Long-Term
Care Hydration Guidelines
The FADONA
Board is working to establish clinical guidelines for
long-term care. These guidelines may be used as a
basis for facility-specific policies and procedures.
The first of these guidelines addresses hydration in
general for residents at risk.
LTC HYDRATION
GUIDELINES
POLICY: Each
resident in a long-term care facility will have
sufficient fluid intake to improve and/or maintain
hydration status based on the resident's individual
needs.
PROCEDURE
- The CDM/RD on
admission will complete a dietary assessment to
establish the individual resident's hydration
needs, then annually and/or upon significant
change.
- A three-day intake
record will be kept to establish whether the
resident is within the fluid range.
- If the
resident/patient does not meet their required
needs, the inter- disciplinary team and the
primary physician will be notified for
intervention.
RESIDENTS AT RISK
PURPOSE: To
identify residents/patients, who exhibit clinical
signs of possible insufficient fluid intake and/or
have lab values that indicate dehydration.
PROCEDURE/PROTOCOL
1. Identifying
residents at risk
A. Risk factors for
dehydration are:
- Coma/decreased
sensorium
- Fluid loss and
increased fluid needs (i.e., diarrhea, fever,
uncontrolled diabetes)
- Fluid restriction
secondary to renal dialysis
- Functional
impairments that make it difficult to drink, reach
fluids, or communicate fluid needs (i.e. aphasia)
- Dementia in which
residents forget to drink or forget how to drink
- Refusal of fluids
- Any infection
- Dehydration
diagnosis/current
- Weight fluctuation
in accordance with MDS standards
- Internal bleeding
- IV therapy
- Feeding tube
- Diuretic therapy
- Antibiotic therapy
- Wound therapy
B. Clinical signs of
possible insufficient fluid intake:
- Altered mental
status/confusion
- Dry skin
- Dry mucus membranes
- Cracked lips
- Poor skin turgor
- Thirst
- Fever/vomiting
C. Abnormal Lab Values:
- Elevated hemoglobin
and hematocrit
- Elevated potassium
(above 5.5)
- Elevated chloride
(normal 95-105)
- Elevated sodium
(normal 135-148)
- Elevated albumin
- Elevated transferrin
- Elevated BUN (normal
7-18)
- Elevated urine
specific gravity
2. Nursing
interventions to promote adequate hydration:
- Notify physician of
abnormal lab values and/or when resident has
clinical signs of dehydration.
- Three-day baseline
intake to establish fluid consumption.
- Review dietary's
initial assessment to identify the resident's
hydration needs.
- Determine if
resident is meeting/ not meeting his/her hydration
needs.
- Develop an
individualized hydration program.
LTC HYDRATION
GUIDELINES
These are your building
blocks, add facility-specific programs for your
finished programs for your finished policies and
procedures.
Example No. 1:
Resident at risk will be given an extra 8 oz. of
fluids per meal. All medication passes will include 6
oz. of fluid. Do an I & O for five days, if
resident not meeting their fluid needs then implement
routine for residents who are not meeting their
hydration needs.
Example No. 2:
Residents not meeting their hydration needs will be
given X amount of cc's per shift and who is
respon-sible for accomplishing this task. When
residents still do not meet their hydration needs, the
physician will be notified, requesting alternative
hydration therapy if compatible with the desires of
the resident and/or family.
Long-Term
Care Interpretive Guidelines: 483.25(j)
Federal Tag #F327
HYDRATION
Based on the comprehensive assessment of a resident,
the facility must ensure that...
F327 (1) The
facility must provide each resident with sufficient
fluid intake to maintain proper hydration and health.
INTENT: 483.25 (j)
The intent of this regulation is to assure that
the resident receives sufficient amounts of fluids
based on individual needs to prevent dehydration.
INTERPRETIVE
GUIDELINES: 483.25 (j)
This corresponds to MDS section L; MDS 2.0
sections G, K, I, J, and L, when specified for use by
the state.
"Sufficient
fluids" means the amount of fluid needed to
prevent dehydration (output of fluids far exceeds
fluids intake) and maintain health. The amount needed
is specific for each resident, and fluctuates as the
resident's condition fluctuates (e.g., increase fluids
if resident has fever or diarrhea).
