Continuous Urine monitoring

[Ashman]

Recently we have been involved in a number of cases where had urine output been more thoroughly monitored, symptoms could have been more readily detected, more focused treatment would have been applied to the patient and therefore better care would have been given in the ER/ICU/OP/Trauma unit.

Has anyone else had this experience?

[Tweety, BSN, RN]

Some of those areas should requie q1h outputs. Our ER has instituted a program of chart audits to make sure nurses are documenting I&O prior to d/c to the floor. I'm thinking there has been a problem there, and they are working on it.

Our ICUs always do q1h urine outputs.

I'm not sure which unit you mean by "OP" is that outpatient? But our med-surg trauma unit might be a problem. We tend to do only q8h I&O but usually catch things at that time before it gets too bad.

Good luck.

[bellehill, RN]

Our ICU does Q1h outputs, unless there is a miracle and we have a patient that can walk to the bathroom, then it is tallied after void. When I worked Med-Surg there was definitely a lack of concern on the part of nurses and techs for urine output and a lot was missed. I don't know of any poor outcomes because of it.

[stevierae]

When a patient is in ICU, particularly, all his hemodynamic monitoring needs to be scrupulous and continuous--and that includes urine output and I&O. In fact, I am dealing with a case (as a legal nurse consultant) right now in which a patient went into renal failure and eventually multi-system organ failure because basic nursing assessments--including I&O--were not done on a continuum. In ICU, the Foley bag needs to be one with a urimeter, and the output generally needs to be at least 30 cc. an hour, or there is a problem. This is standard of care in any critical care arena, including the operating room.

Remember the nursing process--assessment, forming a nursing diagnosis, planning (the creation of an individualized nursing care plan) implementation of that care plan, interventions as needed, and evaluation of those interventions, or what some call reassessments. Assess, reassess, reassess, and reassess!! If you don't, and even if you did but didn't document it, it will come back to haunt you if the patient is harmed and a lawsuit results. Nothing speaks louder than a flow sheet (such as an I&O sheet) blown up to 200x its normal size with areas for documentation left glaringly blank.

[stevierae]

When a patient is in ICU, particularly, all his hemodynamic monitoring needs to be scrupulous and continuous--and that includes urine output and I&O. In fact, I am dealing with a case (as a legal nurse consultant) right now in which a patient went into renal failure and eventually multi-system organ failure because basic nursing assessments--including I&O--were not done on a continuum; changes in status (including urine output) were not reported in a timely fashion, and basic interventions not done. In ICU, the Foley bag needs to be one with a urimeter, and the output generally needs to be at least 30 cc. an hour, or there is a problem. This is standard of care in any critical care arena, including the operating room, and in the ER with any trauma patient--I don't know about other patients in the ER.

Remember the nursing process--assessment, forming a nursing diagnosis, planning (the creation of an individualized nursing care plan) implementation of that care plan, interventions as needed, and evaluation of those interventions, or what some call reassessments. Assess, reassess, reassess, and reassess!! If you don't, and even if you did but didn't document it, it will come back to haunt you if the patient is harmed and a lawsuit results. Nothing speaks louder than a flow sheet (such as an I&O sheet) blown up to 200x its normal size with areas for documentation left glaringly blank.

Also remember that we are first and foremost advocates for our patients. If urine output is dangerously low, a patient may be dehydrated and may respond to more IV fluid or even a fluid challenge-----then again, he may be exhibiting signs of septic shock and impending renal shutdown. It's up to the nurse caring for him to make the phone calls and make the suggestions that need to be made on his behalf, and get orders (or work from standing orders) to carry out various interventions--not just wait for the MDs to show up and do it.

Any patient with fluid issues--or renal issues, or cardiac issues-- in an ICU setting needs to have a CVP line and possibly a PA line, and those, too, are interventions that a nurse can suggest to the MD consultants involved. Too much fluid to remedy poor urine output can quickly throw a compromised patient into CHF, and therefore that fluid, too, needs to be monitored scrupulously. If the urine output doesn't correspond with fluid intake, that patient may be third spacing, and their electrolytes, and possibly BUN and creatinine, will reflect it.

[Tweety, BSN, RN]

I noticed you're in Israel, so they may do things differently there. I&O here is routine. Good luck to you.

[Ashman]

Some of those areas should requie q1h outputs. Our ER has instituted a program of chart audits to make sure nurses are documenting I&O prior to d/c to the floor. I'm thinking there has been a problem there, and they are working on it.

