Hematuria is the term used to describe the presence of blood in the urine. Gross hematuria is urine that appears pink, red, or cola-colored. Sometimes the blood cannot be visualized but is found through a urinalysis called microscopic hematuria. Hematuria itself is not painful; however, other associated symptoms and causes can cause pain.
Blood in the urine can result from infections, trauma, menstruation, medications, and medical conditions such as:
- Urinary tract infection
- Kidney infection
- Kidney or bladder stone
- Enlarged prostate
- Kidney disease or injury
- Rhabdomyolysis
- Cancer
Hematuria is diagnosed through a physical exam and urine test. An imaging test like a CT scan, MRI, or an ultrasound and a cystoscopy may be performed to help visualize the urinary system and determine the cause of the bleeding.
Nursing Process
Haematuria is often a symptom of an underlying medical condition, and its management will vary depending on the causative condition. Treatment typically includes diagnostic testing, monitoring of related symptoms, antibiotic therapy to treat an underlying infection, and patient education.
Nursing Assessment
Haematuria, the presence of blood in the urine, is a condition that warrants thorough assessment by nursing professionals. It can be indicative of a range of underlying health issues, from benign to serious conditions. As frontline healthcare providers, nurses play a pivotal role in the early detection, assessment, and management of haematuria, ensuring patients receive timely and appropriate care.
Patient History
A comprehensive patient history is the cornerstone of nursing assessment in hematuria. This involves gathering detailed information about the patient’s medical history, including any previous episodes of hematuria, family history of urinary tract diseases, and any other relevant conditions such as kidney stones, infections, or malignancies. Nurses should also inquire about recent injuries, medications, and lifestyle factors that might contribute to hematuria.
Physical Examination
Physical examination is crucial for identifying potential causes of hematuria. Nurses should conduct a thorough examination, including:
- Abdominal Examination: Assessing for any masses, tenderness, or distension that may indicate kidney or bladder issues.
- Genitourinary Examination: Inspecting for signs of infection, trauma, or lesions in the genital area.
- Vital Signs: Monitoring blood pressure, as hypertension can be associated with kidney disease, and checking for signs of systemic infection such as fever.
Diagnostic Tests
Nurses play a key role in the collection and interpretation of diagnostic tests for hematuria. These may include:
- Urinalysis: Evaluating for the presence of red blood cells, white blood cells, protein, and other abnormalities.
- Urine Culture: Identifying any bacterial infections that may be causing hematuria.
- Imaging Studies: Coordinating and preparing patients for imaging tests such as ultrasound, CT scan, or MRI to visualize the urinary tract and identify any structural abnormalities.
- Cystoscopy: Assisting in the preparation and post-procedure care for cystoscopy, which allows direct visualization of the bladder and urethra.
Nursing Interventions
Through comprehensive interventions, nurses can significantly impact patient outcomes. By educating patients, managing symptoms, coordinating care, and providing psychosocial support, nurses ensure that patients with haematuria receive holistic and compassionate care, ultimately enhancing their quality of life.
Patient Education
Educating patients about hematuria and its potential causes is essential. Nurses should provide clear information on:
- Condition and Treatment Options: Explaining the possible reasons for hematuria and the importance of further diagnostic evaluations.
- Self-Monitoring: Instructing patients on how to monitor their urine for changes in color and quantity, and to report any new symptoms promptly.
- Lifestyle Modifications: Advising on dietary changes, hydration, and avoidance of substances that may irritate the urinary tract, such as caffeine and alcohol.
Symptom Management
Nurses can provide various interventions to manage symptoms and improve patient comfort:
- Hydration: Encouraging increased fluid intake to dilute the urine and flush out any potential irritants or pathogens.
- Pain Management: Administering prescribed medications for pain relief and advising on non-pharmacological methods such as warm compresses.
- Infection Control: Educating on hygiene practices to prevent urinary tract infections, such as proper wiping technique and wearing breathable underwear.
Coordination of Care
Nurses act as liaisons between patients and other healthcare providers, ensuring seamless care coordination:
- Referral to Specialists: Facilitating referrals to urologists, nephrologists, or other specialists as needed based on the underlying cause of hematuria.
- Follow-Up Care: Scheduling follow-up appointments and ensuring that patients adhere to prescribed treatment plans and monitoring.
