|The Importance of Water
to oxygen, water is the nutrient most needed for life. A person
can live without food for a month, but most people can survive
only three or four days without water. All of us start life
in a watery cradle of amniotic fluid and to this day remain
water's creature. Water makes up 85% of the blood, 70% of
the muscles and about 75% of the brain, and is present in
and around each of our cells.
In the body, water acts as a solvent, coolant, lubricant,
and transport agent. It's needed to regulate body temperature,
carry nutrients, remove toxins and waste materials, and provide
the medium in which all cellular chemical reactions take place.
Fluid balance is vital for body functions and adequate blood
volume. A significant decrease in the total amount of body
fluids leads to dehydration. Dehydration occurs when the amount
of water you take in is less than the amount you are losing.
Fluids can be lost through the urine, skin, or lungs. Along
with fluids, essential electrolytes, such as sodium and potassium,
are also perilously depleted in a dehydrated individual.
Dehydration and the Elderly
Elderly individuals are at a heightened risk for dehydration
because their bodies have a lower water content than younger
people. An elderly person weighing 150 pounds has about seven
liters less water than a young person of the same weight.
As a result of this lower water content, elderly individuals
can become dehydrated more quickly.
Because of visual, cognitive, or motor impairments, elderly
persons may have difficulty getting fluids for themselves.
They also may have only a muted perception of thirst. Unfortunately,
many symptoms of dehydration do not appear until significant
fluid has been lost. Practitioners in the field know that
dehydration can happen very rapidly, in less than an eight-hour
shift. The consequences of dehydration among the elderly can
be life threatening and the symptoms are alarmingly swift.
Nursing facility residents are particularly at risk for dehydration.
According to the article "Preventing Dehydration in the
Elderly" published in the September 1996 edition of Provider
magazine, as many as 75 percent of residents have average
fluid intakes below 1,500 cc per day, while a minimum recommendation
is between 1,500 to 2,000 cc of fluid intake per day. These
residents may need more opportunities and reminders to drink.
Those with disabilities may be unable to get a glass of fluid
without assistance. However, disability is not the only risk
factor. Residents who are not dependent on staff also need
encouragement for sufficient fluid intake.
Even when offered water, residents will refuse the offer
because "I'm not thirsty" or "I've already
had too much to drink today." Many elderly individuals
also exacerbate their risk of dehydration by limiting their
fluid intake in the incorrect belief that they will prevent
incontinence and decrease the number of needed trips to the
bathroom. Residents and staff should be taught that decreasing
fluid intake does not decrease incontinence, nor does it decrease
trips to the bathroom. In fact, as the urine becomes more
concentrated, it irritates the bladder and may increase the
urge to void resulting in frequent small voidings.
Signs and Symptoms of Dehydration
It is important that staff members be able to recognize the
signs and symptoms of dehydration to promptly assure correction
and prevention of complications. Without timely correction,
dehydration can lead to decreased functional ability, predisposition
to falls due to orthostatic hypotension, constipation, predisposition
to infection, and death. According the chapter on "Dehydration:
Prevention and Recognition" published by Long Term
Care Educator, staff members should be alert to the following
• Confusion can be an early sign of dehydration.
Caregivers who work regularly with a resident may be best
able to detect subtle changes in mental status that are present
when dehydration develops. Dehydration should be one of the
first problems suspected when a resident has a sudden change
in mental status.
• Poor skin turgor (elasticity) accompanies
dehydration, but this can be a difficult sign to assess because
most older residents have an age-related reduction in skin
turgor under normal circumstances. If skin turgor is to be
used in assessing for dehydration, the best areas to test
are the skin over the sternum and forehead because these areas
maintain better skin turgor than other areas. Generally, skin
will feel warm and moist with dehydration.
• An inspection of the oral cavity can yield useful insight
into a resident's hydration status. A dry oral mucosa
and dry furrowed tongue are good indicators of dehydration.
