Dehydration
Also Consider: Appetite diminished, Diarrhea, Fever, Nausea, Vomiting
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Risk Factors for Dehydration
Oral fluid intake over 48 hours is decreased
Multiple episodes of vomiting or diarrhea over 24 – 48 hours
Blood glucose is high
Dependent on others for fluids (dementia, tube feeding)
Diuretic use such as furosemide, spironolactone, metolazone, or hydrochlorothiazide
Swallowing difficulties or on thickened liquids
1. Take Vital Signs
Temperature:
Blood Pressure lying:
Blood Pressure Standing:
Heart Rate lying:
Heart Rate standing:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Acute mental status change
Not eating or drinking
Acute decline in ADL abilities
Respiratory: Dry mucus membranes, New cough, abnormal lung sounds
GI: Nausea, vomiting, diarrhea, constipation, abdominal distention or tenderness
GU: New or worsened incontinence, pain with urination, blood in urine
Very low urinary output (<30cc/hr)
Skin: no axillary sweat, any new skin condition, i.e., rash, redness suggesting cellulitis, signs of infection around existing pressure ulcer
Fingerstick glucose (patients with diabetes)
3. Take Action using SBAR Report:
Immediately notify the medical staff & resident representative
BP systolic <90 and more than 20 points below usual, or Heart Rate >120, or lightheadedness or passing out when standing
Notify medical staff & resident representative within the next 16 hours.
Resting Heart Rate >110, or <500 ml 24-hour fluid intake despite encouragement, or low urine output
Notify medical staff on the next business day
Heart Rate intermittently >110, or fluid intake persistently not at goal
Notify medical staff at the next regular rounds
SBAR Report
Situation: "Potential for dehydration associated with:" (low blood pressure) (tachycardia) (lightheadedness) (syncope, loss of consciousness) (very poor intake) (very low unit output)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the problems started, how severe they are, getting worse or staying the same, what treatments have been used.
Abnormal Vital Signs
MOLST / Advance Directives
Recent illness, antibiotics, medication changes, surgery, falls
Recent fluid intake
Blood glucose, if elevated
General observation of patient condition
Diuretic Use & recent dose changes
Fluid restriction, thickened liquids
Restricted diet
Dry mucus membranes, no axillary sweat
Last Sodium, BUN, Creatinine
Tube feeding rate and water flush orders
Availability of IV or clysis hydration (i.e., PICC line)
Assessment: I am concerned about: __________
Recommendations/Requests:
Labs: CBC with manual diff, CMP/Chem14, Lactic Acid, Drug levels
Change in diuretic orders
IV or clysis hydration
Increase tube feed water flushes
Change fluid restriction orders
Speech Therapy consult to evaluate swallowing (if indicated)
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Monitor vital signs, fluid intake/urine output every 4-8 hrs for 2-3 days
Offer fluids frequently – broth, rehydration drinks/solutions
Place on Intake & Output monitoring
Place on 24-hour report for 2-3 days
Obtain lab results (if ordered), and notify medical as needed of:
Significantly abnormal values in blood count or metabolic panel (refer to appropriate Situation)
WBC > 12,000 or neutrophils > 90%
Update care plan regarding fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs
Review status and plan of care with designated representative daily
Update advance directives if appropriate
2025-04-26
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