Psychosocial Support
Hematuria can be a distressing symptom for patients. Nurses provide essential psychosocial support by:
- Emotional Support: Offering reassurance and empathetic listening to address patient concerns and fears.
- Counseling: Providing counseling or referrals to mental health services if needed, especially for patients with chronic or severe conditions.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for haematuria, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for haematuria.
Acute Pain
Inflammation of the urethra, bladder, kidney, or prostate may cause hematuria and painful urination. Trauma to the ureters from renal stones may also cause hematuria and pain.
Nursing Diagnosis: Acute Pain
Related to:
- Disease process
- Inflammatory process
- Presence of blood clots
- Renal calculi
- Urinary tract infection
As evidenced by:
- Dysuria
- Diaphoresis
- Expressive behavior
- Guarding behavior
- Positioning to ease the pain
- Frequent urination
- Hesitancy with urination
- Fever
Expected outcomes:
- Patient will report significant improvement in pain relief when urinating.
- Patient will demonstrate interventions that can help improve pain symptoms.
Assessment:
1. Assess pain characteristics.
If the patient feels pain with urination, it may prevent them from wanting to urinate, which can lead to further problems. Assess the characteristics of dysuria, like burning, itching, urgency, and more.
2. Assess the location of the patient’s pain.
Painful hematuria may be described as flank pain, lower abdominal/suprapubic pain, or pain when urinating. Knowing the location of the pain can help determine possible causes and allow the nurse to monitor the effectiveness of interventions.
Interventions:
1. Encourage the use of non-pharmacologic pain interventions.
The use of heat pads in the lower back and abdomen can help relax the muscles and relieve discomfort associated with dysuria and hematuria.
2. Administer pain and antibiotic medications as indicated.
Analgesics are often prescribed for patients with renal calculi to help relieve discomfort. Antibiotics will treat an underlying infection.
3. Encourage the patient to increase clear fluid intake.
Increasing fluid intake while avoiding beverages like coffee, soda, and alcohol can help increase urine production and facilitate the flushing out of bacteria without irritating the urinary tract system.
4. Encourage frequent voiding.
Urinating frequently facilitates emptying of the bladder, reducing urine stasis, re-infection, and distention.
Deficient Knowledge
Haematuria may or may not be serious, and educating patients on causes and complications is a necessary component of nursing care.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Unfamiliarity of condition
- Inadequate information
- Inadequate interest in learning
- Inability to recall information
As evidenced by:
- Inaccurate follow-through of instructions
- Inaccurate statements about hematuria
- Development of worsening complications
- Missed follow-up appointments
Expected outcomes:
- Patient will verbalize understanding of hematuria, possible complications, and interventions.
- Patient will verbalize when to seek care for hematuria and related symptoms.
Assessment:
1. Assess the patient’s experience with haematuria.
Assess if the patient has ever had haematuria and what the reason was at that time. The patient may already be aware of causes and treatment and can direct further teaching.
2. Assess the patient’s health literacy and readiness to learn.
Health literacy can vary depending on the patient’s situation, complexities of haematuria, and underlying health condition. The patient’s readiness to learn can impact the patient’s adherence to the treatment regimen and health outcomes.
Interventions:
1. Educate on preventing urinary infections.
Haematuria is often the result of a urinary or bladder infection. Instruct the client to maintain perineal hygiene by wiping front to back, urinating after sexual intercourse, not wearing tight clothing, and drinking plenty of water.
2. Educate on diagnostic tests.
Haematuria can signal a malignancy of the bladder, prostate, or kidney cancer. The nurse can prepare the patient for tests and labs that assess for cancer.
3. Teach the patient signs and symptoms that need immediate medical attention.
Haematuria can develop into complications if the underlying cause is left untreated. Encourage the patient to seek medical consultation for fever, changes in urination, foul urine odour, weight changes, or flank pain.
4. Educate about normal instances of haematuria.
Haematuria is expected in some cases. Educate the patient that haematuria is normal after lithotripsy treatment for a kidney stone. A male patient who undergoes a TURP (transurethral resection of the prostate) may notice blood in the urine that will decrease.
Impaired Urinary Elimination
Hematuria is a symptom of another medical condition, like an enlarged prostate or infection, causing impaired urinary elimination.
