Introduction

• Physical and cognitive dependency
• Decreased communication skills
• Decreased ability to self-feed
• Frequency of medication passes (more medicines = more fluid intake)
• Percentage of meal intake
• Fluid intake from both food and fluid

When the fluid need is identified, the next step is to develop a plan to provide the resident with the needed fluids. An easy way to begin is to look at the fluids the resident is already getting at mealtime. Usually at breakfast this is juice, milk and coffee, with coffee and milk at the other meals. Other fluids to include at mealtime are soup, Jell-O, ice cream and sherbet. Many facilities provide water at all meals. Giving the resident more than three beverages at a meal is self-defeating, unless the resident is a large person. Too many fluids will fill the resident up for the meal. This is the main argument against giving nourishments at a meal.

If the resident does not drink milk or a hot beverage with the meal, then juice, ice cream or Jell-O can be given. If the resident does not drink the fluids at mealtime, then additional times are used. The easiest alternate time is with the medication pass. Fluids are given routinely with medicine and Chidester noted that 21 percent of the total fluid intake was given at times other than mealtime. A majority of these extra fluids were given with medications. She found the more medications, the greater the fluid intake. Nursing could use six ounce cups with each medicine pass to increase the fluid intake without another nourishment being passed.

The best time to promote fluid intake is at mealtime. Some facilities identify residents at hydration risk with a star on the tray card, or a different color napkin, or in some other creative way. This helps target those residents needing special attention.

Many facilities have initiated fluid passes to encourage fluid intake. The fluids served may be coffee, tea, juice, flavored Kool-Aid or another juice drink. Some offer only non-caloric drinks because of therapeutic diets. Thickened juices are also provided. These fluid passes usually occur about 10 a.m., after the afternoon nap and with the HS snack. Some facilities may offer coffee time in the afternoon, and serve coffee or juice, ice cream or cookies. Regularly scheduled nourishments for individual residents are another alternative, but tend to increase the workload for both nursing and dietary staff.

The team approach is the best way to encourage residents to get an adequate fluid intake. When the problem is ours and not theirs, solutions are easier to find. What are some ways the team can function to insure an adequate fluid intake? Each department and discipline has a unique opportunity to help with this important mission.

The Physician

1. Have the physician evaluate the need for diuretics and laxatives. Frequently, the elderly are on 2-3 laxatives or diuretics. This is especially important with the resident with a poor fluid intake.
2. Ask to have the need for enemas evaluated. Further, have the dietitian check to see that there is adequate free fluid in the tube feeding. This is usually considered to be 30 cc/kg.

The Nurse

1. Carefully evaluate resident fluid intake.
2. Observe for signs and symptoms of dehydration.
3. Encourage fluid intake.
4. Be aware that drugs, enemas, drainage and suctioning affect fluid balance.
5. Keep accurate intake records and, if possible, output records. (Refer to INTAKE/OUTPUT form later in this module.)
6. Be aware that any major drop in weight in a short time period is probably related to fluid loss.
7. Make sure fluids and snacks are passed.
8. Recommend that food sources of fiber are used in place of laxatives.
9. Give more fluids with med passes.

Nursing Assistants

1. Be aware of residents at risk for dehydration.
2. Know residents in need of assistance with fluid intake.
3. Encourage consumption of at least two fluids at meals.
4. Pass fluids and accurately record fluid intake.
5. Encourage small amounts of fluids each time toileting, turning or visiting a resident.
6. Be aware of any abnormal fluid loss and report to charge nurse.

Dietary

1. Make a variety of fluids available.
2. Make sure thickened fluids are an acceptable product.
3. Have staff monitor amount of fluids discarded and find out why.
4. Have fluids available in the dining room for residents during the day.
5. Rotate juices for variety and interest.
6. Try flavored coffee and tea.
7. Monitor fluids and supplements going to the floor.
8. Indicate those at hydration risk on the resident tray card.

