VOL: 102, ISSUE: 12, PAGE NO: 55
Rachel Gilbert, RN, DipHE, is continence nurse specialist, Kingston Primary Care Trust Older People’s Services, Tolworth Hospital, Surrey
Fluid intake is vital for good general health (Clark, 2003) and particularly to maintain bladder and bowel health, since bladder health is linked to an adequate daily urine output which, in turn, is influenced by fluid intake.
Low fluid intake can contribute to constipation (Addison, 2001; Bush, 2000). Conversely, excessive intake may increase continence problems and voiding activity (Swithinbank et al, 2005; Gray, 2003).
Maintaining an appropriate intake is therefore important for patients with bladder or bowel dysfunction (Addison, 1999).
Some authors have identified that long-term care settings can influence the amount of fluid consumed (Kayser-Jones et al, 1999; Burns, 1992). Since older people are particularly vulnerable to inadequate intake (Nazarko, 2004; 2000) a campaign has been initiated to improve the fluid intake among residents of care homes (English Community Care Association, 2005). Ensuring patients have an appropriate fluid intake has many implications for nursing practice. Some means of ensuring appropriate fluid intake are shown in (Box 1).
The Department of Health (2000) requires that patients with bladder and bowel problems are given general advice about healthy living, which should include information about drinking appropriate fluids in sufficient quantities. The giving of advice on fluids is therefore a crucial nursing role that has the potential to contribute greatly to reducing continence problems, bladder infections and constipation and to promoting general wellbeing (Burns, 1992).
Some older people, or those who have frequency problems, may restrict fluid intake in the belief that this will reduce their problem. In fact, fluid restriction can exacerbate symptoms of urgency, frequency and incontinence, as concentrated urine can irritate the bladder and, over time, poor urine volumes may result in the bladder needing to empty when it is only partially full (Addison, 1999).
Gray (2003) cites research suggesting that the reduced volumes, more concentrated urine and less frequent bladder emptying associated with inadequate intake may also increase the risk of urine infection and bladder cancer.
Appropriate fluid intake
The general consensus is that the average healthy adult needs a daily fluid intake of 1.5L to replace natural loss, but the ideal amount varies between individuals (Addison, 1999). This may depend on several factors, which include illness and disease, age, weight, activity level and external factors such as hot weather (Gray, 2003). The type and timing of the fluid taken can also have an effect on bladder and bowel function.
Caffeine may have a stimulant effect on the bladder (Dallosso et al, 2003) and it is found in coffee, tea, drinking chocolate, cola, and other carbonated drinks. In fact, carbonated drinks are established as a causal factor of bladder over-activity and stress incontinence, even if they are decaffeinated (Dallosso et al, 2003). It is suggested that this is due to high sugar levels, sweeteners and chemicals and not necessarily to any caffeine present (Dallosso et al, 2003).
Caffeine may exacerbate frequency, urgency and nocturnal voiding activity (Addison, 2000). It is a mild diuretic and can increase the amount of urine produced if it is consumed in quantities exceeding 250-300mg per day - the equivalent of three to five cups of coffee, five to eight cups of tea or five to six cans of caffeinated soft drinks (Clark, 2003). Although it does not stimulate gut motility, particularly if the individual is tolerant to it (Addison, 1999), it may increase the water content of the stool and make it loose.
Caffeine affects people in different ways (Joseph 2001), and there is conflicting evidence on the benefits of reducing intake (Wells, 2005). However, because many older people tend to have a higher consumption of tea and coffee, caffeine-containing drinks may form the majority of their fluid intake, and it may be helpful for them to reduce this.
Coffee, whether decaffeinated or not, can stimulate the bowel within minutes of its being consumed, and its laxative effect lasts up to 90 minutes (Addison, 2000; Rao et al, 1998). Patients with constipation may therefore find coffee useful in promoting regular bowel-emptying (Rao et al, 1998). However, those with irritable bowel syndrome may find coffee exacerbates their problem (Brown et al, 1990), and since excess consumption may cause loose stools and urgency, these patients, and those with loose stools or faecal incontinence, may be advised to avoid it (Rao et al, 1998).
Alcoholic drinks can be counted as part of the daily fluid intake. These may help some patients to boost their fluid intake (Nazarko, 2000), although they should be advised to stay within recommended consumption limits of three to four units a day for men and two to three units for women (Department of Health, 2005).
