VOL: 98, ISSUE: 03, PAGE NO: 38
Josef Brown, BSc, RMN, RGN, DipHE, is nurse lecturer; Glenn Marland, BEd, RMN, MN, RNT, DipN, PGCRM, is senior lecturer, both at the School of Health Studies, Crichton University Campus, Dumfries
Meeting patients’ basic needs is an essential part of all health care, but mental health nurses have been criticised for failing to meet the physical requirements of vulnerable patients (Scottish Executive, 1999), for example, hydration. Older people are often dehydrated when they are admitted to hospital and their basic need for adequate fluid intake is not always met.
It is easy for healthy people to take hydration for granted, so the need to maintain adequate fluid intake may not always be uppermost in the minds of mental health nurses. When working with older people with mental illnesses, however, complacency in this regard can have devastating effects. The instinctive focus of acute mental health care on psychological factors can result in a blind spot when it comes to physical needs.
However, if physical health is not maintained the promotion of mental health may be compromised. A deliberate, conscious, consistent and systematic approach to assessment and treatment is vital. With this in mind, an initiative to improve hydration among older people with mental illness was introduced, with some encouraging results.
Dehydration is caused by an inadequate intake or excessive loss of fluid. Adults can become dehydrated in as little as 48 hours, depending on the individual and environmental factors. As humans age, the thirst response naturally decreases; the individual becomes accustomed to a lower fluid intake and the body adapts quickly, resulting in a reduced urge to quench the thirst (Watt, 1991).
People with an organic brain disease, such as Alzheimer’s, may have damaged osmoreceptors, which are situated in the hypothalamus region of the brain and are thought to regulate the body’s thirst mechanism (Watson, 1996). They may also have a degree of cognitive impairment which prevents them from satisfying their thirst or letting others know that they are thirsty.
Mental illnesses such as depression, psychosis, confused states, anxiety, disability and suicidal intent can all diminish fluid intake. The resulting dehydration may, in turn, lead to medical and mental health problems such as hypovolaemia, tachycardia, renal failure, disorientation and hallucinations, which can exacerbate the original dehydration. If there is a concurrent increase of fluid output through vomiting, diarrhoea, polyuria, excessive perspiration or blood loss, the consequences can be severe and even fatal (Alexander et al, 2000; Sansevero, 1997).
Background to the study
Water accounts for 45-75% of total bodyweight, depending on age, the individual and the percentage of body fat. The recommended daily fluid intake is:
- 2-3L for men;
- 1.5-2.5L for women;
- 1-2L for the over-65s (Alexander et al, 2000).
Only a 15-20% fluid loss is requires before death ensues (Beare and Myers, 1999).
A four-month investigation into patient hydration at one admission unit at the Carleton Clinic in Carlisle found that 65% of patients were clinically dehydrated on admission. Between November 2000 and February last year 23 people aged over 65 were examined for the signs and symptoms of dehydration on admission to the clinic. Of these, seven were found to be adequately hydrated, while the other 16, two of whom had been transferred from other hospitals, had some degree of dehydration.
These statistics revealed the need for action and vigorous strategies were therefore adopted to regain and maintain hydration
Like many other mental health units, comprehensive assessment tools and rating scales were available to evaluate mental illnesses and physical health problems but there was no consistent strategy for assessing and monitoring hydration, which has a range of symptoms (Box 1).
The following methods were used to assess patients for dehydration:
- Blood samples were analysed for urea and electrolyte levels;
- The skin was pinched to check elasticity;
- Mucous membranes were examined for dryness;
- Urine samples were tested for concentration;
- Patients were questioned about their fluid intake;
- All medications were analysed to assess start date, adherence, efficacy and requirements;
- Patients were asked whether they were constipated.
Where patients were found to be dehydrated, action was taken to rehydrate them. The process took two to three days.
To prevent dehydration, rehydrate and maintain adequate fluid intake, the following actions were taken:
- A water tower with a cooler was installed, which proved extremely popular;
- The kitchen was left open at all times and patients were encouraged to help themselves to drinks;
- A selection of beverages was made available to give patients a variety of choice;
- Visitors were encouraged to use these facilities to make themselves and patients a drink;
- Jugs of juice were placed on dining-room tables at meal times and topped up regularly;
- Small glasses were replaced by large easy-to-hold beakers;
- Patients who spent a lot of time in their rooms, for whatever reason, were given jugs of water at their bedside;
- Regular beverage rounds were organised.
Visitors were also encouraged to bring in beverages for patients and to take patients to the hospital cafe for a drink, but decaffeinated tea and coffee were recommended because caffeine is a natural diuretic. Staff were also encouraged to take patients to the cafe for a drink.
The dietitian was contacted and asked to talk to staff about the importance of hydration and how to ensure that it is maintained. A clinical nurse specialist was also invited to give a tutorial on the administration and monitoring of external fluids. The monitoring of fluids was standardised across the nursing team, and standardised fluid-balance sheets and care plans were introduced.
Standard blood tests for all new admissions now include urea and electrolyte screening, and any relevant information is passed to the patient’s key worker. Urea of +7-16mmol/L is considered mild dehydration, but is often easily rectified by encouraging and monitoring fluid intake.
Urea of +17-24mmol/L (moderate dehydration) is often rectified in the same way as mild dehydration, but with the addition of subcutaneous fluids.
Patients with urea of +24mmol/L are given intravenous fluids and may be transferred to a general hospital.
Staff have been shown how to help patients with drinks and are encouraged to sit with them, engage them in conversation, offer them a range of drinks and use modified drinking vessels where appropriate.
All patients’ medication is checked, and diuretics and aperients are reviewed. Social factors are examined to identify whether problems relating to dehydration existed before admission and, although this is difficult, attempts are made to correct these.
A range of benefits, both for patients and the clinic, were noted after the initiative. These include:
- The use of antibiotics reduced, indicating a drop in the incidence of infections and reduced pharmacy costs and time spent giving out drugs. It also lowered the chances of further dehydration through gastrointestinal upsets;
- Clinic stays were reduced, which meant that patients were discharged earlier while those awaiting admission to hospital were admitted more quickly and treated sooner;
- Staff had more contact time with patients, which led to more efficient assessment and better communication;
- Patients appeared to be more contented.
Further evaluation is required to relate these benefits conclusively to good hydration.
To identify and correct dehydration, which is an important contributor to poor mental and physical health, mental health nurses must not forget physical nursing care. A structured plan should be implemented to screen admissions and return dehydrated patients to a state of adequate hydration. Finally, nurses should evaluate their work critically and constructively. Prompt and effective assessment of this potential killer can radically improve both care and outcomes.