Symptom: Urinary Dysfunction

Initial Grading Reminder

CTCAE grading of urinary dysfunction:

Grade 1: Asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated
Grade 2: Moderate, local or noninvasive intervention indicated; limiting instrumental ADLs
Grade 3: Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of existing hospitalization indicated; disabling; limiting self-care ADLs
Grade 4: Life-threatening consequences; urgent intervention indicated

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you had any problems urinating in the past? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

Please describe the problem you are having when you urinate (example, pain, dribbling, weak stream, difficulty starting urination, foamy, or bubbly urine). Is it mild, moderate, or severe? Is it limiting your ability to do the things you want to do or take care of yourself?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you nauseated? Do you have a headache? Do you feel sick? Have you had any shortness of breath?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with new onset moderate or worse (or worsening) urinary dysfunction should be seen.

    Patients with any of the red-flag symptoms should be seen immediately. Depending on the severity of shortness of breath, the patient may require an ED visit.

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    Nursing Assessment of Potential Causes

    Nephritis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient look ill?
    • Has there been change in urination?
      • Urine color?
      • Frequency?
    • How much fluid is the patient taking in?
    • Are associated symptoms present?
      • Nausea?
      • Headache?
      • Malaise?
      • Lung edema?
    • Are there symptoms indicative of:
      • Urinary tract infection?
      • Pyelonephritis?
      • Worsening CHF?
    • Are symptoms limiting ADLs?
    • Current or recent use of nephrotoxic medications (prescribed and OTC), other agents?
      • NSAIDs
      • Antibiotics
      • Contrast media or other nephrotoxic agents (contrast dye, aminoglycosides, PPI)?
    • Laboratory abnormalities (elevated creatinine, electrolyte abnormalities)
    • Urinalysis abnormalities (casts)
    • Abdominal or pelvic disease that could be causing symptoms
    • Prior history of renal compromise?
    • Other immune-related adverse effects?
    • Presence of current or prior immune-mediated toxicities, including rhabdomyolysis
    • Is patient volume depleted?

    Differential Diagnosis

    What do you suspect is the cause of the change in urination?