Renal Case Study : Tea-Colored Urine

Renal Case Study : Tea-Colored Urine

Case Scenario:

Carmelita Gomez, age 8, is brought to the Children’s Clinic by her mother because she is nauseated and has vomited three times in the past 24 hours. Her urine has turned "tea colored". Carmelita is lethargic and she is complaining of diffuse abdominal pain. Ten days ago she had a sore throat and fever and stayed home from school for two days. She was not seen by a health care provider at that time. Upon questioning, Carmelita cannot remember needing to urinate in the past 12 hours. On exam, Carmelita is irritable and listless. Renal Case Study : Tea-Colored Urine . She has slight periorbital edema. Carmelita has active bowel sounds with no palpable abdominal masses, but she is tender in all four quadrants. Carmelita is given a presumptive diagnosis of poststreptococcal glomerulonephritis (PSGN), pending laboratory tests.

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Her laboratory values are:

Serum creatinine: 2.3 mg/dL

BUN 26.1 mg/dL

Serum sodium: 142 mEq/L

Potassium 4.2mEq

Specific gravity 1.025 Renal Case Study : Tea-Colored Urine

Phosphorous: 6.3 mEq/dL

Calcium: 7 mEq/dL

UA: hematuria 4+, red cell casts

Antistreptococcal antibody titre: 800U

POINTS TO PONDER:

  1. Which lab values are abnormal?
  2. What clinical manifestations      correspond to the abnormal values?
  3. Describe the changes      (pathophysiology) in the body causing each abnormal value and link the      value to a clinical manifestation present in the patient? Renal Case Study : Tea-Colored Urine
  4. Which values are within normal      limits?
  5. What nursing care needs to be      implemented?
  6. Provide one nursing      diagnosis appropriate to this patient.

Reading

  1. Urinalysis p.1146 (Leeuwen, pg.      546-552)
  2. Culture p.230
  3. Kidney      stone analysis p.696 (Leeuwen, pg. 61,265,426,444)

 

Case    Study Rubric

 

Criteria

Renal Case Study : Tea-Colored Urine

Abnormal Values

What do the labs indicate specific to   this patient

 

values and signs and   symptoms

The relationship between the abnormal   Signs & Symptoms and lab values is clearly demonstrated. **Must be   specific**

 

Pathophysiology used to demonstrate connections between lab results, manifestations and disease process.

Renal Case Study : Tea-Colored Urine

Expected care to be given for exhibited   s/s and lab values. Expected correction of lab values based on care given.   Patient education to prevent recurrence of abnormal lab values.

Quality

Grammar, spelling, APA...

art & science continence focus

UrJnalysis Wilson LA (2005) Urinalysis. Nursing Standard. 19, 35, 51-54. Date of acceptance: March 22 2005.

Summary Urine analysis is an essential component of patient assessment, which is used for screening, diagnosis and planning care. This article discusses specimen collection and reagent strip testing.

Author Lesley A Wilson, a Southampton City

the time of writing, was clinical manager at the Primary Care Trust, Southampton.

Email: lesley.wilsorl@scpct.nhs.uk

Keywords Reagent strips; Urinary tract infection; Urine

These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. Renal Case Study : Tea-Colored Urine . For related articles and author guidelines visit the online archive at www.nursing-standard.co.uk and search using the keywords.

URINE ANALYSIS is an essential part of any initial patient assessment process and all continence assessments should include urine analysis (Artibani etal 2002). Testing urine with reagent strips is quick and easy. It is cost effective in reducing the need for laboratory testing (McGhee 2004).

The functions of urine analysis are (Getliffe and Dolman 2003, McGhee 2004):

• Screening - for systemic disease, for example, diabetes mellitus or renal conditions.

• Diagnosis - to confirm or exclude suspected conditions, for example, urinary tract infection.

• Management and planning-to monitor progress of an existing condition and/or plan programmes of care.

Urine analysis, or urinalysis, within a continence assessment, will be used to identify or exclude infection. It is also a valuable aid to early diagnosis of unexpected pre-existing medical conditions (Fantl etal 1996). Renal Case Study : Tea-Colored Urine . Testing urine using reagent strips relies on a chemical reaction between the reagent on the strip and individual constituents of the urine. It is essential to use the strips according to the instructions and also to be aware of factors that may affect the results, such as specific drugs or the quality of the urine specimen itself.

