With residents sometimes in isolation and wearing masks in various situations due to the COVID-19 pandemic, they are already more vulnerable to dehydration than normal, points out Teresa Remy, DSc, MHA, BSN, LNHA, RN, CDP, QCP, IPCO, director of consulting and clinical services for LeaderStat in Powell, OH. “Add the heat of the summer months on top of that, and providers need to be extra vigilant to prevent resident dehydration.”
Implementing the following steps can help:
Know the resident’s goals of care
“First, you have to know what the resident’s goals are based on their diagnosis,” says Remy. “For example, if a resident has congestive heart failure, that needs to be taken into consideration when you are developing a care plan intervention to ensure they get adequate fluids.”
It’s also important to know the resident’s wishes and preferences, says Jane Belt, MS, RN, QCP, RAC-MT, RAC-MTA, curriculum development specialist for AAPACN. “Advance care planning is crucial to understanding the resident’s wishes. For example, advance care planning can help you understand what types of hydration therapy (artificial or not) a resident wants to receive,” she explains. “It’s their body, it’s their life, and everything you do for them has to be person-centered.”
Be aware of common and uncommon symptoms of dehydration
Elderly residents can exhibit signs of dehydration that are uncommon in younger people, notes Remy. “For example, many elders have muscle fatigue, and you may not recognize it as related to dehydration, but it can be. Similarly, sometimes dizziness also can be a symptom, particularly for people who have immune-system conditions, including rheumatoid arthritis.”
Tiredness is another less common symptom, says Belt. “If a resident says, ‘I just feel so tired today,’ that also can be a warning sign that part of their problem is dehydration.”
More common symptoms are listed in chapter 3 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
Assess for COVID-19 when residents stop eating/drinking
Some nursing home residents across the country have arrived at hospital emergency departments moderately to severely dehydrated during the COVID-19 pandemic, according to anecdotal reports. The issue is that one of the possible symptoms of COVID-19 disease identified by the Centers for Disease Control and Prevention (CDC) is the new-onset loss of taste and/or smell, says Belt.
“A person’s senses of smell and taste are important to wanting to eat and drink,” says Belt. “If those senses of smell and taste are suddenly gone and the person doesn’t have those stimuli telling them to think, ‘Yes, I should eat,’ or ‘Yes, I should drink,’ then they will be much less likely to eat or drink—and the problem is magnified in the elderly.”
Typically, even cognitively intact nursing home residents won’t say anything about their lack of interest in eating or drinking, says Belt. “Therefore, it is up to the staff to notice and report to the nurse that, for example, a resident who always drinks all of her juice didn’t drink all of her juice today. Then if you have good care planning in place, you can step up monitoring and hydration (when clinically indicated) for this resident.”
The COVID-19 pandemic adds an additional layer of complexity and urgency to the already serious problem of dehydration, says Belt. “Increasingly, studies indicate that the loss of those senses of taste and smell may be one of the first indicators—almost a precursor—that someone has COVID-19 even when they have few or no other symptoms.”
If a resident who doesn’t have suspected or confirmed COVID-19 isn’t eating or drinking as usual, that should immediately rouse suspicion for COVID-19, suggests Belt. “In addition to assessing the resident for dehydration, do an assessment for suspected COVID-19. Put the resident in their room, isolate per facility policy. If possible, assess their senses of taste and smell, as well as other symptoms of COVID-19. Some experts have recommended testing taste and smell with a fragrant cup of hot tea or scratch-and-sniff cards. Then call the physician or physician extender to report your assessment findings and your plan to get the resident to eat and drink. Ask what else they recommend and whether the resident can be tested.”
Immediate action is essential, she stresses. “Dehydration is always a slippery slope. Residents can get worse quickly with severe clinical consequences. However, during the COVID-19 pandemic, moving swiftly also can help prevent an outbreak in your facility. You don’t want to wait a day or two to take action.”
The key is to assess residents with signs of dehydration from a holistic perspective as soon as the interdisciplinary team identifies a potential indicator, says Belt. “You can’t just focus on the dehydration. You have to look at every body system and get a full clinical picture of the resident. Dehydration due to loss of taste and smell may be an indicator for COVID-19. However, dehydration could also be the start of some other condition, such as a urinary tract infection. You need to know what else is there so you can tamp down the problem and hopefully prevent it from becoming devastating for the resident.”
Prepare a hydration game plan
In the past, hydration programs could be a little less formal, notes Remy. “For example, a staff member might walk by Mrs. Jones’ room and stop to encourage her to have a drink. However, now you may have to suit up in the appropriate personal protective equipment (PPE), which takes a lot more effort.”
Therefore, it’s important to have a hydration game plan, says Remy. “You want to have planned general interventions in addition to specific interventions on resident care plans. Take a look at how often water and ice are passed and how often fresh fruits or high water-content foods are offered. Then you can add individualized, care-planned interventions for those residents who are high risk or who don’t like to drink a lot of fluids.”
Providers should be creative and tailor the game plan to facility circumstances, says Remy. “For example, one facility set a goal for residents to drink a specific number of ounces, based on the resident’s goals and conditions, each time the nursing staff makes rounds.”
