Hydration Management

Maintaining adequate fluid balance is an essential component of health across the life span; older adults are more vulnerable to shifts in water balance, both overhydration and dehydration, because of age-related changes and increased likelihood that an older individual has several medical conditions. Underhydration and dehydration are the more frequently occurring problem.


A.  Definitions

  1. Dehydration is depletion in TBW content caused by pathological fluid losses, diminished water intake, or a combination of both. It results in hypernatremia (more than 145 mEq/L) in the extracellular fluid compartment, which draws water from the intracellular fluids (Metheny, 2000). The water loss is shared by all body-fluid compartments, and relatively little reduction in extracellular fluids occurs. Thus, circulation is not compromised unless the loss is very large.
  2. Underhydration is a precursory condition to dehydration associated with insidious onset and poor outcomes (Mentes & Culp, 2003). Others have referred to this condition as mild dehydration (Stookey, 2005; Stookey et al., 2005), chronic dehydration (Bennett et al., 2004), or impending water-loss dehydration (Hooper et al., 2011).

Etiological factors associated with dehydration

Environment: Residing in long-term care as compared with community dwelling (Lesnik et al., 2017; Rodrigues et al., 2015)


Staff and family characteristics

Inadequate staff and professional supervision: Kayser-Jones, Schell, Porter, Barbaccia, & Shaw, 1999

Presence of more staff: Namasivayam-MacDonald et al., 2018

Family or caregivers not spending time with patient: Mentes, Chang, & Morris, 2006


Age-related risk factors

Age-related changes in body composition with resulting decrease in TBW: Bossingham et al., 2005; Lavizzo-Mourey et al., 1988; Metheny, 2000

Decreasing renal function: Lindeman, Tobin, & Shock, 1985

Lack of thirst: Farrell et al., 2008; Kenney & Chiu, 2001; Mack et al., 1994; Miescher & Fortney, 1989; Phillips et al., 1984; Phillips et al., 1991

Poor tolerance for hot weather: Josseran et al., 2009


Risk factors: Individual characteristics

Older than 85 years of age: Ciccone et al., 1998; Gaspar, 1999; Goldberg et al., 2014: Lavizzo-Mourey et al., 1988; Mentes et al., 2019; Murray et al., 2015

Female: Gaspar, 1988; Lavizzo-Mourey et al., 1988; Marra et al., 2016; Namasivayam-MacDonald et al., 2018

Semidependent in eating: Gaspar, 1999; Gaspar et al., 2019

Functionally more independent: Gaspar, 1999; Mentes & Culp, 2003

Functionally more dependent (especially with eating): Botigué et al., 2018; Marra et al., 2016; Mentes et al., 2019; Murray et al., 2015; Namasivayam-MacDonald et al., 2018

Few fluid ingestion opportunities: Gaspar, 1988, 1999; O. F. Jimoh, Brown, Bunn, & Hooper, 2019

Inadequate nutrient intake: Gaspar, 1999; McGrail & Kelchner, 2015

Alzheimer’s disease or other dementias or cognitive impairment: Albert, Nakra, Grossberg, & Caminal, 1989, 1994; Botigué et al., 2018; Marra et al., 2016; McGrail & Kelchner, 2015; Namasivayam-MacDonald et al., 2018; Paulis et al., 2018

Four or more chronic conditions: Lavizzo-Mourey et al., 1988

Four medications: Lavizzo-Mourey et al., 1988

Fever: Pals et al., 1995; Paulis et al., 2018; Weinberg et al., 1994

Vomiting and diarrhea: Wakefield, Mentes, Holman, & Culp, 2008

Individuals with infections: Warren et al., 1994

Individuals who have had prior episodes of dehydration: Mentes, 2006

Depression or loneliness associated with decreased fluid intake as identified by nursing staff: Mentes, Chang, & Morris, 2006

Diuretics: thiazide: Wakefield et al., 2008

Diuretics: loop and thiazide: Lancaster et al., 2003

Risk of pressure ulcer: Botigué et al., 2018

Texture modified diet: Botigué et al., 2018; Painter, Le Couteur, & Waite, 2017

Receiving oral nutritional supplement: Marra et al., 2016

Impaired swallowing and/or dysphagia: Botigué et al., 2018

Diabetes: Marra et al., 2016


Interventions for Enhancing Hydration Status

A. Risk identification

Mentes & IVANRC, 2000

  1. Identify acute situations: vomiting, diarrhea, or febrile episodes: Mentes & IVANRC, 2000
  2. Use a tool to evaluate risk: Mentes & IVANRC, 2000
    • Dehydration Risk Appraisal Checklist (LTC): Mentes & Wang, 2010
    • Northumbria Assessment of Hydration (acute care) Risk of insufficient fluid intake: Oates et al., 2017
  3. Use a tool to evaluate adequacy of intake: Drink Diary: O. Jimoh, Bunn, & Hooper, 2015

