URINE TESTING Objectives: After 8 hours of varied classroom activities, the level 2 students will be able to: 1.

Define the following terms: a. Urine b. Urine testing c. Hematuria d. Pyuria e. Dysuria f. Anuria g. Ketone bodies h. Diuretics i. Uric acid j. Gestational diabetes 2. Give the importance and purpose of urine testing. 3. List indications and contraindications 4. Enumerate factors affecting urination 5. Tabulate characteristics of normal and abnormal urine and their corresponding significance. 6. State the different methods of urine collection. 7. Identify the guideline principles involved in urine testing. 8. Explain guidelines in urine testing. 9. Demonstrate beginning skills in performing urine testing. 1. Define the following terms: a. Urine - waste product excreted by the kidney. b. Urine Testing - used to determine any abnormalities in the uterine. c. Hematuria - discharhe of urine containing blood.

d. Pyuria - abnormal presence of pus in the urine e. Dysuria - painful or difficulty in voiding f. Anuria - voiding less 100 ml a day g. Ketone Bodies - are products of fat metabolism and appear in the h. Diuretics - medicine which stimulates flow of urine i. Uric Acid - end product of purine metabolism - white crystalline, colorless substances found in urine. - acid in the urine. j. Gestational Diabetes- is a condition in which women without previously diagnosed diabetes exhibit ---high blood glucose levels during pregnancy 2. The importance and purpose of urine testing: To determine any abnormalities in urine To determine the presence of ketone bodies, glucose and albumin in urine. To monitor proper functioning of the liver and kidney. To assess the needs of the patients urinary problems in order to implement nursing care. To determine the presence of occult blood in urine. Provides physician with valuable information about the urologic and general health of the patient. Helps to know and determine the presence an amount of glucose, ketone bodies and albumin in the urine. Helps determine patients hydration status. Helps detect presence of drugs, urinalysis aids to measure clients fluids intake and urine output. Determine the acidity and alkalinity of urine. To determine the presence of microorganisms, the type of organism , and the antibodies to which the organisms are sensitive To assess the ability of the kidney to concentrate and dilute urine To determine disorders of glucose metabolism To determine levels of specific constituents of urine 3. Indications and contraindications

Indications: part of a routine physical examination suspected urinary tract infection. pain or buring during urination (dysuria) to monitor disease for pregnancy evaluation Contraindications: patient who does not feel the urge to void patient with rendel failure patient with severe electrolyte and/or fluid abnormalities patient is parurectic (or shy bladder sysndrome) 4. The factors affecting urination: Growth and Development Infants and young children are unable to concentrate urine and reabsorb water effectively. Their urine thus appears light yellow or watery. In relation to their small body size, infants and children excrete large volumes f urine. For example, a 6-month-old child who weighs between 10 and 16 pounds excretes 400 to 500 ml of urine daily. The child weighs about 10% of an adults weight but excretes 30% as much urine. A child is unable to control micturition voluntarily until the age of 18 to 24 months. It is usually more difficult for children to control urination than defecation. A child must be able to recognize the feeling of bladder fullness, to hold urine for 1 to 2 hours, and to communicate the sense of urgency to a parent. A child may not gain full control of micturition until the age of 4 or 5. Boys are generally slower than girls. Daytime control of micturition is easier to accomplish than nighttime control and occurs earlier in the childs development, usually by 2 years of age. The adult normally voids 1600 ml of urine daily. The kidney is able to concentrate urine effectively producing normal amber-colored urine. Normally a person does not void excessively during the night because of a reduction of renal blood flow during rest and because of the kidneys ability to concentrate urine. Changes in kidney and bladder function also occur with aging. The kidneys ability to concentrate urine declines. Thus the elderly often experience norturia, excessive urination at night. The bladder loses its muscle tone and capacity to hold urine, resulting in increased frequency of urination. Because the bladder cannot contract as effectively, an elderly person often retains urine in the bladder after voiding. Residual urine increases the risk for bacterial growth. Socio-cultural Factors The habits of micturition are no exception. North Americans expect toilet facilities to be private, whereas some Europeans accept less private communal toilet facilities as a way of life. There are also gender differences in toilet behavior. Men share public urinals and women use enclosed cubicles. Toilet habits begin when children attempt to mimic parents behaviors. Social expectations influence the time when it is proper to urinate. For example, school children are expected to wait until recess to urinate or raise their hands for permission to use the toilet. Psychological Factors Anxiety and emotional stress do not exchange the characteristics of urine, although they may affect the character of feces. However, a client who is highly anxious may feel a greater sense of urgency and experience increase of urination. An anxious person may have the urge to void even after voiding only a few minutes earlier. Anxiety may also prevent a person from being able to urinate completely. Emotional tension makes it difficult to relax abdominal and perineal muscles. If a person is unable to relax the external urethral sphincter completely, voiding may be incomplete and urine will be retained in the bladder. Personal Habits Some people follow complex routines before defecation. Usually fewer rituals precede urination. Privacy is the most essential condition for most people. Taking time to urinate allows a person to relax fully so that urine retention does not occur. During urination some individuals need distractions to promote relaxation, such as reading pr singing. Muscle tone Weakness of abdominal and pelvic floor muscles impairs bladder contraction and control of the external urethral sphincter. Poor control of micturition can result from muscle wasting caused b prolonged immobility, stretching of muscles during childbirth, menopausal atrophy, and damage to muscles from trauma. Continuous drainage of urine through an indwelling catheter causes loss of bladder tone. The bladder remains relatively empty and this is never stretched to its capacity. When a muscle fails to be stretched regularly, atrophy develops. When a catheter is removed, the client may have difficulty regaining urinary control. Fluid Intake

