Stressed out about overnight urine output

[Ioreth]

First off, I'm six months in. I know just enough to know that I know nothing. I did well in school, but now I'm second-guessing myself a lot and it is interrupting my sleep. I don't even know if what I'm stressing about really is something that was worth worrying about, or if I'm making mountains out of molehills.

Three nights ago I was giving report on a patient that had been on our unit for about a week. She had a perforated bowel that had been corrected, which involved several drains (most of which by this time were clamped) and many rounds of IV antibiotics and ongoing IV fluid. Our unit doesn't generally have patients with bowel preforations, but the hospital was full and so we got a lot of med-surg overflow. Despite not being our usual patient, I think we had been handing her needs pretty well. This patient had been on a normal diet for a few days and had a foley catheter out two days prior. The previous day, she suddenly started having diarrhea all day and chose not to eat at all because of the diarrhea. Day shift notified the physician who said to start measuring all output and notify in 24 hours if diarrhea is ongoing.

When I got shift report for the night shift on this patient, she was exhausted. All she wanted to do was sleep. The physician was at the bedside when I took report, so I made sure that he was updated everything I got in report and he seemed unconcerned. No new orders, just some discontinued ones that were no longer pertinent, but nothing regarding output - just monitor. I got the patient comfortable and let her sleep, beyond the usual interruptions to hang antibiotics and take vitals, etc. It was a really busy shift and we were understaffed so we each had 1-2 more patients than usual for this unit and mine were particularly needly. At 5 AM, I noticed that she hadn't had any output at all this shift, neither urine nor stool. I asked her if she needed to use the bathroom when I hung the 5 AM antibiotics, but she said she didn't need to yet. IV fluids were running all night at 75 mL/hr, with 200 mL/hr intermittent antibiotics. I mentioned it to my charge and she said not to worry about it but to let day shift know.

I somehow got everything that needed to be done taken care of with my other patients and felt great going into report. The patient with the perforated bowel was my last one to hand off. The nurse that I handed off to seemed very upset about the lack of output. She wanted to know why I hadn't notified the physician, why I hadn't bladder scanned the patient, why I hadn't just gotten the patient up and forced her to use the bathroom. All I could say is "I'm sorry" over and over again and I felt awful. I knew that a bladder scan was warranted, but I honestly was racing to get all the other stuff done, and it slipped my mind. The ongoing nurse looked at the previous day shift totals and was pointing to the unmeasured output, but completely ignoring the measured stools and telling me that the patient hasn't had enough output of any kind. I remember the day shift CNA mentioning that neither she nor the patient knew if urine was mixed with stool in those measured occurrences, so it was measured as stool only as a "best guess". I can't remember exact totals, but it was over 2000 mL. Then the ongoing nurse was asking me why a C-diff test hadn't been done. I could only answer that there hadn't been any output my shift. When we went into the patient's room together, she continued to talk about the problem of the low output and that I should have gotten the patient up. This was in front of the patient, and I felt like I was being humiliated purposely. The patient was still groggy from being abruptly woken and stated that she really didn't need to pee yet, but might be able to in a couple of hours. This nurse also went on to correct me on how to properly clamp these particular drains, which had been managed the same way by 4 other experienced nurses earlier in the week. Again, her attitude was suggesting to me (and to the patient) that I was incompetent.

I haven't been back to work, but this has been on my mind the entire three days since work. All I could think about was that it might have been dumping syndrome, but how do you even manage dumping syndrome? It might have been dehydration which is entirely reasonable with diarrhea, but I know that I checked oral mucous membranes and there were IV fluids running all night. I know that lots of patients just pee less at night and I know she peed just before I took report on her. I work again tonight and I dread interacting with that day shift nurse. She has a pretty stern demeanor and is generally difficult to read. I have seen her straight up bully other new nurses, but I've not been on the receiving end of that kind of treatment. I'm also dreading being in this patient's room, if she's even still there, because I feel like our raport was shattered.

I'm just a nervous wreck and I haven't really slept well because I keep thinking about this. I can't shake the feeling that I really screwed up here.

[Susie2310]

Reading the OP it sounded to me as though the patient was in Acute Renal Failure after having diarrhea all day long; if so, I think this could explain the lack of urine output overnight. I think it would be interesting to know what the patient's BUN, creatinine, and potassium levels were.

[JKL33]

14 hours ago, KatieMI said:

2). In the world of clinical medicine, to "fix" mind about just one thing, whatever it might be, automatically means making at least one mistake and usually more of them.

Wise.

[K+MgSO4, BSN]

My background is colorectal, hepatobillary and gasteoentrology nursing.