Staff should be cautioned that residents who are taking certain
medications (such as anticholinergic drugs) may have dry oral
mucosas in the absence of dehydration.
• An assessment of vital signs will reveal a decrease
in blood pressure and increase in pulse
when dehydration is present.
• A review of bowel elimination patterns can assist in assessing
dehydration. Recent diarrhea can offer an explanation for
a dehydrated state, while constipation is a
common occurrence when dehydration exists. Likewise, bladder
elimination patterns can provide useful insights: excess voiding
can contribute to dehydration while scanty output
can indicate insufficient fluid intake. Concentrated
urine is a common sign.
• Because such a large percentage of the body is comprised
of fluid, weight loss is often present.
If any of the above symptoms are noted, steps should be taken
as soon as possible to further assess the resident for dehydration
and take corrective action as necessary.
Taking a Proactive Approach to Preventing Dehydration
The best defense against dehydration is prevention. Illinois
Council facilities are utilizing a variety of proactive
strategies to identify residents at risk for dehydration,
monitor their fluid balance, and establish institutional policies
and programs to ensure that all residents receive adequate
hydration. The following are some of recommendations that
have been suggested by Illinois Council homes:
• Routinely monitor residents for signs of dehydration such
as cracked lips, dry oral mucous, poor skin turgor, and dark
urine color. Observe the residents' consumption of fluids
to determine if they have reduced the amount of liquids they
usually drink. Pertinent observations should be recorded in
the nursing notes.
• Keep a list of residents at high risk of dehydration in
the nurses' station and other strategic locations to remind
others to monitor residents' fluid intake. Consider placing
a symbol, such as a drop of water, near the beds of those
residents at risk of dehydration as a sign for staff members
to encourage fluid intake.
• Establish hydration protocols to be instituted immediately
when acute symptoms or illness threaten fluid and electrolyte
• Schedule fluid administration at least three times a day
between meals. Older people tolerate frequent administration
of fluid in smaller quantities better than infrequent larger
• To maintain hydration, note the residents' preferences
for type and temperature of fluids, and individualize the
hydration plan to encourage compliance.
• Review residents' medications to assess possible impact
of fluid and electrolyte levels.
• Leave filled, fresh water pitchers at residents' bedside
and assure that residents are able to easily reach
pitchers and glasses. Supply straws and special
drinking glasses to assist residents as necessary.
• Staff should offer a variety of fluids at a variety of
times and tell residents what the purpose of this procedure
is. For example, the dietary staff could add a glass of water
to each meal. Activities such as discussion or music groups
should include the offering of beverages.
• Arrange for residents to eat meals and have snacks with
other residents. Residents typically consume more food and
fluids in a social setting.
• Offer at least a full glass of fluid with medications.
Studies have shown that residents tend to drink the entire
amount of fluid offered.
• CNAs can offer small amounts of fluid every time they interact
with a resident during care delivery; i.e., toileting, after
a transfer, after getting dressed, after rehab or therapy
or range of motion exercises.
• Instruct residents, staff, and families about the importance
of hydration. Involve the resident and family in establishing
and meeting hydration goals.
• Teach staff to use a direct, positive approach when administering
fluids. Avoid asking: "Do you want something to drink?"
Instead say: "Here is some cool, refreshing water for
you Mrs. Jones." Older people may not feel thirsty and
may not recognize their need for fluid.
• Consider giving residents water bottles (such as those
used by athletes) to carry with them around the facility.
On a regular basis, be sure to fill the residents' water bottles
with their favorite cool beverages.
• Offer residents a variety of delicious beverages on a beverage
cart. Have a staff member provide drinks from this cart to
residents on a daily basis.
• Sponsor a cocktail hour for residents to enjoy their favorite
beverages and socialize. Facilities might consider having
a bar with different bottles and attractive colors where residents
can come up and order their drinks.
