Dehydration Presentation 6j6q4t

DEHYDRATION Presented By: Madison Jordan Adagio Health Dietetic Intern 2016-2017

Definition • Lack of adequate fluid in the body • “Loss of water and salts essential for normal body

function” –Medical Dictionary • “Occurs when the body does not have as much water and

fluids as it should” –MedLinePlus • “Occurs when you use or lose more fluid than you take in,

and your body doesn’t have enough water and other fluids to carry out its normal functions”—Mayo Clinic

Etiology: Dehydration • Water deprivation, diabetic ketoacidosis (DKA), diabetes

insipidus, diarrhea, vomiting • INFANTS/CHILDREN: diarrhea caused by bacterial or

viral agents; a leading cause of death in third world countries • ADULTS: medications with diuretic effects, low-carb diets, GI disorders (IBS), intense workouts, pregnancy, high alcohol consumption

Pathophysiology • Negative balance of fluids from either: a) decreased intake b) increased output (renal, GI, insensible losses) c) fluid shift (i.e. ascites, burns) • Decrease in total body water can cause reductions in

both intracellular and extracellular fluid volumes

Categorization • Dehydration can be categorized according to osmolarity

(serum sodium) and severity • IMPORTANT because osmolarity can suggest the cause

of dehydration RISK FACTORS: -infants and children (75% body water) -elderly -people with chronic illnesses -people who work or exercise outside

Types of Dehydration: Osmolarity • Isonatremic (isotonic): Sodium130-150 mEq/L

dehydration does not effect the concentration of sodium (electrolytes) in extracellular fluid • Hypernatremic (hypertonic): Sodium >150 mEq/L

dehydration results in an increased sodium (electrolytes) concentration in extracellular fluid • Hyponatremic (hypotonic): Sodium <130 mEq/L

dehydration results in a decreased sodium (electrolytes) concentration in extracellular fluid

Isonatremic Dehydration • Most common; 80% of cases • Serum sodium 130-150 mEq/L

Possible Causes: -inadequate intake -repeated vomiting -diarrhea -severe bleeding

Hypernatremic Dehydration • More water than sodium is lost from the body, extracellular

fluid has increased concentration of sodium and becomes hypertonic regarding the intracellular fluid, therefore extracting water from the cells • Serum sodium >150 mEq/L Possible Causes: -poorly treated diabetes (water depletion) -heat stroke/excessive sweating -End-stage renal disease -certain diuretics -water deprivation -salt excess

Hyponatremic Dehydration • More sodium than water is lost from the body, sodium

concentration of the extracellular fluid decreases and become hypotonic and water moves into the cells • Serum sodium <130 mEq/L Possible Causes: -GI obstruction, fitsula, ileus -pancreatitis -trauma -chronic malnutrition -diuretics (furosemide, mannitol)

Types of Dehydration: Severity • Mild: when the body has lost about 3-5% of it’s

total fluid • Moderate: when the total fluid loss reaches 6-9% • Severe: when the body reaches 10% fluid loss,

considered an emergency

Mild Mild

Mild Mild 3-5% Weight Loss 3-5%Mild Mild Weight Loss 3-5% Weight Loss 3-5% Weight Loss Normal 3-5% Blood pressure Weight Loss Weight Loss

3-5% Blood Blood pressure Normal Normal Blood pressure Normal Blood Pressure Normal Pulse pressure Normal Blood pressure Normal

Pulse Normal Pulse Normal Pulse Normal Pulse Normal Pulse Behavior Behavior Normal Normal Normal Behavior Normal Behavior Normal Normal Behavior Membranes Moist Membranes Behavior Membranes Moist Normal Moist Membranes Moist Tears Present Membranes Moist Present Tears Tears Present Membranes Moist Tears Present Cap. Refill 2 seconds Cap. Refill 2 seconds Tears Cap. RefillPresent 2 seconds Cap. Refill 2 seconds SG >1.020 Tears Urine Present Urine SG >1.020 Urine SG >1.020

Urine UrineSG SG Cap. Refill Urine SG

>1.020 >1.020 2 seconds >1.020

Moderate Moderate

Severe Severe

Moderate Severe Moderate Severe 6-9% >10% Moderate Severe 6-9% > Or = 10% Moderate Severe 6-9% >10% 6-9% >10% 6-9% >10%Shock Orthostatic

6-9% >10% Orthostatic Shock Orthostatic Shock Orthostatic Orthostatic Shock Shock Increase Tachycardic Orthostatic Shock Increase Tachycardic Increase Tachycardic Increase Tachycardic Increase Tachycardic Increase Lethargic Tachycardic Irritable Irritable Lethargic Irritable Lethargic Irritable Lethargic Irritable Lethargic Dry Parched Dry Parched Irritable Lethargic Dry Parched Dry Parched Decrease Absent Dry Parched Decrease Absent Decrease Absent Dry Decrease Absent Parched 2-4 seconds >4 seconds 2-4 seconds >4 seconds Decrease Absent 2-4 seconds >4 seconds 2-4 seconds >4 seconds >1.030 Oliguria Decrease Absent >1.030 Oliguria >1.030 Oliguria >1.030 Oliguria >1.030 Oliguria 2-4 seconds >4 seconds

>1.030

Oliguria

Signs & Symptoms • Infant/Children: dry mouth and tongue, no tears when crying, no wet diapers for three hours, sunken eyes/cheeks, sunken soft spot on top of skull, irritability • Adult: extreme thirst, less frequent urination, darkcolored urine, fatigue, dizziness, confusion