A perforated bowel puts a patient at risk of sepsis due to faceal contamination of the peritoneal cavity. The "lots of drains" suggest that she had a lot of wash out as well as the routine abdo drain or 2. She is a number of days post op and starts having diahorrea and stops eating (and drinking?) for the day. The exhaustion could be just from having to go to the bathroom more that day or could be an indicator of dehydration. While "healthy " people don't get up to void overnight they do produce urine as shown by their morning pee. Seeing as this lady is not currently healthy I would suggest she is getting dehydrated, early AKI.

I would of scanned her bladder but that is 14 yrs of experience in the speciality talking.

I agree she is not dumping unless she has had some recent upper GI surgery, those at risk of dumping are aware of how to manage it as it not a comfortable experience. Also check hospital policy regarding CDiff samples, but like you said no poop means no sample.

Regarding tonight, go in, get report and see what has happened to her during the shift you weren't there for. Discuss with the patient what has happened today, patients pick up on nasty nurses as well. Explain your plan for the shift and make sure she is across it but don't come over as anxious.

Best of luck.

[Susie2310]

10 hours ago, Susie2310 said:

Reading the OP it sounded to me as though the patient was in Acute Renal Failure after having diarrhea all day long; if so, I think this could explain the lack of urine output overnight. I think it would be interesting to know what the patient's BUN, creatinine, and potassium levels were.

I want to add that if the patient had been hypovolemic after the day long diarrhea, especially if they already had kidney problems, this could have resulted in Acute Renal Failure and anuria. I think this was what the oncoming nurse was concerned about when he/she was concerned about the lack of urine output overnight; he/she was making the point that it would have been appropriate to monitor urine output periodically during the shift in order to observe for symptoms of Acute Renal Failure and to notify the physician promptly of a decreased or absent urine output.

I understand that it was night time and the patient would normally be sleeping, but I would have wanted to observe for changes in LOC which could indicate Acute Renal Failure. The patient's feeling tired and wanting to sleep after day long diarrhea may also have been due to lethargy that would result due to Acute Renal Failure.

[Ioreth, ADN, RN]

So last night at the start of shift I asked about this patient. Apparently she peed shortly after I left and went back to more of a normal appetite and excretion habits. No other issues and she discharged yesterday.

I talked to the day nurse that I gave report to that day. Although I was careful in how I phrased things (thank you, Nursing Psych and therapeutic communication), she was very defensive and said that she needed to correct me immediately, not wait to leave the room. I think that working with her may be a struggle or at least touchy.

I floated for the first time to another unit last night and it went awesome. I love the unit I was hired to, but it is nice to see how another unit does things.

[KatieMI, BSN, MSN, RN]

2 hours ago, Susie2310 said:

I want to add that if the patient had been hypovolemic after the day long diarrhea, especially if they already had kidney problems, this could have resulted in Acute Renal Failure and anuria. I think this was what the oncoming nurse was concerned about when he/she was concerned about the lack of urine output overnight; he/she was making the point that it would have been appropriate to monitor urine output periodically during the shift in order to observe for symptoms of Acute Renal Failure and to notify the physician promptly of a decreased or absent urine output.

I understand that it was night time and the patient would normally be sleeping, but I would have wanted to observe for changes in LOC which could indicate Acute Renal Failure. The patient's feeling tired and wanting to sleep after day long diarrhea may also have been due to lethargy that would result due to Acute Renal Failure.

1). patient was, apparently, improving. JPs were out. She had bowel function (therefore, no third spacing in the bowel expected). She was ambulatory (therefore, not "lethargic", just sleepy). VSs were all stable (you gotta have MAP 65 or below to start to compromise renal function, and it is comes to that when BP hits approximately 85/50, at which point you would tear the phone apart). She was on continuous fluids (which, BTW, make people less thirsty and feeling less hunger).

Under this circumstances one needs to be quite sick with already good deal compromised renal function to develop AKI with "anuria" in just 12 h. If that would be the case, vitals would change. They did not.

2). "anuria" is when there is no output at all for 24 h or more. 0.5 ml/kg or less within 24 h is "oliguria". Both need to be observed for FULL 24 HOURS to become diagnostic.

3). Patient's potassium I expect to be norm or low (diarrhea + fluid), providing the diarrhea really happened. It could be those small loose BMs frequently seen as part of "recovering bowel syndrome" (part of which is hypokalemia).

4) In case of acute renal failure, "lethargy" is a symptom of metabolic encephalopathy. It happens from significantly elevated BUN (azotemia) (BTW, creatinine plays no role in it. It is not toxic, it is just a marker of severity of the process) . For that, patient needs BUN > at least 75. It physiologically cannot happen in 24 h except for very selected circumstances (uncontrolled massive crash syndrome, severe trauma, massive burns, all of that with poor fluid management and shock). And quick elevation of BUN would be picked by physician the day before at least.

