Nursing Manual

Fatal Four Topic: Dehydration

1. Immobility or physical limitations where individuals cannot access fluids independently.
   
   
2. Dysphagia or discoordination of swallow mechanisms with refusal of fluids in an attempt to protect their airway.
   
   
3. Suppression of thirst mechanism so individuals do not recognize when they are thirsty.
   
   
4. Speech/communication limitations preventing individuals from effectively requesting something to drink when they are thirsty.
   
   
5. Medical conditions where fluid loss can potentially cause dehydration if not monitored and treated appropriately, i.e. kidney disease, altered ADH levels, diabetes mellitus, and diabetes insipidus.
   
   
6. Cerebral palsy or other medical conditions where poor oral control is exhibited and the individual loses body fluid through drooling excessively.
   
   
7. Medications that affect body fluid balance.
   
   
8. Marginal fluid intake.
   
   

• Physician has written the diagnosis.
  
  
• Hospitalization or outpatient treatment with intravenous fluids for dehydration.
  
  
• Person takes a medication which affects the body's fluids such as a diuretic.
  
  
• Person has a history of ongoing difficulty with drinking fluids (refuses, spillage, etc.).
  
  
• Physician orders a minimum amount of fluid each day and staff is monitoring fluid intake.
  
  
• Person cannot independently access fluids or communicate to staff when they are thirsty.
  
  
• Person urinates less than usual or more than usual.
  
  
• Has a protocol for dehydration.
  
  
• No one is reviewing information being collected on fluid intake.
  
  
• Weight record reflects a rapid weight loss.
  
  
• Frequent history of vomiting/diarrhea.
  
  
• Individual has an ileostomy.
  
  

• Elevated B.U.N.
  
  
• Hypernatremia (high sodium)
  
  
• Elevated hematocrit
  
  
• Toxic levels of medications, (i.e., antiepileptic drugs, lithium)
  
  
• Elevated urine specific gravity
  
  
• Urine sodium and potassium increases and urine pH decreases
  
  

1. Circulatory
   • Fast heart rate
   • Low blood pressure
   • Kidney
   • Decreased urine output
   • Dark concentrated urine
2. Skin
   • Dry
   • Less elastic
   • Sticky mucous in mouth
   • Dry lips
   • Warm to touch
3. Neurological
   • Dizziness
   • Weakness
   • Confusion
   • Decreased level of alertness
   • Seizure
   • Coma
4. Gastrointestinal
   • Decreased or hyperactive bowel tones
   • Distended, firm abdomen
5. Psychosocial
   • Transition (e.g., new staff, or person is in a new home) can interfere with fluid intake.
   • Depression can lead to decreased fluid seeking.

• Reports about poor fluid intake, infrequent or excessive urination, fevers, diarrhea, or vomiting that does not resolve in a timely manner.
• Interview staff about change in level of alertness, awareness, functioning, or daily activities.

• Is based on a professional assessment of the person's health care:
  
  
  • Problems
  • Support needs
• Identifies:
  • Measurable and appropriate goals
  • Specific interventions
  • By whom and how frequently the data will be monitored
• Refers to an individualized dehydration protocol that contains:
  • Risk factors for dehydration specific to the person
  • Prevention strategies
  • Signs and symptoms of dehydration
  • Interventions specific to the person.
  • Reminders for the staff to call 911 if they believe the person appears gravely ill or they are concerned about their immediate health and safety

• Person exhibits strong peripheral pulses and normal blood pressure
  
• Person's laboratory values for blood and urine remain within normal limits
  
• Person's weight does not fluctuate rapidly
  
• Person's fluid intake is adequate
  
• Medication levels remain within range as set by physician

• Physician, dietician, or nursing recommendations for daily fluid requirements
  
  
• Monitoring, recording of daily fluid intake and output
  
  
• Adjustment of fluids (increasing intake if vomiting, diarrhea or increased sweating)
  
  
• Creative ways of presenting acceptable fluids to the person
  
  
• Guidelines to staff on when to be concerned and how to intervene
  
  
• Weighing the person as ordered by R.N., dietician or physician
  
  
• Offering fluids on a regular schedule per 24-hours if person cannot access independently
  
  
• Possible speech therapy evaluation to look at treatment of dysphagia issues and prescribed interventions for equipment, safest way to present liquids.
  
  
• Monitor vital signs and capillary refill
  
  
• Consider the possible administration of additional fluids as ordered, through route other than oral
  
  
• Teaching/instruction to care givers on any interventions
  
  
• Monitoring and recording person's physical response to decreased fluids or replacement of fluids
  
  
• Dehydration protocol
  
  
• Reporting observations to the physician PRN
  
  
• Implement training programs or develop methods for persons to access fluids independently or teach to request fluids, i.e. teaching them to turn on tap, sign for water, etc.
  
  

• Analysis and review of interventions on appropriate data collection sheets used by R.N. or care givers
  
  
• Review and continue to monitor the person's responses
  
  
• Review the person's and staff's training needs