Thursday, January 29, 2015

The Balancing Act of Hydration

ដកស្រង់ពីអត្ថបទ The balancing act of hydration


តុល្យភាពទឹក គឺ សំដៅទៅលើជាតិទឹកដែលរាងកាយរបស់យើងត្រូវការ ដើម្បីដំណើរការជាធម្មតា និង សម្រាប់សុខភាពទូទៅរបស់យើងផងដែរ។ មិនចំពោះមនុស្សវ័យក្មេង ឬ វ័យកណ្តាល ឬ វ័យចាស់នោះឡើយ កង្វះជាតិទឹកក្នុងខ្លួនអាចបង្ករបញ្ហាសុខភាពមួយចំនួនធំ ជាពិសេសមនុស្សចាស់ ឬ វ័យចំណាស់។ 

គួរកត់ចំណាំផងដែរថា ហានិភ័យនៃការខ្សោះជាតិទឹកក្នុងរាងកាយកើនមានឡើងតាមវ័យបស់យើង។ វ័យយើងកាន់តែចាស់ សិរីរាង្គកាយរបស់យើងមានការផ្លាស់ប្តូរ វាធ្វើឱ្យវាមានការពិបាកក្នុងការរក្សាលំនឹងសទិសភាពរយាងកាយ ផងដែរវាប៉ះពាល់ដល់តុល្យភាទឹក និង អំបិលនៅក្នុងរាងកាយរបស់យើង 

ការផ្លាស់ប្តូរដែលធ្វើឱ្យមនុស្សចាស់ភាគច្រើនងាយនឹងខ្សោះជាតិទឹកពីខ្លួនរួមមាន:
  • ការថយចុះនៃការផ្ទុកជាតិទឹកបានពេញលេញនៅក្នុងរាងរាងកាយ
  • ការថយចុះនៃអារម្មណ៍ស្រេកទឹក (គួរចំណាំ: ខ្សោះជាតិទឹកនោះ គឺ មិនមានអារម្មណ៍អាចដឹងភ្លាមៗនោះឡើយ) 
  • ការថយចុះនៃមុខងារតម្រងនោមដែលបង្កឱ្យសារធាតុរាវជាច្រើនត្រូវបានបញ្ចេញទៅជាទឹកមូត្រ
អាយុកាន់តែចាស់ ហានិភ័យមហានៃការធ្វើចលនាអាចបណ្តាលអោយ:
  • ការថយចុះនៃការដើរទៅរកទឹកទទួលទាន នេះដោយសារតែចល័តកម្មមានកម្រិត ឬ អស  មត្ថភាពក្នុងការប្រាស្រ័យទាក់ទងអំពីសម្រេកទឹក 
  • ការប្រើប្រាស់ថ្នាំ ដែលបណ្តាលអោយមានផលប៉ះពាល់ដល់តុល្យភាពសារធាតុរាវឧទា ហរណ៍ ថ្នាំបញ្ចុះទឹកនោម (Diuretics) ថ្នាំបន្ទន់លាមក (Laxatives) និង ថ្នាំព្យាបាលជម្ងឺលើសឈាម (ACE inhibitors)

    សញ្ញានៃកង្វះជាតិទឹក
    • សាកល្បងច្បឹចស្បែកហើយលែងវាវិញ - ជាធម្មតាស្បែករបស់យើងអាចវឹល ត្រឡប់មកកាន់សភាពដើមវិញដោយគ្មានពន្យាពេល (តែចំពោះមនុស្សចាស់វិញភាពយឺតរបស់ស្បែកបានបាត់បង់)។ 
    • និន្រ្ទាលភាព (Lethargic)
    • ព្យាកល់ភាព (Confuse)
    • ទល់លាមក (constipation)
    • គ្រុនក្តៅដោយគ្មានមូលហេតុ (Fever without obvious reason)
    • វឹលមុខ (Dizziness)
    • ដួល (Fall) ។

    • The typical signs of dehydration (eg, reduced skin turgor, thirst) may be absent in older people6
      Look for signs of lethargy, confusion, constipation, fever with no obvious cause, dizziness and falls.8
    • Assess the severity of dehydration based on symptomssodium levels and how quickly the dehydration developed8
      Consider hospitalising older people with severe dehydration and/or a severe salt balance disturbance.8
    • Advise your older patient and/or their carer to consume at least 1.5 litres of water eachday9
      Use the fluid calculator to determine how much fluid an individual needs (patients with end-stage kidney disease or chronic heart failure will require less water — assess and advise on a case-by-case basis).910
    • Use verbal prompts to encourage drinking between meals in cognitively impaired older people11
      Providing older people with the beverages they prefer is helpful for those with less cognitive impairment. 11

    The risk of dehydration increases with age

    Summer is upon us and it's time to think more carefully about adequate hydration, especially for older patients. As we age, physiological changes occur that make the body less able to maintain homeostasis and affect water and salt balance.8
    These changes make older people more susceptible to dehydration due to:
    • decreased total body water stores 12
    • decreased sense of thirst (dehydration is not felt as quickly)7
    • decreased kidney function causing more fluid to be excreted in urine.1013
    Growing older comes with greater risk of disabilities and comorbidities that may result in:
    • reduced access to drinks due to limited mobility or inability to communicate thirst 13
    • use of medicines that interfere with fluid balance, eg, diuretics, laxatives and ACEinhibitors.3

    Why is hydration important?

