Managing oral hydration In: Evidence-based geriatric nursing protocols for best practice


Guideline Developer(s)

Hartford Institute for Geriatric Nursing

Date Released

2008 (revised 2012)

Evidence Supporting the Recommendations

References Supporting the Recommendations

Albert SG, Nakra BR, Grossberg GT, Caminal ER. Vasopressin response to dehydration in Alzheimer's disease. J Am Geriatr Soc. 1989 Sep;37(9):843-7. PubMed
American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology. 1999 Mar;90(3):896-905. PubMed
Armstrong LE, Maresh CM, Castellani JW, Bergeron MF, Kenefick RW, LaGasse KE, Riebe D. Urinary indices of hydration status. Int J Sport Nutr. 1994 Sep;4(3):265-79. PubMed
Armstrong LE, Soto JA, Hacker FT Jr, Casa DJ, Kavouras SA, Maresh CM. Urinary indices during dehydration, exercise, and rehydration. Int J Sport Nutr. 1998 Dec;8(4):345-55. PubMed
Burns D. Working up a thirst. Nurs Times. 1992 Jun 24-30;88(26):44-5. PubMed
Ferry M. Strategies for ensuring good hydration in the elderly. Nutr Rev. 2005 Jun;63(6 Pt 2):S22-9. [28 references] PubMed
Gaspar PM. What determines how much patients drink. Geriatr Nurs. 1988 Jul-Aug;9(4):221-4. PubMed
Hart M, Adamek C. Do increased fluids decrease urinary stone formation. Geriatr Nurs. 1984 Jul-Aug;5(6):245-8. PubMed
Lavizzo-Mourey R, Johnson J, Stolley P. Risk factors for dehydration among elderly nursing home residents. J Am Geriatr Soc. 1988 Mar;36(3):213-8. PubMed
Mentes JC, Iowa-Veterans Affairs Research Consortium. Hydration management protocol. J Gerontol Nurs. 2000 Oct;26(10):6-15. [83 references] PubMed
Mentes JC. A typology of oral hydration problems exhibited by frail nursing home residents. J Gerontol Nurs. 2006 Jan;32(1):13-9; quiz 20-1. PubMed
Metheny N. Fluid and electrolyte balance. In: Nursing considerations. 4th ed. St. Louis (MO): Lippincott, Williams, & Wilkins; 2000. p. 3-12,24-6.
Mueller KD, Boisen AM. Keeping your patient's water level up. RN. 1989 Jul;52(7):65-8. PubMed
Musson ND, Kincaid J, Ryan P, Glussman B, Varone L, Gamarra N, Wilson R, Reefe W, Silverman M. Nature, nurture, nutrition: interdisciplinary programs to address the prevention of malnutrition and dehydration. Dysphagia. 1990;5(2):96-101. PubMed
Robinson SB, Rosher RB. Can a beverage cart help improve hydration. Geriatr Nurs. 2002 Jul-Aug;23(4):208-11. PubMed
Simmons SF, Alessi C, Schnelle JF. An intervention to increase fluid intake in nursing home residents: prompting and preference compliance. J Am Geriatr Soc. 2001 Jul;49(7):926-33. PubMed
Vivanti A, Harvey K, Ash S, Battistutta D. Clinical assessment of dehydration in older people admitted to hospital: what are the strongest indicators?. Arch Gerontol Geriatr. 2008 Nov-Dec;47(3):340-55. PubMed
Wakefield B, Mentes J, Diggelmann L, Culp K. Monitoring hydration status in elderly veterans. West J Nurs Res. 2002 Mar;24(2):132-42. PubMed
Warren JL, Bacon WE, Harris T, McBean AM, Foley DJ, Phillips C. The burden and outcomes associated with dehydration among US elderly, 1991. Am J Public Health. 1994 Aug;84(8):1265-9. PubMed
Weinberg AD, Pals JK, Levesque PG, Beal LF, Cunningham TJ, Minaker KL. Dehydration and death during febrile episodes in the nursing home. J Am Geriatr Soc. 1994 Sep;42(9):968-71. PubMed

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Mobile Device Resources

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Maintenance of body hydration
  • Decreased infections, especially urinary tract infections
  • Improvement in urinary incontinence
  • Lowered urinary pH
  • Decreased constipation
  • Decreased acute confusion
Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic 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

Not stated

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

Not stated

Identifying Information and Availability

Bibliographic Source(s)

Mentes JC. Managing oral hydration. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 419-38.

Adaptation

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

Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Author: Janet C. Mentes, PhD, APRN, BC, FGSA, Associate Professor, University of California, Los Angeles, Los Angeles, CA

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Mentes JC. Managing oral hydration. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p. 369-90.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.

