Mostafa SHABAN, Huda Hamdy MOHAMMED, Sahar HASSAN

1Community Health Nursing Department College Of Nursing, Jouf University, Sakaka, Saudi Arabia; 2Maternal and Newborn Department, Faculty of Nursing, Cairo University, Cairo, Egypt; 3Department of Community Medicine, Hammurabi College of Medicine, University of Babylon, Babylon, Iraq

ABSTRACT As dehydration is related to negative health outcomes in the elderly, including an increased risk of disability and death, prevention may help improve health, functional status, and quality of life. Dehydration diagnosis can be challenging in the elderly as the traditional physical indications of dehydration may be absent or ambiguous. Numerous etiologies place the elderly at an increased risk. The role of the community health nurse (CHN) derives from the responsibilities attached to her, and the Betty Neuman’s Systems Model of health care with three levels of protection is usually applied to the CHN. In this mini-review, we try to integrate the Betty Neuman’s Systems Model with the results of identified articles. This study includes a literature search of reputable international databases such as SpringerLink, PubMed, Embase, and Wanfang, particularly for the period 2005 to the present. Ten articles that met the qualifying criteria were included in this study. The findings of this study draw a picture of the role of CHN in preventing dehydration across the three levels of prevention as mentioned by Betty Neuman.

Keywords: Community health nurse, dehydration, elderly, prevention

INTRODUCTION

In the elderly, dehydration is typically defined as a reduction in total body water (TBW) content caused by pathologic fluid loss, reduced fluid intake, or a combination of the two. When TBW is depleted due to pathologic fluid loss, reduced water intake, or a combination of the two, hypertonic dehydration ensues.[1]Both hypotonic dehydration (in which more sodium than water is lost and extracellular fluid is depleted) and isotonic dehydration (in which both water and sodium are depleted) result in extracellular fluid loss. The elderly are vulnerable to a number of variables that enhance their risk of dehydration. Some of these variables may be physiological, such as the loss of the subcutaneous fat layer, which causes the skin to become dry and wrinkled and makes fluid loss easier. Which includes several changes such as lack of saliva secretion and slow emptying of the stomach as well as the ability to absorb minerals leads to increased exposure to dehydration.[2]

When looking at the first part of the digestive system, which is the mouth, it is exposed to dry mouth as a result of the lack of saliva secretion and the difference in the sense of thirst. If we look at the urinary system, the elderly are subjected to several changes, such as a decrease in the glomerular filtration rate, as well as the relaxation of the pelvic muscles, which leads to enuresis in some elderly. This leads to the loss of more fluids that are not replaced in the appropriate amount as a result of decreased sense of thirst.[3]In addition, the poor mental state and the low level of memory of the elderly also make them forget to take appropriate supplements of water and fluids. Therefore, all of the above factors increase the risk of the elderly being exposed to dehydration.[4]

The non-physiological factors, such as the environment surrounding the elderly which includes the lack of a permanent source of clean water or the presence of a family member to remind the elderly of the need to drink water, are considered among the dangerous factors leading to dehydration. Furthermore, hot environments are considered one of the factors that lead to dehydration in the elderly, especially in the summer, knowing that the elderly do not have the ability to adapt. Moreover, the sense of temperature changes sufficiently to make it adapt to it as a result of the physiological changes mentioned previously.[5]

Nursing assessments should be tailored such that the causes and kinds of dehydration may be identified. Geriatric nurses and carers play a critical role in the prevention of dehydration. Because symptoms can have numerous origins, these data should be taken as a whole. For example, a patient exhibiting signs of hypovolemia should not be considered dehydrated because there could be other explanations, such as a fractured pelvis.[6]Adequate dehydration prevention necessitates understanding of the physiological characteristics of the aged, as well as knowledge of risk factors for dehydration related to sickness, social factors, climatic impacts, and medical practices.[7]

Dehydration in community-dwelling individuals may cause a delay in rehabilitation or hospitalization. Dehydration-related problems must be avoided through prevention, monitoring, and management. Of course, prevention is ideal, and nurses should be aware of the higher risk of dehydration in the elderly.[8]Nurses should stimulate fluid intake in all old who do not require fluid restriction, monitor fluid intake in elderly patients with episodic diseases, prescribe tube feedings with a suitable amount of fluid, and, of course, begin rehydration as soon as dehydration begins.[9]

The elderly are a system that responds to environmental stresses[10][Figure 1]. Physiological, psychological, social, developmental, and spiritual factors influence the client. A fundamental or core structure protected by resistance lines composes the client system.[11]Normal health is defined as the normal defense line defended by a flexible defense line. The nature of stressors might be intrapersonal, interpersonal, or extrapersonal, and they can arise from the internal, external, or artificial environment. When stresses breach the system’s adaptive level of defense, the system is compromised and its lines of defense are activated.[12]On a wellness-disease continuum, the system is portrayed as deteriorating toward disease. Depending on the availability of energy, the system will be repaired with the normal defense line restored to its former level, below, or above.[13]

There are three different types of nursing interventions used to prevent illness. Primary prevention occurs before the stressor invading the system; secondary prevention occurs after the system has responded to the invading stressor; and tertiary prevention occurs after secondary prevention, when the system has been reconstituted.[14]

The provision of medical care to patients is the primary focus of the work of community health nurses (CHNs). In addition, CHNs educate members of the community about how to improve and preserve their own health to reduce the number of illnesses and fatalities that occur in the community. They are responsible for the organization of educational gatherings, the distribution of flyers, the performance of health tests, the distribution of prescriptions, and the administration of vaccines.

