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## Complete Summary

#### GUIDELINE TITLE

Dehydration and fluid maintenance.

#### BIBLIOGRAPHIC SOURCE(S)

American Medical Directors Association (AMDA). Dehydration and fluid
maintenance. Columbia (MD): American Medical Directors Association
(AMDA); 2001. 28 p. \[15 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline was reviewed by the
original Steering Committee and is still considered to be current as of
Jan 2007. This review involved new literature searches of electronic
databases followed by expert committee review of new evidence that has
emerged since the original publication date.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Dehydration, including:

    -   hypertonic dehydration

    -   hypotonic dehydration

    -   isotonic dehydration

-   Other fluid/electrolyte imbalances, including:

    -   excess water retention or intake

    -   excess water and salt retention

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Geriatrics

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Health Care Providers\
Nurses\
Pharmacists\
Physician Assistants\
Physicians\
Social Workers

#### GUIDELINE OBJECTIVE(S)

-   To improve the quality of care delivered to patients in long-term
    care facilities

-   To guide the identification and management of dehydration and
    fluid/electrolyte imbalance in older adults residing in the
    long-term care settings

-   To present approaches that attempt to minimize the occurrence of
    dehydration and fluid/electrolyte imbalance

#### TARGET POPULATION

Elderly residents of long-term care facilities

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Screening/Diagnosis/Evaluation**

1.  Using a stepwise approach, evaluation of patients for physiological
    and functional signs and symptoms of dehydration or another
    fluid/electrolyte imbalance

2.  Assessment for clinical conditions and environmental factors that
    increase risk for dehydration or fluid/electrolyte imbalance

3.  Medical evaluation as indicated \[physical examination, medical
    history, laboratory testing (sodium, potassium, chloride,
    bicarbonate, blood urea nitrogen, creatinine, calcium, glucose,
    hemoglobin, hematocrit, serum osmolality, urinalysis, urine sodium,
    urine osmolality)\]

4.  Classification of nature and severity of fluid/electrolyte imbalance

5.  Identification of causes for dehydration or other fluid/electrolyte
    imbalance

**Management/Treatment**

1.  Interdisciplinary care planning

2.  Symptom management

3.  Treatment of causes and risks where appropriate

4.  Management of specific deficits and imbalances, as indicated, such
    as fluid and electrolyte replacements or fluid restrictions. Fluid
    replacement may be by various routes, including oral,
    hypodermoclysis, nasogastric or gastrostomy tube or intravenous

5.  Provision of general support to patients

6.  Monitoring of patients response to interventions (e.g., vital signs,
    weight, fluid intake, laboratory tests as clinically indicated) and
    subsequent adjustments of interventions as needed

7.  Monitoring the status and treatment of underlying causes of
    dehydration and review of relevant medications.

#### MAJOR OUTCOMES CONSIDERED

-   Fluid and electrolyte status

-   Comfort and well-being of patients

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The guideline was developed by an interdisciplinary work group using a
process that combined evidence- and consensus-based thinking. The groups
were composed of practitioners involved in patient care in the
institutional setting. Using pertinent articles and information and a
draft outline, the group worked to make a simple, user-friendly
guideline that focused on application in the long term care
institutional setting.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

All American Medical Director Association (AMDA) clinical practice
guidelines undergo external review. The draft guideline is sent to
approximately 175+ reviewers. These reviewers include American Medical
Director Association physician members and independent physicians,
specialists, and organizations that are knowledgeable of the guideline
topic and the long-term care setting.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

I.  **Recognition**

> **Step 1**
>
> **Is the patient dehydrated or does the patient have a
> fluid/electrolyte imbalance?** Consider seriously the presence of a
> fluid/electrolyte imbalance whenever a patient experiences new
> symptoms or a decline of an existing condition that cannot be readily
> attributed to another cause. Fluid/electrolyte imbalances must be
> identified promptly because they can increase the risk of subsequent
> decline and may be life threatening.
>
> Using a stepwise approach, carefully evaluate the patient for
> physiological and functional signs and symptoms of dehydration or
> another fluid/electrolyte imbalance (see \"Signs and Symptoms That May
> be Associated with Dehydration\" below). First, perform a careful,
> focused medical history. Information from the patient\'s history that
> may suggest a hydration problem includes