Risk factors for the
resident becoming dehydrated are:
- Coma/decreased
sensorium;
- Fluid loss and
increased fluid needs (e.g., diarrhea, fever,
uncontrolled diabetes);
- Fluid restriction
secondary to renal dialysis;
- Functional
impairments that make it difficult to drink, reach
fluids or communicate fluid needs (e.g., aphasia);
- Dementia in which
residents forget to drink or forget how to drink;
- Refusal of liquids;
- Did the MDS trigger
RAPs on hydration? What action was taken based on
the RAP?; and
- Consider whether
assessment triggers RAPs and are RAPs
well-followed.
A general guideline for
determining baseline daily fluids needs is to multiply
the resident's body weight in Kg times 30cc, (2.2 lbs
=1Kg), except for residents with renal or cardiac
distress. An excess of fluids can be detrimental for
these residents.
Florida Department
of Health Awards Contract for CNA Testing
Recent correspondence
from Barbara Conditt, program operations
administrator, Florida CNA Registry, indicated that
there will be a new Florida CNA exam effective January
2002.
The Florida Department of Health (DOH) has awarded the
contract for the Nursing Assistant Testing Services to
Experior Assessments, LLC, and Chauncey Group
International, effective Jan. 1, 2002. There was a
significant delay in making the award that will affect
the availability of testing in early January. However,
both the DOH and the new testing companies are working
ardently to ensure that testing is available
throughout the state as quickly as possible.
Experior and Chauncey Group are national testing
companies with more than 40 years of experience
providing professional examinations to state and local
licensing and certification boards in 43 states. The
Chauncey Group has a long history of providing nurse
aide competency evaluation programs, administering
tests to more than 335,000 nurse aides since July
1989. To service this contract, Experior Assessments,
with an office in Gainesville, will be providing the
operational support while Chauncey Group will be
providing the test and test development support.
We recognize that the long-term care industry and
training programs are anxious to get details and
information on the testing and registration process.
The vendor anticipates having the registration forms
and the Candidate Information Bulletin available on
their website by Dec. 19, 2001, so it is recommended
that you check the website periodically for
information. The web address is www.experioronline.com.
The Candidate Information Bulletins and registration
forms are expected to be shipped to state-approved
training programs before the end of December.
In its initial meetings with representatives from the
new testing companies, DOH staff was impressed with
their commitment to the successful transition of this
testing program and overcoming the challenges of
launching this program with very short notice.
Both Experior and Chauncey Group are very sensitive to
the time concerns that the industry faces in having
candidates tested within a four-month period. They are
likewise aware of the increasing staffing requirements
for nursing assistants that may create a greater
demand for testing services while the new contract is
being implemented.
DOH is addressing the details with the current vendor
for transitioning the registrations of candidates who
have remaining eligibility to test, or who may even
have registered and paid for testing that they will
not be able to take before the contract ends.
Lastly, Experior has asked that if your facility or
training program has space available that you might be
willing to make available for testing on a periodic
basis, please contact Tana Thomas at (800)
888-8421, ext. 321, or Renee Stephens at ext. 315.
For applications contact:
Experior Assessments
2100 NW 53rd Ave.,
Gainesville, FL 32653-8100;
(888) 277-3500
www.experiononline.com
Thoughts
From the QUIN Council Liaison
By Reuben Bowie, RN,
MS, CDONA — FADONA’s Liaison to the QUIN Council
As I sat in the last
QUIN Council meeting, I could not help but think how
certain legislative decisions impact our organizations
and our profession. It seemed logical and benign when
the decision was made to move the Board of Nursing
(BON) to Tallahassee where all of the other
professional boards had their offices. Now that it has
become a reality, the impact is that many of the Board
staff have opted to remain in Jacksonville, the
executive director among them.
Wayne NeSmith is currently acting as interim executive
director of the Board of Nursing while a search is
conducted for a replacement. With the staff not up to
full strength, we can expect delays in the licensure
process at a time when we are all struggling with a
shortage of nurses and with mandated, increased nurse
staffing levels looming in the new year.