The objective of this review was to summarize the role of CHNs in the prevention of elderly dehydration in the scope of application of Betty Neuman’s System Model.

METHODS

In December 2021, a comprehensive search of four databases, SpringerLink, PubMed, Embase, and Wanfang data, yielded all published publications on the issue. The authors use the search terms “role of community health nurse” or “dehydration prevention in elderly” or “role of the nurse in the prevention of elderly dehydration” and “elderly dehydration”. The authors looked for research in all sorts of publications, but were restricted to English-language original papers. In addition to examining the reference lists of the included studies, relevant systematic reviews, and published clinical trials, the authors additionally reviewed the reference lists of relevant referenced publications. The authors included all studies giving data on the role of nurses in preventing dehydration in the elderly. The exclusion criteria included repeated studies, instances that overlapped, and studies that did not match the aforementioned criteria. Two researchers separately retrieved data from included publications using a standardized method, and any differences were handled by agreement. Mendeley was used to get certain articles. The percentage of agreement between the two reviewers was 97.6%. After reviewing all titles and eliminating duplicates, ten papers met the inclusion criteria and were included in the review [Figure 2].

Figure 1: Neuman’s System Model

Figure 2: Search and selection of eligible studies

RESULTS AND DISCUSSION

Primary prevention of dehydration in the elderly

Dehydration in the elderly is avoidable. Despite this, injuries continue to be the greatest cause of death and a significant cost to the health-care system. Primary care nurse practitioners who provide care to older persons can reduce the risk of dehydration by employing particular screening and prevention measures.[15]Nurses are supposed to identify patients at risk of dehydration, educate them of their hydration needs, and document how identified risks will be treated; however, there is no formal evaluation method to assist them in identifying at-risk patients. This exposes patients to variances in practice; chronic dehydration develops over time, necessitating careful, systematic, standardized, and regular examinations.[16]

There is a set of interventions, which include educating the elderly with the need to refute the idea that drinking water increases their access to the bathroom and to clarify that drinking water protects against dehydration.[17]Many authors have advocated for the use of care packages that include extensive assessments of physical capacities (including swallowing and toileting), risk assessments, and the establishment of targets for individual fluid requirements, all accompanied by suitable monitoring measures.[18]

Obtain a patient history to determine the likely origin of the fluid disturbance, which will aid in guiding therapies. This can involve acute trauma and bleeding, decreased fluid intake due to cognitive abnormalities, or prolonged diarrhea. Assess or educate the patient to check weight on a daily and consistent basis, using the same scale and preferably at the same time of day, to facilitate accurate measurement and trend tracking, and to evaluate hydration status in relation to dietary consumption. Determine whether or not the patient has been on a fluid restriction. The majority of fluid enters the body by drinking, water in foods, and water generated by food oxidation. Vital indicators should be monitored and documented. To maintain an effective cardiac output, sinus tachycardia may occur in the presence of hypovolemia. The pulse is usually weak and erratic if there is an electrolyte imbalance.

CHN acts as an educator in the prevention of elderly dehydration in different ways.

Proper nutrition

Many factors that impair food and hydration intake raise the risk of malnutrition, which leads to a steady loss of lean body mass. Because restoring body cell mass is more difficult in the elderly, preventative nutritional support with enough energy, protein, and micronutrient consumption should be addressed in every elderly patient.[19]A thorough examination encompasses much more than just a basic nutritional assessment and should consider the person’s overall physical, mental, and emotional state. This will lead to a greater knowledge of how to address the nutritional needs of the elderly in a practical manner.[20]

Exercise

In older adults, regular exercise has been found to benefit blood pressure, diabetes, lipid profile, osteoarthritis, osteoporosis, neurocognitive function, and dehydration. Regular physical exercise is also associated with a decreased risk of death and age-related disease in older adults.[21]The nurse can aid in monitoring chronic disease risk variables and health improvements by examining medication side effects and monitoring changes in blood pressure, cholesterol, blood glucose, and body weight at baseline and during exercise progression. If older adults have questions or concerns about their health, the nurse can also act as a resource and liaison with their primary care physician.[22]

Stress management

Stress symptoms may present differently as we age. Appropriate stress management helps improve the quality of life for the elderly, so the nurse should be aware of the different stress management strategies among the elderly. However, as they age, older folks continue to experience stressful situations.[23]Alternatively, other elders are concerned about a likely decline in their health, mobility, and independence. Younger people typically find it easier to get through stressful moments and move on, but as they get older, the way they deal with stress and how their body processes it may change, so making appropriate stress management is important skills to face the elderly periods.[24]