-   Decreased fluid intake or increased output

-   Change in mental status

-   Weight loss of 3-5 percent within 30 days

-   Constipation

-   Use of medication that promotes excessive urination or affects
    sodium and potassium balance

> **Signs and Symptoms That May Be Associated with Dehydration**
>
> *Physiological Signs and Symptoms*

-   Recent rapid weight loss

-   Dry eyes and/or mouth

-   Change in mental status

-   Fever

-   Vomiting

-   Postural hypotension

-   Small amount of concentrated urine

-   Urinary tract infections

-   Pulse \>100 beats/minute and/or systolic blood pressure \<100 mmHg

-   Dizziness

> *Functional Signs and Symptoms*

-   Lethargy and weakness

-   Change in mental status

-   Falling

-   Change in ability to carry out activities of daily living

-   Increased combativeness and confusion

> The presence of multiple signs and symptoms may provide a more urgent
> or specific indication that the patient has a fluid or electrolyte
> imbalance. Recent rapid weight loss is often an important clue because
> it may reflect progressive depletion of fluid volume. (The loss of 1 L
> of fluid results in a weight loss of 1 kg, or 2.2 lb.)
>
> If relevant symptoms or abnormalities are identified, involve a
> physician or other health care practitioner as soon as possible to
> identify the possible causes of those symptoms (which may include
> fluid/electrolyte imbalance, medical illness, infection, etc.).
>
> If dehydration or another fluid/electrolyte imbalance is identified,
> define its severity to determine the urgency of further assessments
> and interventions (see \"Characterizing the Severity of
> Fluid/Electrolyte Imbalance\" below). Mild deficits are usually
> readily correctable or can continue without causing major decline.
> Moderate or severe deficits, however, require prompt interventions and
> at least partial correction.
>
> **Characterizing the Severity of Fluid/Electrolyte Imbalance**
>
> ***Mild***: Some deficits or abnormalities in laboratory values exist,
> but they do not seriously impair the patient\'s circulation, organ
> function, or level of functioning. Examples:

-   Marginally elevated blood urea nitrogen (BUN) or high or low sodium
    in a patient taking diuretics

-   Increased thirst in a patient who has had diarrhea for two days but
    is still drinking adequate amounts of fluid

> ***Moderate***: Some deficits or lab abnormalities exist that impair
> or are likely to impair circulation or organ function but are not
> immediately life threatening. Example:

-   Mildly increased lethargy or confusion or decrease in blood pressure
    in a patient with a sodium level of 155 mEq/L whose consumption of
    food and fluids is reduced as a result of influenza

> ***Severe***: Deficits or abnormalities causing significant,
> life-threatening risks or problems with circulation, organ function,
> or activities of daily living. Examples:

-   Rapid recent BUN elevation to \>100 mg/dl in a patient whose BUN was
    normal a month ago

-   Rapidly increasing lethargy and confusion in a patient with a recent
    illness whose sodium is now 123 mEq/L or who is hypotensive

> If dehydration is suspected, go immediately to Step 3 to begin
> assessment.
>
> **Step 2**
>
> **Is the patient at risk for dehydration or fluid/electrolyte
> imbalance?** If the patient is not currently dehydrated and has either
> no fluid/electrolyte imbalance or a mild fluid/electrolyte imbalance,
> it is important to identify the risk for development or progression of
> these conditions. Caregivers should pay close attention to clinical
> conditions and environmental factors that may increase risk for
> dehydration or fluid/electrolyte imbalance (see \"Conditions and
> Factors That May Increase Risk for Dehydration or Fluid/Electrolyte
> Imbalance\" below). At the same time, caregivers should be aware that
> normal aging, end-of-life processes, and other clinical conditions can
> produce many of the same findings. If a patient appears to be at risk,
> the caregiver should document this observation and address the
> conditions or factors that present the risk.
>
> **Conditions and Factors That May Increase Risk for Dehydration or
> Fluid/Electrolyte Imbalance**
>
> *Clinical Conditions*