Occupational Therapy

1. Assist resident in learning or regaining self-feeding skills.
2. During a therapy session, offer the resident a fluid.
3. Explain importance of drinking during a therapy session.

Speech Therapy

1. Help the resident obtain a safe swallow.
2. Check on the acceptance and quality of the thickened liquids.
3. Identify preferred fluids.
4. Encourage fluid intake.

Physical Therapy

1. Offer resident a drink prior to or after therapy session.
2. Discuss importance of drinking during therapy.

Respiratory Therapy

1. Be aware of fluid loss through suctioning and breathing treatments.

Activities

1. Provide fluids as part of program.
2. Discuss importance of drinking during activity session.
3. Coordinate with dietary to avoid repetition of fluids.
4. Find ways to incorporate fun fluids into activities.
5. Have a drink along with resident during a one-on-one.

Social Work

1. Have a drink along with resident during a one-on-one.
2. Learn fluid preferences from family on admission, especially in the confused resident.
3. Have families bring preferred fluids from home.
4. Encourage families to include a drink as part of their visit.

SUGGESTIONS TO INCREASE THE FLUID INTAKE OF THE ELDERLY RESIDENTS YOU SERVE

1. Put a special dot on the diet card so staff knows this resident needs more fluids.
2. Use a larger coffee cup. Coffee and tea are considered diuretics and can cause fluid loss; however, this is no reason to overlook an accepted source of fluids.
3. Give a larger amount of fluid with medications.
4. Work on activities and therapies to encourage fluid intake during the day.
5. Serve fruit juice mixed with diet white soda (such as diet 7-Up) with medications to add flavor and fizz. One of my favorite combinations is Fresca and cranberry juice cocktail. Residents rarely refuse these refreshing drinks.
6. Have a juice or a variety of beverages passed twice daily.
7. Offer popsicles, ice cream, soup, and gelatin (Jell-O) to your non-drinkers. I found residents who are confused like ice-cream sandwiches as a finger food. Pudding pops and push-ups are also favorites. Slushes can be flavorful and refreshing.
8. Homemade milkshakes flavored with peanut butter, sherbet, strawberries, bananas or other fresh fruit can offer variety.
9. Write a goal on the care plan for adequate fluid intake and have a team approach to get all the needed fluids.
10. Ask the family to assist with fluid intake when they come. Allow the family access to fluids. Ask them to include a drink as part of each visit. Making fluid intake fun and delicious are keys to success with fluids. The consequences of poor fluid intake are more difficult than providing adequate fluids in the first place.
11. Offer a variety of flavored coffees or teas.
12. Have a morning coffee hour and an afternoon tea.
13. Assign the passing of fluids to a single staff member as their sole job responsibility.
14. ave a cocktail hour - with or without alcoholic beverages.
15. Offer 8 ounces of water with AM cares.
16. Offer fluids with each meal.
17. Have a sign (such as a cactus, a rainbow, or coffee cup) outside the resident's door that communicates hydration risk.
18. Use a stack of med cups for small amounts of fluid during the day. Keep a running tally on the bedside table for easy calculation.
19. Hand the resident 4 ounces of fluid each time fluids are passed and encourage the resident to "drink it up!"
20. Provide fluids at an activity each day when residents wake up from their nap.
21. Keep a glass handy to give a resident a nice cold drink after toileting.

COUNTING FOOD AS PART OF FLUID

Included is a table of the fluid content of many foods served in long-term care. Note the fluid intake on the general menu is equal to 2095 cc. This includes both fluids and solid foods. Look at the food groupings to determine which foods provide the most fluids. The surprising groupings are:

• Main dish
• Vegetables
• Eggs
• Fruit
• Cereal
• Desserts (non-baked)

Some organizations based fluid intake in food on the basis of the calories provided in their general menu. This means a 2000 calorie diet provides 2000 cc if 100 percent is eaten, 1500 cc if 75 percent is eaten, 1000 cc if 50 percent is eaten, and so forth.

Using this method to ensure adequate fluid intake in residents is more realistic.

Standard Fluid Measurements

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