.2 lb)). Patient refusal of nutrition and hydration Inability to swallow (obstruction of the oesophagus)Other causes of obligate water loss Severe hyperglycemia, especially in diabetes mellitus Glycosuria Uremia Diabetes insipidus Acute emergency dehydration event Foodborne illnessPreventionDehydration is best avoided by drinking sufficient water. The greaterthe amount of water lost through perspiration, the more water must beconsumed to replace it and avoid dehydration. Since the body cannottolerate large deficits or excesses in total body water, consumption ofwater must be roughly concurrent with the loss (in other words, if oneis perspiring, one should also be drinking some water frequently).For routine activities in which a person is not perspiring to any largedegree, drinking when one is thirsty is sufficient to maintain hydration.However, during exercise, relying on thirst alone may be insufficient toprevent dehydration from occurring. This is particularly true in hot
environments or for those older than 65. For an exercise session, anaccurate determination of how much fluid is necessary to consumeduring the workout can be made by performing appropriate weightmeasurements before and after a typical exercise session, todetermine how much fluid is lost during the workout.Drinking water beyond the needs of the body entails little risk whendone in moderation, since the kidneys will efficiently remove anyexcess water through the urine with a large margin of safety.A persons body, during an average day in a temperate climate suchas the United Kingdom, loses approximately 2.5 litres of water.[citationneeded] This can be through the lungs as water vapor (about 350ml),through the skin by perspiration (100ml) and by diffusion through theskin (350ml), or through the kidneys as urine (1000-2000ml, about900ml of which is obligatory water excretion that gets rid of solutes).Some water (about 150-200ml, in the absence of diarrhea) is also lostthrough the bowels. In warm or humid weather or during heavyexertion, however, the water loss can increase by an order ofmagnitude or more through perspiration; all of which mustbe promptly replaced. In extreme cases, the losses may be greatenough to exceed the bodys ability to absorb water from thegastrointestinal tract; in these cases, it is not possible to drink enoughwater to stay hydrated, and the only way to avoid dehydration is toeither pre-hydrate or find ways to reduce perspiration (through rest,a move to a cooler environment, etc.)A useful rule of thumb for avoiding dehydration in hot or humidenvironments or during strenuous activity involves monitoring thefrequency and character of urination. If one develops a full bladder atleast every 3–5 hours and the urine is only lightly colored or colorless,chances are that dehydration is not occurring; if urine is deeplycolored or urination occurs only after many hours or not at all, waterintake may not be adequate to maintain proper hydration.When large amounts of water are being lost through perspiration andconcurrently replaced by drinking, maintaining proper electrolytebalance becomes an issue. Drinking fluids thatare hypertonic orhypotonic with respect to perspiration may havegrave consequences (hyponatremia or hypernatremia, principally) asthe total volume of water turnover increases.
If water is being lost through mechanisms suchas vomiting or diarrhea, an imbalance can develop very quickly into amedical emergency.During sports events such as marathons, athletes take frequent waterstops and water breaks to avoid dehydration. The claim that purewater without isotonic additives can prevent dehydration is questioned,however, and the European Food Safety Authority states that reducedbody water content is only a symptom of dehydration and not whatdrinking water controls. Drinking water without replenishingelectrolytes may instead lead to developing hypotonic dehydration.TreatmentThe treatment for minor dehydration often considered the mosteffective, is drinking water and stopping fluid loss. Plain water restoresonly the volume of the blood plasma, inhibiting the thirst mechanismbefore solute levels can be replenished. Solid foods can contributeto fluid loss from vomiting and diarrhea.In more severe cases, correction of a dehydrated state isaccomplished by the replenishment of necessary waterand electrolytes (through oral rehydration therapy or fluidreplacement by intravenous therapy). As oral rehydration is lesspainful, less invasive, less expensive, and easier to provide, it is thetreatment of choice for mild dehydration. Solutions used forintravenous rehydration must beisotonic or hypotonic. Pure waterinjected into the veins will cause the breakdown (lysis) of red bloodcells (erythrocytes).When fresh water is unavailable (e.g., at sea or in adesert), seawater, alcohol, and even urine will worsen the condition.For severe cases of dehydration where fainting, unconsciousness, orother severely inhibiting symptom is present (the patient is incapableof standing or thinking clearly), emergency attention is required. Fluidscontaining a proper balance of replacement electrolytes are givenorally or intravenously with continuing assessment of electrolytestatus; complete resolution is the norm in all but the most extremecases.Some research indicates that artificial hydration to alleviate symptomsof dry mouth and thirst in the dying patient may be futile.
References Ira R. Byock, M.D., "Patient Refusal of Nutrition and Hydration: Walking the Ever-Finer Line." American Journal Hospice & Palliative Care, pp. 8–13. (March/April 1995)