Voiding!

TX.RN.Shannon · Sep 13, 2018

Is it a 8 or 12 hour shift? If it is 8 hours---say he's already in bed, pretty alert and healthy, sleeping well--no big deal. Now for a 1w hour shift---I wanna see the pee!

ohsosarah20, BSN · Sep 13, 2018

8 hr shift! Definitely need to see the pee on a 12 :)

Miss.LeoRN · Sep 13, 2018

I usually just make sure they have gone at some point on my shift, which is a 12 hour night shift. Unless they are very old, or very ill, or as you state some reason to be concerned on why or why not they are voiding, the patient will typically go at some point in the evening prior to bed, or in the early morning when they wake up (typically right before shift change or as vitals begin). That's good enough for me. Also, if I have a concern about a patient, one of the first persons I am going to consult on it is my aide because they are the person likely to be assisting the person.

meanmaryjean, DNP, RN · Sep 13, 2018

If my person has IV fluids running anything above KVO I am expecting urine at some point in time.

TX.RN.Shannon · Sep 13, 2018

So I wouldn't be so concerned, as long as there's no IV running. And I'd check---maybe they peed at 2145, which means 2-10 would take credit. She may not have to go again until morning-especially the elderly, who either have poor PO intake, or limit fluids so they don't get up to void during the night.

Now if there's IV fluids going at more than KVO (30ish ml/per hour), I'm expecting something.

JKL33 · Sep 13, 2018

Neither your coworkers' rule of thumb nor your commonsense approach can be applied in blanket fashion but must take into account the specific of the patient's condition and the goals of the POC.

The fact that healthy non-hospitalized people are likely able to sleep through the night without waking to urinate doesn't dictate the case for hospitalized patients and their individual conditions - for example, your patient receiving even moderate rate maintenance fluids may very well be doing better on hydration than numerous non-hospitalized folks who have difficulty getting in the recommended amounts of fluids per day (and even if they are, they aren't taking it in around-the-clock).

I think overall it's better to ask yourself whether this person should be voiding or not.

However, "voiding" is fairly frequently conflated with "making urine," which is probably the issue you are noticing. Just because someone with a foley should be able to be observed making X mls of urine per hour doesn't mean that every human being who doesn't have a foley must void a minimum of X mls of urine once per hour ATC.

Sour Lemon · Sep 13, 2018

At the very least, I check for bladder distention or just ask the patient what their "normal" is.

KelRN215, BSN, RN · Sep 13, 2018

8 hr shift! Definitely need to see the pee on a 12 :)

As you said in your OP, most adults sleep through the night without waking to pee. It's certainly not concerning if a sleeping adult doesn't wake to void between the hours of 11pm-7am though, of course, there are clinical reasons why you might expect someone to wake to void on the night shift. But, as a general rule, no it's not something to be concerned about if an adult doesn't void overnight. I pee before bed and then when I wake up in the morning.

Chrispy11, ASN, RN · Sep 15, 2018

I'm curious on others thoughts on this topic. Voiding is obviously important to keep track of, but I don't typically worry at night if my patient hasn't voided but my co workers do. My thoughts are this, if they haven't had any bladder issues, Foley's removed, or any other issues, why should I expect my patients to void at night? I don't typically void at night, but I do in the mornings...like most individuals. So...thoughts? I'm open to learning, and I've tried to tell some people this but it's quickly shut down, and usually with no rhyme or reason other than "textbook" you should be voiding.

I won't give you text book, but rather my personal experience after surgery. I was a patient while I was in nursing school. I was hooked up to an IV for fluids and had SCDs on. I woke up at 2300 having to void. I called and no one came and I gave it 20 minutes. After having to call again I politely stated that it was my second call and I really wanted to save them from having to remake my bed. Some one came to my assistance 10 seconds later. Just saying, if someone's on fluids, they're going to have to go. It's not like a person can keep up their regular routine in a hospital without being a fall risk. Some people just can't hold it the entire night. I was usually the person who did just before bed and mornings. People just aren't on their regular schedule in a hospital. Can't really compare it to your regular night's sleep since no one wakes you up for vitals and blood tests. Just put yourself in the patients' shoes to answer your question. :)

DisneyNurseGal, BSN, RN · Sep 15, 2018

Great question! One of those conundrums that comes with working night shift. I did it for 4 years on a Step Down Med ONC unit, so i've been there.

I do not think the question is cut and dry. Like many things in nursing it depends on so many other factors. First, it would depend on how much they urinated on the previous shift. We would follow the rule-of-thumb 30ml/hour (calculated Q4), but if they had had a decent bladder emptying before they went to bed, I would use my critical thinking and let them sleep. If they were running fluids 125-150ml/hour, after 5-6 hours or so, the patient is going to have a very full bladder that should be emptied in the middle of the night. Also, it is depending on the patient's diagnosis or comorbidities, if they are at risk for sepsis, I sure as heck am going to wake them up because I am watching for signs of decreased end organ perfusion (again this patient is probably on fluids so see comment above). A patient with a history of renal issues or poor kidney labs, I might be inclined to wake them. Finally, all of our patients are woken in the 5am hour either by labs or our CNAs. They are toileted at that time so if I did let them sleep, I can have some current urine charted, and so when the patient was woken for bedside shift report, they did not ask to go to the bathroom then and slow down handoff.

So, as you can see, it is not a cut and dry answer. On a 12 hour shift, I wanted each of my patients to pee at least twice before I was not concerned.

I understand what you were saying about how you can go all night without peeing, but I would reply with these patients are not at home, and we are tasked with keeping them safe, and unfortunately that includes an assessment of the whole person, including urinary system, even in the middle of the night.

For me, it all came down to communication. I would tell all of my patients before they went to sleep, that I would be lightly waking them in the middle of the night to assess many things (Vital signs, neurological status, pain, NAMDU etc) and to ask them if they needed to pee. i've caught many a dropping blood sugar with this practice but that is a post for another day.

MunoRN, RN · Sep 15, 2018

As with pretty much everything, it's patient specific. Even if they're getting IV fluids I don't necessarily expect all everything that went in to come right back out if the purpose of the IV fluids is that they are dehydrated, the point of the IV fluids in that case would be for a portion of the volume to be retained. DKA patients for instance often don't void for their whole first day, which isn't necessarily due to an inability to make urine, it's due to their body appropriately holding onto the fluid. You should also consider their typical voiding volume, if they've got a nurse's bladder and can wait until they've got a liter in their before voiding then I would expect them to void less frequently even though they're making plenty of urine. If you're not sure if they're not making urine or just haven't voided the urine they've made, then bladderscanners are handy.