    Apart from avoiding the negative outcomes associated with dehydration, such as increased hospitalisation and possible mortality, some of the positive outcomes of adequate hydration include:
    • reduced risk of falls — postural hypotension has been identified as one of the risk factors for falls in older people. Adequate hydration may prevent postural hypotension. Consider this as part of a multi-factorial falls prevention strategy.4
    • less constipation — inadequate fluid intake is a cause of chronic constipation.3 In individuals who are not adequately hydrated, drinking more water can increase stool frequency and enhance the beneficial effect of daily dietary fibre intake.5
    • may help prevent UTIs — maintaining adequate hydration levels may help prevent UTIs.14

    A timely diagnosis and adequate hydration

    A timely diagnosis and adequate treatment of dehydration are important to reduce the risk of adverse outcomes.15 However, an early diagnosis is often difficult because the typical dehydration symptoms are less obvious in older people.8
    Observe patients for the following effects of dehydration:10
    • lethargy
    • confusion
    • constipation
    • fever with no obvious cause
    • dizziness
    • falls.

    When is dehydration severe?8

    • Signs that may indicate severe dehydration include hypotension, delirium, decline in consciousness or a substantial decrease in urine volume, high or low sodium levels. Note that these signs are non-specific and may be seen in other illnesses and syndromes.
    • Sudden loss of body water or salt, such as from vomiting and dehydration, can cause severe dehydration.

    Monitoring with a urine colour chart

    urine colour chart may be helpful in monitoring hydration status. However the effectiveness of this has only been validated in a sub-group analysis in people with adequate renal function (defined as creatinine clearance ≥ 50 mL/min in this study).16 Urine colour chart monitoring is not appropriate for people using incontinence pads.17
    Pale straw-coloured urine usually indicates normal hydration status; as urine darkens, poorer hydration is more likely.17 Remember that certain medicines (such as aspirin, warfarin and vitamins) and foods (such as fresh fruits and vegetables) can discolour urine.3 The colour chart is most effective when the average urine colour is calculated over several days.17

    Which form of dehydration?

    Suspect a certain form of dehydration based on the medical history, medicines use and signs and symptoms in the individual.

    Table 1. The different forms of dehydration1


    Sodium level / Serum osmolality
    Suspect when?
    Isotonic
    Balanced loss of sodium and water
    During a complete fast eg, for surgery/procedure
    After vomiting and diarrhoea (i.e. loss of large amounts of water and electrolytes in gastric contents)
    Hypertonic
    Water losses greater than sodium losses.
    Hypernatraemia (serum sodium levels > 145 mmol/L) and hyperosmolality (serum osmolality > 300 mmol/kg)
    Fever — results in loss of water through the lungs and skin, combined with limited ability to increase fluid intake
    Clinical signs may include:
    • abnormal subclavicular and thigh skin turgor
    • dry oral mucosa
    • recent change in consciousness
    Hypotonic
    Sodium loss exceeds water loss.
    Serum sodium decreased (< 135 mmol/L) and serum osmolality low (< 280 mmol/kg)
    Diuretic use
    SSRI use.18 (Consider monitoring fluid intake and serum sodium levels in older people who have recently been prescribed SSRIs18)

    When is oral fluid replacement appropriate?

    Oral fluid replacement is preferred to parenteral fluid replacement (subcutaneous/intravenous) or nasogastric feeding in the absence of severe symptoms and when fluids can be restored gradually over time.8
    Oral rehydration solutions or ice-blocks that contain appropriate amounts of electrolytes (eg, Hydralyte, Gastrolyte) may help treat mild dehydration.1920
    Sports drinks do not necessarily contain enough electrolytes to be an adequate substitute for oral rehydration solutions, and they often have a high sugar content.19
    Older people with severe dehydration and/or a severe salt imbalance should be hospitalised for parenteral fluid replacement therapy.8
    Too much fluid and improper monitoring may result in congestive heart failure and death.1Monitor the patient for signs of fluid overload including orthopnoea, shortness of breath, alterations in sleep patterns, or increased confusion.1

    Preventing dehydration is important

    An older person can become dehydrated even after a day of reduced intake.3
    Preventing dehydration requires an awareness of the physiological changes in older people as well as knowledge of risk factors for dehydration such as acute illness, hot weather and medicines that impact the fluid balance.8

    Assessing fluid status and reducing dehydration risk

    Assessing fluid status and dehydration risk can be performed by doctors and other health professionals such as visiting nurses, accredited pharmacists and carers.1
    Assessment includes a review and potential adjustment of:
    • food and fluid intake — patients consuming less than 50% of their meals are at risk of dehydration.21
    • medicines and concurrent medical illnesses — reducing or eliminating diuretics that are not clinically indicated may improve fluid balance. After stopping diuretics, monitor the patient for excessive weight gain, blood pressure elevation or signs of congestive heart failure. 1
    • environmental factors — in hot weather using fans and air conditioning and increasing free water intake may help prevent dehydration.1

    Dehydration prevention measures

    A US study in two aged-care facilities showed verbal prompting to drink between meals was effective in improving fluid intake in cognitively impaired older people while less cognitively impaired people increased their fluid intake if they were given the beverages they preferred.11
    Some tips to prevent dehydration include:22
    • offer or encourage water and fluids at all mealtimes
    • when giving medicines offer slightly larger volumes of water
    • encourage drinking small amounts consistently throughout the day
    • hot water with a piece of fruit such as lemon can appeal to those who prefer a hot drink
    • encourage water consumption in the morning for those concerned about increased toilet visits in the night from late evening drinks
    • use a Fluid Intake Tracker tool to encourage fluid consumption.
    Educate patients and their families or caregivers on the importance of hydration, the risk factors for dehydration and to report to their doctor when there is a reduced intake of fluid.3

    Let your patients know

    With summer now upon us and daily temperatures increasing, it is important to:
    • remind your patients that adequate fluid intake is important
    • remember young children, older adults and people with chronic illnesses are most at risk of developing dehydration
    • know the safest approach is to prevent dehydration in the first place
    • remind parents of young children to regularly offer water in hot weather.

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