Maintaing adequate fluid balance is an essential component of health across the lifespan; older adults are more vulnerbale 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.  Dehydration is the more frequent occurrence in older adults (Warren et al., 1994; Xiao, Barber, & Campbell, 2004).  In fact, avoidable hospitalization for dehydration in older adults have increased by 40% from 1990 to 2000, at a cost of $1.14 billion (Xiao et al., 2004), and is one of the Agency for Healthcare Research and Quality's 13 ambulatory care-sensitive conditions.  

Not only will careful attention to hydration requirements of older adults help prevent hospitalizations for dehydration but will also decrease associated conditions such as acute confusion and delirium; adverse drug reactions (Doucet et al., 2002); infections; and increased morbidity associated with bladder cancer (Michaud et al., 1999), coronary heart disease, stroke (Rodriguez et al., 2009), and other thromboembolytic events (Kelly et al., 2004).  Further, dehydration has been associated with longer hospital stays for rehabilitation and for readmission to hispital (Gordon, An, Hayward, & Williams, 1998).  Even in healthy community-dwelling older adults, physical performance and cognitive processing is affected by mild dehydration (Ainslie et al., 2002).  

Nursing Standard of Practice Protocol: Managing Oral Hydration

Janet C. Mentes, PhD, APRN, BC

Evidence-Based Content - Updated August 2012

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. The text is available here.

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

Background and Statement of Problem
Parameters of Assessment
Nursing-Care Strategies
Evaluation and Expected Outcomes
Follow-up Monitoring of Condition
Relevant Practice Guidelines


To minimize episodes of dehydration in older adults.


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 over hydration and dehydration, because of age-related changes and increased likelihood that an older individual has several medical conditions. Dehydration is the more frequently occurring problem.

Background and Statement of Problem

A. Definitions

1. Dehydration is depletion in total body water (TBW) content due to pathologic fluid losses, diminished water intake, or a combination of both. It results in hypernatremia (more than 145mEq/L) in the extracellular fluid compartment, which draws water from the intracellular fluids. 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 precursor condition to dehydration associated with insidious onset and poor outcomes (Ref 1). Others have referred to this condition as mild dehydration (Ref 2; 3) or chronic dehydration (Ref 4).

B. Etiologic factors associated with dehydration

1. Age-related changes in body composition with resulting decrease in TBW. (Ref 5; 6; 7)

2. Decreasing renal function. (Ref 8)

3. Lack of thirst. (Ref 9, 10, 11, 12, 13, 14)

4. Poor tolerance for hot weather. (Ref 15)

C. Risk Factors

1. Patient characteristics

a. More than 85 years of age (Ref 16; 17; 18)
b. Female (Ref 17; 19)
c. Semi-dependent in eating (Ref 16)
d. Functionally more independent (Ref 1; 16)
e. Few fluid ingestion opportunities (Ref 16; 19)
f. Inadequate nutrient intake (Ref 16)
g. Alzheimer’s disease or other dementias (Ref 20; 21)
h. Four or more chronic conditions (Ref 17)
i. Four medications (Ref 17)
j. Fever (Ref 22; 23)
k. Vomiting and diarrhea (Ref 24)
l. Individuals with infections (Ref 25)
m. Individuals who have had prior episodes of dehydration (Ref 26)
n. Diuretics: thiazide (Ref 24), loop and thiazide (Ref 27)

2. Staff and family characteristics

a. Inadequate staff and professional supervision (Ref 28)
b. Depression or loneliness associated with decreased fluid intake as identi-
fied by nursing staff (Ref 29)
c. Family or caregivers not spending time with patient (Ref 29)

Parameters of Assessment (Ref 30)

A. Health history

1. Specific disease states: dementia, congestive heart failure, chronic renal disease, malnutrition, and psychiatric disorders such as depression. (Ref 19; 20; 25)

2. Presence of comorbidities: more than four chronic health conditions. (Ref 6)

3. Prescription drugs: number and types. (Ref 6)

4. Past history of dehydration, repeated infections. (Ref 26)

B. Physical Assessments (Ref 30)

1. Vital signs

2. Height and weight

3. Body mass index (BMI) (Ref 31)

4. Review of systems

5. Indicators of hydration

C. Laboratory Tests

1. Urine-specific gravity. (Ref 26; 32)

2. Urine color. (Ref 26; 32)

3. Blood urea nitrogen (BUN)/creatinine ratio

4. Serum sodium

5. Serum osmolality

6. Salivary osmolality

D. Individual fluid intake behaviors. (Ref 26)

Nursing-Care Strategies

A. Risk Identification (Ref 30)

1. Identify acute situations: vomiting, diarrhea, or febrile episodes

2. Use a tool to evaluate risk: Dehydration Appraisal Checklist (see Resources)

B. Acute Hydration Management

1. Monitor input and output. (Ref 23)

2. Provide additional fluids as tolerated. (Ref 23)

3. Minimize fasting times for diagnostic and surgical procedures. (Ref 33)

C. Ongoing Hydration Management

1. Calculate a daily fluid goal. (Ref 30)

2. Compare current intake to fluid goal. (Ref 30)

3. Provide fluids consistently throughout the day. (Ref 34; 35)

4. Plan for at-risk individuals

a. Fluid rounds. (Ref 36)