5). there were minimal reasons for concern and they could be dispelled by 5 min nursing assessment ( VSs, oropharyngeal mucous moisture, bowel sounds and bladder scan). There were no indications for any immediate interventions. C diff test was in fact contraindicated. Everything that had to be done was 5 min assessment and letting the patient to sleep a few more hours. There was nothing to call doc about, and I am glad that the OP was not pushed into doing this, because she likely would be yelled at in addition to all her grievances.

Regarding that another nurse, she is just a typical task-oriented bully and needs to be dealt with accordingly. Should it happen with my patient and I got to know the story (and I somehow always get to know such things), she would be banned from caring for anyone from my census list.

[Tweety, BSN, RN]

1 hour ago, KatieMI said:

1). patient was, apparently, improving. JPs were out. She had bowel function (therefore, no third spacing in the bowel expected). She was ambulatory (therefore, not "lethargic", just sleepy). VSs were all stable (you gotta have MAP 65 or below to start to compromise renal function, and it is comes to that when BP hits approximately 85/50, at which point you would tear the phone apart). She was on continuous fluids (which, BTW, make people less thirsty and feeling less hunger).

Under this circumstances one needs to be quite sick with already good deal compromised renal function to develop AKI with "anuria" in just 12 h. If that would be the case, vitals would change. They did not.

2). "anuria" is when there is no output at all for 24 h or more. 0.5 ml/kg or less within 24 h is "oliguria". Both need to be observed for FULL 24 HOURS to become diagnostic.

3). Patient's potassium I expect to be norm or low (diarrhea + fluid), providing the diarrhea really happened. It could be those small loose BMs frequently seen as part of "recovering bowel syndrome" (part of which is hypokalemia).

4) In case of acute renal failure, "lethargy" is a symptom of metabolic encephalopathy. It happens from significantly elevated BUN (azotemia) (BTW, creatinine plays no role in it. It is not toxic, it is just a marker of severity of the process) . For that, patient needs BUN > at least 75. It physiologically cannot happen in 24 h except for very selected circumstances (uncontrolled massive crash syndrome, severe trauma, massive burns, all of that with poor fluid management and shock). And quick elevation of BUN would be picked by physician the day before at least.

5). there were minimal reasons for concern and they could be dispelled by 5 min nursing assessment ( VSs, oropharyngeal mucous moisture, bowel sounds and bladder scan). There were no indications for any immediate interventions. C diff test was in fact contraindicated. Everything that had to be done was 5 min assessment and letting the patient to sleep a few more hours. There was nothing to call doc about, and I am glad that the OP was not pushed into doing this, because she likely would be yelled at in addition to all her grievances.

Regarding that another nurse, she is just a typical task-oriented bully and needs to be dealt with accordingly. Should it happen with my patient and I got to know the story (and I somehow always get to know such things), she would be banned from caring for anyone from my census list.

Most excellent response.

I will respectfully disagree that there is "minimal reason for concern". I definitely wouldn't say ARI or anuria, but what do we know about the urine output for this. patient? Nothing. Could be her bladder is full and no worries. Her saying she didn't have to urinate after more than 12 hours might indicate she's behind.

Could be she's not meeting the minimum acceptable urine output and we can intervene. Granted, no huge red flags here to get excited about, but some concern is warranted in my opinion.

Urine output is an assessment. One can have low urine output and normal vital signs but it would still need addressing, just like someone with a fever can have stable vital signs. Why wait until the patient is symptomatic in other ways?

But we have no idea because we've let it go over 12 hours to the next person.

Again, all I can relate to is how I personally practice and share that. Obviously not everyone practices this way.

[Susie2310]

1 hour ago, KatieMI said:

1). patient was, apparently, improving. JPs were out. She had bowel function (therefore, no third spacing in the bowel expected). She was ambulatory (therefore, not "lethargic", just sleepy). VSs were all stable (you gotta have MAP 65 or below to start to compromise renal function, and it is comes to that when BP hits approximately 85/50, at which point you would tear the phone apart). She was on continuous fluids (which, BTW, make people less thirsty and feeling less hunger).

Under this circumstances one needs to be quite sick with already good deal compromised renal function to develop AKI with "anuria" in just 12 h. If that would be the case, vitals would change. They did not.

2). "anuria" is when there is no output at all for 24 h or more. 0.5 ml/kg or less within 24 h is "oliguria". Both need to be observed for FULL 24 HOURS to become diagnostic.

3). Patient's potassium I expect to be norm or low (diarrhea + fluid), providing the diarrhea really happened. It could be those small loose Bfs frequently seen as part of "recovering bowel syndrome" (part of which is hypokalemia).