Availability of Companion Documents

The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 16, 2008. The information was verified by the guideline developer on August 4, 2008. This NGC summary was updated by ECRI Institute on June 25, 2013. The updated information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Scope

Disease/Condition(s)
  • Dehydration
  • Underhydration
Guideline Category

Evaluation
Management
Prevention
Risk Assessment

Clinical Specialty

Family Practice
Geriatrics
Internal Medicine
Nursing

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Hospitals
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

To provide a standard of practice protocol to minimize episodes of dehydration in older adults

Target Population

Older adults

Interventions and Practices Considered

Assessment/Evaluation

  1. Health history
  2. Physical assessments
  3. Laboratory tests
  4. Assessment of fluid intake behavior
  5. Risk identification: Dehydration Risk Appraisal Checklist

Management

  1. Acute hydration management
  2. Ongoing hydration management
  3. Follow-up monitoring
Major Outcomes Considered
  • Dehydration
  • Urinary tract infections
  • Urinary incontinence
  • Urinary pH
  • Constipation
  • Acute confusion

Recommendations

Major Recommendations

Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.

Parameters of Assessment (Mentes & Iowa-Veterans Affairs Nursing Research Consortium [IVANRC], 2000 [Level I])

  • Health history
    • Specific disease states: dementia, congestive heart failure, chronic renal disease, malnutrition, and psychiatric disorders such as depression (Albert et al., 1989 [Level III]; Gaspar, 1988 [Level IV]; Warren et al., 1994 [Level IV])
    • Presence of comorbidities: more than four chronic health conditions (Lavizzo-Mourey, Johnson, & Stolley, 1988 [Level IV])
    • Prescription drugs: number and types (Lavizzo-Mourey, Johnson, & Stolley, 1988 [Level IV])
    • Past history of dehydration, repeated infections (Mentes, 2006 [Level IV])
  • Physical assessments (Mentes & IVANRC, 2000 [Level I])
    • Vital signs
    • Height and weight
    • Body mass index (BMI) (Vivanti et al., 2008 [Level IV])
    • Review of systems
    • Indicators of hydration
  • Laboratory tests
    • Urine-specific gravity (Mentes, 2006 [Level IV]; Wakefield et al., 2002 [Level IV])
    • Urine color (Mentes, 2006 [Level IV]; Wakefield et al., 2002 [Level IV])
    • Blood urea nitrogen (BUN)/creatinine ratio
    • Serum sodium
    • Serum osmolality
    • Salivary osmolality
  • Individual fluid intake behaviors (Mentes, 2006 [Level IV])

Nursing Care Strategies

Risk Identification (Mentes & IVANRC, 2000 [Level I])

  • Identify acute situations: vomiting, diarrhea, or febrile episodes
  • Use a tool to evaluate risk: Dehydration Risk Appraisal Checklist

Acute Hydration Management

  • Monitor input and output (Weinberg et al., 1994 [Level I]).
  • Provide additional fluids as tolerated (Weinberg et al., 1994 [Level I]).
  • Minimize fasting times for diagnostic and surgical procedures (American Society of Anesthesiologists, 1999 [Level I]).

Ongoing Hydration Management

  • Calculate a daily fluid goal (Mentes & IVANRC, 2000 [Level I]).
  • Compare current intake to fluid goal (Mentes & IVANRC, 2000 [Level I]).
  • Provide fluids consistently throughout the day (Ferry, 2005 [Level VI]; Simmons, Alessi, & Schnelle, 2001 [Level II]).
  • Plan for at-risk individuals
    • Fluid rounds (Robinson & Rosher, 2002 [Level IV]).
    • Provide two 8-oz. glasses of fluid, one in the morning and the other in the evening (Robinson & Rosher, 2002 [Level IV]).
    • "Happy hours" to promote increased intake (Musson et al., 1990 [Level V]).
    • "Tea time" to increase fluid intake (Mueller & Boisen, 1989 [Level V]).
    • Offer a variety of fluids throughout the day (Simmons, Alessi, & Schnelle, 2001 [Level II]).
  • Fluid regulation and documentation
    • Teach able individuals to use a urine color chart to monitor hydration status (Armstrong et al., 1994 [Level IV]; Armstrong et al., 1998 [Level IV]; Mentes, 2006 [Level IV]).
    • Document a complete intake recording including hydration habits (Mentes & IVANRC, 2000 [Level I]).
    • Know volumes of fluid containers to accurately calculate fluid consumption (Burns, 1992 [Level IV]; Hart & Adamek, 1984 [Level III]).

Follow-up Monitoring of Condition

  • Urine color chart monitoring in patients with better renal function (Armstrong et al., 1994 [Level IV]; Armstrong et al., 1998 [Level IV]; Wakefield et al., 2002 [Level IV]).
  • Urine specific-gravity checks (Armstrong et al., 1994 [Level IV]; Armstrong et al., 1998 [Level IV]; Wakefield et al., 2002 [Level IV]).
  • 24-hour intake recording (Metheny, 2000 [Level VI]).

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion-criteria.aspx.

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.

To get started, log in or create your free account Create Account