b. Provide two 8-oz. glasses of fluid, one in the morning and the other in the evening. (Ref 36)

c. "Happy hours" to promote increased intake. (Ref 37)

d. "Tea time" to increase fluid intake. (Ref 38)

e. Offer a variety of fluids throughout the day. (Ref 35)

5. Fluid regulation and documentation

a. Teach able individuals to use a urine color chart to monitor hydration status. (Ref 26; 39; 40)

b. Document a complete intake recording including hydration habits. (Ref 30)

c. Know volumes of fluid containers to accurately calculate fluid consumption. (Ref 41; 42)

Evaluation and Expected Outcomes

A. Maintenance of body hydration. (Ref 1; 35; 36)

B. Decreased infections, especially urinary tract infections. (Ref 1; 36; 43)

C. Improvement in urinary incontinence. (Ref 44)

D. Lowered urinary pH. (Ref 42)

E. Decreased constipation. (Ref 36)

F. Decreased acute confusion. (Ref 45)

Follow-up Monitoring of Condition

A. Urine color chart monitoring in patients with better renal function. (Ref 32; 39; 40)

B. Urine specific-gravity checks. (Ref 32; 39; 40)

C. 24-hour intake recording. (Ref 5)

Relevant Practice Guidelines

A. Hydration Management Evidence-Based Protocol available from the University of Iowa College of Nursing Gerontological Nursing Interventions Research Center, Research Dissemination Core. Author: Janet Mentes, revised 2010.

For Definition of Levels of Quantitative Evidence Click Here

From Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition. © Springer Publishing Company, LLC.


1. Mentes, J., & Culp, K. (2003). Reducing hydration-linked events in nursing-home residents. Clinical Nursing Research, 12,210–225. Evidence Level III.

2. Stookey, J.D. (2005). High prevalence of plasma hypertonicity among community-dwelling older adults: Results from NHANES III. Journal of the American Dietetic Association, 105(8), 1231-1239. Evidence Level IV.

3. Stookey, J.D., Pieper, C.F., & Cohen, H.J. (2005). Is the prevalence of dehydration among community-dwelling older adults really low? Informing current debate over the fluid recommendations for adults aged 70+ years. Public Health Nutrition, 8(8), 1275-1285. Evidence level IV.

4. Bennett, J.A., Thomas, V., & Riegel, B. (2004). Unrecognized chronic dehydration in older adults: Examining prevalence rate and risk factors. Journal of Gerontological Nursing, 30(11), 22-28; quiz 52-23. Evidence Level IV.

5. Metheny, N. (2000). Fluid and electrolyte balance. In Nursing Considerations (4th Ed., pp. 3–12, 24–26). St. Louis, MO: Lippincott, Williams, & Wilkins. Evidence Level VI.

6. Lavisso-Mourey, R., Johnson, J., & Stolley, P. (1988). Risk factors for dehydration among elderly nursing-home residents. Journal of the American Geriatrics Society, 36, 213–218. Evidence Level IV.

7. Bossingham, M.J., Carnell, N.S., & Campbell, W.W. (2005). Water balance, hydration status, and fat-free mass hydration in younger and older adults. American Journal of Clinical Nutrition, 81(6), 1342-1350. Evidence Level II.

8. Lindeman, R., Tobin, J., & Shock, N. (1985). Longitudinal studies on the rate of decline in renal function with age. Journal of the American Geriatrics Society, 33, 278–285.

9. Farrell, M.J., Zamarripa, F., Shade, R., Phillips, P.A., McKinley, M., Fox, P.T.,...Egan, G.F. (2008). Effect of aging on regional cerebral blood flow responses associated with osmotic thirst and its satiation by water drinking: A PET study. Proceedings of the National Academy of Sciences of the United States of America, 105(1), 382-387. Evidence Level III.

10. Kenney, W. L., & Chui, P. (2001). Influence of age on thirst and fluid intake. Medicine & Science in Sports and Exercise, 33, 1524–1532. Evidence Level V.

11. Mack, G., Weseman, C., Langhans, G., Scherzer, H., Gillen, C., & Nadel, E. (1994). Body fluid balance in dehydrated healthy older men: Thirst and renal osmoregulation. Journal of Applied Physiology, 76, 1615–1623. Evidence Level III.