4) In case of acute renal failure, "lethargy" is a symptom of metabolic encephalopathy. It happens from significantly elevated BUN (azotemia) (BTW, creatinine plays no role in it. It is not toxic, it is just a marker of severity of the process) . For that, patient needs BUN > at least 75. It physiologically cannot happen in 24 h except for very selected circumstances (uncontrolled massive crash syndrome, severe trauma, massive burns, all of that with poor fluid management and shock). And quick elevation of BUN would be picked by physician the day before at least.

The OP provided good information, but without seeing the patient, assessing them, knowing their medical history, reason for admission, current medical problems including recent labs, etc. we are making our best guess as to what happened. My response/guess was based on the fact that we don't know what the patient's medical history and current medical problems were beyond those described by the OP.

I have certainly experienced patients become hypovolemic from prolonged diarrhea which has resulted in Acute Renal Failure/Acute Kidney Injury. Since we have limited patient information it seemed reasonable to consider this could be a possibility. The patient was described by the OP as very tired; in Acute Renal Failure lethargy due to the ARF can appear similar to tiredness.

Stable vital signs means the vital signs are unchanging. Patients who are dead have stable vital signs. My understanding was that the patient was on a med-surg unit and would likely have had their vital signs taken q 4 hours. I agree that one would expect Acute Renal Failure to be reflected in the vital signs, but I considered the possibility that the vital signs might not have been taken correctly. Also, I don't think we were told what the vital signs were in the OP.

MAP is very relevant, but IF the patient already had significant chronic renal failure their kidneys would be more sensitive to the insult of fluid loss r/t the diarrhea. I have seen patients with significant chronic renal failure (not on dialysis) go into Acute Renal Failure with a far shorter period of diarrhea than the OP described.

When I said "anuria" I meant the complete lack of production of urine. I agree that one would expect vital signs to change if this is the case, but we don't know when vital signs were taken, how frequently they were taken, or what they were if I recall correctly from the OP so this wasn't sufficient for me to exclude this.

I have seen Acute Renal Failure with severe lethargy develop quickly in a patient with compromised renal function albeit that the patient had other significant medical problems taking place at the same time and had significant co-morbidities, as is not unusual in a patient on a med-surg unit.

[TriciaJ, RN]

On 2/3/2020 at 7:28 AM, Ioreth said:

Thank you all who have replied. You've given me lots to think about. Even though I've seen this nurse behave rudely to new nurses, I honestly didn't think it applied to me. I thought that I had simply screwed up horribly. And maybe I did. In any case, this gives me a new perspective.

Nope. It was absolutely not okay to rip you a new one at the bedside. I hope you can take this nurse aside at some early opportunity and call her out on this. "I understand you had some issues with how I handled things, and I would be glad to discuss my rationales with you. However, that was not a conversation to be had in front of the patient. You damaged the patient's confidence in her care and you seriously damaged my rapport with her. That was completely inappropriate and unprofessional." Make firm eye contact and keep your voice low but firm. If she starts to argue, just repeat that the bedside was not the appropriate venue for that conversation.

If your hospital has bought into Service Excellence, that nurse's behaviour was an example of managing down. A big no-no.

It might feel very intimidating to call her out, but trust me it will be very empowering. It will also greatly diminish your attractiveness as a bully target.

[JKL33]

3 hours ago, Ioreth said:

I talked to the day nurse that I gave report to that day. Although I was careful in how I phrased things (thank you, Nursing Psych and therapeutic communication), she was very defensive and said that she needed to correct me immediately, not wait to leave the room.

If having a private conversation, the appropriate response to that is "No. You did not." I'm serious. Make good eye contact while you're at it.

If you have approached someone to try to acknowledge their help and their concern; tried to revisit a scenario to learn something and/or to clear the air a little and they refuse to engage, then they just need to hear the bottom line and they need to know you are serious about it.

If she was so sure there was an ongoing dire emergency kidney failure situation and needed a STAT bladder scan, then she didn't have time to be messing around correcting you and pointing out that she also didn't like the way things were clamped. Period. She is just lying about her own motivation and being a jerk. Learn what you can from this for your sake and your patients' sake, but don't feel bad due to the behaviors of this person. People who act that way don't feel too good about themselves unless they constantly find ways to tell themselves they are better than so-and-so (in this case, you).

[LibraSunCNM, BSN, MSN, CNM]

2 hours ago, JKL33 said:

People who act that way don't feel too good about themselves unless they constantly find ways to tell themselves they are better than so-and-so (in this case, you).

This. The world is full of people like this and the nursing world is no exception to that rule. TriciaJ and JKL offered excellent examples of ways to communicate with people who act this way.