However, because alcohol has a diuretic effect it may increase urine production. This, combined with its sedative effects, may lead to episodes of incontinence. More specifically, white wine can increase wind production and beer can have a laxative effect (Digestive Disorders Foundation, 2005a, b).
These are an increasingly popular alternative to tea and coffee, but they are not suitable for everyone, as they have a range of different properties. For example:
- Nettle can have a diuretic effect;
- Chamomile may relax bladder spasm;
- Ginger and peppermint may relieve wind;
- Liquorice may relieve constipation;
- Rosehip, orange and rhubarb should be avoided by people with loose stools (Addison, 1999).
As with all herbal medicines, patients should seek further information before taking herbal teas and excessive intake should be avoided (Medicines and Healthcare products Regulatory Agency, 2005).
Fruit Juices are generally good for health but some specific properties should be noted;
- Some studies suggest that drinking 200ml of cranberry juice twice each day may help to prevent recurrent bladder infections or cystitis (Drugs and Therapeutics Bulletin, 2005). However, its definitive mode of action has not been established and the evidence for use is still inconclusive (Drugs and Therapeutics Bulletin, 2005). It should be avoided by patients taking warfarin as it may increase the drug’s anticoagulant effect (MHRA, 2004);
- Grapefruit juice should be avoided with some medications; for example, antihistamines, statins and calcium channel blockers, so it is important to consult the leaflets supplied with all medications;
- Orange juice is rich in vitamin C, but excessive consumption can cause diarrhoea;
- High intake of acidic juices may exacerbate the symptoms of rheumatoid arthritis, gastric irritation and interstitial cystitis.
The timing of fluid consumption can affect patients’ ability to maintain continence and when they experience symptoms of frequency, urgency and nocturnal voiding. While irregular intake is best avoided, Addison (1999) reports that patients with bladder problems often find it helpful to time their fluid intake to fit in with their lifestyle, even if this makes it difficult to maintain regular intake throughout the day. Furthermore, it is important that they are empowered to plan their recommended fluid intake around activities such as socialising or shopping. People with nocturnal voiding activity may find it helpful to reduce their fluid intake at least two hours before going to bed if they have already consumed their daily requirement (Addison, 1999).
Assessment is essential if the cause of bladder and bowel problems is to be addressed effectively (Benson, 2003). Reviewing a patient’s fluid intake and output is an important element of continence assessment and is a core nursing activity (Morrison, 2000).
When patients do have these problems, accurate recording of both intake and output is essential. Terms such as ‘up to toilet’ or ‘PUd ++’ do not constitute accurate measurement and should be avoided in favour of specific information. McConnell (2002) stresses that nurses must not delegate the monitoring task unless the person given the responsibility for recording intake and output understands its importance and relevance. However, Burns (1992) found that nurses failed to keep accurate records, and that patients’ fluid intake was significantly underestimated.
The aim of assessing fluid intake is to gain information on the amount, time and type of fluid consumed (Addison, 1999). This can be recorded using tools such as an intake and output chart (fluid balance chart) or a bladder diary. Observation should be made of patients’ urine: its colour, odour and specific gravity, and whether or not it tests positive to nitrites. Clinical signs of a urine infection and of dehydration and constipation should also be looked for:
- Urine infection - pyrexia, pain, uncharacteristic confusion;
- Dehydration - lethargy, headaches, dry mucous membranes and reduced skin elasticity, although Shepherd (2001) reports that this latter sign is less reliable in older people because of the ageing process;
- Constipation - passage of hard, dry stools, abdominal distension and discomfort.
Ensuring intake is appropriate
After the findings of the fluid assessment have been analysed, the nurse should provide advice that is appropriately tailored to address any problems with the patient’s fluid intake. The goal may be to increase or reduce intake or to alter the type or timing of consumption.
Involving patients in setting any goals with regard to fluid intake, and ensuring that they understand the rationale behind them, will help concordance. Enabling patients to take an active role in ongoing monitoring can also be helpful if they have the cognitive abilities to do so. Some patients find that recording data acts as a biofeedback tool, helping them to recognise, for example, that drinking large quantities of fluid during the evening or overnight increases the likelihood of their experiencing an increase in voiding activity or incontinence.
Fluid intake has an important role in maintaining bladder and bowel health and general wellbeing. Nurses must understand the effect of patients drinking both too much and too little fluid. This will enable them to complete an accurate assessment of fluid intake.
- This article has been double-blind peer-reviewed.
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