Simply Dehydration

blondy2061h, MSN, RN · Jan 23, 2009

75 ml/hr isn't a very impressive rate if they thought it was dehydration.

Tolle_lege · Jan 23, 2009

yeah, I wondered about that too.

rnmi2004 · Jan 23, 2009

Any hx of HF going on here?

Tolle_lege · Jan 23, 2009

No HF although she did have kidney stones last year per report of another nurse in my facility..

kmoonshine, RN · Jan 23, 2009

Ok, I'm going to take a stab at this one...

Pts that are hypernatremic can't receive rapid IV fluid therapy to try to correct the imbalance (it must be done slowly). Quickly adding IV fluids (which would be hypotonic when compared to the pts blood composition) would cause water to move from a high concentration (outside the cell) to a low concentration (inside the cell), causing cells to swell leading to cerebral edema, seizures, etc.

Her input is greater than her output because fluid is shifting back into the cells - which essentially is rehydrating her.

A sodium level of 148 is much better! You can't expect to go from 169 to 140 in a day - f this happened, the pt would most likely die due to cerebral edema.

Simple dehydration (elevated BUN, tachy, with little electrolyte imbalance) can be resolved quickly with IV fluids if the person is healthy. A sodium level of 169 is very high, and the pt is lucky to still be around.

She's institutionalized and appears to be unable to communicate her needs (ie thirst). Pair this with diuretics, and you're asking for trouble! People who can't that they are thirsty are at high risk for electrolyte imbalances and dehydration.

Tolle_lege · Jan 23, 2009

Any idea why this would change when there was no apparent change in her day fluid intake level over the last year? I mean she was getting about 1500 ml a day. Just seems strange. I don't think that I drink 1500 ml a day!

Virgo_RN, BSN, RN · Jan 23, 2009

Any idea why this would change when there was no apparent change in her day fluid intake level over the last year? I mean she was getting about 1500 ml a day. Just seems strange. I don't think that I drink 1500 ml a day!

What has her average fluid output been running? How often is she weighed? How certain can you be that the I&Os are correct?

morte, LPN, LVN · Jan 23, 2009

What has her average fluid output been running? How often is she weighed? How certain can you be that the I&Os are correct?

bingo, i have done enough long term care, to know that the I+O's can be a figment of the imagination...

the nurse needs to physically assess,,,skin turgor, etc

kmoonshine, RN · Jan 23, 2009

http://www.mcc.ca/objectives_online/objectives.pl?lang=english&loc=obj&id=99-1-E

http://www.medcalc.com/sodium.html

http://clinicalcases.org/2004/05/hypernatremia-due-to-dehydration-in.html

Possible causes: diuretics, fever, diarrhea, vomiting, decreased intake (is it possible that some of her oral fluids are bing miscalculated?). There's also other conditions that can cause hypernatremia (metabolic, diabetes insipitus, and so on). The main cause of dehydration and hypernatremia in the elderly is decreased intake (due to stroke, dementia, altered thirst mechanism, etc) and inability to request oral fluids (dementia, altered mentation, aphasia, etc). I think its recommended for the elderly to consume 30ml/kg of oral fluids/day. Assuming she is 60kg, she should have a minimum of 1800ml of oral fluids, evenly spaced throughout the day (unless excess fluids are contraindicated, as in kidney failure, chf, etc).

The pt's hypernatremia probably began long ago (chronic in nature). She probably has been building up a fluid deficit for weeks now and it all caught up to her. Also - is she able to adequately swallow her fluids? You said they are thickened; there's no chance she had a bout of aspiration pneumonia which exaccerbated her fluid "debt" (decreased intake with fever, tachy, diaphoretic, increased respirations, etc - all would increase insensible losses)?

Tolle_lege · Jan 23, 2009

Thanks for the input everyone... This client has been in this same facility for several years, which has a 3:1 ratio with caregivers and a nurse at each house. I have only worked here two weeks.

When at our facility she uses a brief so no exact I and O just voids x 2 or 3 a shift. Here weekly weights have not fluctuated very much, but she is on a weight control diet Over the last 3 mos she fluctuates between 158 and 154. Not weight change over over 2 lbs in the last three weeks.

I can't be sure of I and O because this is what the acute care nurse at the hospital told me, when I called at 1130 in the am and asked what 24 I and O was she added it up for me!

The labs were ordered because the MD visited and she did physically assess the client, and made no noted of appearing dehydrated.

She is elderly, but does not have DM. She is on synthroid and tegretol, and takes ibuprophen 1.2 g a day.

It is possible that she is just not being offered enough fluids anymore, but the staff is actually very caring and attentive with a low ratio...

I thought that possibly she might be having kidney issues, but perhaps it is just dehydration...

Virgo_RN, BSN, RN · Jan 23, 2009

There could be so many things going on here. Hopefully the doctors are on top of it and ordering the appropriate diagnostics, and will figure it out. I wouldn't mind an update when you find out what's going on.