Symptom: Blood in the Urine

Initial Grading Reminder

CTCAE grading of blood in the urine:

Grade 1 (Mild): Asymptomatic; clinical or diagnostic observations only; intervention not indicated
Grade 2 (Moderate): Symptomatic; urinary catheter or bladder irrigation indicated; limiting instrumental ADLs
Grade 3 (Severe): Gross hematuria; transfusion, IV medications or hospitalization indicated; elective endoscopic, radiologic, or operative intervention indicated; limiting self-care ADLs
Grade 4 (Life-threatening): Life-threatening consequences; urgent radiologic or operative intervention indicated

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you ever had blood in the urine in the past? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Do you have a prior history of urinary tract infections? Any associated urinary symptoms (increased frequency, incontinence, or pain during urination)?

Grade the symptom

Ask the patient:

Can you see the blood in your urine? How red is the water in the toilet? Do you feel faint? Are you able to take care of yourself? Is it painful when you urinate?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you experiencing fever, chills, nausea, headache, shortness of breath, or dizziness?

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

    Any new blood in the urine should be evaluated.

    Patients with any of the red-flag symptoms should be seen immediately.

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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 blood in the urine?