B. Acute hydration management

Monitor input and output: Weinberg et al., 1994

Provide additional fluids as tolerated: Weinberg et al., 1994

Minimize fasting times for diagnostic and surgical procedures: Parameters, 2017

Offer subcutaneous or intravenous fluid in parallel with encouraging oral fluid intake for those experiencing dehydration and who are unable to drink: Volkert et al., 2018

C. Chronic/long-term hydration management

Systematic reviews of evidence have not identified a specific intervention for the management of dehydration and/or inadequate fluid intake (Abdelhamid et al., 2016; Bunn et al., 2016; Herke et al., 2018; Volkert et al., 2018). An individualized resident-centered care plan that considers the following strategies is needed (Volkert et al., 2018)

Provide fluids consistently throughout the day

Bak, Wilson, Tsiami, & Loveday, 2018; Bunn, Jimoh, Wilsher, & Hooper, 2015; Ferry, 2005; Hodgkinson et al., 2003; F. O. Jimoh et al., 2015; O. F. Jimoh et al., 2019; Mentes, Chang, & Morris, 2006; Oates & Price, 2017; Robinson & Rosher, 2002; Simmons, Alessi, & Schnelle, 2001; Volkert et al., 2018

Specific Effective Strategies

Plan fluid intake as follows: 75%–80% delivered at meals, and 20%–25% delivered during nonmeal times such as medication times and planned nourishment times: Volkert et al., 2018

Offer a variety of fluids keeping in mind the individual’s previous intake pattern: Bunn et al., 2015; Godfrey, Cloete, Dymond, & Long, 2012; Schnelle et al., 2010; Simmons et al., 2001; Volkert et al., 2018; Wilson et al., 2019: Zembrzuski, 1997

Integrate fluid rounds midmorning and late afternoon, where caregiver provides additional fluids: Spangler, Risley, & Bilyew, 1984

Standardize fluid with medication administrations to a prescribed amount; e.g. 180 mL (6 oz.) per administration time: O. F. Jimoh et al., 2019; Mentes & Culp, 2003

Provide 2–8 oz. glasses of fluid in a.m. and p.m: Robinson & Rosher, 2002

If taking thickened liquids, encourage intake (water intake lower when taking thickened liquids as compared with thin liquids): McGrail & Kelchner, 2012, 2015; Painter et al., 2017

Select between-meal snacks that will increase water intake: Marra et al., 2016

Provide fluids between waking and breakfast: O. F. Jimoh et al., 2019

Provide reminders/prompts to drink fluids: Bak et al., 2018; Bunn et al., 2015; Godfrey et al., 2012; Oates & Price, 2017

Offer a variety of fluids with consideration for residents’ preference: Godfrey et al., 2012; Mentes, Chang, & Morris, 2006; Robinson & Rosher, 2002; Schnelle et al., 2010; Simmons et al., 2001; Wilson et al., 2019

Interventions and Strategies


Make drinking opportunity a pleasurable and social experience

Abdelhamid et al., 2016; Cook, Hodgson, Hope, Thompson, & Shaw, 2019; Godfrey et al., 2012

Specific Effective Strategies

“Happy Hours” in the afternoon, where residents can gather together for additional fluids and socialization: Mentes, Chang, & Morris, 2006; Musson et al., 1990

“Tea Time” in the afternoon, where residents come together for fluids, nourishment, and socialization: Mueller & Boisen, 1989

Encourage resident to have meals in the dining room: Reed, Zimmerman, Sloane, Williams, & Boustani, 2005; Volkert et al., 2018

Create a noninstitutional dining experience: Reed et al., 2005, Volkert et al., 2018

Create a drink-friendly environment: Cook et al., 2019

Ensure utensils and level of assistance are resident centered

Specific Effective Strategies

Use of modified fluid containers based on resident’s intake behaviors (e.g., ability to hold cup, to swallow): Bak et al., 2018; Mueller & Boisen, 1989; Reedy, 1988

Use high-contrast tableware during meals for residents with dementia: Dunne, Neargarder, Cipolloni, & Cronin-Golomb, 2004

Provide the appropriate level of assistance to enhance intake: Bunn et al., 2015; Godfrey et al., 2012; Marra et al., 2016

Increase toileting routine (in combination with other strategies): Bunn et al., 2015; Schnelle et al., 2010; Spangler et al., 1984; Tanaka et al., 2009; Zembrzuski, 2006

Interventions and Strategies


Ensure care providers (formal and informal) are knowledgeable of hydration needs and management strategies

Specific Effective Strategies

Bunn et al., 2015

Provide staff with education on hydration management (in combination with other strategies): Beattie, O’Reilly, Strange, Franklin, & Isenring, 2014; Greene et al., 2018; Oates & Price, 2017; Volkert et al., 2018; Zembrzuski, 2006

Coordinate staff communication about hydration such as certified nursing assistant (CNA) handoff reports or documentation in nursing care plan.: Mentes, Chang, & Morris, 2006; Ullrich & McCutcheon, 2008

Provide a staffing ratio that allows the needs of the residents to be met: Namasivayam-MacDonald et al., 2018; Reed et al., 2005

