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Practice educator

Ensuring hydration

Reports have highlighted concerns that patients are not receiving enough fluids in hospital, but simple routine tasks present an ideal opportunity to tackle dehydration

In this article…

  • Why dehydration is an important issue
  • Opportunities to provide oral fluids on a medical ward
  • Signs and symptoms of dehydration

 

Wilson N, Best C (2011) Ensuring Hydration. Nursing Times; 107: 28, early online publication

Keywords: Hydration, Assessment, Teamworking

  • This article has been double-blind peer reviewed

5 key points

  • The recent focus on nutrition has meant that drinking adequate fluid is often not seen as important
  • Routine early identification of dehydration can improve outcomes for older people
  • Routine tasks can provide opportunities to observe or encourage patients to drink
  • Nurses should support other healthcare workers to recognise the importance of patients’ appropriate fluid intake
  • Initiatives to address dehydration, such as protected mealtimes, should complement existing practice

Some patients are experiencing difficulty in obtaining oral fluids while in hospital (Care Quality Commission, 2011). The CQC described one instance in which a doctor had to prescribe water because they were so concerned patients were not receiving sufficient fluid. This report highlights a great need to improve essential and fundamental aspects of care for the most vulnerable patients in hospital.

Over the past 15 years, the focus, both nationally and internationally, has been on improving the nutritional care of inpatients (British Association of Parenteral and Enteral Nutrition, 2011; Age UK, 2010; Department of Health and the Nutrition Summit Stakeholder Group, 2007). Initiatives such as the protected mealtimes scheme (Robinson, 2004) and red-tray systems (Bradley and Rees, 2003) have attempted to address problems of poor nutrition and hydration.

However, the focus in many cases has been on “nutrition” while drinking adequate fluid is often not seen as an important issue. The National Patient Safety Agency, supported by the Royal College of Nursing, has attempted to raise awareness of the importance of hydration for all patients with their Water for Health hydration toolkit (NPSA and RCN, 2007). This was intended to push hydration to the front of clinical practice but there is little evidence to support the success of such campaigns.

Recently, the issue of hydration has been raised again by the National Association of Care Catering, which launched the first Dehydration in Older People Awareness Week and produced a Tool Box Talk kit. Unfortunately, publicity of this initiative was fairly low key in terms of nursing awareness. So is this a missed opportunity?

Why dehydration is important

Dehydration is one of the most common fluid and electrolyte imbalances in older adults (Hodgkinson et al, 2003). Any reduction in fluid consumption can affect bowel function, urinary output and skin integrity (Benelem, 2010). If mild dehydration is not recognised or is left uncorrected, the effects can be serious and
sometimes result in death (Begum and Johnson, 2009).

Fundamental skills

Identifying dehydration relies on good assessment skills. Nurses have the appropriate skills to identify the problem and plan timely and appropriate care that may prevent the need for invasive fluid therapy (Webber, 2009). These fundamental nursing skills taught in training are all too easily lost once working in a busy clinical environment (Kalisch, 2009). They should be embedded in everyday practice and embrace many of the concepts connected with nursing models, for example those of Roper et al (2000), which examine the essential activities of daily living. 

Caring can present a number of opportunities for nurses to continually assess, plan, implement and revaluate the effectiveness of care. This does not come solely from completing written assessments or formulating computer-generated plans; it can be undertaken while nurses carry out routine activities such as personal care, medicine administration, physiological observations and dressing changes. These can be opportunities to observe or encourage patients to take fluids.

Nurses need to identify and address hydration needs using a variety of initiatives including screening, protected mealtimes, red trays and red jugs. These should be used to support practice, rather than seen as replacements for a common-sense approach to care.

The most commonly cited amount of fluid an individual should drink per day is 2L. However, there have been numerous suggestions about what should be an adequate fluid intake; these range from 1.5-3L per day (Scales and Pilsworth, 2008; NPSA and RCN, 2007). This variation depends on an individual’s height, weight and level
of activity, as well as their surrounding temperature and fluid losses (Hodgkinson et al, 2003).

