MDS Alert

Published on Tue Jul 24, 2007 PDF

Identify residents with hidden risk, use creative ways to encourage intake.

Coding dehydration in Section J or I that occurred on the facility's watch can leave your facility high and dry with surveyors and plaintiff attorneys. That's why an ounce of prevention -- or however many ounces of fluid a resident requires -- is the best medicine for heading off this common problem.

The challenge: People who are at highest risk for dehydration sometimes escape the radar screen. For example, be on the lookout for the "sippers," suggests nursing professor Janet Mentes, APRN, PhD, BC, at the University of California at Los Angeles. These residents are "older, more cognitively intact people who tend to have a history of low hydration or dehydration," says Mentes. "If you give them an eight-ounce glass of water, they will refuse it or not drink much of it."

Other people at risk for dehydration who tend to fall through the cracks include large people, like men, who have greater fluid needs, adds Debra Miller, a dietitian at Heritage Enterprises in Bloomington, IL.

Don't go completely by the book: The RAI manual sets 1,500 ml in 24 hours as the minimum threshold that a resident should receive, including beverages, and water in high-fluid content foods, such as gelatin and soup. But a registered dietitian or physician should determine the resident's fluid needs based on his or her size and health status and document that information in the chart, said Michelle McDonald, RN, MPH, a clinical consultant presenting during a Centers for Medicare & Medicaid Services' webcast on Section J.

Also be aware of these conditions, which pose hidden risks for low hydration:

• Residents with dysphagia receiving thickened liquids. This dietary intervention can pave the way for low hydration if residents skip the liquids because they find them unpalatable, says Marian Scharwachter, a registered dietitian and CEO of provider platforms for Myziva.com.

• Psychoactive medications that cause mild sedation can make the person less likely to drink on her own, says Clare Hendrick, a geriatric nurse practitioner and consultant in San Clemente, CA.

• Moderate dementia in someone who can drink independently. The person who can drink on her own may forget to do so, says Mentes. Yet staff don't focus on helping her because she doesn't need ADL assistance with feeding and drinking.

• Hot weather in which the facility's cooling system isn't keeping pace.

Consider These Preventive Strategies

Experts suggest several ways to prevent low hydration or keep it from tipping into dehydration.

• Jazz up your beverages.  Eunice S. Smith Home offers residents with dementia who don't drink well sparkling waters with a little coloring and flavor in them, reports Joy Barr, RN, MDS coordinator at the Alton, IL facility. "We do taste tests as activities where residents taste the various waters," she adds. For example, they'll say to residents: "'Have you even drunk blue water?' And that gets their excitement up."

Clever idea: A CNA at Eunice C. Smith Home found that residents would drink if she proposed a toast. "So we do a lot of toasts throughout the day," says Barr. "We say, 'Let's toast to the fact that there's not freezing rain today,' and everyone picks up their glasses and drinks because it's a toast."

• Address incontinence fears that impact a resident's willingness to drink fluids. If you find out someone refuses to drink for fear of having more incontinence, educate the person, suggests Mentes. Let them know that drinking more fluid may help incontinence because "concentrated urine irritates the urinary sphincter and can cause more incontinence," she says. Also offer the resident a work-up for the incontinence. Mentes worked in one facility where nurse practitioners assessed every resident with incontinence to see what measures might help.

Look for this hidden risk: In some cases, a resident may refuse liquids because he fears falling if hetries to get up alone to use the toilet, cautions Hendrick. In that case, individualize a care plan intervention to make sure he has assistance when he needs it.

• Give "sippers" small, frequent amounts of fluids. Those are the residents who are likely to refuse or barely drink from a full glass of water. One facility uses little paper cups at the bedside to offer frequent servings of fluids. The ounces add up if staff offers a resident a small cup several times a shift.

• Increase fluid content in the diet. "If someone is eating well, they are getting about 1,000 cc of fluid through their food," says Miller.

But if the resident tends not to drink well, you can increase that amount by offering more ice-cream, gelatin, thin soups, popsicles and cereal with milk, she says.

• Teach staff to automatically help residents drink more fluid as part of their care routines. CNAs can use verbal cueing to remind a cognitively impaired resident to drink each time they enter the person's room, suggests Scharwachter. And nursing staff can give residents an extra cup of water with meds at med pass, advises Hendrick.

• Care plan to include the family in encouraging the resident to offer the person fluids when they visit, says Scharwachter. Also, keep drinks at the nursing station to give to family members when they visit. Ask them to give one to their loved one, says Hendrick.

• Assess whether a resident on thickened liquids is drinking them. Also don't add the thickening agent until just before you serve the fluid, counsels Mentes.

Editor's note: For an article in Long-Term Care Survey Alert on strategies for making thickened liquids palatable, e-mail your request to editormon@aol.com. Also see the next MDS Alert for how to code dehydration accurately on the MDS and its impact on the QI/QM and RUG placement.