-   Dementia or cognitive impairment

-   Fever (including low-grade fever)

-   Diarrhea

-   Vomiting

-   Dependence on staff for eating and drinking

-   Use of medications that can cause dehydration (e.g., diuretics,
    phenytoin, lithium, laxatives)

-   Draining wounds or pressure ulcers

-   Excessive sweating

-   Rapid breathing

-   Gastrointestinal bleeding

-   Previous episodes of dehydration

-   Difficult or painful swallowing

-   Depression

-   Small amount of dark or concentrated urine

-   Excessive urination

-   Nothing-by-mouth or fluid-restriction orders

-   Chronic comorbidities (e.g. stroke, diabetes, congestive heart
    failure)

-   Infection

-   Dizziness

> *Environmental Factors*

-   Tube feeding

-   Use of specialty beds

-   Lack of social or family support

-   Inadequate staffing

-   Language barriers

-   Isolation

-   Restraints

-   Facility-specific factors that may expose patients to excessive heat
    (e.g. malfunctioning air conditioners)

> **Risk Reduction**. A facility-wide hydration program can contribute
> significantly to decreasing the risk of dehydration. The certified
> nursing assistant (CNA) can be a major resource for this program.
> Regular rounds for fluid distribution, one-on-one help with consuming
> fluids, records of fluid intake and output if indicated, and reporting
> of warning signs that caregivers have been trained to recognize all
> play a part in a facility-wide effort to reduce the risk of hydration
> problems.
>
> Hydration should be considered part of everyone\'s job. Every staff
> member should be trained to help manage hydration and to offer fluids
> as appropriate, and all staff should be involved in managing
> hydration. All caregiving staff should pay attention to such issues as
> why a patient may not be consuming fluids that are offered and
> ensuring that a patient\'s liquid preferences are identified.
> Questions about these issues should be asked of patients or of their
> family members or other advocates when patients are unable to respond.

II. **Assessment**

> **Step 3**
>
> **Is a medical workup appropriate?** An appropriate workup may help to
> identify or characterize a current dehydration or fluid/electrolyte
> imbalance or to define the risks for developing these problems. A
> physical examination and laboratory tests help to confirm the
> diagnosis and guide patient management (see \"Criteria for Clinical
> Diagnosis of Dehydration\" below).
>
> **Criteria for Clinical Diagnosis of Dehydration**
>
> For a clinical diagnosis of dehydration to be made, the following
> minimal criteria must be present:

-   Suspicion of increased output and/or decreased intake

-   At least two physiological or functional signs or symptoms
    suggesting dehydration (e.g., dizziness, dry mucous membrane,
    functional decline)

-   A BUN/creatinine ratio of \>25:1 OR orthostasis (defined as a drop
    in systolic blood pressure [\>]{.underline}20 mmHg on a change in
    position) OR a pulse of \>100 beats/minute OR a pulse change of
    10-20 beats/minute above baseline with a change in position

> 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. It is not necessary to complete a
> workup on every patient, and not all of those who would benefit from a
> workup require comprehensive testing. It is important to define the
> level of workup that is appropriate for each patient and to consider
> non-interventional approaches.
>
> If a patient has a living will or other advance directive specifying
> that no artificial hydration or nutrition be administered, clinicians
> should discuss with the patient and others involved in the patient\'s
> welfare whether a workup should proceed. If a medical workup is not
> performed, the reasons for this decision should be clearly documented
> in the patient\'s medical record.
>
> **Step 4**
>
> **Perform pertinent additional assessment as needed**. If dehydration
> or a fluid/electrolyte imbalance is identified or suspected and a
> medical workup is considered appropriate, the next step is to carry
> out additional assessment sufficient to define the nature of the
> problem, clarify its severity (see \"Identifying the Nature of a
> Fluid/Electrolyte Imbalance\" below), and identify relevant causes
> (see \"Categories of Causes of Fluid/Electrolyte Imbalance\" below).
> Generally, the workup should enable an accurate diagnosis to be made
> and relevant interventions to be identified. In some cases, however,
> the workup may be limited by the patient\'s condition and ability to
> cooperate in the assessment. Other facility staff should assess
> environmental and other factors that may be causing or contributing to
> the problem or risk.
>
> The **medical history** should include:

-   A review of existing diagnoses and conditions that may be causing or
    contributing to dehydration

-   A review of dehydration risks, signs, and symptoms, such as
    lightheadedness or altered mental status, and significant changes in
    fluid intake and output and in usual body weight

-   A review of current medications

-   A review of any orders such as nonessential fluid restrictions that
    may affect hydration status

-   A review of recent bowel history

-   Additional information from the patient\'s family members and from
    other members of the interdisciplinary health care team, if
    indicated, which may supplement data already collected

> The **physical examination** should include:

-   Vital signs (pulse rate, respiratory rate, body temperature, weight)

-   Orthostatic blood pressure (see \"Blood Pressure, Pulse, and
    Dehydration\" below)

-   Evaluation of any significant swallowing difficulty

> **Identifying the Nature of a Fluid/Electrolyte Imbalance**

-   ***Primarily fluid deficit (hypertonic dehydration)***: More water
    than salt is being lost (e.g., because of excess diuretic use,
    infections, fever, or diabetes insipidus).

-   ***Primarily sodium deficit (hypotonic dehydration)***: More salt
    than water is being lost (e.g., because of diuretics or salt-wasting
    renal disease).

-   ***Combined water and sodium deficit (isotonic dehydration)***: Both
    salt and water are lost proportionately (e.g., because of diuretics
    or severe or prolonged diarrhea or vomiting).

-   ***Excess water retention or intake***: Water is retained
    inappropriately (e.g., because of syndrome of inappropriate
    antidiuretic hormone secretion.) or excess free water is ingested to
    correct isotonic fluid loss.

-   ***Excess water and salt retention***: Both water and salt are
    retained inappropriately (e.g., because of heart or liver failure).

> **Categories of Causes of Fluid/Electrolyte Imbalance**

-   Inadequate intake (e.g., dysphagia, dementia, delirium)

-   Excessive loss (e.g., diarrhea, fever, diuretics)

-   Impairment of the body\'s ability to balance and manage
    fluids/electrolytes (e.g., renal failure; heart failure;
    cerebrovascular accident; syndrome of inappropriate antidiuretic
    hormone secretion; diuretics, angiotensin-converting enzyme (ACE)
    inhibitors, and other medications)

-   Combinations of the above

> **Blood Pressure, Pulse, and Dehydration**
>
> Warning signs in blood pressure and pulse measurements that suggest
> dehydration may include the following:

-   Decline in systolic blood pressure of [\>]{.underline}20 mm Hg when
    blood pressure is taken (for example) sequentially in lying,
    sitting, and standing positions (at 30 seconds and at 1, 2, and 3
    minutes)

-   Pulse increase of 10-20 beats/minute from baseline with a position
    change

-   Pulse of [\>]{.underline}100 beats/minute

> Certain laboratory tests (see \"Laboratory Tests That May Help to
> Characterize the Nature and Severity of Fluid/Electrolyte Imbalance\"
> below) may help to characterize the nature and the severity of a
> fluid/electrolyte imbalance, especially when high or low sodium has
> been identified or is suspected.
>
> If identification of the causes of dehydration or fluid/electrolyte
> imbalance is appropriate, it should proceed until:

-   a cause is identified or

-   it is determined that a cause cannot be identified OR that the cause
    cannot or should not be treated OR that identifying a cause would
    not change the treatment or ultimate outcome.

