Abnormal findings are charted as a chain — finding, severity, comparison to baseline, the risk it creates, and the skilled action taken.
New cloudy, foul, or bloody urine, dysuria, or suprapubic or flank pain — concerning for urinary tract infection.
New confusion, agitation, or functional decline in an older adult with a urinary source — concerning for UTI with possible early urosepsis.
Suprapubic distension with inability to void and discomfort, or an elevated post-void residual — concerning for acute urinary retention.
Absent catheter output with bladder distension — concerning for catheter obstruction.
Gross hematuria or clots, especially on an anticoagulant — requiring evaluation and bleeding-risk review.
A catheter insertion or suprapubic site with erythema, purulence, or tenderness plus fever — concerning for a catheter-associated infection.
Decreasing urine output with rising weight, increasing edema, or dyspnea — concerning for acute kidney injury or fluid overload.
Symptoms or laboratory trends indicating worsening renal function or an electrolyte disturbance — requiring provider collaboration and medication review.