If fluids and the concentration of electrolytes and solutes are in equilibrium, an increase in fluid intake causes an increase in urine production. Ingested fluids increase the bodys circulating plasma and thus increase the volume of glomerular filtrate and urine excreted. The ingestion of certain fluids has direct influence on urine production and excretion. Alcohol inhibits the release of antidiuretic hormone. (ADH) and thus promote urine formation. Coffee, tea, cocoa, and cola drinks that contain caffeine increase diuresis and the frequency of micturition. Foods that contain high fluid content, such as fruits and vegetables, may also increase urine production. Disease conditions Several diseases conditions affect the ability to micturate. Any lesion of peripheral nerves leading to the bladder causes loss of bladder tone, reduced sensation of the bladder fullness and difficulty in controlling urination. For example, diabetes mellitus and multiple sclerosis cause neuropathies that alter bladder function. Diseases that slow or hinder physical activity interfere with the persons ability to void. Rheumatoid arthritis, degenerative joint disease, and Parkinsonism are examples of conditions that make it difficult to reach and use toilet facilities. Renal and bladder disease obviously affects micturition. Acute renal disease, such as glomerulonephritis, reduces the volume of urine produced. Chronic renal disease initially causes the kidney to release large volume of poorly concentrated urine. Surgical procedures The stress of surgery initially triggers the General Adaptation Syndrome where the posterior pituitary gland releases an increased amount of ADH, which increases water reabsorption and reduces urine output. The surgical client is often in and altered state of fluid balance before surgery, which aggravates the reduction in urine output. The stress response also reduces the level of aldosterone, resulting in reduction in urine output in an effort to increase circulatory fluid volume. Anesthetic agents and narcotic analgesics slow the glomerular filtration rate, reducing urine output. Clients recovering from anesthesia and deep analgesia are often unable to sense bladder fullness and are unable to initiate or inhibit micturition. Spinal anesthetics, in particular, create the risk of urinary retention because of the inability to sense the need to void. Surgery involving the lower abdominal and pelvic structures can impair urination because of local trauma to surrounding tissues. The edema and inflammation associated with the healing process may obstruct the flow of urine from the bladder or urethra, interfere with relaxation of pelvic and sphincter muscles, or cause discomfort during voiding. After surgery involving the bladder and urethra, the clients routinely need urinary catheters. Medication Various medications influence the volume of urine excreted or change the characteristics of urine. Diuretics prevent the reabsorption of water and certain electrolytes in the kidney tubules, resulting in an increased urine output. Because of the high proportion of water in the urine a client taking diuretics has light-colored urine. Certain medications change the color of urine. Drugs that Discolor Urine Drug Color of Urine Amitriptyline (Elavil) Blue-green Cascara Yellow to red Danthon (Mondane, Dorbane) Pink to red Phenytoin (Dilatin) Pink to red to red-brown Indomethacin (Indocin) Green Methyldopa (Aldoment) Red Phenazopyridine (Pyridium) Orange to red Phenothiazines (Thorazine, Mellaril) Pink to red to red-brown Riboflavin (vitamin B2) Yellow Rifampin (Rifadin) Bright orange-red Warfarin sodium ( Coumadin) Orange

