FLORIDA STATE HOSPITAL STATE OF FLORIDA OPERATING PROCEDURE DEPARTMENT OF NO. 150-62 CHILDREN AND FAMILIES CHATTAHOOCHEE, June 14, 2017

Medical, Psychiatry & Nursing

POLYDIPSIA MANAGEMENT

1. Purpose: To provide the least restrictive interventions needed to prevent physical problems and/or life-threatening situations related to excessive water drinking (polydipsia) caused by either psychotherapeutic medications or psychogenic polydipsia (excessive fluid seeking behavior).

2. Policy: The physician will identify residents who have polydipsia. Residents identified will be managed according to these guidelines, unless a physician writes individualized treatment and/or management orders for a specific resident. Physician also applies to Advanced Registered Nurse Practitioners and Physician Assistants.

3. References:

a. Smith, F.S., Duell D.J., and Martin, B.C., Clinical Nursing Skills. Basic to Advanced Skills. Pearson Prentice Hall

b. Hutcheon, D., Psychogenic Polydipsia (Excessive Fluid Seeking Behaviour), BC Psychologist, Spring 2013. Pg. 15-16

c. Illowsky, B.P. and Kirch, D.G. Polydipsia and Hyponatremia in Psychiatric Patients. Am J Psychiatry 145:6, June 1988, pg. 675-683

d. Goldman, M., Lushens, D., Prevention of Episodic Water Intoxication with Target Weight Procedure. Am J Psychiatry 1987; 144: 365-366

e. Department of Children & Families Operating Procedure 155-26 Safe and Supportive Observations of Residents

4. General Considerations:

a. Polydipsia is increased thirst and excessive fluid intake of greater than 3L per day. It is a symptom (evidence of a disease state), not a disease in itself.

b. Psychogenic polydipsia is the compulsion to seek out and drink large quantities of fluids, thus putting them at risk of water intoxication. As is often the case, psychogenic polydipsia can be especially observed in residents who have mental illness (especially in the schizophrenia spectrum) and/or developmental disability.

c. Signs and symptoms of water intoxication include headache, confusion, irritability, drowsiness and changes in personality and/or behavior.

d. For the purpose of Florida State Hospital, this policy applies only to polydipsia as a side effect of psychotherapeutic medications or as part of a mental illness and/or developmental disability.

This Operating Procedure supersedes: Operating Procedure 150-62 dated June 10, 2016 OFFICE OF PRIMARY RESPONSIBILITY: Clinical Director DISTRIBUTION: See Training Requirements Matrix June14,2017 FSHOP150-62

e. Individuals afflicted with polydipsia (of any type) have been known to seek fluids from any source possible.

f. The ‘target weight’ for a particular resident is the weight obtained at 0600 and the specific gravity of sodium and urine are both within normal range (based on laboratory standards).

g. The ‘dry body weight’ is the average weight at daily 0600 hours during the previous five (5) days.

h. All staff should be on the lookout for any resident demonstrating behaviors of excessive fluid intake, and then report this observation to the ward nurse immediately.

i. Some objective data associated with fluid excess include: increase in blood pressure, pulse rate and respirations; decrease in urine specific gravity; blood hematocrit may be less than three times the hemoglobin; serum sodium may be within normal range or less than 135 mEq/L; blood urea nitrogen (BUN) is decreased (except in heart or renal failure); and more than 60 mL/hour of urine output.

5. Behavioral Management:

a. All residents identified by a physician as having polydipsia will have an initial target weight evaluation and a re-evaluation every three (3) months and as needed.

b. Target weight evaluation will be obtained by:

(1) Nothing by mouth (NPO) for two hours (4 AM-6 AM) with 1:1 special to ensure that no fluids are ingested.

(2) At the end of the two hours:

(a) Have the resident empty his/her bladder.

(b) Obtain urine specimen for specific gravity.

(c) Weigh resident and record weight.

(d) Obtain electrolytes.

(e) Continue 1:1 special until lab results are obtained.

(3) If the urine specific gravity is within normal range, the weight obtained at 0600 (6:00 AM) will become the target weight, unless otherwise specified by physician.

(4) If the urine specific gravity is below normal range, the following guidelines will apply:

(a) The resident will be placed on fluid restriction consisting of 120 cc with meals, 60 cc with medication(s), and 120 cc every 4 hours.

(b) The resident will be placed on a 1:1 level of observation or will remain within visual contact by staff until an accurate target weight is obtained utilizing Steps 1-3 above. Steps 1-3 may be completed daily or as ordered by a physician, based on lab results obtained (as part of the process for determining the target weight).

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(c) After a ‘target weight’ is established, the resident will be weighed every two (2) hours while awake.

(d) Each weight will be recorded on the appropriate flow sheet.

(5) The maximum weight gain ‘allowance’ above target weight is five (5) pounds (lbs.), unless otherwise specified by physician. When a resident reaches five (5) or more pounds above target weight, the following steps will be taken:

(a) The resident will be placed on continuous visual observation for 8 hours.

(b) The resident will be placed on fluid restriction of 120 cc with meals, 60 cc with medication, and 120 cc fluid every 4 hours.

(c) STAT electrolytes will be drawn.

(6) A resident’s 1:1 level of observation will be discontinued after eight (8) hours if:

(a) The resident exhibits no signs/symptoms of water intoxication, or

(b) The resident’s weight is within target weight or below the maximum weight gain allowance.

(7) Any resident identified as having polydipsia will have this issue addressed in their Recovery Plan and in the monthly physician’s orders outlining plan.

(8) At the time the Recovery Plan is reviewed (every 6 months and annually), the nurse will re-evaluate the resident’s dry body weight. The dry body weight is the average weight at daily 0600 hours during the previous five (5) days. If there is a five pound weight gain or loss, the nurse will re- establish the maximum weight gain ‘allowance’ by the initial assessment method.

6. Pharmacological Management:

a. There is no medication approved by the Food and Drug Administration for the treatment of polydipsia.

b. Clozapine in low doses have been effective in very few studies. The use of clozapine will be considered ‘off-label’ and will need to be approved through Florida State Hospital’s Clozaril Clinic.

c. A Medication Exception Request (MER) will be completed and approved prior to the use of clozapine for polydipsia.

7. Training Requirements: A check in the box below indicates which employees within the department are required to read this operating procedure and when they will receive training at Florida State Hospital. Employees within identified departments will also be required to review the policy each time it is updated:

New Discipline Worksite Annual Department Employee Specific Education Update Orientation Training All Employees Clerical Dental

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New Discipline Worksite Annual Department Employee Specific Education Update Orientation Training Dieticians, Laboratory, Special Therapy, X-Ray Techs DirectCare X Emergency Operations Environmental Services (Aramark) Financial Services Food Services Health Information Services Human Resources Information Systems Legal Materials Management Nursing X Operations & Facilities (Aramark) Pharmacy X Physician/ARNP/PA (Prescriber) X Professional Development Psychology Quality Improvement RecoveryPlanning X Rehab Services Resident Advocacy/Risk Mgt. Social Services X Supervisors/Managers Volunteer Services Other:

MARGUERITE J. MORGAN Hospital Administrator, Florida State Hospital

SUMMARY OF REVISED, ADDED OR DELETED MATERIAL

Policy was reviewed with no changes necessary at this time.

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