Our ICUs always do q1h urine outputs.

I'm not sure which unit you mean by "OP" is that outpatient? But our med-surg trauma unit might be a problem. We tend to do only q8h I&O but usually catch things at that time before it gets too bad.

Good luck.

You will have to pardon me, I have just been thrust into this urine output monitoring mess, in order to find a better way. We tend also to do only q8h I&O, even when they should be q1h. Personally I have this gut feeling that urine output really is a vital sign, but there are just no tools available to show it.

The truth is that through my research I am finding that the time element is really crucial. For example if the reading was taken after 45 minutes instead of an hour, or 6.5 hours instead of 8. How are we supposed to determine if there is a trend in the urine output over time if we do not have continuous monitoring? Imagine what it would be like if there was an automatic reading?

In addition, the business of getting down under the bed, attempting to take a reading - that's always fun.

[Ashman]

Our ICU does Q1h outputs, unless there is a miracle and we have a patient that can walk to the bathroom, then it is tallied after void. When I worked Med-Surg there was definitely a lack of concern on the part of nurses and techs for urine output and a lot was missed. I don't know of any poor outcomes because of it.

I really do not think it was a lack of concern, but rather it is a clumsy, crude and cumbersome procedure for an estimated measuring urine output.

Personally I have a gut feeling that urine output is really a vital sign, but there are no tools to measure it. Urine output is indicative of a all sorts of conditions: Renal function, perfusion or failure, Shock, Jaundice, Dehydration, hypervolemia, response to meds, pulmonary edema - as I think about it the list seems endless.

Aren't we not reaching the level of care we could/should be by not monitoring urine output more closely?

[Ashman]

When a patient is in ICU, particularly, all his hemodynamic monitoring needs to be scrupulous and continuous--and that includes urine output and I&O. In fact, I am dealing with a case (as a legal nurse consultant) right now in which a patient went into renal failure and eventually multi-system organ failure because basic nursing assessments--including I&O--were not done on a continuum; changes in status (including urine output) were not reported in a timely fashion, and basic interventions not done. In ICU, the Foley bag needs to be one with a urimeter, and the output generally needs to be at least 30 cc. an hour, or there is a problem. This is standard of care in any critical care arena, including the operating room, and in the ER with any trauma patient--I don't know about other patients in the ER.

Remember the nursing process--assessment, forming a nursing diagnosis, planning (the creation of an individualized nursing care plan) implementation of that care plan, interventions as needed, and evaluation of those interventions, or what some call reassessments. Assess, reassess, reassess, and reassess!! If you don't, and even if you did but didn't document it, it will come back to haunt you if the patient is harmed and a lawsuit results. Nothing speaks louder than a flow sheet (such as an I&O sheet) blown up to 200x its normal size with areas for documentation left glaringly blank.

Also remember that we are first and foremost advocates for our patients. If urine output is dangerously low, a patient may be dehydrated and may respond to more IV fluid or even a fluid challenge-----then again, he may be exhibiting signs of septic shock and impending renal shutdown. It's up to the nurse caring for him to make the phone calls and make the suggestions that need to be made on his behalf, and get orders (or work from standing orders) to carry out various interventions--not just wait for the MDs to show up and do it.

Any patient with fluid issues--or renal issues, or cardiac issues-- in an ICU setting needs to have a CVP line and possibly a PA line, and those, too, are interventions that a nurse can suggest to the MD consultants involved. Too much fluid to remedy poor urine output can quickly throw a compromised patient into CHF, and therefore that fluid, too, needs to be monitored scrupulously. If the urine output doesn't correspond with fluid intake, that patient may be third spacing, and their electrolytes, and possibly BUN and creatinine, will reflect it.

I agree completely. However could you imagine doing hemodynamic monitoring, manually, and crouched down under the bed? To do proper continuous urine output monitoring with a maybe less labor-intensive procedure for monitoring associated with it, we need to have a new way of effecting the measurement wouldn't you say?

[stevierae]

I agree completely. However could you imagine doing hemodynamic monitoring, manually, and crouched down under the bed? To do proper continuous urine output monitoring with a maybe less labor-intensive procedure for monitoring associated with it, we need to have a new way of effecting the measurement wouldn't you say?

