Mallett and Dougherty (2000: 424) define urinalysis as ‘the testing of the physical characteristics and composition of freshly voided urine’. Urinalysis is a useful, non-invasive test and can be used to obtain a baseline assessment for future comparison, detect abnormalities in urine composition or to monitor the progress of an existing condition. In mental health, we also use urinalysis to monitor substance misuse. In my experience, this investigation is no longer routinely done on
admission. It tends to be reserved for MHSUs presenting with a ‘drug-induced’ psychosis. How- ever, with the incidence of physical illness rising, it would be appropriate to reintroduce it as a routine observation.
Urine testing can be performed in the clinical area using the standard reagent ‘dip sticks’, or a urine sample may be sent for more specific pathology testing (see Table 4.16). Urinalysis is a useful screening method for diabetes. Here you will find positive readings for glucose (glyco- suria) and ketones (ketonuria). As the body loses weight, fat is used as an energy source and this is excreted in urine as ketones. This also occurs in people with eating disorders such as anorexia nervosa.
Citrome et al. (2003) found that those taking clozapine were more likely to have glucose screening than those taking other medications. This is a clear problem when trying to compare typical and atypical medications for prevalence of diabetes. It may also present as an inequal- ity in health care, as metabolic risks can occur with all types of antipsychotic medications.
Table 4.15 Procedure for taking a PEFr reading
Step Action Rationale
1 Prepare equipment Peak flow meter, clean single- use mouth piece, pen and chart for recording result
to ensure effective monitoring and prompt recording of reading 2 Decontaminate hands Wash hands or use alcohol rub to promote infection control and
minimize cross-infection 3 Explain and demonstrate
procedure for the MHSU
Ensure MHSU is paying attention and is clear about what they need to do
to ensure the MHSU knows how to do the procedure and gain consent 4 Ask MHSU to stand and
blow into the meter
Ensure MHSU has formed an effective seal around the mouthpiece
to minimize risk of air escaping leading to incorrect reading 5 Repeat this process
for three consecutive readings
record the best of the three readings
always observe for poor technique;
advise the MHSU that if they feel dizzy they should wait for a few seconds more before next attempt 6 Replace and safely
dispose of used equipment
Dispose of single-use equipment
to prevent accidental re-use, cross- infection
7 Record and document your findings
Ensure you are familiar with the standard way to record and document PEFr readings
the appropriate chart should be completed accurately for comparison with past or future readings
8 Communicate findings 1 Inform MHSU of the outcome and be prepared to answer any queries they may have
to reassure the MHSU
9 Communicate findings 2 report any abnormalities to the nurse in charge
In case immediate intervention is required or for continuity of care 10 Communicate findings 3 record findings in the MHSU’s
case notes
So that other members of the team are aware of them
11 Decontaminate hands again
Wash hands or use alcohol rub to promote infection control and minimize cross-infection
Equipment
For a routine urinalysis test, you will need the following: reagent strips; a secure sample of urine, either in a sample pot or other appropriate container; a watch with a second hand to time the reagent reaction; and gloves and an apron in case of splashing.
Procedure for urinalysis
This procedure will focus on a midstream sample of urine. First, ensure the privacy and dignity of the MHSU giving the sample. Then ensure that they minimize cross-infection by providing aids for getting the urine into the receptacle; this might be a clean single-use bed pan or urinal bottle. Also advise the MHSU to wash their hands following this.
Once the sample has been obtained, take any supplementary measurements; for example, in the case of fluid balance accurately record the quantity of urine voided on the chart.
Table 4.17 shows the stages in the procedure.
Other aspects of urinalysis
Through observation, you should be able to tell if there is a potential problem with a urine sample. The colour, smell, and presence of floating particles may indicate an infection. How- ever, we must always perform the urinalysis test to obtain an accurate assessment. You should remember that the colour of urine may have changed for innocent reasons, for example eating beetroot can cause discolouration (British National Formulary [BNF] 2013). Some antibiotics can also cause discoloration – rifampicin, for example, can give urine an orange tinge. Urine normally smells slightly aromatic but diabetes mellitus can give it a fruity smell due to the pres- ence of acetone (Dougherty and Lister 2008).