> **Laboratory Tests That May Help to Characterize the Nature and
> Severity of Fluid/Electrolyte Imbalance**

-   ***Highly recommended***: sodium, potassium, chloride, bicarbonate
    (electrolytes), blood urea nitrogen (BUN), creatinine

-   ***Recommended***: calcium, glucose, hemoglobin, hematocrit, serum
    osmolality

-   ***Optional***: urinalysis, urine sodium, urine osmolality

> To facilitate proper patient management, categorize the causes or, at
> a minimum, identify likely categories of causes of the patient\'s
> dehydration or other fluid/electrolyte imbalance. Document this
> information in the patient\'s medical record. Often, several
> categories of causes will occur simultaneously (e.g., increased loss
> of salt and water caused by diuretics, which leads to decreased fluid
> intake as a result of lethargy and confusion). Typically, several
> causes must be addressed simultaneously to correct the problem. For
> example, it may not be enough to give intravenous fluids to a patient
> who is continuing to lose excessive salt and water while remaining on
> diuretics or angiotensin-converting enzyme (ACE) inhibitors. Consider,
> in addition, decreasing or eliminating any medications that may be
> contributing to the patient\'s fluid loss.
>
> **Step 5**
>
> **Evaluate and document findings related to dehydration or
> fluid/electrolyte imbalance**. Summarize the nature, severity, and
> causes of the patient\'s fluid/electrolyte imbalance or risk and
> assess the impact on his or her functioning and quality of life. The
> clinician\'s findings should describe the diagnoses or conditions that
> are contributing to the patient\'s current fluid/electrolyte status or
> explain why these could not be established or why finding them would
> not likely change the approach or the ultimate results. Refer to the
> original guideline document for examples of documentation related to
> varieties of fluid/electrolyte imbalance.

III. **Treatment**

> **Step 6**
>
> **Are the causes and consequences of the patient\'s dehydration or
> fluid/electrolyte imbalance to be treated?** If it is decided to treat
> the causes of the patient\'s dehydration or fluid/electrolyte
> imbalance or to intervene to correct or prevent a fluid deficit or
> electrolyte imbalance, proceed to Step 7. If the cause of the
> patient\'s dehydration is not clear, continue to look for that cause
> while providing appropriate support and symptomatic management. If it
> is decided not to treat or intervene because the patient has a
> terminal or end-stage condition or because the patient or family has
> requested no intervention, or for any other valid clinical reason,
> document the reasons for this decision in the patient\'s medical
> record.
>
> **Step 7**
>
> **Develop and implement an interdisciplinary care plan**. The
> interdisciplinary team involved in managing fluid/electrolyte balance
> should include certified nursing assistants (CNAs), registered or
> licensed nurses, the physician, and dietary staff. Other clinicians
> who may be involved as needed include the consultant pharmacist,
> psychiatrist, psychologist, speech pathologist, social worker, and
> physical and occupational therapists.
>
> The physician and other members of the care team should discuss the
> findings of the assessment and, in concert with the patient and the
> patient\'s family or advocate, develop a plan aimed at restoring and
> maintaining adequate fluid/electrolyte balance. The plan should:

-   Treat causes and risks where appropriate

-   Address the patient\'s specific deficits and imbalances

-   Provide overall patient support

> **Step 8**
>
> **Prescribe appropriate treatments for the patient\'s dehydration or
> fluid/electrolyte imbalance**. Factors influencing the choice of
> treatment include:

-   The patient\'s underlying diagnoses or conditions that are causing
    or contributing to dehydration or fluid/electrolyte imbalance

-   The patient\'s risks or potential complications that may influence
    the type and speed of rehydration efforts

-   The patient\'s preferences as expressed by the patient or by family
    members or other advocates

-   Availability of experienced providers and staff to administer
    treatments and monitor the patient\'s status

> In managing fluid and electrolyte imbalance, it is important to
> understand how a chosen treatment course relates to the nature,
> causes, and severity of the problem. Ensure that decisions to use or
> not use potential treatment options (taking into account the
> patient\'s overall state of health, patient or advocate preferences,
> and any existing advanced directives) are discussed with the patient
> and the patient\'s family or advocate and documented in the medical
> record.
>
> **Treating causes and risks**. Identify possible treatments for the
> patient\'s diagnoses or conditions that may be affecting
> fluid/electrolyte balance or causing dehydration, as in the following
> examples:

-   Treat the pneumonia or heart failure causing symptoms of lethargy
    and confusion that have resulted in decreased fluid intake.

-   Stop or reduce the dosage of the antibiotics that has caused
    diarrhea, which has led to excessive fluid loss.