I hear you. I wonder if urologists, nephrologists, or shock-trauma specialists have a more sophisticated and more efficient device for getting accurate urine outputs--automatically--every hour on the hour.

What a great invention that would be, if it doesn't already exist! Seems like some sort of probe, inserted into the bladder along with the catheter (I know they have urinary catheters that have temperature probes attached to them; this should be just as easy and user friendly) would be what's needed--seems like some creative engineer could figure it out and patent it.

I guess right now all we can do is to always use a Foley bag with a urimeter, and maybe just hang it over the foot of the bed----it really doesn't need to be under the bed and difficult to access; Foleys these days have anti-reflux valves--and make sure that it gets emptied, every hour on the hour, and documented each time, so as to ensure that urine output remains compatible with fluid intake, and procduction is at least 30 cc./hr.

[Ashman]

I hear you. I wonder if urologists, nephrologists, or shock-trauma specialists have a more sophisticated and more efficient device for getting accurate urine outputs--automatically--every hour on the hour.

What a great invention that would be, if it doesn't already exist! Seems like some sort of probe, inserted into the bladder along with the catheter (I know they have urinary catheters that have temperature probes attached to them; this should be just as easy and user friendly) would be what's needed--seems like some creative engineer could figure it out and patent it.

I guess right now all we can do is to always use a Foley bag with a urimeter, and maybe just hang it over the foot of the bed----it really doesn't need to be under the bed and difficult to access; Foleys these days have anti-reflux valves--and make sure that it gets emptied, every hour on the hour, and documented each time, so as to ensure that urine output remains compatible with fluid intake, and procduction is at least 30 cc./hr.

Using the Foley bag with a urimeter is the way we go. Unfortunately the urimeter that we use has a reservoir of only 250 ml. So, wouldn't you know it, when the staff finally got around to taking the measurement, the patient had maintained an average of more than 30 cc/hr for the shift, because there had been overflow (unmeasured of course). Such a situation is not particularly conducive for determining the patient's trend in urine output.

This is one of the reasons that this whole subject has been thrust upon me.

Personally I have a gut feeling that urine output is really a vital sign, but there are no real tools to measure it. Urine output is indicative of a all sorts of conditions: Renal function, perfusion or failure, Shock, Pre-operative/ Post-operative complications, Dehydration, hypervolemia, response to meds, urinary tract infection, pulmonary edema - as I think about it the list seems endless.

In any case while doing my research for an alternative, the amount of literature which appears with "accurate" accounts of urine output (eg. "decreased urine output", "urine output was low", and my favorite "down to a trickle") is hurrendously the norm. While true continuous accurate accounts seem to be virtually only in research situations.

In any case, I appreciate the help. If I ever find an alternative, I'll be in touch.

[stevierae]

Using the Foley bag with a urimeter is the way we go. Unfortunately the urimeter that we use has a reservoir of only 250 ml. So, wouldn't you know it, when the staff finally got around to taking the measurement, the patient had maintained an average of more than 30 cc/hr for the shift, because there had been overflow (unmeasured of course). Such a situation is not particularly conducive for determining the patient's trend in urine output.

This is one of the reasons that this whole subject has been thrust upon me.

Personally I have a gut feeling that urine output is really a vital sign, but there are no real tools to measure it. Urine output is indicative of a all sorts of conditions: Renal function, perfusion or failure, Shock, Pre-operative/ Post-operative complications, Dehydration, hypervolemia, response to meds, urinary tract infection, pulmonary edema - as I think about it the list seems endless.

In any case while doing my research for an alternative, the amount of literature which appears with "accurate" accounts of urine output (eg. "decreased urine output", "urine output was low", and my favorite "down to a trickle") is hurrendously the norm. While true continuous accurate accounts seem to be virtually only in research situations.

In any case, I appreciate the help. If I ever find an alternative, I'll be in touch.

The staff needs to look at what's in the top of the bag--that is, where the urimeter is--every hour. That section has a separate valve, or stopcock. Read how much is in THERE after one hour, record it, and then empty that little bit of urine (however much you have just measured in the urimeter) into the Foley bag itself utilizing the urimeter stopcock. It only takes a few seconds. Repeat the process every hour.

Are you saying your staff is reluctant to do this--that they simply refuse to do hourly urine outputs, and won't measure the volume that collects in the urimeter reservoir---that they wait until the Foley bag itself is full, or an entire shift has passed? That's sure not good for an ICU setting.