12. Miescher, E., & Fortney, S. (1989). Responses to dehydration and rehydration during heat exposure in young and older men. American Journal of Physiology, 257(26), R1050–R1056. Evidence Level III.

13. Phillips, P., Rolls, B., Ledingham, J., Forsling, M., Morton, J., Crowe, M., et al. (1984). Reduced thirst after water deprivation in healthy elderly men. New England Journal of Medicine, 311, 753–759. Evidence Level III.

14. Phillips, P., Bretherton, M., Johnston, C., & Gray, L. (1991). Reduced osmotic thirst in healthy elderly men. American Journal of Physiology, 261, R166-R171.

15. Josseran, L., Caillere, N., Brun-Ney, D., Rottner, J., Filleul, L., Brucker, G., & Astagneau, P. (2009). Syndromic surveillance and heat wave morbidity: A pilot study based on emergency departments in France. BMC Medical Informatics and Decision Making, 9, 14. Evidence Level IV.

16. Gaspar, P. (1999). Water intake of nursing-home residents. Journal of Gerontological Nursing, 25(4), 22–29. Evidence Level IV.

17. Lavisso-Mourey, R., Johnson, J., & Stolley, P. (1988). Risk factors for dehydration among elderly nursing home residents. Journal of the American Geriatrics Society,36, 213-218.

18. Ciccone, A., Allegra, J. R., Cochrane, D. G., Cody, R. P., & Roche, L. M. (1998). Age-related differences in diagnoses within the elderly population. American Journal of Emergency Medicine, 16, 43–48.Evidence Level IV.

19. Gaspar, P.M. (1988). What determines how much patients drink? Geriatric Nursing, 9(4), 221-224. Evidence Level IV.

20. Albert, S.G., Nakra, B.R., Grossberg, G.T., & Caminal, E.R. (1989). Vasopressin response to dehydration in Alzheimer’s disease. Journal of the American Geriatrics Society, 37, 843–847. Evidence Level III.

21. Albert, S.G., Nakra, B.R., Grossberg, G.T., & Caminal, E.R. (1994). Drinking behavior and vasopressin responses to hyperosmolality in Alzheimer’s disease. International Psychogeriatrics, 6(1), 79–86. Evidence Level III.

22. Pals, J.K., Weinberg, A.D., Beal, L.F., Levesque, P.G., Cunnungham, T.J., & Minaker, K.L. (1995). Clinical triggers for detection of fever and dehydration. Implications for long-term care and nursing. Journal of Gerontological Nursing, 21(4), 13-19. Evidence Level IV.

23. Weinberg, A., Pals, J., Levesque, P., Beals, L., Cunningham, T., & Minaker, K. (1994). Dehydration and death during febrile episodes in the nursing home. Journal of the American Geriatrics Society, 42, 968–971. Evidence Level IV.

24. Wakefield, B.J., Mentes, J., Holman, J.E., & Culp, K. (2008). Risk factors and outcomes associated with hospital admission for dehydration. Rehabilitation Nursing, 33(6), 233-241. Evidence level IV.

25. Warren, J., Bacon, E., Harris, T., McBean, A., Foley, D., & Phillips, C. (1994). The burden and outcomes associated with dehydration among U.S. elderly, 1991. American Journal of Public Health, 84, 1265–1269. Evidence Level IV.

26. Mentes, J. (2006). A typology of oral hydration problems exhibited by nursing-home residents. Journal of Gerontological Nursing, 23(1), 13–21. Evidence Level IV.

27. Lancaster, K.J., Smiciklas-Wright, H., Heller, D.A., Ahern, F.M., & Jensen, G. (2003). Dehydration in black and white older adults using diuretics. Annals of Epidemiology, 13(7), 525-529. Evidence Level IV.

28. Kayser-Jones, J., Schell, E.S., Porter, C., Barbaccia, J.C., & Shaw, H. (1999). Factors contributing to dehydration in nursing homes: Inadequate staffing and lack of professional supervision. Journal of the American Geriatrics Society, 47(10), 1187-1194. Evidence Level IV.

29. Mentes, J.C., Chang, B.L., & Morris, J. (2006). Keeping nursing home residents hydrated. Western Journal of Nursing Research, 28(4), 392-406; discussion 407-418. Evidence Level IV.

30. Mentes, J. C., & Iowa-Veterans Affairs Nursing Research Consortium (2000). Hydration management protocol. Journal of Gerontological Nursing, 26(10), 6-15. Evidence Level I.

31. Vivanti, A., Harvey, K., Ash, S., & Battistutta, D. (2008). Clinical assessment of dehydration in older people admitted to hospital: What are the strongest indicators? Archives of Gerontology and Geriatrics, 47(3), 340-355. Evidence Level IV.

