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Keep on sippin'

Nearly every month, Mrs. D, 89, comes into our hospital's urgent care facility with a raging urinary tract infection. Though she's healthy otherwise and has good renal function, she consistently shows a high-normal hematocrit, a high-normal serum osmolality, and other signs and symptoms of dehydration. I want to encourage her to increase her fluid intake, but she enjoys drinking only caffeinated coffee. How can I help her?-P.T., IDAHO


First, tell your patient not to postpone fluid intake until she feels thirsty. Older adults have a decreased thirst drive, even when dehydrated.1 By the time she feels thirsty, she may already be experiencing mild dehydration. Older adults have less total body water so they're at increased risk for dehydration.

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In the presence of good health and good renal function, 2,700 mL water per day (about 600 mL of fluid from food plus eight to nine 8-oz glasses of fluid) has been recommended, though not well studied.1 Share these ideas with your older patients:


* Get some light unbreakable cups and glasses with long handles and tip-proof bases that are easy to hold and carry.


* Keep a cup of water (or other noncaffeinated, nonalcoholic fluid) with you everywhere, especially when you're in bed or watching TV, to remind yourself to drink.


* Have a full cup (at least 8 oz or 240 mL) of juice or water at each meal and drink it all. Noncaffeinated coffee or tea is okay in moderation.


* Plan mid-morning and afternoon "fluid breaks" with fruit or vegetable juice, water, milk, low-salt soup or broth, or any other noncaffeinated fluid you enjoy.


* Eat more food with high fluid content, such as oatmeal. Add milk for even more fluid. Gelatin, pudding, ice pops, ice-cream bars, frozen yogurt, sorbet, and sherbet make delicious fluid-filled snacks.


* Cottage cheese and yogurt are also liquid-rich, and milk is nutritious. Hot cocoa made with milk has significantly less caffeine and much more nutrition than decaf coffee. Fresh fruit and vegetables such as celery and lettuce are full of fluid.




1. Popkin BM, D'Anci KE, Rosenberg IH. Water, hydration, and health. Nutr Rev. 2010;68(8):439-458. [Context Link]



Don't call me[horizontal ellipsis]

In the facility where I work, hospital policy and procedure requires nurses to call the healthcare provider whenever a patient's blood glucose level exceeds 250 mg/dL. Several primary healthcare providers write orders stating they aren't to be called unless blood glucose levels exceed 350 mg/dL. We nurses feel we're failing in our advocacy role if we don't call the healthcare provider for orders when a patient with an elevated glucose level is trending in the wrong direction. How should the nursing team handle this?-K.D., VA.


Our consultant, a nurse attorney, says that an order that deviates from facility policy is a potential breech of the facility's standard of care, creating potential safety and liability issues. If some healthcare providers are writing orders contrary to hospital policy without an adequate explanation or clinical reason, our consultant advises the following:


* Orders that conflict with hospital policy should be reported through channels to nursing administration and the facility's medical leadership, who need to work together to resolve the conflict as soon as possible.


* If a nurse receives an order that deviates from hospital policy, he or she should inform the healthcare provider that hospital policy requires another action and that the nurse must adhere to that standard. If the healthcare provider objects to this, he or she should pursue the matter through proper channels.


* The nurse needs to document that he or she notified the healthcare provider of the blood glucose level and the action taken. If the nurse doesn't feel that the healthcare provider responded appropriately, the nurse should inform the direct supervisor and complete an event report.



If hospital policy and a healthcare provider's order conflict, hospital policy wins. That's the facility's standard of nursing care and the legal basis on which a nurse's actions would be judged if a patient were harmed.