327.

These three numbers probably don't mean anything to you unless they happen to be your lucky lottery numbers, that is, until I put the letter "F" in front of them. F327. Now you are probably thinking about the long-term care survey "F tag" numbers. F327 is the tag number assigned to the regulation on hydration. This regulation states that the facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. The issue of adequate hydration is not only important because it is a regulatory requirement but because water is the most vital nutrient. Although we could live several weeks without food, we could only survive a few days without water.

Functions of Water
       Water performs many essential functions in the human body. One of the primary functions is to provide turgor or fullness to the body tissues. In other words, water gives us shape by exerting fluid pressure on the cell membranes. Females are approximately 50 to 55 percent water, while males are about 55 to 65 percent water.1 The higher water content in most men is due to their higher muscle content. Water makes up about three fourths of the weight of lean tissue and less than one fourth of the weight of fat.2 For example, a man weighing 165 pounds is carrying about 90 to 107 pounds of water. Water serves as the medium for all life-supporting chemical reactions in our body.3 It is essential because it is the necessary chemical solvent on which various body tissue solutions are based.1 Water also maintains stable body temperature. Depending on the climate, the skin will adjust its water loss in order to maintain an acceptable body temperature. As perspiration is evaporated, the body is cooled. Water is also important in maintaining blood volume, carrying nutrients and waste products throughout the body, and acting as a lubricant and cushion around joints and other areas of the body, such as inside the eyes.2

Risk Factors and Symptoms
       The primary safeguard against dehydration is the thirst mechanism. Thirst occurs as a result of even small fluid losses.4 As we age, the thirst mechanism becomes less sensitive, and many elderly and infirm patients may not even recognize thirst due to altered cognition or sensory impairments. Other risk factors for dehydration include diarrhea, fever, uncontrolled diabetes, dementia, fluid restrictions, diuretic therapy, functional impairments, such as not being able to hold a drinking cup, urinary tract infections, internal bleeding, and swallowing disorders. When a patient is assessed as having one or more risk factors for dehydration, it is important to be able to recognize the symptoms of dehydration and have an action plan. Table 1 outlines the common symptoms of dehydration.

Estimating Fluid Needs
        It is often said that we need to drink eight glasses of water each day. While this is a good general rule, more precise estimates of fluid needs may be based on caloric intake or body weight. According to the National Academy of Sciences/National Research Council (NAS/NRC), it is impossible to set a general water requirement. This is because the requirement is the amount necessary to balance the insensible losses (which can vary markedly) and maintain a tolerable solute load for the kidneys (which may vary with dietary composition and other factors). Rather than set a Recommended Dietary Allowance (RDA) for water, the NAS/NRC advises that 1mL/kcal of energy expenditure can be recommended as the water requirement for adults.5 As with most recommendations, this is for adults under average conditions of activity and in average climates. The recommendation may be increased to 1.5mL/kcal to cover variations in activity level, sweating, and solute load.5
       The second method of estimation is based on body weight. For patients with normal fluid status, 30mL/kg of body weight is recommended.6 The estimate may range from 25-35mL/kg body weight depending on the clinical condition of the individual. For example, a patient with congestive heart failure would require 25mL/kg body weight, while a dehydrated patient would be assessed at the higher end of the range. It is important to note that the minimum recommendation regardless of caloric intake or weight is 1500mL/day. Table 2 summarizes these different methods of estimation.

Action Plan
       The prevention and treatment of dehydration is the responsibility of the entire care team. Dehydration can begin in only a few hours, so it is important to constantly monitor for the warning signs. Staff members should be trained to have a heightened awareness of dehydration particularly in the warmer months. This can be accomplished with inservice education programs, messages in the employee newsletter, pocket guides listing the signs and symptoms for which to watch, and various incentive/reward programs.
       Most treatment plans focus on providing a wide array of beverage choices at frequent intervals throughout the day. Although water is always a good choice, fluids may also include juice, milk, ice chips, fruit ices, sorbets, soups, gelatins, ice cream, and medical nutrition supplements, such as shakes. Foods with a high water content may also contribute to the overall daily fluid intake. Table 3 lists the percentage of water in some common foods. Caffeinated and alcoholic beverages are not emphasized, because they may have a diuretic effect. However, in moderation, these beverages may be acceptable, if they are what the patient desires. Table 4 lists strategies that may be used to combat dehydration.
       Several new drinking supplies are available to promote independence when it comes to hydration. A hydration system from Nutritional Focus (Indianapolis, Indiana) consists of a bag similar to an enteral feeding bag that is connected to a line with a mouthpiece at the end. The bag is filled with any fluid, and rather than drinking from a cup, the patient simply drinks from the mouthpiece. This company also distributes a drinking cup that delivers one teaspoon of liquid at a time for patients who have swallowing problems or who are at risk of aspiration. These special cups can be fitted with angled or straight mouthpieces, have non-skid bases, and are leak proof.

Conclusion
       Dehydration is an important issue, because water is vital to basic survival. Rather than manage this problem begrudgingly, have some fun with your hydration programs. Invent a facility signature beverage, plan a "soda shoppe" party, have a recipe contest, decorate the water pitchers, add variety to your beverage selection, and raise a glass to good health and good survey reports!