Table 1 Summary of extracted data

Inter rater repeatability 70–95% agreement.

Specificity

62%, (95% CI 52–72%)

32%, (95% CI 23–43%)

56%, (95% CI 46–66%)

65% (95% CI 55–75%)

The authors identified tongue dryness as a clinical feature to identify dehydration amongst older people. Further studies were recommended.

Presence of mild dehydration:

71.4%,(OR 4.4 (95% CI 0.8–26.1))

57.1%, (OR 3.0 (95% CI 0.5–15.8))

57.1%, (OR 2.3 (95% CI 0.4–12.0))

88.7%, (OR 2.6 (95% CI 0.2–24.6))

14.3%, (OR 5.8 (95% CI 0.3–106.4))

The authors reported that physical, rather than biochemical, parameters more often identified mild dehydration.

Patient’s scores evaluated within 3 days of admission and at discharge. Scores on the DRAC did not significantly change between admission and discharge and were not correlated with laboratory measures of dehydration.

40 items were reduced to 17 based on frequency distribution. The remaining factors were examined for their association with dehydration, which varied from −0.012 (female gender) to 0.567 (urinary incontinence). See Table 3 for the factors included. Overall there was low to moderate association with dehydration. An increased number of risk items indicate a greater overall risk.

The authors concluded that the management of fluid and electrolyte balance requires a complex mixture of skills including knowledge, expertise and an understanding of the underlying physiological principles of fluid balance in the body. The use of multiple patient assessment cues should be used by nurses to differentiate between and respond to the various causes of dehydration. Actions include education for older adults on adequate fluid intake, visual reminders to drink, increased offering of fluids between meals and special drinking apparatus or swallowing exercise.

Recommendations were to assess 24 h fluid intake, urine colour, and symptoms associated with dehydration risk before formalising an individual hydration plan.

96 records were audited showing an increase from 40% to 100% in risk identification, but there was no improvement in hydration management. The audit tool was useful in identifying current practice, to facilitate change with the aim to improve clinical outcomes in residential homes.

Approach categories included: administration, work with clinical staff and in service education activities. An assessment tool, administrative and education guidelines and brain storming sheets are included to allow the reader to initiate a prevention of dehydration programme. Items on the assessment chart had equal weighting. A higher risk of dehydration was assumed if more factors were present.

Audit results indicated inadequate staff knowledge about the assessment and management of fluid volumes. Nine principles were developed to improve hydration management. The bundle included urine colour charts and a drinks tick chart for patients. Staff were provided with a range of tools for auditing and recording hydration.

Hydration management should be defined in three stages: risk identification, intervention and review. Individual management plans should include a statement regarding the frequency that patients are to be offered drinks. The DRAC was divided into the following sections: Significant health conditions/situations, intake behaviours, medications and laboratory results with female gender and aged over 85 also higher risk factors.

Dehydrated patients had a non-significant higher median test strip Usg and refractometer Usg and Ucol than those hydrated. The within-subject agreement between the refractometer Usg and nurse’s opinion was 84%. Refractometer agreed with 40% of urine test strip Usg. Agreement between refractometer Usg and Ucol was 67%. The results do not support the use of the urine test strip urine specific gravity as an early indicator of dehydration.

Urine colour averaged over several readings provides another tool in assessing dehydration status with individuals with adequate renal function when compared against urine specific gravity. The authors concluded that the method is low intensity and low cost but further study is needed to improve generalizability.

Patient questionnaires −142 distributed, 44 returned suggesting the drinking aid was easy to use.

Post-intervention significant improvements seen in TBW (p = 0.001), bowel movements (p = 0.04), reduction in laxative use (0.05), decline in number of falls (0.05) and decline in costs (0.05). 53% of participants always consumed an additional 8 oz of beverage mid-morning and mid-afternoon. The authors conclude that providing two additional glassed of fluid per day is a simple intervention and can make an important difference in a resident’s quality of life.

Significant correlations with fluid intake changes were: age (r = −.32, P = .015), BMI (r = .45, P = .001), and MMSE (r = − .494, P = .000). The intervention was effective in increasing fluid intake. Verbal prompting alone was effective in improving fluid intake in the more cognitively impaired residents, whereas preference compliance was needed to increase fluid intake among less cognitively impaired residents.

Post intervention

0% (two participants over hydrated)

There was an overall decrease in dehydration, and significant improvements in mean urinometer scores (p < 0.002)

Survey had a 33% response rate. 79.2% had received the poster pack and 69.8% had displayed them. Posters were displayed on wards 54.7% of the time. 45.3% of respondents had a policy to monitor hydration, 15.1% had a policy but felt it needed updating, 28.3% did not respond to the question and 11.3% of respondents did not have a policy to monitor hydration. Challenges preventing hydration monitoring− 22.6% compliance of documentation. 17% keeping up to date with current practice and 11.3% raising staff awareness on the importance of monitoring. 64.2% felt staff would benefit from more training.

8 of 11 NHS trusts were using the tool. The five key points introduced included: All patients should have their fluid needs assessed, a plan should be made for each patient, fluid intake should be managed continuously, hydration should be reviewed for early detection of deterioration, and education for all should underpin the principles of successful fluid management.

The toolkit comprised factsheets; checklists and advice presented in 11 sections from the RCN nutrition now campaign.

In the case study presented, success was signalled by normal skin and tongue turgor, urine output in adequate amounts with normal specific gravity, pulse, blood pressure and absence of risk factors.

38% of staff reported conducting fluid intake/output assessments. Nursing staff scored higher.

Knowledge (% correct)

47

76

63

15

The results demonstrated a need to enhance awareness and assessment skills.

Recommended 20 points to encourage water consumption. Some of these included: using visual aids for patients at increased risk, to offer larger volumes of fluid when giving out medication and to include patients, family and friends in hydration promotion.

The article presents a summary of previously published information to increase the readers knowledge of definitions, risk factors and intervention included in the DRAC.