Nursing Diagnosis: Impaired Urinary Elimination
Related to:
- Disease process
- Inflammatory process
- Obstruction
- Infectious process
- Prostatic hypertrophy
- Trauma
As evidenced by:
- Dysuria
- Frequent voiding
- Urinary hesitancy
- Urinary retention
- Urinary incontinence
- Urinary urgency
- Nocturia
Expected outcomes:
- Patient will be able to achieve a normal elimination pattern without dysuria, incontinence, or urgency.
- Patient will verbalize interventions that can help prevent urinary retention.
Assessment:
1. Assess the patient’s usual elimination patterns.
Assessing the patient’s baseline elimination pattern can help determine the possible causes of the current impairment, developing complications, and the effectiveness of treatment.
2. Assess and review the results of urinalysis.
Urinalysis can reveal the presence of bacteria, blood, casts, protein, ketones, and more, which can lead to the diagnosis of an acute or chronic condition.
3. Monitor kidney function labs.
BUN, creatinine, and GFR results should be monitored for altered kidney function causing impaired urinary elimination.
Interventions:
1. Monitor the patient’s intake and output.
Documentation of the patient’s intake and output can help determine and monitor hydration status and urinary function.
2. Insert a urinary catheter.
If the patient is unable to void and is experiencing distention, the nurse can insert an indwelling catheter. This can allow for accurate output measurement and visualization of urine color and concentration.
3. Encourage bladder training.
Establishing a regular elimination pattern by voiding every 2-3 hours (even when the urge isn’t felt) can train the bladder to empty.
4. Consult with urology.
The nurse may consult with the urology team for further instructions. Diagnostic tests such as uroscopy or kidneys/ureters/bladder (KUB) ultrasound may be necessary.
Risk for Imbalanced Fluid Volume
Hematuria may be caused by severe or prolonged dehydration, placing the patient at risk for imbalanced fluid volume.
Nursing Diagnosis: Risk for Imbalanced Fluid Volume
Related to:
- Altered fluid intake
- Disease process
- Inflammatory process
- Dehydration
- Bleeding
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain urine output within the normal range of 0.5-1.5 ml/kg/hr.
- Patient will remain free from symptoms of dehydration, as evidenced by stable vital signs, good skin turgor, and moist mucous membranes.
Assessment:
1. Assess the possible factors that contribute to the cause of haematuria.
Various factors and diseases like infection or injury of the bladder, urethra, and kidneys, cancer, calculi, or severe cases of dehydration can cause haematuria. It is vital to determine the cause to plan an appropriate treatment regimen.
2. Assess and monitor the patient’s intake and output.
Since dehydration can contribute to haematuria, it is important to assess and monitor the patient’s intake and output and current hydration status.
3. Assess urinalysis.
Haematuria may be easily observable or found through microscopic examination. A complete urinalysis can indicate signs of dehydration, such as a high specific gravity, dark urine colour, and the presence of crystals (stones).
Interventions:
1. Monitor the patient’s kidney function.
Kidney function is evaluated through the serum BUN and creatinine levels. Since the kidneys are integral to urine output, it is important to monitor renal perfusion and function for any complications such as kidney disease.
2. Encourage adequate fluid intake.
Adequate fluid intake will prevent dehydration and help flush out the urinary system. Severe and frequent dehydration can damage the kidneys and further aggravate haematuria. IV fluids may be necessary if dehydration is severe.
3. Insert a urinary catheter as ordered.
For patients with gross haematuria and difficulty urinating, a urinary catheter may be inserted to aid urination and irrigation and to closely monitor urine output.
4. Prepare and assist in blood transfusion as indicated.
Severe injury or trauma to the kidneys or urinary tract may result in blood loss, requiring transfusion.
Risk for Urinary Tract Injury
Hematuria may be caused by trauma or injury from urinary catheters.
Nursing Diagnosis: Risk for Urinary Tract Injury
Related to:
- Latex allergy
- Trauma or injury
- Catheter insertion
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will remain free of any urinary tract injury.
- Patient will experience normal urinary elimination patterns without pain or blood.
Assessment:
1. Assess the patient’s elimination patterns and characteristics.
Evaluating the patient’s elimination patterns and characteristics, including frequency, consistency, volume, and color, can help determine existing urinary tract injuries and evaluate any complications that arise.
2. Assess and review imaging studies.
Cystoscopy is a diagnostic imaging test that can help visualize the bladder for injury or other causes of hematuria.
