Dehydration

Dehydration

essential to body function and health. Water content decreases from birth to old age; in neonates, approximately 75% of the body weight is water content; by adulthood, the percentage has decreased to approximately 60%; in the elderly, only about 55% of the body weight is water content. The sharpest decline in fluid volume occurs within the first 10 years of life.

Dehydration

Dehydration excessive loss of fluid from the body occurs when the loss of fluid exceeds the fluid intake.

Causes

Excessive fluid loss, reduced fluid intake, third-space fluid shift, or a combination of these factors can cause fluid volume losses

Other causes of fluid loss include:

hemorrhage excessive perspiration acute renal failure with polyuria abdominal surgery vomiting or diarrhea nasogastric drainage excessive GI suctioning diabetes mellitus with polyuria or diabetes insipidus fistulas excessive use of laxatives aggressive diuretic therapy Fever excessive fluid removal with hemodialysis or peritoneal dialysis therapy

Possible causes of reduced fluid intake include:

dysphagia coma environmental conditions preventing fluid intake psychiatric illness. Fluid shifts may be related to: initial phase of a burn acute intestinal obstructions acute peritonitis pancreatitis crushing injuries pleural effusion ascites accumulation of blood around a hip fracture.

The pathophysiology of dehydration

The pathophysiology of dehydration involves a number of mechanisms. The loss of body fluids causes an increase in blood solute concentration that increases osmolality. Serum sodium levels rise. In an attempt to regain fluid balance between intracellular and extracellular spaces, water molecules shift out of the cells into the concentrated blood

The pathophysiology of dehydration

. This process, combined with increased water intake and increased water retention in the kidneys, usually restores fluid balance. But without sufficient water in the extracellular space, fluid continues to shift out of the cells into the extracellular space, causing the cells to shrink and impairing cellular function

Complications
Complications include hypotension, risk of falls related to hypotension, and decreased cardiac output and perfusion to tissues and organs. Severe dehydration can progress to hypovolemic shock

Other complications include renal failure from decreased renal perfusion and, without intervention, death

What happens in hypovolemic shock

In hypovolemic shock, vascular fluid volume loss causes extreme tissue hypoperfusion Internal fluid losses can result from hemorrhage or third-space fluid shifting External fluid loss can result from severe bleeding or from severe diarrhea, diuresis, or vomiting

Inadequate vascular volume leads to decreased venous return and cardiac output The resulting drop in arterial blood pressure activates the bodys compensatory mechanisms in an attempt to increase vascular volume If compensation is unsuccessful, decompensation and death may occur.

Assessment

An assessment may reveal numerous symptoms affecting many body systems 1- orthostatic hypotension due to increased systemic vascular resistance and decreased cardiac output 2- . Tachycardia induced by the sympathetic nervous system to increase cardiac output 3- . Physical findings may include flattened neck veins related to decreased circulating fluid volume 4- sunken eyeballs related to decreased total fluid volume with consequent dehydration of connective tissue and aqueous humor

5- Urine will be dark amber in color and decreased in volume 6- diminished skin turgor due to decreased fluid in the dermal layer 7- The patient may also exhibit weakness , irritability

Diagnostic tests

Hematocrit is elevated. Serum osmolality is elevated (greater than 300

mOsm/kg; in patients with diabetes insipidus, osmolality ranges from 50 to 200 mOsm/kg). Serum sodium level is elevated (greater than 145 mEq/L). Urine specific gravity is greater than 1.030 (in patients with diabetes insipidus, specific gravity is usually less than 1.005).

Treatment

The patient with severe dehydration will require I.V. fluid replacement. I.V. fluids should be hypotonic, low-sodium solutions, such as dextrose 5% in water
Avoid rapid administration of the I.V. solutions, because this will cause fluid to move from the veins into the cells and result in edema. Fluids should be administered gradually, over a period of 48 hours.

ALERT

Rapid administration of I.V. solution can cause edema, which in turn may progress to cerebral edema, a potentially fatal complication

nursing diagnoses

Deficient fluid volume related to inadequate fluid intake and active fluid loss Decreased cardiac output related to decreased fluid volume Impaired oral mucous membranes related to dehydration Risk for injury related to dizziness or hypotension

Nursing interventions

1- Obtain a patient history to determine the cause of the fluid imbalance. 2- Insert a urinary catheter, as ordered for accurate monitoring of fluid output. 3- Encourage the patient to increase oral intake of fluid 4- Provide oral fluids of the patients preference, and place within easy reach. 5- Assist the patient if hes unable to feed himself or hold a cup. 6- Avoid acidic juices if the patient has impaired oral membrane integrity

Nursing interventions

7- Provide I.V. fluid replacement if the patient cant orally consume adequate amounts of fluid.
8- Provide meticulous oral care and assess mucous membranes. 9- Provide meticulous skin care and lubrication. 10- Turn and reposition if the patient is immobile.

11- Institute safety precautions if the patient is experiencing orthostatic hypotension, dizziness, or alterations in mental status 12- Administer an antidiarrheal or antiemetic, if appropriate. Review medications that can contribute to fluid loss (diuretics), and obtain an order to discontinue or adjust dose

Monitoring

1- Assess and record weight at the same time each day. 2- Monitor vital signs for fever, hypotension, and tachycardia. 3- Assess and record daily intake of fluid intake and output. 4- Monitor color and amount of urine output

5- Monitor serum electrolytes and urine osmolality. 6- Monitor active losses of fluid from drainage, suctioning, vomiting, or bleeding. 7- Assess and record changes in mental status or neurologic functions

Closely monitor very young patients and elderly patients for dehydration, because individuals in these groups are susceptible to fluid loss due to inability to communicate thirst or obtain fluid without assistance Inaccurate assessment of output related to absorbent products such as diapers also places these patients at risk. Fluid loss may also occur in these populations due to diarrhea or vomiting, or due to perspiration caused by fever

Patient teaching

1- Describe and provide information on causes of fluid loss or decreased oral intake of fluid. 2- Provide information on the care plan and the importance of maintaining proper nutrition and fluid intake. 3- Refer the patient to home care services if continued monitoring or I.V. fluid administration is required. 4- Discuss signs and symptoms of dehydration, and instruct the patient and his family to immediately report this information to their health care provider

Patient teaching

5- Teach the patient and his family how to monitor daily intake and output and weight. 6- Provide information on medications and dietary supplements that can cause diuresis and lead to dehydration.

Prepared by ; Jaber Alnami ER staff Nurse(Sabya General Hospital)

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