-   Stop or reduce the dosage of diuretics that has caused excessive
    diuresis and/or the ACE inhibitors that may have worsened the
    patient\'s sodium imbalance after diuretics caused excessive sodium
    loss.

> **Addressing deficits and imbalances**. Replace approximately half of
> a fluid deficit within the first 24 hours. Replace the remaining
> deficit within the next 48-72 hours. This time frame may vary
> depending on the patient\'s symptoms and the risk of side effects
> caused by the rate of rehydration. A fluid-deficit calculation tool
> can be found in Table 13 of the original guideline document. Monitor
> the patient\'s response and adjust interventions accordingly.
>
> Assess the patient\'s overall stability, paying particular attention
> to pulse and blood pressure. As a rule, treat hypertonic dehydration
> (water loss exceeding sodium loss, resulting in elevated sodium) with
> normal saline if the patient is hemodynamically unstable and with
> half-normal saline if the patient is hemodynamically stable. Treat
> hypotonic dehydration (sodium loss exceeding water loss, resulting in
> low sodium) with normal saline whether the patient is hemodynamically
> stable or unstable. Exceptions may be necessary in specific patient
> circumstances. For example, rapid infusion of normal saline may cause
> fluid volume overload in a patient with a markedly decreased cardiac
> ejection fraction.
>
> Ensure that treatment is based on an understanding of the underlying
> causes of the problem. For example, one of two approaches to treating
> a clinically significant low sodium level (generally, \<125 mEq/L) may
> be appropriate depending on the cause of the problem. If the cause is
> salt and water loss, administration of fluids and salt may be
> indicated. If the cause is excessive water intake or retention, fluid
> restriction may be necessary. Administration of excessive plain
> (solute-free) fluids to a patient who already has water overload or
> low sodium can exacerbate the imbalance and make related symptoms
> worse.
>
> **Choosing routes of administration**. Unless contraindicated and
> provided that the patient can swallow safely, offer fluids by mouth
> frequently as well as assistance with drinking and eating as
> necessary. Packaged oral rehydration solutions can be very effective
> for the relatively stable patient with fluid/electrolyte imbalance who
> is able to drink.
>
> A patient who is unstable because of an underlying fluid volume
> deficit will probably require intravenous rehydration. Hospitalization
> should be considered unless ruled out in an advance directive or
> unless the deficit can be steadily corrected while the patient is
> closely monitored in the long-term care facility.
>
> Consider hypodermoclysis (clysis), the subcutaneous administration of
> replacement fluids, if this option is available and if intravenous
> hydration is not essential, difficult to administer, or not desired.
> Subcutaneously administered fluids have been shown to be absorbed
> effectively and can be used to achieve rehydration. However, this
> approach cannot be used to deliver medications or supplemental
> potassium. The use of clysis may satisfy a family that wishes an
> end-stage or dying patient to receive hydration while avoiding the use
> of intravenous lines or other invasive measures.
>
> Consider a nasogastric or gastrostomy tube if other means of adequate
> hydration are not feasible. However, take all of the patient\'s
> circumstances into account before proceeding with such measures.
> Hydration by means of a tube may be inappropriate in circumstances
> such as that of a severely demented patient with a very poor overall
> prognosis who cannot swallow. Although intravenous and feeding-tube
> infusions are valuable in managing responsive conditions, patients
> with irreversible diseases or end-stage conditions usually experience
> multisystem failures that prevent effective maintenance of
> fluid/electrolyte balance even when fluids are provided artificially.
> If the patient or substitute decision maker elects not to receive
> treatment, document the reasons for withholding treatment.
>
> **Providing general support**. Review existing diet orders and remove
> any nonessential fluid and salt restrictions. Be aware that diets of
> altered consistency (e.g., pureed foods and thickened liquids) may be
> so unpalatable that they result in decreased patient intake. Such
> diets are sometimes ordered because of a swallowing abnormality or
> symptom, but the risk of aspiration may be outweighed by the risk of
> weight loss and dehydration. The physician must make a rational
> assessment of relative risks and benefits when coexisting problems
> suggest incompatible interventions.
>
> If a fluid/electrolyte imbalance is causing lethargy or delirium,
> provide additional help with activities of daily living until the
> acute problem resolves. If possible, a member of the health care team
> should discuss the diagnosis and treatment recommendations with the
> patient and the patient\'s family or advocate.