Diagnostic Tests: • Blood tests: electrolyte levels, BUN and

creatinine-often increased in dehydration • Urinalysis: evaluate how much urine is being

produced, examine the color and concentration

Medical Nutrition Therapy • Most effective replace fluids and electrolytes • Infants/Children: Pedialyte (solution with water, salt, and

electrolytes) • Adults: Sports drinking containing electrolytes (Gatorade) • Severe Dehydration: Intravenous

fluids (controlled, and absorbed quickly)

Coding & Reimbursement Dehydration (ICD10 code-E86.0) Approximate Synonyms: Dehydration due to radiation Dehydration hypernatremic Dehydration secondary to radiation Dehydration, mild Dehydration, moderate Dehydration, severe Hypernatremic dehydration Mild dehydration Moderate dehydration Severe dehydration

References & Resources • http://medicine.missouri.edu/childhealth/s/dehydration.pdf • http://www.ehealthstar.com/dehydration/types-pathophysiology • http://emedicine.medscape.com/article/906999 • Armstrong , Lawrence E. Diagnosing Dehydration? Blend evidence with clinical

observation. Volume 19, Issue 6: “Clinical Nutrition & Metabolic Care”. November 2016. • Cheuvront, Samuel N. Dehydration: Physiology, Assessment, and Performance.

Comprehensive Physiology. 10 Jan 2014 • Finberg, Laurence E. “Dehydration in Infancy and Childhood.” Pediatrics in Review

23 (2010): n. pag. Web. • Tam, Ron K, Wong. Comparison of clinical and biochemical markers of dehydration

with the clinical dehydration scale in children: a case comparison trial. BioMed June 2014.

Central, Ltd. 16

CASE STUDY: MR. W 64 year old white male

Medical History • Medical conditions: Hypertension, Depression, Psychotic

disorder • Medications: Norvasc, Heparin, Tamiflu, Pravachol, Zoloft, Tylenol, Zofran, Ambien, Vitamin D3 • Smoking status: never smoked • Alcohol use status: alcohol never used • Pt 302 to psychiatric unit on 1/6/17 placed on 15 minute

observation with suicide precaution, was doing well for awhile then declined, stopped eating, drinking and sleeping • D/c to general medical floor 1/31/17 for examination and IVF, put on bed rest, catheter inserted

Socio-economic History • Divorced with one daughter • Currently unemployed, previously worked at a car dealership • Lives in Group Home • Mental/Emotional status: Group Home house coordinator

noticed he turned off heat, stopped caring for himself, not eating or bathing, he has been isolative and withdrawn, paranoid and delusional about police being after him because he “did not pay for housing”, believes grandchildren are dead from an accident which appears not to be true, described his mood to be a bit down, pt knew it was January 2017 and that he was in a “psychiatric ward”, believes the hospital is keeping him here forever

NUTRITION CARE PROCESS

Nutrition Assessment • Diet Hx: general diet, has not had anything PO for a few days,

refusing all meals • 64 y.o. Height: 5ft 6in weight: 169.5 lb/75.8 Kg

IDW:142 lb/64.5Kg

• ission Dx: Dehydration (ICD10 code-E86.0) • Chief complaint: altered mental status, decreased oral intake,

dehydration, confusion, unable to walk without assistance, somewhat unresponsive • Skin: cracked, dry mouth/lips • GI: no bowel movement recently noted

Lab

Value

High/Low/WDL

Glucose, Fasting 128

High

BUN

40

High

Creatinine

1.0

WDL

Sodium

150

High

Potassium

3.2

Low

Chloride

107

WDL

Calcium

9.2

WDL

Albumin

4.3

WDL

Bilirubin

1.1

High

AST

54

High

ALT

47

High

White Blood Cell 10.9

High

HGB/HCT

18.6/53.3

High/High

Total Cholesterol

212

High

LDL Cholesterol

149

High

Influenza B

Positive

Nutrition Diagnosis Statement • PES #1: Inadequate fluid intake related to psychological

disorder as evidence by decreased fluid intake and refusal to drink fluids

• PES #2: Inadequate energy intake related to decreased

appetite and psychological disorder as evidence by decreased PO intake

Nutrition Intervention • Start patient on intravenous fluids to correct electrolyte

imbalance (per MD ordersD5 1/2NS@75mL/hr) • Encourage patient to eat and drink as tolerable • Order Ensure Enlive (350 Kcal, 20 g protein each) three

times per day (TID) at each meal (B/L/S)

Nutrition Monitoring & Evaluation • Reevaluation: every 3-4 days • Monitor: • Weight trends • Nutrition related labs (electrolytes) • Nutrition intake

Labs after 7 days on IVF Lab

Value

High/Low/WDL

Glucose, Fasting

97

WDL

BUN

14

WDL

Creatinine

0.8

WDL

Sodium

138

WDL

Potassium

4.2

WDL

Chloride

106

WDL

Calcium

8.4

LOW

Albumin

3.4

WDL

Bilirubin

0.9

WDL

White Blood Cell

7.6

WDL

HGB/HCT

16.3/48.1

WDL/WDL

Results • Day 8 D/C back to psych unit • Dehydration-resolved • IVF-D/C • Tamiflu x 7 days • Follow-up with pt every 3-4 days • Continue monitoring PO intake