Abnormalities detected by urinalysis
It is important that you are aware of what each reagent pad on the strip is measuring.
Table 4.18 illustrates how urinalysis should be seen within a mental health context and gives both the medical terms that we should be familiar with and possible causes.
Table 4.16 Different types of urine samples Type of sample Use
Specimen for ‘dipstick’ a routine urine sample for testing Catheter specimen of
urine (CSU)
a sample that is removed from a catheter. this may require a syringe and needle, so be careful of needle stick injury or accidentally perforating the catheter bag
Specimen for cytology a urine sample sent to a lab for testing, e.g. for a urinary tract infection Midstream specimen of
urine (MSU)
a ‘sterile’ sample of urine where the person begins to pass urine, stops momentarily, and then passes a sample into a receptacle
Early morning specimen of urine (EMU)
a sample taken first thing in the morning to ensure ‘everything’ is tested 24 hour collection Used to check kidney function or identify the presence of filtrate such as creatinine. the urine sample should be refrigerated to reduce degradation random urine drug
screen
For MHSUs on a drug rehabilitation programme, they will be required to remain
‘clean’. random urine screening seeks to detect drug use. this is a normal sample taken at any time, day or night. the MHSU needs to be observed to ensure the sample is their own and not one that is smuggled in
Specific gravity in urinalysis
‘Specific gravity measures the concentration of urine solutes, which reflects the kidney’s capacity to concentrate urine, this capacity is among the first functions lost when renal tubu- lar damage occurs’ (Buffington and Turner 2004: 146). It is also referred to as relative density.
Using the model of homeostasis, normal specific gravity ranges from 1.010 to 1.025. Specific gravity below 1.010 or above 1.025 may indicate a problem with renal function, as the kidneys are not filtering or retaining solutes as they should be.
Urine pH
An acidic or alkalinic urine specimen indicates that pH homeostasis is in a state of imbalance.
This may suggest a problem with the kidney’s ability to maintain a normal pH range.
Table 4.17 Procedure for urinalysis
Step Action Rationale
1 Prepare equipment Watch with second hand, reagent strips, gloves (possibly an apron also), pen and chart for recording result
to ensure effective monitoring and prompt recording of reading
2 Examine reagent strips
Check that they are not out of date and that they have been stored appropriately
If out of date or stored inadequately, the reagent strip may have reacted to moisture in the air. Do not use, as it will give a false reading
3 Remove one reagent strip and replace lid
Do not touch the reagent pads to minimize biased readings and ensure secure storage for next time 4 Dip reagent strip
into the sample
Immerse the reagent strip in the urine sample
to ensure that all reagent pads have been activated
5 Carefully remove the reagent strip
Extract the strip at an angle to allow excess urine to run off safely
this will prevent excess urine running through the different reagent pads, which will affect readings
6 Use your watch to begin timing as reagent pads activate at different times
Ensure readings are taken at the correct intervals
Failure to record at correct intervals will invalidate the readings
7 Record and document your findings
Ensure you are familiar with the standard way of recording urinalysis results
the appropriate chart should be completed accurately for comparison with past or future readings
8 Communicate findings 1
Inform MHSU of the outcome and be prepared to answer any queries they may have
to reassure the MHSU
9 Communicate findings 2
report any abnormalities to the nurse in charge
In case immediate intervention is required or for continuity of care 10 Communicate
findings 3
record findings in the MHSU’s case notes
So that other members of the team are aware of them
11 Decontaminate hands again
Wash hands or use alcohol rub to promote infection control and minimize cross-infection
Urine glucose and ketone tests
Urinalysis can be a useful test in the monitoring of glucose and ketone levels, which are important in screening for T2D. However, the standard way of monitoring glucose is through blood glucose testing. The presence of ketones in urine may indicate that the person’s own fat reserves are being used as an energy source. Ketones would be evident in cases of anorexia nervosa or diabetic ketoacidosis.