IV. **Monitoring**

> Patients with dehydration or fluid/electrolyte imbalance must be
> reassessed regularly. Certified nursing assistants (CNAs) and other
> direct caregivers who spend the most time with patients from day to
> day are well positioned to monitor hydration status. They should be
> encouraged and trained to do so and to report patient activities or
> statements that suggest a hydration problem. Every member of the
> interdisciplinary care team should be vigilant in providing patients
> with fluids.
>
> Review all patients\' hydration status periodically. Patients who have
> recently had a fluid/electrolyte imbalance or who are at higher risk
> for fluid/electrolyte imbalance should be reviewed more frequently, as
> indicated by their clinical condition.
>
> **Step 9**
>
> **Monitor the patient\'s response to treatment and adjust
> interventions as needed**. Close daily monitoring is essential while a
> patient\'s dehydration or fluid/electrolyte imbalance is being
> actively corrected (see \"Monitoring Acute Rehydration\" below).
> Ongoing monitoring of patients\' fluid/electrolyte status should
> include checking for signs and symptoms that may indicate dehydration
> (see \"Step 1\" above). Also check the patient\'s clinical and
> emotional responses to treatment.
>
> **Monitoring Acute Rehydration**

-   Check vital signs, weight, and, if feasible, orthostatic blood
    pressure.

-   Assess adequacy of fluid intake, being alert for signs of
    overhydration, such as progressive edema or rapid weight gain
    ([\>]{.underline}0.5 kg/day, or [\>]{.underline}1 lb/day ).

-   Repeat pertinent laboratory tests as clinically indicated to ensure
    that fluid/electrolyte balance is being restored effectively or
    until it is concluded that the desired fluid/electrolyte balance
    cannot be restored.

-   Check patients receiving intravenous fluids at least once per shift
    for the first 24-48 hours. In most cases, notify the clinician of
    the patient\'s status within the first 24 hours.

> The value of monitoring fluid intake and output is limited. Intake
> monitoring may be more accurate in individuals who are completely
> dependent on staff for fluid intake. Output is often difficult to
> document accurately. Alternative monitoring indicators may include
> body weight, laboratory values (e.g., BUN/creatinine ratio, sodium,
> osmolality), and observations of a decreased volume of concentrated
> urine. Any clinically appropriate monitoring indicators that a
> facility chooses to use are reasonable provided they are used
> systematically.
>
> When checking laboratory values, focus on trends. For example, a
> gradually increasing or decreasing sodium level deserves close
> attention and repeat monitoring, whereas a sodium level that is high
> or low normal but stable may be clinically insignificant.
>
> **Step 10**
>
> **Monitor the status and treatment of underlying causes of dehydration
> and review relevant medications**. Continue to adjust or stop
> medications that may affect fluid intake, fluid balance, appetite,
> thirst, or level of consciousness as indicated until hydration status
> is stable or improving and the risk of further imbalances is
> minimized. If the underlying causes are not readily treatable,
> document why the problem cannot be treated or why the treatment is not
> working.
>
> **Step 11**
>
> **Reassess and modify the interdisciplinary care plan as indicated**.
> Modify the care plan to reflect decisions that are made to change or
> discontinue any treatments or to continue cause-specific treatments.

#### CLINICAL ALGORITHM(S)

An algorithm is provided for the recognition, assessment, treatment, and
monitoring of fluid and electrolyte imbalances.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The guideline was developed by an interdisciplinary workgroup using a
process that combined evidence- and consensus-based thinking.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

By implementing the steps described in this guideline, health care
providers in long-term care facilities can meet the needs of patients
and their families, advocates, and policymakers for adequate and
compassionate management of hydration and fluid/electrolyte balance.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This clinical practice guideline is provided for discussion and
educational purposes only and should not be used or in any way relied
upon without consultation with and supervision of a qualified physician
based on the case history and medical condition of a particular patient.
The American Medical Directors Association, its heirs, executors,
administrators, successors, and assigns hereby disclaim any and all
liability for damages of whatever kind resulting from the use, negligent
or otherwise, of this clinical practice guideline.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The implementation of this clinical practice guideline (CPG) is outlined
in four phases. Each phase presents a series of steps, which should be
carried out in the process of implementing the practices presented in
this guideline. Each phase is summarized below.