Find out what residents like to drink/eat
Even when COVID-19 is not a factor, dehydration is a significant concern during the summer months. “To keep residents hydrated, you have to know what each resident likes,” says Belt. “Trying to get someone to drink water when they don’t enjoy the taste of water won’t work. Can you put flavorings in the water they will enjoy? Can you use actual fruit slices like strawberries, lemons, or limes to flavor the water in a way they like?”
“You can’t assume that everyone likes water,” agrees Remy. “Even people who do like water sometimes get tired of it and don’t want to drink. If you have a resident who is at risk for dehydration, find out what their likes are.”
Some residents may prefer to eat foods with high water content, says Remy. “Find out if they like watermelon, cantaloupe, oranges, apples, carrots, or other fruits and vegetables with high water content. It’s not as hydrating as drinking a cup of water, but the resident will still have good water and good nutrient intake if they are able to eat those types of foods.”
Anything that melts is always a good option in the summer, adds Belt. “This could include popsicles, smoothies, milkshakes, or even ice chips.”
Implement non-food options
Sometimes issues other than the types of available foods and drinks can impact hydration. For example, one option may be to involve family, says Belt. “Isolation has been very hard on elderly residents. If a resident is not drinking, you could, for example, set up a call with a family member, such as their daughter. The daughter could call and say, ‘Hi, Mom. Let’s have some morning juice today and talk while we drink it.’ You want to think outside the box and find ways to inspire the resident to drink.”
Monitoring in-room air temperatures can also be helpful, adds Remy. “Regulations set temperature requirements. However, there can be variations from room to room. For example, direct sunlight generally can improve a person’s mood and make them feel like eating or drinking. However, a room that gets a lot of afternoon sun can become pretty warm and contribute to dehydration without staff realizing it because they’re not sitting there in the bed or in a chair with the sun shining directly on them the way it does on the resident.”
Music is another in-room option that can help residents feel happy and more relaxed so they want to eat or drink, says Belt. “However, again, person-centered care is important. What music does the resident like? What you like and what they like could be at opposite ends of the spectrum.”
Good oral care also can encourage residents to eat and drink, says Belt. “When nursing assistants are pressed for time, unfortunately they don’t always prioritize oral care. However, a mouth doesn’t feel good when it is not very clean. Start residents off with a clean mouth, and if you get them to brush their teeth after meals, that would be wonderful as well to clean their mouth and palate.”
Note: The Head to Toe (H2T) Infection Prevention Toolkit from the Centers for Medicare & Medicaid Services (CMS) offers resources on providing person-centered mouth care, in addition to skin care and urinary care, to prevent common infections, including bacterial pneumonia.
Finally, some residents are on medications that can basically heat up their bodies from the inside out, notes Remy. “It’s always good to have a cool cloth on the back of their neck or on their forehead to help these types of residents stay cool and reduce their risk for dehydration.”
Pay extra attention to sun lovers
“Many residents love to sit in the sun, so outdoor time can inspire them to drink, but unfortunately it also can lead to dehydration. In addition, some residents are on medications that cause sun sensitivity (for example, antibiotics, antihistamines, cholesterol-lowering drugs in the statin family, nonsteroidal anti-inflammatory drugs, diuretics, etc.), says Belt. “Don’t let residents go outside without sunscreen on if you can help it. Give them a hat. Try to get them under an umbrella or some shade. Make sure they have their beverage of choice next to them where they can easily drink it—and staff can encourage them to drink it—when they are out in the sun. Have them come in every hour for a cool drink as well. Their hydration should be constantly monitored when they are outside.”
This is especially important during the COVID-19 pandemic, stresses Remy. “With some states allowing visitations now, residents are being allowed to go outside to have monitored visitations. Sometimes they sit outside for hours wearing a mask in the heat,” says Remy. “Masks add an extra layer of risk for residents who already may have issues regulating their temperature or their thirst mechanism. Those residents need a very customized, individualized care plan that addresses those dehydration risks and ensures they stay well-hydrated out there.”
Consider hypodermoclysis for dehydrated residents
“The use of hypodermoclysis has provided an additional route for hydration for residents showing signs of dehydration because finding a vein in an elderly person who is dehydrated can be very difficult. In addition, inserting that needle for IV fluids can be painful for the resident, and you certainly don’t want to induce more pain in someone who already may be feeling badly,” says Belt. “Consequently, when these residents aren’t eating or drinking, many nurses will ask the physician or physician extender for an order to insert a hypodermoclysis line to nip dehydration in the bud. It offers a variety of ways to make sure a resident stays comfortable while receiving necessary hydration.”
Note: Several studies, including this one, have favorably assessed the use of hypodermoclysis to treat dehydration in the long-term care setting.
Get the whole team involved
All hands should be on deck to prevent dehydration, says Belt. “In addition to encouraging residents to consume beverages and snacks with high water content, nursing assistants, activities staff, and other staff members can help find out what residents would like to drink. For example, they may ask the resident, ‘What tastes good when you are warm? What makes you think of the time you went to the beach in the summer? What did you drink when you were on the beach?’ These types of conversations not only help you personalize care, they also can help residents feel more positive by thinking of better times.”
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