Further testing may be necessary, such as culture and sensitivity testing under laboratory

NURSING STANDARD

conditions, to identify organisms responsible for infection and to determine the most effective treatment. Twenty-four hour collection is used to measure substances such as steroids, red or white blood cells, electrolytes (for example, chloride, potassium, calcium, sodium) or to determine the urine osmolality (the concentration of molecules in fluid) (Tortora and Grabowski 2003). Renal Case Study : Tea-Colored Urine

Urine analysis using reagent strips

There is a wide variety of reagent strips available for testing urine. The choice depends on the reason for analysis. One example is of strips that are specifically for diabetes testing- these measure glucose or ketone levels or both in the urine. The most commonly used reagent strips are Multistix® SG, Multistix® 8SG and Multistix® lOSG. Multistix® 1OSG has the greatest number of reagents. It tests specific gravity and pH and shows the presence of glucose, protein, ketones, blood, bilirubin, urobilinogen, leukocytes and nitrite, when present, in the urine specimen. Multistix® SG tests for glucose, protein, ketones, urobilinogen, bilirubin, specific gravity (SG) and pH (six reagents plus SG). Multistix® 8SG does not test for urobilinogen and bilirubin but tests for leukocytes and nitrite (eight reagents plus SG). Renal Case Study : Tea-Colored Urine . Specific gravity Specific gravity is a measure of the total solute concentration in a fluid and, in healthy individuals, is 1.002-1.035. High values are indicative of dehydration and low values are found when a person has a high fluid intake and may indicate diabetes insipidus, renal failure, hypercalcaemia (raised blood calcium levels) or hypokalaemia (lowered blood potassium).

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High amounts of protein or glucose present in the urine can affect specific gravity readings. If urine pH is greater than 6.5, adding 0.005 to the specific gravity reading on the reagent strip will increase its accuracy. Urine specific gravity is reduced in older adults as the kidneys' ability to concentrate urine is diminished (Bayer Diagnostics Europe (BDE) 2004, McGhee 2004). pH pH is an indication of acidity or alkalinity: a pH of 7.0 is neutral. Renal Case Study : Tea-Colored Urine . Any reading below 7.0 indicates acidity and greater than 7.0 indicates alkalinity. The pH of urine reflects the pH ofthe body fluids and in healthy urine pH is normally between 4.5 and 8.0. Low values are found in patients with

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diabetic ketoacidosis, starvation atid potassium depletion. Low values may also indicate a predisposition to the formation of renal or bladder calculi. High values are often indicative of urinary tract infection with ammonia forming organisms, but can be due to vomiting or consumption of large amounts of antacids.

The most common cause of high pH readings is stale urine specimens. A high protein diet or ammonium chloride medication can produce a low acid reading. A diet high in vegetables, citrus fruits or dairy products and exposure of urine at room temperature can produce a high alkaline reading (BDE 2004). Renal Case Study : Tea-Colored Urine . Glucose When blood glucose is raised and concentration of glucose in plasma exceeds the renal threshold, glucose will be present in the urine. The most common causes of glycosuria are diabetes mellitus or glucose infusion. Glucose can also be present in urine during pregnancy without blood glucose being raised. The presence of glucose in the urine should be further investigated by fasting blood sugar sampling (BDE 2004, McGhee 2004).

High doses of salicylates or levodopa may produce false negatives by masking the presence of glucose and high doses of ascorbic acid, or the presence of ketones may depress the development of colour on the reagent strip. These effects may be minimised by testing an early morning urine specimen, before medication has been taken. Protein Reagent strips are most sensitive to albumin. Renal Case Study : Tea-Colored Urine . The presence of the protein albumin in the urine is indicative of increased permeability of the basement glomerular membrane due to the presence of infection. Protein is also found in the urine in pre-eclampsia.

Ealse positive results in respect of the presence of protein may be obtained in alkaline urine or with the use of disinfectants such as chlorhexidine or benzalkonium. Further investigations, including urine culture and microscopy, should always be carried out when protein is found in the urine to detect urinary tract infection, renal conditions such as glomerular nephritis or pre- eclampsia during pregnancy (BDE 2004, McGhee 2004). Renal Case Study : Tea-Colored Urine . Ketones Ketones, such as acetoacetic acid and acetone, are produced during fat metabolism. Presence of ketones in urine indicates excessive breakdown of body fat. The most common causes of ketonuria are fasting (starvation), especially accompanied by fever and vomiting (most often seen in children), and diabetic ketoacidosis with grossly uncontrolled type 1 diabetes.

Ketoacidosis - glucose and ketones in the urine - is life-threatening and should be investigated to determine blood sugar levels: patients require urgent treatment (insulin) (BDE 2004, McGhee 2004). Ealse positive results in respect ofthe presence of ketones in the urine can result from some drugs such as levodopa or captopril (BDE 2004). Blood The presence of blood in urine is associated with diseases ofthe kidneys or urinary tract, the most common being infection, calculi, benign prostatic hypertrophy and renal disease, such as polycystic kidneys, glomerulonephritis or tumours. Renal Case Study : Tea-Colored Urine . Trauma such as fractured pelvis can cause haematuria. Blood may also be present in urine as a result of urinating during menstruation.