I.  **Recognition**

    -   Define the area of improvement and determine if there is a CPG
        available for the defined area. Then evaluate the pertinence and
        feasibility of implementing the CPG.

II. **Assessment**

    -   Define the functions necessary for implementation and then
        educate and train staff. Assess and document performance and
        outcome indicators and then develop a system to measure
        outcomes.

III. **Implementation**

     -   Identify and document how each step of the CPG will be carried
         out and develop an implementation timetable.

     -   Identify individual responsible for each step of the CPG.

     -   Identify support systems that impact the direct care.

     -   Educate and train appropriate individuals in specific CPG
         implementation and then implement the CPG.

IV. **Monitoring**

    -   Evaluate performance based on relevant indicators and identify
        areas for improvement.

    -   Evaluate the predefined performance measures and obtain and
        provide feedback.

Appendix I of the original guideline document provides a
quality-improvement monitoring instrument that contains indicators for
reviewing hydration status.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

End of Life Care\
Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Medical Directors Association (AMDA). Dehydration and fluid
maintenance. Columbia (MD): American Medical Directors Association
(AMDA); 2001. 28 p. \[15 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2001 (reviewed 2006)

#### GUIDELINE DEVELOPER(S)

American Medical Directors Association - Professional Association

#### GUIDELINE DEVELOPER COMMENT

Organizational participants included:

-   American Association of Homes and Services for the Aging

-   American College of Health Care Administrators

-   American Society of Consultant Pharmacists

-   Center for Health Information

-   National Association of Directors of Nursing Administration in
    Long-Term Care

-   National Association of Geriatric Nursing Assistants

-   National Conference of Gerontological Nurse Practitioners

#### SOURCE(S) OF FUNDING

Corporate supporters of this guideline include Bristol Meyers Squibb and
Ross Products Division Abbott Laboratories.

#### GUIDELINE COMMITTEE

Steering Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Larry W. Lawhorne, MD, CMD, Project Chair

Steven Levenson, MD, CMD, Chair Clinical Practice Committee

*Steering Committee Members*: Donna Brickley, RN; Lisa Cantrell, RN;
Charles Cefalu, MD, MS; Joseph Gruber, RPh, FASCP, CGP; Larry Lawhorne,
MD, CMD; Steven Levenson, MD, CMD; Susan Levy, MD, CMD; Betty
MacLaughlin-Fransden, RN, NHA; Harlan Martin, RPh, CCP, FASCP; Geri
Mendelson, RN, CNAA, M.Ed, NHA, MA; Evvie F. Munley; Jonathan Musher,
MD, CMD; Judith Passerini, CNHA, CAS, Fellow; Mary Pat Rapp, MSN, RN;
William Simonson, Pharm.D, FASCP, CGP

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline was reviewed by the
original Steering Committee and is still considered to be current as of
Jan 2007. This review involved new literature searches of electronic
databases followed by expert committee review of new evidence that has
emerged since the original publication date.

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print copies: Available from the American Medical Directors Association,
10480 Little Patuxent Pkwy, Suite 760, Columbia, MD 21044. Telephone:
(800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site:
[www.amda.com](http://www.amda.com/)

#### AVAILABILITY OF COMPANION DOCUMENTS

The following companion document is available:

-   Guideline implementation: clinical practice guidelines. Columbia,
    MD: American Medical Directors Association, 1998, 28 p.

Electronic copies: Not available at this time.

Print and CDROM copies: Available from the American Medical Directors
Association, 10480 Little Patuxent Pkwy, Suite 760, Columbia, MD 21044.
Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web
site: [www.amda.com](http://www.amda.com/)

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on December 3, 2002. The information
was verified by the guideline developer on December 10, 2002.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. For more information,
please contact the American Medical Directors Association (AMDA) at
(800) 876-2632.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008