Encourage family involvement and support

Mentes, Chang, & Morris, 2006

Promote Self-Management of Hydration

Provide education to improve individuals’ hydration health literacy: Picetti et al., 2017

Individuals who are cognitively intact and physically capable can be taught to use the Drinks Diary to self-monitor their fluid intake.: Jimoh et al., 2015

Assist to establish individuals' fluid intake goal based on the calculated fluid recommendation.: Volkert et al., 2018

Individuals who are cognitively intact and visually capable can be taught how to note changes in their level of hydration through the use of a color chart, to compare with the color of their urine. The chart is most accurate in individuals with better renal function.: Armstrong et al., 1994, 1998; Mentes, Wakefield, & Culp, 2006

Fluid Regulation and Documentation

Note: Frequency of documentation of fluid intake will vary from setting to setting and is dependent on an individual’s condition.

Document a complete intake recording, including hydration habits: Mentes & IVANRC, 2000

Create fluid volume list of each utensil to accurately calculate fluid consumption: Burns, 1992; Hart & Adamek, 1984

Implement use of the Drinks Diary: F. O. Jimoh et al., 2015


A. Health history

Mentes & IVANRC, 2000

Specific disease states: dementia, congestive heart failure, chronic renal disease, malnutrition, and psychiatric disorders such as depression: Albert et al., 1989; Gaspar, 1988; Warren et al., 1994

Presence of comorbidities: more than four chronic health conditions: Lavizzo-Mourey et al., 1988

Prescription drugs: number and types: Lavizzo-Mourey et al., 1988

Past history of dehydration, repeated infections: Mentes, 2006

B. Physical assessments

Complete an exam that includes vital signs, height, weight, BMI (Vivanti et al., 2008), review of systems, Mentes & IVANRC, 2000

C. Focused assessment on indicators of hydration

Chief complaint of fatigue: Hooper et al., 2015

D. Laboratory tests (Mentes & Gaspar, 2020)

Urine specific gravity: Mentes, 2006; Wakefield et al., 2002

Urine color: Mentes, 2006; Wakefield et al., 2002

BUN–creatinine ratio: Mentes & Gaspar, 2020

Serum sodium: Mentes & Gaspar, 2020

Serum osmolality and a serum osmolality estimation equation based on serum measures of urea, glucose, sodium, and potassium: Siervo, Bunn, Prado, & Hooper, 2014

Salivary osmolality: Fortes et al., 2015

E. Assessment of ingestion behaviors and hydration habits

Individual fluid-intake behaviors: Mentes, 2006

Subcategory of hydration patterns (can drink, cannot drink, will not drink, end of life): Mentes, 2006

Missing drinks between meals: Hooper et al., 2015

Screen hospitalized older adults using the NoAH: Oates et al., 2017



A.  Maintenance of body hydration (Mentes & Culp, 2003; Robinson & Rosher, 2002; Simmons et al., 2001)

B.  Decreased infections, especially urinary tract infections (McConnell, 1984; Mentes & Culp, 2003; Robinson & Rosher, 2002; Murry et al., 2015)

C.  Improvement in urinary incontinence (Spangler et al., 1984)

D.  Lowered urinary pH (Hart & Adamek, 1984)

E.  Decreased constipation (Murray et al., 2015; Robinson & Rosher, 2002)

F.   Decreased acute confusion (Mentes et al., 1999)

G.  Improved fluid intake

H.  Improved hydration health literacy (Picetti et al., 2017)



A.  Urine color chart monitoring in patients with better renal function (Armstrong et al., 1994, 1998; Wakefield et al., 2002)

B.  Urine specific gravity checks (Armstrong et al., 1994, 1998; Wakefield et al., 2002)

C.  Twenty-four-hour intake recording (Metheny, 2000)

D.  Drinks Diary to document fluid intake in individuals who are cognitively intact (F. O. Jimoh et al., 2015)

E.  Hydration Health literacy (Picetti et al., 2017)

F.   Salivary Osmolality (Volkert et al., 2018)



A.  Hydration management evidence-based protocol available from the University of Iowa College of Nursing Gerontological Nursing Interventions Research Center, Research Dissemination Core. Authors: Janet Mentes and Phyllis Gaspar, revised 2019.

B.  ESPEN (European Society for Clinical Nutrition and Metabolism) guideline on clinical nutrition and hydration in geriatrics (Volkert et al., 2018).

C.  Dehydration and Fluid Maintenance in the Long-Term Care Setting Clinical Practice Guideline by The American Medical Directors Association, 2009.



BMI             Body mass index

BUN            Blood urea nitrogen

IVANRC    Iowa–Veterans Affairs Nursing Research Consortium

MMSE         Mini-Mental State Examination

NoAH         Northumbria Assessment of Hydration

TBW            Total body water


Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 12:  Gaspar, P., & Mentes, J. (2021) Managing Oral Hydration in the Older Adult.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 157-177).  New York: Springer.


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