3. Review the indication of an indwelling urinary catheter.
Hematuria may be caused by the insertion or the presence of a urinary catheter. It is important to determine the appropriateness of continuing catheterization.
Interventions:
1. Select the correct size and type of catheter.
If catheterization is necessary, reduce the risk of injury by selecting the correct size and type of catheter and insert using sterile technique.
2. Take caution with patients who are confused.
Patients who are confused or do not understand the presence of the catheter are at risk for pulling on the catheter and causing injury and bleeding. Keep the catheter out of view, such as under blankets, provide constant staff supervision, keep the patient distracted, or apply mitten restraints as a last resort.
3. Closely monitor and secure the placement of the urinary catheter.
Properly secure the catheter to the leg to reduce friction from movement. Ensure the catheter remains unobstructed without kinks below the level of the bladder.
4. Discontinue the catheter as soon as possible.
Once the patient is cleared to void normally, discontinue the catheter to reduce the risk of CAUTI and further injury.
Nursing Diagnoses and Rationales for Haematuria
1. Risk for Infection
Rationale: Hematuria can be associated with urinary tract infections (UTIs), which may cause or exacerbate the presence of blood in the urine. The risk of infection increases if there is an obstruction, such as kidney stones or tumors, which can hinder urine flow and create a breeding ground for bacteria. Implementing strict infection control measures, monitoring for signs and symptoms of infection, and administering prophylactic or therapeutic antibiotics as needed are essential to reduce this risk. Ensuring proper hydration and encouraging frequent urination can also help flush out bacteria.
2. Acute Pain
Rationale: Patients with hematuria may experience acute pain due to underlying conditions such as kidney stones, urinary tract infections, or trauma. Pain management is critical in providing comfort and improving the patient’s quality of life. Nurses should assess the intensity, location, and characteristics of pain and administer appropriate analgesics and non-pharmacological interventions, such as warm compresses or relaxation techniques, to alleviate discomfort.
3. Anxiety
Rationale: Hematuria can be a distressing symptom, leading to significant anxiety for patients who may fear a serious underlying condition, such as cancer. Providing emotional support, clear communication, and education about the potential causes and diagnostic processes involved in identifying the source of hematuria can help alleviate anxiety. Nurses should actively listen to patients’ concerns and provide reassurance throughout their care.
4. Deficient Knowledge
Rationale: Patients and their families may lack understanding about the causes, diagnostic procedures, and management of hematuria. This knowledge deficit can lead to poor adherence to treatment plans and increased anxiety. Providing comprehensive education about hematuria, including its potential causes, diagnostic tests, and treatment options, can empower patients and families to actively participate in their care and make informed decisions. Educational materials and one-on-one counseling sessions can be effective in addressing this knowledge deficit.
5. Impaired Urinary Elimination
Rationale: Hematuria may be accompanied by difficulty in urination or changes in urinary patterns due to underlying conditions such as obstructions, infections, or bladder dysfunction. Assessing urinary patterns, encouraging adequate fluid intake, and monitoring for signs of urinary retention or obstruction are essential steps in managing impaired urinary elimination. In some cases, catheterization may be necessary to ensure proper urine flow and prevent complications.
6. Risk for Bleeding
Rationale: Hematuria indicates the presence of bleeding within the urinary system, which may be due to conditions such as trauma, kidney stones, or anticoagulant therapy. Monitoring for signs of increased bleeding, such as changes in urine color or volume, and ensuring that the patient is not on medications that could exacerbate bleeding are critical. Educating patients on signs of serious bleeding and when to seek immediate medical attention is also important.
7. Fatigue
Rationale: The presence of blood in the urine and the underlying causes of hematuria can lead to fatigue, either through the loss of blood or secondary symptoms such as pain and infection. Assessing the level of fatigue, promoting rest, and providing supportive care can help manage this symptom. Encouraging a balanced diet and appropriate hydration can also support overall health and energy levels.
REFERENCES
- Hematuria (Blood in the Urine). NIDDK. https://www.niddk.nih.gov/health-information/urologic-diseases/hematuria-blood-urine
- Hematuria. Urology Care Foundation. 2022. https://www.urologyhealth.org/urology-a-z/h/hematuria
- Hematuria. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/15234-hematuria
- Blood in Urine (Hematuria). WebMD. https://www.webmd.com/digestive-disorders/blood-in-urine-causes
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
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