Ascorbic acid can reduce the sensitivity ofthe reagent and captopril may also cause reduced reactivity ofthe strip. Haematuria should always be investigated to exclude serious medical conditions such as malignancy (BDE 2004, McGhee 2004). Bilirubin It is not normally possible to detect bilirubin in the urine and its presence is usually indicative of liver or gallbladder disease such as viral or drug induced hepatitis, paracetamol overdose, late stage cirrhosis, gallstones and carcinoma ofthe head ofthe pancreas. Renal Case Study : Tea-Colored Urine . Drugs such as rifampicin may affect the result by masking a small reaction and chlorpromazine may cause a false positive result in respect ofthe presence of bilirubin in the blood (BDE 2004, McGhee 2004). Urobilinogen The presence of urobilinogen in urine is related to the production of bilirubin and conversion of bilirubin to urobilinogen in the digestive tract. It may indicate liver or blood disorders, such as hepatitis, sickle cell disease and thalassaemia, or it may indicate biliary tract obstruction such as gallstones or carcinoma of the pancreas. Ealse negative results can be produced by a stale urine specimen (BDE 2004, McGhee 2004). Therefore it is important to test the sample soon after collection. Leukocytes Leukocytes in urine confirm the presence of inflammation. The most common reason for infla mmation of the urinary tract is infection. Renal Case Study : Tea-Colored Urine . If urine has a high specific gravity or high glucose levels, or when cefalexin or tetracycline are used, false negative results may be experienced. Nitrofurantoin, which colours urine brown, and any other substance causing abnormal urine colour may mask the reaction on the strip (BDE 2004, McGhee 2004).

Nitrite Nitrite is only found in the urine in the presence of infection. Most of the organisms implicated in urinary tract infection, such as Escherichia coli, Proteus, Pseudomonas and Klebsiella species. Streptococcus faecalis and Staphylococcus aureus (GtxWiitlQQi) c&use

52 may 11:: vol 19 no 35 :: 2005 MURSING STANDARD

nitrate (normally present in urine) to be converted to nitrite. A negative result, however, does not exclude infection, as not all infecting organisms are able to convert nitrate to nitrite. Renal Case Study : Tea-Colored Urine

Large amounts of ascorbic acid can cause a false reaction but in urine with a high specific gravity, sensitivity to the reagent is reduced. It is not necessary to treat asymptomatic urinary tract infection with antibiotics as resistant organisms may result (Getliffe 2003, BDE 2004).

Specimen collection

The reliability of urine analysis is dependent on the quality of the urine specimen. This applies when the analysis is using reagent strips or for laboratory testing. At the time of collection, or soon after, urine should be examined visually for clarity, colour and any odour should be noted (a 'fishy'smell is suggestive of infection) (Figure 1).

Procedure for specimen collection:

• Early morning specimen (first void of the day) is preferable for routine analysis as it is more concentrated and results will have greater accuracy. Renal Case Study : Tea-Colored Urine

• Urine should be passed directly into a clean container such as a bedpan or sterile receptacle for laboratory specimens. It is not necessary to wash before passing urine but sometimes this may be appropriate, especially when collecting a mid-stream specimen for culture and microscopy. Contamination ofthe specimen could lead to misdiagnosis. If it is necessary to wash before passing urine, ensure all traces of soap are removed and the skin is dried thoroughly. Renal Case Study : Tea-Colored Urine

• The sample should be placed in a sterile container.

• The container should be labelled - especially if the test is not to be carried out immediately or the specimen is being sent to the laboratory- and to avoid mistakes when more than one patient's specimen has been collected for analysis.

• When testing urine using reagent strips, it is more reliable to test the urine immediately. If this is not possible, test within four hours of collection.

• Specimens can be refrigerated immediately after collection at a temperature of 4-8"C, but must be allowed to return to room temperature before testing.

Factors affecting results

Urine should be analysed as soon after the specimen has been collected as is practicable. The following factors can affect the analysis of results (BDE2004):

• Bilirubin and urobilinogen are relatively unstable compounds when subjected to light and at room temperature, so it is important to use fresh urine to obtain the most accurate results. Renal Case Study : Tea-Colored Urine

• Exposure of unpreserved urine at room temperature for a considerable period of time may result in an increase in micro-organisms in the urine and a change in pH.

• Bacterial growth of contaminating organisms in urine may produce a positive blood reaction.

• Urine that is high in alkaline may show false positive results in respect of the presence of protein.