Despite these changes, the BON’s activities continue
with some extremely important issues on the agenda for
the quarterly meeting in Tampa on Dec. 5, 6, and 7,
2001: The reciprocity rule allowing nurses licensed in
other states for two years to be licensed in Florida;
review of CNETS (Canadian licensure exam) versus NCLEX
as substantially equivalent; proposal to change the
HIV/AIDS continuing education requirement to
bioterroism and adding a requirement on prevention of
medication errors; and LPN supervision and
credentialing. Long-term care nurses can no longer
afford to sit back and let things happen. Our
schedules have always been busy. But now, some of us
are even busier as a result of changes mandated by
SB1202. We need to participate whenever we have the
opportunity to be heard. What will be the impact of
legislation to put schools of nursing under the
Department of Education instead of the Board of
Nursing? Now is the time to let your legislators know
your opinions. These are the types of issues that
impact the nursing shortage.
The Florida Hospital Association has been especially
active in addressing the nursing shortage and a great
partner with other QUIN Council members in looking for
viable solutions. They formed an advisory committee
which in turn has accomplished a great deal during
2000–2001 through the use of sub groups. The
retention work group provided two series on
”Leadership and Management Education” for nurse
managers; published in Nursing Update a list of
programs, policies and practices that are seen as
“nurse satisfiers”; provided an educational
program of best practices and sponsored a seminar,
“Keep Your Nurses For Life.”
The recruitment group updated a recruitment packet
that included presentations, speeches and tools to use
in elementary, middle and high schools; and worked
with ABC affiliate WFTV Channel 9 in Orlando on a
statewide ad campaign that promotes nursing as a
career and portrays a positive image of nursing. The
data/research work group conducted a number of
surveys. Among the contributions of the image work
group was the creation of a nursing website, <http://
www.nursinginFlorida.com> to provide
information on nursing as a career, where and how to
find education, licensing and employment and it
created a nursing theme for Florida, “Nursing in
Florida — caring people caring for people.” The
academia, service and the student nurse work group is
currently working to build bridges to improve
relationships between academia and service.
The legislative/regulatory work group in conjunction
with FNA, FONE, and deans and directors of nursing
programs coordinated a nursing shortage summit for
legislators clarifying the extent of the nursing
shortage, what is being done by hospitals,
associations and academia and what could be
accomplished with assistance from legislation.
On Oct. 8, 2001, Gov. Bush addressed the Nursing
Workforce 2nd Annual Statewide Summit. He pledged
support in finding creative solutions to the nursing
shortage while recognizing budget constraints.
Participants hoped that consideration will be given to
a nursing loan forgiveness program, expanded funding
for nurse scholarship, loan and grant programs,
increased funding for nurse salaries and decreased
nurse-patient ratios, and upgraded tech-nology. With
BON’s move to Tallahassee, Wayne NeSmith is the
interim executive director. Florida Nurses Association
continues to support a FADONA member on the QUIN
Council as one of its three representatives because of
a commitment to representation for long-term care.
FNA is encouraging participation in the Magnet Nursing
Services Recog-nition Program of the American Nurses
Credentialing Center. Widespread interest exists in
Magnet Hospitals and Long-Term Care Certifications.
However, FNA must develop a strategy to promote the
program among nurse executives. Cost is a factor.
FNA is opposed to mandating staffing levels and offers
ANA staffing principles as a guideline because of the
many factors that affect staffing needs. Nursing
judgement and flexibility are needed for best
practice.
With a focus on retention of nurses, QUIN council is
starting to look at ways to facilitate socialization
into the profession and nursing student socialization.
Deans and directors of nursing programs have prepared
a side-by-side comparison of nursing shortage bills
that have been proposed nationally with
recommendations from the American le of
Colleges of Nursing. Community college faculty have
expressed some concern with the professional ethics,
values and conduct of some of their students. It is
imperative that health care organizations continue to
be selective and get references from schools before
hiring new graduates if we are to maintain
professional integrity, positive image and attract
quality to our facilities and profession.
Florida Organization of Nurse Executives is looking
forward to its spring conference, “Models of Nursing
Care Delivery,” Feb. 1–4, 2002, a Fascination
Cruise. They are also planning a “Best Practices”
conference.
The many activities and contributions of QUIN Council
member groups
attest to the power of “Quality and Unity In
Nursing.” May it motivate you to become involved in
shaping our profession in a way we can be proud of, to
work together, take control and not accept whatever
happens by default. I am grateful for my continued
association with this group.
|
