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 doesnt have enough water and other fluids
to carry out its normal functionsMayo 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 its
total fluid

Moderate: when the total fluid loss reaches 6-9%

Severe: when the body reaches 10% fluid loss,

considered an emergency
 Mild
Mild Moderate
Moderate Severe
Severe
Weight Loss Mild
Mild
3-5%
Moderate
Moderate
6-9% Severe Severe
>10%
Weight Loss 3-5%Mild Moderate
6-9% Severe
> Or = 10%
Weight Loss 3-5%Mild 6-9%Moderate >10%Severe
Weight Loss
Blood pressure 3-5%
Weight Loss Normal
3-5% 6-9%
Orthostatic
6-9% >10%
>10%Shock
Weight Loss
Blood Blood pressure
Normal3-5% Orthostatic
6-9% Shock
>10%
Normal Orthostatic Shock
Blood pressure Normal Orthostatic
Pressure
Blood
Pulse pressure Normal
Normal
Blood pressure Normal Orthostatic Shock
Increase
Orthostatic Shock
Tachycardic
Shock
Pulse Normal Increase Tachycardic
Pulse Pulse
Pulse
NormalNormal Increase
Increase Tachycardic
Tachycardic
Pulse
Behavior NormalNormal Increase Tachycardic
Increase Lethargic Tachycardic
Behavior Normal
Normal Irritable
Irritable Lethargic
Behavior Normal Irritable Lethargic
Behavior Behavior Normal
Membranes Normal
Moist Irritable
Dry
Irritable Lethargic
Lethargic
Parched
Membranes
BehaviorMembranes Moist
Normal
Moist Dry
Dry Irritable Parched
Parched Lethargic
Membranes Moist Dry Parched
Tears Present Decrease Absent
Membranes
Tears Tears
Moist Present Dry Decrease Parched
Absent
Membranes Tears Present
Moist Present
Decrease
Dry
Decrease
Absent
Absent Parched
Cap. Refill 2 seconds 2-4 seconds >4 seconds
Cap. Refill 2 seconds 2-4 seconds >4 seconds
Tears Cap. RefillPresent
Cap. Refill 2 seconds
2 seconds Decrease
2-42-4 seconds
seconds Absent
>4 seconds
>4 seconds
Tears Urine SG
Urine SG
Present
>1.020 >1.030 Decrease Oliguria Absent
>1.020 >1.030 Oliguria
Urine SG >1.020 >1.030 Oliguria
Urine
UrineSG
SG >1.020
>1.020 >1.030
>1.030 Oliguria
Oliguria
Cap. Refill 2 seconds 2-4 seconds >4 seconds

Urine SG >1.020 >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, dark-

colored 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/uploads/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 Central, Ltd. 16
June 2014.
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 Adm weight: 169.5 lb/75.8 Kg IDW:142 lb/64.5Kg

Admission 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 212 High
Cholesterol
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 ordersD5 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