FIGURE 1 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ H

Urine analysis using reagent strips

Obtain urine specimen

> Frank haematuria (exclude menstrual blood) or

• Obviously infected

Check urine for colour. clarity and odour

r

Urine analysis with reagent strips (Box 1)

r \

Positive to: * Glucose • Ketones • Protein • Blood • Nitrite • Leukocytes * Bilirubin • Urobilinogen

r

Report results and take further action

Negative to: * Glucose • Ketones > Protein • Blood • Nitrite • Leukocytes • Bilirubin > Urobilinogen

Consider re-testing if urine was not tested soon after specimen collection

r

> Discard specimen

• Report no evidence of any pathology as indicated by urine analysis

Further investigation: • Laboratory testing for culture and sensitivity • Fasting blood sugar • Further specific testing as appropriate, for example. Renal Case Study : Tea-Colored Urine

24-hour urine collection

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• Glucose in urine may reduce its pH as a result of metabolism of glucose by organisms present in the urine.

• The presence of urea splitting organisms that convert urea to ammonia may cause urine to become more alkaline.

Preservatives can sometimes be used but these also can affect the accuracy ofthe results, for example:

• Thymol - commonly used but can give false positive reactions for albumin.

• Formaldehyde - can give false positive results for glucose if using the tablet test.

• Hydrochloric acid-most usually recommended for 24-hour urine collections; often used to determine steroid concentrations. Hydrochloric acid also helps preserve cell structures.

• Boric acid - usually added to preserve bacteria

Reagent strip procedure

* Examine appearance of urine for colour, clarity and odour

• Dip the reagent strip briefly into fresh, well-mixed urine. Immerse reagent areas completely and remove immediately to prevent reagents dissolving

• Run edge of strip along the container, holding the strip horizontally. Renal Case Study : Tea-Colored Urine . This will remove excess urine and prevent mixing of chemicals from adjacent reagent areas

• When the appropriate time has elapsed according to reagent strip instructions, compare test areas closely with the corresponding colour chart on bottle label to determine the result

• Record results according to local policy

• Take further appropriate action dependent on the results obtained

present in urine but excessive concentrations can prevent bacterial growth during culture. Sensitivity ofthe leukocyte reagent on the strip may be reduced.

Visual reading of reagent strips

It is essential to follow the specific instructions included with the reagent strips: refer to the label and the packaging (Box 1). Reagent strips are designed to react progressively, producing colour changes for positive reactions along the strip at specified times. It is important to read the strip at the specified time for each reagent to obtain accurate results. These times are found on the label ofthe bottle containing the strips. Renal Case Study : Tea-Colored Urine . Strips should never be stored in alternative containers: they have a relatively short shelf life and strips that have expired may not give an accurate result. The expiry date is located on the bottle.

Computerised urine analysers are available to read the strips, and show the analysis on a small screen, then print out the results to include in the patient's records. The advantage of using an analyser is greater accuracy, convenience, ease of use and time savings. However, with many services under budgetary constraints, purchasing this type of equipment may not be feasible. Renal Case Study : Tea-Colored Urine

For use in the community, where less frequent testing may be required, Multistix® GP is available. Multistix® GP has the same reagents as Multistix® 8SG but each bottle only contains 25 strips compared with 100 in Multistix® 8SG and Multistix® lOSG.

Conclusion

Urine analysis is an essential part ofthe health assessment process. It is a valuable tool in screening for systemic diseases, for example, diabetes mellitus and the diagnosis of existing conditions such as infection. The use of reagent strips is quick, easy and economical. Their use can reduce the need for further expensive laboratory testing and greatly enhance the care planning process NS

References

Artibani W, Andersen JT, Gajewski JB et al

(2002) Imaging and other investigations. In

Incontinence. Second edition. Second

Intemational Consultation on Incontinence,

1-3 July 2001, Paris, 465.

Bayer Diagnostics Europe (2004) Your

Practical Guide to Urine Analysis. Bayer

Healthcare, Newbury, Berkshire.

Fantl JA, Newman DK, Coiiing J et al (1996)

Urinary incontinence in adults: acute and chronic

management. Ciinicai Practice Guideiine, Number

2 (1996 update). Agency for Health Care Policy

and Research, Rockville MA.

Getiiffe K (2003) Catheters and catheterisation.

In Getliffe K, Dolman M (Eds) Promoting

Continence: A Ciinicai and Research Resource.

Bailliere Tindall, Edinburgh, 259-301. Renal Case Study : Tea-Colored Urine

Getliffe K, Doiman M (2003) Normal and

abnormal bladder function. In Getliffe K, Dolman

M (Eds) Promoting Continence: A Ciinicai and

Research Resource. Second edition. Bailliere

Tindall, Edinburgh, 21-51.

iVicGhee iVI (2004) Lab investigations. Practice Nurse. 28, 9,19-26.

Tortora G, Grabowsi<i SR (2003) Principies of Anatomy and Physioiogy. Tenth edition. John

Wiley & Sons, Nev;/ York NY.

Renal Case Study : Tea-Colored Urine