• Make drinks more appealing by the use of "props"
that are colorful and inexpensive, such as lemonade pitchers
and glasses, cocktail decorations, or a fruit garnish.
• During activities, use a blender to mix juice combinations
for the residents to enjoy such as kiwi and strawberry; vanilla
and root beer soda; ginger ale in cranberry juice; and orange
and pineapple juice.
• Ask the residents for their ideas on delicious drink ideas
that can be created during activity programs. Consider the
creation of frozen liquids such as lemon ice, popsicles, and
gelatin desserts. Try developing a "juice bar" with
a variety of juices, Italian ices, and snow cones.
• For residents with disabilities, the occupational therapist
may be able to recommend self-help devices such as long flexible
straws and spouted or two-handled cups. For residents with
increased stiffness, commonly seen in the later stages of
Alzheimer's disease, a cup with a cut-out on the upper rim
for the nose allows the cup to be tilted enough for the resident
• Ask surveyors if they will offer something to drink to
residents they interview during the survey, as part of the
overall facility efforts to prevent dehydration.
• When offering fluids, avoid offering beverages that contain
caffeine or alcohol since both have dehydrating properties.
• Educate families about the importance of promoting hydration
while they visit in and/or out of the facility.
• Take ice water and other beverages on all outings and offer
at frequent intervals.
• Before walking through the zoo, museum, park, etc. provide
each resident with a personal water bottle. These are easy
to carry and refill and should be marked with the resident's
name before distribution.
• If residents refuse fluids on an outing, give them a salty
snack. This will increase their tendency to accept a drink.
• Make sure that water fountains in the facility are low
enough to facilitate use by residents in wheel chairs. Include
a cup dispenser and wastebasket next to the drinking fountain.
For easier use, adaptive "handles" can be purchsed
to make dispensing easier.
Activity Ideas that Encourage Hydration
The activity professional is in a unique position to encourage
residents to increase their fluid intake. The social structure
of interactions used by these professionals offer many opportunities
to offer "liquid refreshments" as a natural part
of the activity. The following are some simple ideas to add
to any current activity program:
• Decorate a cart and stock it with a variety of juices and
water when making room visits. Begin the visit by sharing
a beverage of choice. In many instances this will trigger
fond memories of going to the soda fountain for a cherry Coke
or sipping lemonade at a church picnic. This same idea can
be utilized when staff or volunteers take the "library
cart" from room to room.
• Incorporate a "juice break" into small group
activities held on each floor or unit. The residents appreciate
this time to rest and socialize with those around them.
• Use specific beverages as part of a reminiscing group.
For example, have the group squeeze lemons and make lemonade.
You'll be surprised at the many stories connected with this
• Have a "taste-test" and have the residents guess
the flavor of the juice, soft drink, tea, coffee, shake, etc.
they are drinking.
• Hold an afternoon "tea" where small groups can
gather over a cup of tea or other beverages and just visit
or discuss a specific topic.
• As the residents wait for the dining room to open, use
the opportunity to provide a liquid appetizer such as tomato
juice, orange juice, V-8 juice, etc.
• Have a Happy Hour before the evening meal and offer non-alcoholic
drinks. Almost any mixed drink can be made without alcohol,
i.e., a virgin Bloody Mary.
• Always have water and/or a variety of other beverages available
when on outings or when sitting outside with the residents.
• Using "real" cups and glasses makes beverages
more appealing; when living in the community, this is what
the residents used.
• During cooking group, have glasses of water with floating
slices of lemon and ice cubes at each resident's place when
the activity begins. Keep refilling their glasses as the meal
is prepared and eaten.
Dehydration in nursing home residents is a common and dangerous
problem requiring the involvement of the entire interdisciplinary
team. Every opportunity to encourage residents to drink should
be used, not only by nursing staff, but dietary, activities,
social services, volunteers, and family. By taking a proactive
approach to preventing dehydration, staff members can make
great progress in reducing unnecessary hospitalizations and
maximizing resident health and well-being.