To this day, after seven years of hospitalist medicine, I have yet to figure out why nurses from all walks of life consider low urine output per hour a nursing emergency. This is an honest question about a real clinical issue that interrupts nursing, doctor and patient care issues at all hours of the day and night. Somewhere in the Bible of nursing education there must be a law that says any patient producing less than 30 cc of urine output per hour, regardless of age or baseline renal function, must constitute a decreased urine output nursing emergency.
Are nurses taught that low urine output is equivalent to hypotension? Are nurses taught that reduced urine per hour is equivalent to tachycardia? What exactly is it about reduced urine output that makes them drop what they are doing and call the doctor at 4 am to inform them that Mrs Smith's urine output is only 200 cc for the last eight hours.
Happy: Is the blood pressure normal?
Happy: Is the heart rate normal?
Happy: Is the patient sleeping comfortably?
Happy: Then why did you wake me up from my comfortable sleep?
Nurse: Because she had low urine output.
Happy: And why are you concerned about that? What is her creatinine?
Nurse: I don't know. I'll check
10 minutes of searching... catching some more zzz's while waiting.
Nurse: It's 2.5
Happy: Is it different from the day before?
Nurse: I don't know. Let me check
5 minutes of searching...catching some more zzz's
Nurse: It's the same
Happy: How old Is Mrs Smith?
Nurse: She's 92
Happy: What's your concern
Nurse: She has decreased urine output
Happy: Why are you checking her for low urine output. Do you want me to discontinue the foley?
Nurse: No, she's having problems getting up.
Happy: So what is your concern for her low urine output
Nurse: It's decreased.
At this point I'm banging my head on the night stand.
Happy: You have to understand. Calling me at 5 am because a 92 year old with chronic kidney disease who has low urine output as her baseline does not do your education justice. If you're calling me with a concern, you have to be able to explain to me what your concern is. If you don't want to be treated like a robot, then you must stop acting like one. Please. Take an order that says stop checking her urine output, and if your nursing fears tells you to check it anyway, please don't call me unless it's less than 10cc per hour for, let's go with 8 hours this time.
Nurse: But what if she goes into kidney failure
Happy: She is in kidney failure. As is just about every 92 year old that walks this earth.
I simply do not understand the emergency nursing concerns with low urine output per hour. I would love to have some nurses explain to me their thought processes when calling and why they never know what the current or previous creatinine or current vital signs are when calling. Vital signs are a window to the patient's status. A number that represent the patient's urine output per hour is meaningless without a meaningful understanding of the clinical situation for which it must be understood.
Reduced urine output per hour must be interpreted with at least some basic science understanding that all nurses should have received. Urine production is a sign of kidney filtration. When blood flows into the kidney, it passes by a network of glomeruli and tubules that allow for the exchange of fluids and metabolites for the production of your pee pee. If you have underlying chronic kidney disease, you will have decreased urine output per hour as your baseline. If you have advanced age, you will have low urine output as your baseline. We lose some kidney function every year as a consequence of age and biology starting in our third decade of life.
If you want to call the hospitalist to express your concerns about low urine output per hour in the 92 year old with a baseline creatinine of 2.5, you must at least have the decency to understand why you're calling. Simply stating that it's low and therefore establishing a need to notify the physician is a robot mentality. It does not do a nurses education justice.
Please, as a professional courtesy, use critical nursing skills when calling decreased urine output. What's important is not where they are at, but rather where they came from. Is low urine output taught as a vital sign that is engrained into the nursing psyche on the same level as hypotension and heart rate? Is it engrained as a critical nursing value that must be immediately addressed, regardless of clinical history?
I don't know. I've never gone to nursing school. But remember, if the patient is making urine, the patient has kidney function. How much? I ask the question does it matter on an emergency basis at 5 am? Are their electrolytes critically abnormal? Are they hypoxemic? Do they require increasing oxygen needs? Is their blood pressure low or their heart rate high? Are they tachypneic. These are the values that matter to patient care in clinical medicine.
If you can answer these questions, you have done more to evaluate the patients' current clinical situation than all the urine output calculations you've done on your shift. From the hospitalist position, decreased urine output means nothing when that is the only reason a nurse is calling. Please provide your physician the courtesy of understanding your patient's history before you call them with your concerns. If you understand physiology, your concerns will often be alleviated on their own. All I ask is that you understand why you're calling and why you are concerned. If you can't answer these simple questions, you need some more continuing medical education fast. With that said, give me a hypotensive 20 year old in septic shock making 5 cc in the last hour and now you're talkin'.