Environmental sanitation

Proper environmental sanitation in the elderly homes helps improve quality of life and health status of the elderly and preventing environmental hazards helps to prevent different risk factors for many diseases. Therefore, nurses should be aware of strategies of improving quality of elderly environment, thus improving health status of the elderly.[25]It is critical to detect and eliminate potential risk factors for diseases such as cancer, diabetes mellitus, and cardiovascular problems to lessen the burden of age-related diseases. Environmental exposure is one of the modifiable risk factors that influence the aging process.[26]As a result, we need to better understand the risks of environmental exposure to the elderly. Pollutants and chemicals in the environment have a negative impact on the homeostatic status of aging, frequently resulting in the development of some diseases at an earlier age than predicted.[27]

Secondary prevention: Early treatment of diagnosed elderly clients with dehydration

When patients suffer from illnesses that increase their risk of dehydration, they require specialized medical and nursing care. Elderly persons who have one or more of the risk factors listed above nearly always require the support of informal and/or official caregivers to guarantee prompt treatment in the event of an attack.[28]

When a patient is dehydrated, health-care practitioners should ascertain the following: (a) the patient’s fluid deficit (through body weight monitoring); (b) the rate at which the dehydration developed; and (c) whether the patient is dehydrated purely from water loss or from combined water and salt loss.[29,30]On this basis, adequate rehydration therapy should be utilized and monitored, at the very least during the most susceptible phases of dehydration, by frequently weighing the patient and ordering pertinent laboratory tests. When determining the optimal course of treatment and rehydration therapy, special emphasis should be paid to the fluid supplement’s composition. A dietitian and a speech therapist are necessary to give practical counsel to individuals with dysphagia.[31,32]

Role as a case finder

CHN should act as a case finder for cases of dehydration among elderly clients, as early case finding aids in the treatment of diagnosed cases of dehydration. Nurses should perform screening in different areas of the community to find and diagnose cases of dehydration, and regular surveys about risk factors for dehydration and early signs aid in the treatment of cases of dehydration.[33,34]

Role as a clinician

The nurse acts as a clinician in situations of dehydration in the three degrees of dehydration (mild, moderate, and severe) and provides the appropriate treatment for the client.[35]Maintain proper oral fluids to prevent further dehydration for those stages in mild to moderate dehydration. In severe cases, either oral dehydration therapy or intravenous fluid theray is given as prescribed and according to the general health status of the elderly.[36,37]

Role as a collaborator

The nurse will participate in a multidisciplinary approach to organizing efforts between different community settings to raise awareness of the importance and dangers of elderly dehydration.[38]Several meetings with policymakers in the community will aid in policy development. Public education and awareness raising are also important components in preventing elderly dehydration.[39]

Tertiary prevention of elderly dehydration: Rehabilitation of diagnosed client

Tertiary prevention, on the other hand, comprises dehydration rehabilitation; the final objective of the oral rehydration procedure is a patient who is not thirsty, displays no signs of dehydration, and has begun to pass urine properly. If there are still abnormal losses at this point, they must be replaced as previously indicated.[40]If no anomalous losses occur, the patient will only require a normal diet. Dehydration in the elderly is associated with significant morbidity, mortality, and expense.[36]Approximately half of those hospitalized for dehydration died during their stay.[41]Men, African-Americans, and the elderly are the most vulnerable for dehydration complications.[42]

Role as a researcher

The nurse acts as a researcher in various ways. Frequent studies about risk factors and signs and symptoms are critical in preventing geriatric dehydration. The nurse should do both longitudinal and cross-sectional studies to discover risk factors for dehydration.[43]

Role as a rehabilitator

The nurse should act as a rehabilitator to prevent further dehydration difficulties in the elderly by maintaining a high level of hydration and regaining their previous state before dehydration crises.[33]

Role as an educator

The nurse serves as an educator on how to maintain an appropriate level of quality of life for the elderly, as well as how to deal with handicap and how to cope with current health status.[44]

CONCLUSION

Dehydration causes a variety of problems. Inadequate evaluation and failure to execute preventative measures or therapy can have an impact on patient care. Community nurses must be highly aware of the need to diagnose, promote, and treat concerns of dehydration in order to assist avoid problems from occurring. Promoting and maintaining appropriate hydration is thus one of the most important aspects of care, and all nurses in any health-care environment must remember this. Nonetheless, these are duties that must be completed not just by the individual community nurse practitioner but also by managers and all other stakeholders involved in policy planning for high-quality person-centered care in the community. Therefore, it is clear from the current review that the role of the CHN is a vital role in preventing dehydration in the elderly, especially on the application of the Newman model, which draws a theoretical framework for the application of these roles, especially the survey and diagnosis stage, which is an important basis for treating and avoiding the risks of complications of dehydration.

This review implies (a) research on the issue of dehydration in the elderly, which is a thorny issue for the elderly; (b) an attempt to apply the Neuman’s System Model as a basis for the CHN to provide health care for the elderly; and (c) shedding light on the role of the CHN in terms of the three levels of protection in preventing dehydration in the elderly.

The limitations of the review are as follows: (a) the lack of research that includes the role of community nurses in particular and their role in caring for the elderly and (b) some research that includes dehydration in the elderly is not open-access articles.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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