Diagnostic Examination Examination of the urinary system can influence micturition. Certain procedures such as an intravenous pyelogram or urogram require that the client not take fluids orally before the test. A restriction in the fluid intake commonly lowers urine output. Diagnostic examination (for example, cystoscopy) that involve direct visualization of urinary structures may cause localized edema of the urethral passageway and spasm of the bladder sphincter. The client often has urinary retention following such as procedure and may pass red- or pink-tinged urine because of bleeding resulting from trauma to the urethral or bladder mucosa. 5. Characteristics of Normal and Abnormal Urine and their Corresponding Significance:

CHARACTERISTICS Amount in 24 hours (adult)

NORMAL 1200-1500 ml

ABNORMAL and THEIR CORRESPONDING SIGNIFICANCE Under 1200 ml o Decreased fluid intake o Kidney failure Over 1500 o Diabetes o Diuretics o Increased fluid intake

Color

Straw, amber or transparent

Dark amber o Insufficient fluid intake resulting in concentrated urine Cloudy o Infectious process Dark orange o Drugs (e.g., Pyridium) Red or dark brown o Disease process causing blood in urine

Consistency

Clear liquid

Mucus plungs miscid, thick o Infectious process Offensive o Infectious process Microorganisms present o Infection of the urinary tract Under 4.5 o Urinary tract infection Over 8 o Uncontrolled diabetes o Starvation o Dehydration

Odor

Faint chromatic

Sterility

No microorganisms present 4.5 to 8

Ph

Specific gravity

1.010 to 1.025

Under 1.010 o Diabetes Insipitus o Kidney Disease o Overhydration Over 1.025 o Diabetes milletus o Underhydration

Glucose

Not present

Present o Diabetes milletus Present o Diabetic coma o Starvation o Prolonged vomiting Occult o Bright red

Ketone bodies (acetone)

