The Importance of Urine Output in Clinical Practice

By Ma. Christabel L Dualan, RM RN

Objectives and Learning Outcomes

The main objective of this report is to stress the importance of proper urine
output monitoring and referral in the clinical practice.

After reading this report, one should be able to:

 Discuss the normal physiology and pathophysiology of urination; list diseases

that can affect urine output and identify patients who will be vulnerable to
disturbance of their urine output.

 Discuss nursing and other health care staff responsibility regarding monitoring of
urine output

Introduction and Background

Urine output is pertinent in the assessment and monitoring of a patient’s fluid

balance status which is important for assessing early clinical deterioration.Urine
output often is used as a marker of acute kidney injury but also to guide for fluid
resuscitation in critically ill patients. Therefore, early recognition of AKI, appear to be
potential areas of improvement of patient's prognosis.

Recent events in the ward have shown that areas of improvement are needed in
terms of understanding of good fluid balance monitoring, correct identifications of
patients requiring monitoring, completion of intake and output charts, and
importance of early referral for at risk patients.

Physiology and Pathophysiology of Urination

 The word urine comes from the one of its components, uric acid. Each day the
body forms 1000-2000 mL of urine; the amount is influenced by several factors,
including mental and physical health, oral intake and blood pressure. Urine is 95%
water; the remainder is nitrogenous waste and salts. It is usually transparent yellow
because of urochrome a pigment resulting from the body’s destruction of
hemoglobin. Urine is slightly acidic with a pH of 4.6 to 8 and a specific gravity of
1.003 to 1.030. Healthy urine is sterile but at room temperature it rapidly
decomposes and smells like ammonia as a report of the breakdown of urea

There are three steps in the process of urine formation:

1. Glomerular filtration- involves the filtration of plasmas by the glomerulus.

Filtered substances include water. Sodium, chloride,bicarbonate, potassium, glucose,
urea, creatinine, and uric acid.

2. Tubular reabsorption- the filtrate enters Bowman's capsule and

then moves through the tubular system of the nephron and is
either reabsorbed (placed back into the systemic circulation) or excreted as urine.

3. Tubular secretion- the formed urine drains from the collecting tubules, into the
renal pelvis, and down each ureter to the bladder. The filtrate that is secreted as
urine usually contains water, sodium, chloride, bicarbonate, potassium,
urea, creatinine, and unc acid. Amino acids and glucose typically are reabsorbed and
not excreted in the urine. Protein molecules, except for periodic small amounts
of globulins and albumin, also are rcabsorbed. Transient proteinuria in small
amounts (<150 mg/dl) is not considered a problem. Persistent and
elevated protcinuria may indicate glomerular damage. Glycosuria (glucose in the
urine) occurs when the glucose concentration in the blood
and glomerular filtration exceeds the ability of the tubules to reabsorb the
glucose summarizes the physiology and pathophysiology of urine fomlation.

Urine flows from the renal pelvis through the ureter into the bladder.
Peristaltic waves help to move the urine to the bladder. Nomtally, urine flows in one
direction because of this peristaltic action and buttocks the ureters enter
the bladder at an oblique angle. Reflux of urine (urine that flows backward) can
occur secondary to an overdistended bladder or other problems and may cause
infections.

The desire to urinate comes from the feeling of bladder fullness. A

nerve reflex is triggered when approximately 150-250 ml of urine accumulates.
During urination, the bladder muscle contracts and the sphincter muscles relax,
forcing urine out of the bladder and urethra through the urethral meatus. If there is
any interference or abnormality of these muscles, the bladder may not empty
completely or empty uncontrollably (incontincnce).

Oliguria and Anuria

The term oliguria or hypouresis is used to describe decreased urine output of

below 500 mL/ day. This condition is caused by fluid and electrolyte imbalances,
kidney disfunction or urinary tract obstruction. Patients usually have a decrease in
urine output after a major operation that may be a normal physiological response to

fluid/ blood loss – decreased glomerular filtration rate secondary to hypovolemia

and/or hypotension or due to a response of adrenal cortex to stress -increase
in aldosterone (Na and water retention) and antidiuretic hormone (ADH) release.

The term anuria refers to the cessation of urine excretion by the kidneys or the
production of less than 100 mL/day and may result from kidney dysfunction.Failure
of kidney function, which can have multiple causes including medications or toxins
(e.g., antifreeze, cephalosporins, ACEIs); diabetes; high blood pressure. Stones or
tumours in the urinary tract can also cause it by creating an obstruction to urinary
flow. In males, an enlarged prostate gland is a common cause of obstructive
anuria. Acute anuria, where the decline in urine production occurs quickly, is usually
a sign of obstruction or acute renal failure. Acute renal failure can be caused by
factors not related to the kidney, such as heart failure, mercury poisoning, infection,
and other conditions that cause the kidney to be deprived of blood flow.
 A decrease in patient’s urine output can be a sign of acute kidney injury (AKI).
There is accumulating evidence that patients developing AKI have an increase
relative risk of death. Occurrence of AKI is a marker of severity of the underlying
acute illness but also appears as an independent factor associated with mortality in
critically ill patients, in sepsis, pneumonia, or cardiac surgery. The mechanistic
pathways of such an association remain elusive, with intrication of inflammation,
metabolism, and apoptotic phenomena. Remote organs damage has been suggested
in several experimental studies. Ischemic-induced AKI has been found to induce
myocardial apoptosis, to activate lung inflammatory and apoptotic pathways, and to
increase lung water permeability.

Urine Output Assessment and Responsibilities

As mentioned before, oliguria and anuria can be a sign of hypovolaemia and

acute renal failure. Therefore fluid balance must be accurately monitored so deficits
can be corrected and complications prevented. It is important to identify oliguria so
that timely and appropriate interventions are carried out to re-establish urine output
and protect renal function. This may prevent further deterioration and progression
to acute renal failure.

Nurses and nursing assistants should be able to record fluid input and output
accurately. All patients admitted in the ward are assessed at least once at the end of
each shift for urine output. Listed below are examples of patients vulnerable for
disturbances in urine output.

 Patients with ongoing intravenous infusion

 Patients on NPO or on restricted fluids

 Patients with in dwelling urinary catheter

 Patients with history of oliguraia, urinary retention

 Patients that underwent major surgical operation

 Elderly patients

 Critically ill patients and patients with medical conditions that affect fluid
balance, for example heart failure, renal failure, malnutrition or sepsis.

Healthcare Team Responsibility for Urine Output Monitoring and Referral

Charge Nurse and Staff Charge

 Ensure patients who require monitoring are identified

 Ensure urine output (as well as other parameters in the intake and output sheet)
are documented at the end of each shift.

 Refer patients identified with urine output imbalance, deterioration and

concerns to medical staff

 Carry out doctor’s order for management of oliguria and anuria

Nursing Assistant

 Ensure all patients admitted in the ward have intake and output monitoring
sheet at bedside.

 Give intructions or reminders to patients or relative to fill up the intake and

output form at bedside

 Inform the charge or the staff nurse for any concern or imbalance regarding
urine output.

Medical Staff

 Review I&O charts daily

 Respond to referral regarding UO imbalance

 Order appropriate medical intervention for oliguria or anuria.

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