For those who work in urgent care, and the emergency room, how many times have patients come in, especially the older adult, and they are dehydrated? Often you find it hard to get an IV going, the veins collapse and roll. The person may not even remember when they took in the last fluids. Their skin “tents” when pinched, their lips are cracked and dry and they appear to have “cotton mouth” and poor oral hygiene.
Dehydration can be a major issue with patients / residents in facilities due to inability to physically reach for the water pitcher (if even within reach), do not like water or even better, they do not want to drink because of having to go to the bathroom. Where is the nursing staff and the administration? Do they not see this problem?
During the review of a case presented to me for deviations in the Nursing Standard of Care, the dietary assessment is included or should be. If it has not been included, this is a part of the medical records which need to be requested during discovery. A Register Dietician has calculated the calorie and fluids needed for the patient / resident depending on weight and disease process. The patients likes and dislikes are included in the assessment and part of the plan of care.
The older adult is always at greater risk for dehydration than younger people because of the many physical changes that occur in the aging process. I like to call it the “maturing process”. In facilities this is especially important because fluids may not be easily available nor provided by staff, within reach such as left on the bedside table or overbed table that cannot be easily reached.
The lack of staff and time is sadly often the problem to provide hydration. It is very time consuming to feed and provide fluids during the meals and medication passes. It can take between 30 to 45 or more minutes for each meal.
The older population is a group that cannot be rushed during meals. They consume their food and fluids at their own pace, sometimes with cueing and staff assistance. Additionally, the nursing staff, due to lack of staff and time, have not even looked at the dietary plan of care daily assessed hydration needs.
Accurate and appropriate documentation by each shift is required to monitor and assess the patient / resident. Without this documentation and knowledge of the dietary plan of care, there is a lack of communication between shifts and other facility personnel.
For example: A patient may be assessed by dietary requiring a daily 1500 ml of fluids and 1500 kcal. This is necessary to maintain and provide hydration and nourishment. If the resient / patient is not consuming the required amounts, there is a reason and it must be investigated and plan of care updated.
Many and sadly too many of my cases reflect the lack of fluids, lack of nutrition, evening snack for diabetics and the patient / resident declines. The staff was not sufficient to meet the needs of the person entrusted in their care.
Additionally the staff fails to notice the signs and symptoms of dehydration to prevent this problem and provide treatment. The staff has failed to notice signs of the dry mouth, lack of oral care on a daily and regular basis, the eyes have became sunken and the urination decreases and / or the urine color is dark and foul smelling.
Dehydration increases the risk for other medical problems due to toxic wastes, and bacteria not being able to be flushed from the body. Some of the medical problems include but not limited to urinary infections, confusion, falls and often with injury, kidney stones and damage.
Not only is lack of fluids provided to a nursing home resident or hospital patient a cause and problem of dehydration leading to infection, but the use of urinary catheters, diabetes, falls, and lack of mobility increase the risk.
If an individual is not independent in their mobility to get to the bathroom on a regular basis and there is lack of staff to assist, they may not eliminate as necessary. Toxins and bacteria build up, they sit is soiled and wet briefs and linens leading to skin breakdown, infections and again increase the risk of dehydration because they do not want to drink fluids. If they drink fluids, they will have to go to the bathroom more often and they do not receive the needed assistance.
The responsibility of hydration is the caregivers, the professionals in the facility, the director of nursing, the nursing supervisors and the facility administrator. Everyone in the facility is responsible and there is delegation of the care, the report from shift to shift, and the accurate and appropriate documentation. 
A facility must ensure that a qualified dietitian is utilized in planning, manage and implementing dietary service activities in order to assure that the residents receive adequate nutrition. This includes both food and fluids.
 42 CFR 483.60 Food and nutrition services.