Not present

Blood

Not present

 Kidney disease o Hemorrhage

6. The different methods of urine collection. 1. Urinalysis Sample involves the measurement of the common constituents of urine, requires only a specimen obtained with normal voiding. Guidelines: The client may void into a clean urine cup, a urinal or a bedpan. The client must void before defecating so feces do not contaminate the specimen. If a woman is having menstrual period, the nurse makes note of this on the specimen requisition in case of red blood cells appear in the urine. All specimens are labeled with the clients name, the date, and the time of collection. 2. Clean-Voided or Midstream specimen collection of a clean voided specimen of urine in a sterile container during the middle portion of the voiding Guidelines: The nurse instructs the client on the method for obtaining a clean-voided specimen. Both female and male clients receive a clean washcloth with soap or a disinfectant towel to wash the urethral meatus. FEMALE CLIENT: Wear sterile gloves. Spread the labia well, and keep them apart until the specimen is obtained. Clean the area at the external meatus with sterile gauze or cotton balls and antiseptic soap and water. Move the gauze or cotton balls from the meatus toward the anus, and use one piece of gauze or one cotton ball for each stroke. Have the client void 30 ml and discard this urine. Position the sterile specimen container near but not touching the meatus and ask the client to void forcibly if she is lying down. This prevents collecting a specimen that has dribbled down and across the perineal area. Stop collecting urine before the client empties her bladder. Release the labia. Allow the client to continue emptying her bladder and discard the urine not needed for the specimen. Use a sterilized bedpan to collect the midstream specimen if the client has difficulty voiding into the container, and then transfer the urine into the sterile specimen container. Label the specimen container appropriately and send the specimen to the laboratory. It is easier for the client to obtain the specimen while using toilet facilities rather than sitting on a bedpan. Immediately after obtaining the specimen the nurse places a sterile top securely over the container and labels it with the clients name, the date, and the time of collection. Urine Specimens must reach the laboratory within 1 hour of collection or else be refrigerated to 4 degrees Celsius. Urine that stands in a container at room temperature fosters bacterial growth. MALE CLIENT: Wear sterile gloves. Retract the foreskin to expose the glans penis in the uncircumcised male client. Clean the area of the external meatus with sterile gauze or cotton balls and antiseptic soap and water. Move gauze or cotton balls in a circular manner at the meatus, and move down the shaft of the penis a few inches. Have the client void about 30 ml and discard this urine. Have the client void directly into the sterile container. Stop collecting urine before the client empties his bladder. Allow the client to empty his bladder and discard this urine. Return the foreskin to its normal position to prevent swelling and irritation of the glans penis. Use a sterilized urinal to collect the midstream specimen if the client has difficulty voiding into the container, and then transfer the urine into the sterile specimen container. Label the specimen container appropriately and send the specimen into the laboratory. It is easier for the client to obtain the specimen while using toilet facilities rather than sitting on a bedpan. Immediately after obtaining the specimen the nurse places a sterile top securely over the container and labels it with the clients name, the date, and the time of collection.

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Urine Specimens must reach the laboratory within 1 hour of collection or else be refrigerated to 4 degrees Celsius. Urine that stands in a container at room temperature fosters bacterial growth. Sterile Specimen collection of urine is obtained from indwelling catheter. Guidelines: Urine specimens should not be collected for culture from urine drainage bags unless it is the first urine drained into a new sterile bag. When catheterizing a client, the nurse collects the specimen as soon as urine flows from the catheters end. After filling the sample container the nurse either withdraws the catheter (if the catheterization is performed only for a sample) or connects the indwelling catheter to a drainage tube. If a client already has an indwelling catheter, the nurse uses a sterile syringe to withdraw the urine specimen. A 3 ml syringe with a small-gauge needle (23- or 25- gauge) is best. A large gauge needle is more likely to leave a permanent hole through which urine may leak from the system. It is safe to insert a needle directly into the end of a self-sealing rubber catheter. Silastic, plastic or silicone catheters are not self-sealing. The nurse wipes the catheter or port with a disinfectant swab. Inserting the needle at a 30-degree angle ensures entrance into the catheter lumen. To ensure that urine will be in the tubing or catheter, the nurse may clamp the tubing just below the site chosen for specimen withdrawal. The nurse must be careful not to raise the tubing, which returns urine to the bladder. After obtaining the specimen the nurse transfers the urine into a sterile using sterile aseptic technique. Twenty-Four-Hour Urine Specimen requires a client to collect all urine during a specific 24-hour period. Guidelines: The 24-collection period begins after the client urinates. The nurse indicates the starting time on the gallon urine jar or bottle and on the laboratory requisition. The nurse discards the first sample. The client then collects all urine voided in the 24-hour period. Any missed specimens will make the test results inaccurate. The nurse should remind the client to void before defecating so that urine is not contaminated by feces. The 24-hour collection jar usually either contains a preservative or requires refrigeration. The client should void the last specimen as close as possible to the end of the 24-hour period. Double-Voided Specimen is used to test urinary glucose, requires the client to void twice in succession discarding the first specimen. Guidelines: The urine specimen must be fresh for accurate measurement of glucose and ketones. Stagnant urine that has been in the clients bladder for several hours does not reveal the amount of glucose and ketones in the urine at the time of testing. Ideally the client voids 30 to 45 minutes before the time a test specimen is required. The nurse discards the first specimen and then has the client drink at least 8 ounces of water or another preferred liquid. The client the voids a second or double-voided specimen for testing. The second specimen accurately reflects the urine that was recently filtered by the kidney. Urine Collection in Children Guidelines: Offering young child fluids 30 minutes before requesting a specimen may help. The nurse must use terms for urination that the child can understand, such as pee-pee or tinkle. A young child may be reluctant to void in unfamiliar receptacles. A potty chair or bedpan placed under the toilet is usually effective. The nurse must use special collection devices for infants, or toddlers who are not toilet trained. Clear, plastic, single-use bags with self-adhering material can be attached over the childs urethral meatus. The nurse prepares an infant by first washing the genitalia, perineum, and surrounding skin with soap and water or an antiseptic.

