Long-Term Care Survey Alert

Be on the lookout for this subtle change that can signal dehydration.

For many long-term residents, summer fun includes picnics and trips to the park, zoo, or ballgames. And to make sure these outings don't include a detour to the emergency department to treat a resident with hyperthermia or dehydration, cover these safety bases.

1. Check the heat index before venturing outdoors. The heat index factors in the humidity. Thus, "the weatherman may report that it's 70 degrees, but due to the humidity, it's equivalent to 75  r 80 degrees," says Susan Duda-Gardiner, RN, BSN, LNHA, director of clinical services for the Illinois Council on Long Term Care, speaking on behalf of the Health Care Council of Illinois.

Beware: "Heat index values were devised for shady, light wind conditions," says the Centers for Disease Control & Prevention. And "exposure to full sunshine can increase heat index values by up to 15 degrees F." (For more information on how the heat index works, go to www.nws.noaa.gov/om/heat/index.shtml.)

2. Dress to ward off heat and sun. For example, residents should dress in light, cool clothing in layers, even when just going outside, suggests Myrtle Klauer, ADC, CAP, director of resident services at the Illinois Council and speaking for the Health Care Council of Illinois. Residents should also don hats to protect their heads and faces from the sun.

Example: Male nursing home residents where Klauer used to work wore baseball caps with their names on them during outdoor activities. (Staff kept the hats in plastic bags for infection control purposes.) The women wore wide-brimmed hats. "We made sure everyone slathered up with at least 30 [sun protection factor] sunblock and that it was reapplied," Klauer recalls.

3. Get residents to drink plenty of fluids. In some cases, you have to get creative to get residents to drink, says Duda-Gardiner. Provide popsicles or non-sugary juices. You can take powders along to make lemonade, for example, although you have to check the sugar and salt content."

Another trick: Klauer's facility used to take residents to the Cubs games in Chicago and allow them to eat salty foods (unless contraindicated). That way, the residents would get thirsty and be eager to drink fluids.

The staff would also put ice in residents' reusable water bottles for them to take on warm-weather outings. The ice in the bottles, which had the residents' names on them, would melt into cool drinking water. "We'd also take huge thermos bottles of water," she relays. We told the residents and volunteers (many of whom were also seniors) to drink fluids every 15 minutes or so on a summer outing."

2 tips: Avoid caffeinated beverages which cause diuresis and increase a person's heart rate, counsels Judy Beizer, PharmD, a professor at St. John's University in Queens, N.Y. "For example, don't serve iced tea or iced coffee. You could serve a non-caffeinated herbal tea and non-caffeinated soft drinks." Also be on the lookout for residents, especially those in wheelchairs, who may limit their fluid intake because they don't want to burden staff with helping them to the toilet, advises Klauer.

4. Keep it cool. Transport residents in an air-conditioned bus or vehicle where residents can sit if they get too warm. "When we went on picnics in the park," says Klauer, "we always made sure there was a shelter available." The park also had a gravel pathway ideal for pushing people in wheelchairs. Also avoid excursions that will include too much walking or wheeling.

For example, says Klauer, when going on an outing to the zoo, "the staff would meet us at the bus and take our picnic equipment and coolers to a shaded area." Then the staff and residents would board the tram and tour the zoo and attend a dolphin show before the picnic. "Everyone just loved it."

Tip: Take enough staff and volunteers. Klauer's facility had a licensed nurse and extra CNA accompany residents on trips of six hours or longer. "Many of the staff going on the outing were also CNAs," she explains. The staff also took a lot of volunteers along, many of whom were residents' family members.

5. Be alert to changes in mental status. The first sign of dehydration in elderly people may be an altered mental status, Duda-Gardiner cautions. "The person may become very quiet initially, for example." If you sense a change, "ask the person if they feel lightheaded, and get them into the shade or a cool place." (For  signs and symptoms of heat stroke in the elderly, and recommended interventions, see page 52.)

6. Provide a brief re-acclimation period when returning to the facility. "When ambulatory residents and volunteers returned to the cool facility from outdoors, we instructed them to sit for three to four minutes on benches inside the door," says Klauer. All staff at the facility kept an eye on the returning travelers during that time.

Reasoning: "We find that people can get cold and clammy and dizzy when they move from the hot outdoors into the much colder facility," Klauer says.