Wards are notoriously warm and patients are in an unfamiliar environment over which they have little control; they are often reliant on others to provide them with fluid or assistance to drink. Add that to the fact that they may well be experiencing some of the symptoms of dehydration (highlighted in Box 1), and it is clear to see why the need to consider this fluctuation in fluid requirements has never been more important.

Box 1. Identifying dehydration

Using their observational skills, nurses may be able to spot that a patient’s hydration needs are at risk or not being met as they may display some of the following:

  • Dry mouth and lips
  • Dry, sunken eyes
  • Fragile, dry skin
  • Difficulty holding a cup/dexterity problems
  • Thirst
  • Headache
  • Tiredness
  • Feeling dizzy
  • Speech difficulties
  • Disorientation/confusion
  • Passing small amounts of dark-coloured concentrated urine infrequently
  • Constipated stools/difficultly passing or absence of bowel motions
  • Hypotension
  • Tachycardia

When assessing for dehydration, nurses need to consider whether patients are experiencing any of the following:

  • High output stomas/fistula
  • Pyrexia
  • Sudden weight loss
  • Oedema
  • Ascites
  • Diarrhoea
  • Coughing, choking or swallowing difficulties
  • Abnormal blood biochemical markers

Box 2 gives an insight into opportunities to provide fluids when caring for patients on a busy medical ward. Although nurses are often juggling a number of priorities, teamworking with healthcare assistants, student nurses, housekeepers and ward clerks can ensure effective delivery of care to the most vulnerable patients.

Box 2. Opportunities to provide fluids

Handover Ensure nutrition, hydration and elimination needs are part of handover discussions so patients at risk can be highlighted.

Organisation of care Walk around the patients with the support staff, such as your healthcare assistant or student nurse, working with you. Highlight patients who are particularly vulnerable and ensure fluid balance or food intake charts are available for completion.

Breakfast This is a great opportunity to communicate with patients and observe them eating breakfast. Provide encouragement regarding both nutrition and hydration.

Personal care Any patients who require support with washing and dressing can be observed for dry skin and mouth, sunken eyes and lethargy, which may indicate poor hydration.

Medicine round Observe patients taking their medication. Provide positive reinforcement to encourage them to take their medicines with adequate fluid or food. Document fluid intake. Prepare
and administer intravenous medications and use this opportunity to focus on patients who may have, for example, infections or acute illness.  Encourage them to consume more fluid to support recovery.

Patient observations This is an opportunity to record vital signs that may indicate reduced hydration, for example hypotension or tachycardia. If support staff are recording observations, they should feed back any abnormal readings they find. 

Communicating with other staff Liaise with HCAs or student nurses to share and discuss initial observations of patients and re-evaluate their care, agreeing a continued or modified action plan.

Drinks Rather than one member of staff undertaking the drinks round, a member from each team should attempt to carry this out, as patients may require modified consistency fluids or support with consuming fluid. Patients at risk should be encouraged to continue to consume fluid, with support from healthcare workers. 

Preparing for lunchtime Patients should be encouraged to prepare for mealtimes, and offered help to use the toilet facilities and to wash their hands. Protected mealtimes should be initiated 15 minutes before food and drink is served, non-urgent activities should be minimised, visiting should be kept to those who wish to support patients with eating and drinking, and all staff should focus on food and fluid service.

Midday medicine round or handover Medicine rounds should be undertaken while the other team member hands over to the afternoon staff, remembering to embed the key components of nutrition, hydration and elimination within the handover. Fluid balance charts should be checked for accurate recording. Fresh water should be given out by the support staff for the afternoon period.

Conclusion

While ensuring adequate nutrition is important and reflected in strategic policy, the need to ensure adequate hydration may have been underestimated. Dehydration can rapidly lead to serious physiological problems and, when left untreated, result in the death of patients in our care. It is essential that with all the competing and changing demands in nursing, we seize opportunities to work differently and efficiently so patients receive the essential essence of care they require.

Neil Wilson is senior lecturer, adult nursing,  Manchester Metropolitan University, and secretary for the National Nurses Nutrition Group (NNNG); Carolyn Best is nutrition nurse specialist, Winchester and Eastleigh Healthcare Trust, and communications officer for the NNNG

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