Thorough drying, is necessary, since the bags adhesive does not stick to a moist, powdered, or oily surface. The nurse attaches the bag from back to front, first to perineum and then toward the symphysis pubis. In girls the perineum should be stretched tightly to ensure that the bag has a leak-proof fit. In boys, the scrotum and penis fit inside the collection bag. A diaper is placed over the bag. The nurse checks the bag frequently and removes it as soon as urine is available. For a clean-voided specimen the nurse uses a sterile collection bag. 7. The principles involved in urine testing: a) Anatom y and Physiology - Urine is produced by the kidneys, and plays a vital role in maintaining homeostasis by removing excess water, electrolytes such as sodium, chloride, potassium, and calcium ions, urea and other metabolites from the blood. Urine excreted by healthy kidneys is sterile. The production of urine is called diuresis. - In anatomy, the urinary bladder is a hollow, muscular, and distensible (or elastic) organ that sits on the pelvic floor in mammals. It is the organ that collects urine excreted by the kidneys prior to disposal by urination. Urine enters the bladder via the ureters and exits via the urethra. - The kidneys are complicated organs that have numerous biological roles. Their primary role is to maintain the homeostatic balance of bodily fluids by filtering and secreting metabolites (such as urea) and minerals from the blood and excreting them, along with water, as urine. b) Microbiology - The nurse must do special precautions which are needed in the care of the incontinent patients to keep skin dry and to avoid infection. - The containers used should be clean and sterile at all times. - Recommended that a sterile globe be warm during the cleaning and collection of urine. c) Chemistry Normal composition of urine is water - 95 per cent, other major and common constituents are sodium - 0.4 per cent, ammonia - 0.05 per cent, phosphates - 0.6 per cent, urea - 2 per cent, sulfate - 0.2 per cent and creatine, urobilinogen, casts, etc. in minute quantities. Normally, soluble substances are excreted in the urine. The use of benedicts solution to determine the volume of sugar present in the urine pH of the urine indicates the acid- base organic waste

d) Pharmacology - Diuretics are drugs that are used to increase urine output. Some drugs, such as Amitriptyline (Elavil) gives a different color of the urine rather than the straw, amber or transparent which is normal. e) Physics. - Specific gravity of urine is the relation it bears to the weight of water. To separate solids from the liquid portion of urine, urine is placed in a centrifuge that operates on the principle that the solid particles are thrown to the outside. f) Psychology - Frequent urination may be caused by excitement, anxiety or fear. The client must be relaxed. Privacy must be maintained to avoid embarrassment. Adequate time to urinate is also important to most people. g) Sociology - The nurse is responsible for instructing the client about the urine collection or for obtaining sample urine from a client. Through out the conversation, nurse-patient interaction is acquired. And this interaction strengthened through a focus on continuity of care delivered within the context of interdisciplinary collaboration thereby improving patient and staff satisfaction 8. Guidelines in urine testing: Nurse is responsible for instructing client about urine collection or for obtaining a sample of urine from client. A cooperative client can be instructed to put the specimen into a clean or, in some instances, a sterile container. ( are should be taken that the outside of container is not contaminated) Nurse should be able to recognize deviations from normal in the urinalysis. Specimen should be packaged & labeled before prompt delivery to the laboratory. Explanation to the chart & careful documentation of the type of specimen, collection site and date and time are vital nursing interventions.