32. Wakefield, B., Mentes, J., Diggelmann, L., & Culp, K. (2002). Monitoring hydration status in elderly veterans. Western Journal of Nursing Research, 24, 132–142. Evidence Level IV.

33. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: A report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. (1999). Anesthesiology, 90(3), 896–905. Evidence Level I.

34. Ferry, M. (2005). Strategies for ensuring good hydration in the elderly. Nutrition Reviews, 63(6), S22–S29. Evidence Level V.

35. Simmons, S., Alessi, C., & Schnelle, J. (2001). An intervention to increase fluid intake in nursing home residents: Prompting and preference compliance. Journal of the American Geriatrics Society, 49, 926–933. Evidence Level II.

36. Robinson, S., & Rosher, R. (2002). Can a beverage cart help improve hydration? Geriatric Nursing, 23, 208–211. Evidence Level IV.

37. Musson, N., Kincaid, J., Ryan, P., Glussman, B., Varone, L., Gamarra, N., et al. (1990). Nature, nurture, nutrition: Interdisciplinary programs to address the prevention of malnutrition and dehydration. Dysphagia, 5, 65–101. Evidence Level V.

38. Mueller, K., & Boisen, A. (1989). Keeping your patient’s water level up. RN, 52, 65–66, 68. Evidence Level V.

39. Armstrong, L., Maresh, C., Castellani, J., Bergeron, M., Kenefick, R., La Grasse, K., et al. (1994). Urinary indices of hydration status. International Journal of Sport Nutrition, 4, 265–279. Evidence Level IV.

40. Armstrong, L., Herrera-Soto, J., Hacker, F., Kavouras, S., & Maresh, C. (1998). Urinary indices during dehydration, exercise, and rehydration. International Journal of Sport Nutrition, 8, 345–355. Evidence Level IV.

41. Burns, D. (1992). Working up a thirst. Nursing Times, 88(62), 44–45. Evidence Level IV.

42. Hart, M., & Adamek, C. (1984). Do increased fluids decrease urinary stone formation? Geriatric Nursing, 5(6), 245–248. Evidence Level III.

43. McConnell, J. (1984). Preventing urinary tract infections: Nursing measures alone reduced UTI in a nursing home. Geriatric Nursing, 5(8), 361–362. Level III.

44. Spangler, P., Risley, T., & Bilyew, D. (1984). The management of dehydration and incontinence in nonambulatory geriatric patients. Journal of Applied Behavior Analysis, 17, 397–401. Evidence Level III.

45. Mentes, J., Culp, K., Maas, M., & Rantz, M. (1999). Acute confusion indicators: Risk factors and prevalence. Using MDS data. Research in Nursing & Health 22, 95-105.

Last updated - August 2012

Journal Articles

Batscha, C. (1997). Heat stroke. Keeping your patients cool in the summer.Journal of Psychosocial Nursing, 35(7), 12-17. (L)

Critchlow, J., & Bauer-Wu, S. M. (Dec 2002). Dehydration in terminally ill patients. Perceptions of long-term care nurses. Journal of Gerontological Nursing, 28(12), 31-9, Quiz 48-9.

Feinsod, F. M., Levenson, S. A., Rapp, K., Rapp, M. P., Beechinor, E., & Liebmann, L. (Mar-Apr 2004). Dehydration in frail, older patients in long-term care facilities. Journal of the American Medical Directors Association, 5(2 Suppl), S35-41.

Gaspar, P. (1999). Water intake of nursing home patients. Journal of Gerontological Nursing, 25(4), 22-29. (R)

Kayser-Jones, J., Schell, E., Porter, E., Barbaccia, J., & Shaw, H. (1999). Factors contributing to dehydration in nursing homes: Adequate staffing and lack of professional supervision. Journal of the American Geriatrics Society, 47, 1187-1194. (R)

Mentes, J. C. (2000). Hydration management: A long-term care nursing intervention to prevent acute confusion and other hydration-linked events. Unpublished doctoral dissertation, University of Iowa, Iowa City. (R)

Mentes, J. C, & Culp, K. (Aug 2003). Reducing hydration-linked events in nursing home patients. Clinical Nursing Research, 12(3), 210-25, Discussion 226-8.

Robinson, B. E., & Weber, H. (Mar-Apr 2004). Dehydration despite drinking: Beyond the BUN/Creatinine ratio. Journal of the American Medical Directors Association, 5(2 Suppl), S67-71.

Thomas, D. R., Tariq, S. H., Makhdomm, S., Haddad, R., & Moinuddin, A. (Mar-Apr 2004). Physician misdiagnosis of dehydration in older adults. Journal of the American Medical Directors Association, 5(2 Suppl), S30-4.

Last updated - January 2005