Decoding the UA
A NurseEXP Field Guide to Urinalysis for post acute and long term nurses
← Back to GuidesNo alarms, no monitors, just a cup of information waiting to be read. Hydration, infection risk, kidney performance, and metabolic clues show up fast. Once you know what matters, a UA stops being random values and starts telling you what the body is doing.
SNF Add Ons
Post Acute and Long TermIn SNF, a UA is rarely random. It is usually ordered because something changed. The job is not to panic. The job is to connect the dots.
- Acute mental status change, new confusion, or lethargy.
- New incontinence pattern, urgency, or frequency.
- Low grade fever or chills with no clear source.
- Decline in appetite, participation, or mobility.
- Dark urine with poor intake or low output trend.
- New suprapubic discomfort, dysuria, or flank tenderness when the resident can report it.
- Baseline cognition and what changed, with a concrete example.
- Vital sign trend, not one set.
- Intake and output trend, especially recent poor intake.
- Recent antibiotics, recent cultures, and history of resistant organisms.
- Collection method and contamination risk.
Sample quality changes everything
A clean collection keeps you from chasing a fake problem.
Clean catch midstream
- Clean the area thoroughly.
- Start voiding first.
- Collect midstream without stopping flow.
- Finish voiding outside the container.
Twenty four hour collection
- Discard the first void to mark the start time.
- Collect all urine for the next twenty four hours.
- Keep the container cold throughout collection.
Foley and straight cath collection
Defensible specimensIn SNF, the fastest way to bad data is pulling a specimen the wrong way. When in doubt, follow facility policy and keep it clean.
- Do not pull from the bag.
- Use the sampling port per policy with aseptic technique.
- Label promptly and send quickly.
- Document method and reason, especially for change in condition.
- Use when ordered and when contamination risk is high.
- Document tolerance and specimen handling.
- Correlate results with symptoms and baseline.
How Urine Gets Analyzed
The fast screen. Great for clues, not great for solo conclusions.
The close up view. Cells, bacteria, casts, and crystals that sharpen the story.
The confirmation test for infection. Names the organism and helps match effective antibiotics.
Reading What the Body Is Saying
Clear and pale usually means the system is cruising, especially with stable vital signs and intake.
- Dark amber: Concentrated urine. Dehydration is common. Consider liver involvement if other signs fit.
- Red or pink: Blood can be present. Think stones, trauma, infection, or irritation.
- Cloudy: Cells, bacteria, protein, or crystals may be in the mix.
- Unusual colors: Medications and dyes love to leave fingerprints.
Specific gravity tells you how hard the kidneys are working to concentrate fluid.
- Low: Dilute urine. Overhydration or impaired concentration can show up here.
- High: Concentrated urine. Dehydration is common. Glucose in urine can also push this up.
Urine leans slightly acidic by default. Big shifts usually mean something else is driving it.
- More acidic: High protein intake or metabolic imbalance.
- More alkaline: Infection, diet patterns, or prolonged vomiting.
- Glucose: Blood sugar crossed the renal threshold, so it spills into urine.
- Ketones: The body is burning fat instead of glucose. Pair with the resident presentation, not just the strip.
- Nitrites: Certain bacteria convert nitrates to nitrites, so nitrites can be a strong clue.
- Leukocyte esterase: White blood cells are responding to irritation or infection.
- Blood: Infection, stones, inflammation, trauma, or structural irritation.
- Protein: Renal stress or damage, cardiac overload, and pregnancy related conditions such as preeclampsia.
This can be a liver and bile flow clue. It is not a UTI marker.
- Liver involvement: Hepatic disease patterns can show up with other symptoms and labs.
- Biliary obstruction: Can align with jaundice or abnormal liver function tests.
This helps support liver and hemolysis context when paired with the resident presentation and other labs.
- Elevated patterns: Can align with liver dysfunction or hemolysis context.
- Low or absent patterns: Can align with bile flow obstruction context.
Microscopy
The close up viewMicroscopy is where the story gets sharper. This is often the section that tells you whether the dipstick was noise or signal.
- WBCs: Supports inflammation. Stronger when paired with symptoms and infection pattern.
- RBCs: Hematuria pattern. Think stones, infection, irritation, trauma, or anticoagulants.
- Bacteria: Consider colonization versus infection, especially in long term.
- Squamous cells: Contamination hint, especially with poor collection.
- Casts: Can point toward renal involvement. Escalate if the resident is declining or renal concerns are present.
- Crystals: Can be incidental or stone related. Correlate with pain and hematuria patterns.
- Yeast: Can show up with diabetes, antibiotics, or contamination. Correlate with symptoms.
Culture
Name the organismCulture is for when you need confirmation and targeted treatment. It supports the right antibiotic and also supports the decision to not treat when the picture does not match.
- There is a clear change in condition plus infection pattern on UA.
- Symptoms are present and the resident is not improving.
- There is history of resistant organisms or recurrent infections.
- There is fever or systemic illness concerns.
- Resident is stable and asymptomatic.
- Collection quality is poor and contamination risk is high.
- The goal is reassurance rather than decision making.
Likely UTI pattern. Bacterial activity plus an inflammatory response. Correlate with symptoms, vital signs, and culture if ordered.
Metabolic warning. Often seen in uncontrolled diabetes. Pair with blood glucose, mental status, and hydration assessment.
Fluid deficit pattern. The kidneys are conserving aggressively. Check intake trend, output trend if tracked, mucous membranes, and blood pressure.
UTI reality check
Do not auto diagnoseColonization happens. Cloudy urine happens. A positive UA can happen. Infection is a clinical picture, not a single box checked on a lab.
- Foul smell alone.
- Cloudy urine alone.
- Bacteria on UA without symptoms.
- Chronic baseline confusion with no change from baseline.
- New fever with behavior or vital sign change.
- Dysuria, suprapubic pain, new urinary complaints when reportable.
- Leukocytes with nitrites plus a clear change in condition.
- Rigors, persistent vomiting, or signs of systemic illness.
Nurse moves after a UA
What to do nextA UA is not the end of the story. It is a checkpoint. Your next steps should be simple, repeatable, and defensible.
- Confirm collection method and contamination risk.
- Reassess vitals and compare to baseline trend.
- Review intake trend and output trend if tracked.
- Check current meds and recent antibiotic timeline.
- Look for symptoms that match the pattern, not just the lab.
- Trend mental status and functional decline across the shift.
- Escalate when there is fever, systemic illness concerns, or clear new symptoms.
- Escalate persistent hematuria patterns or new gross blood.
- Escalate suspected dehydration with instability or significant decline.
- Request culture when infection is suspected, per order or provider direction.
What to trend on shift
SNF WorkflowWhen you write your note or call the provider, these trends do the heavy lifting.
- Vital signs trend, including temperature trend.
- Mental status trend and baseline comparison.
- Pain or discomfort, including suprapubic or flank if reportable.
- Functional trend, appetite, participation, mobility, sleepiness.
- Intake trend and output trend if tracked.
- Urine appearance trend, not one moment in time.
- Recent antibiotic timeline and response.
- Prior culture history and resistant organism history if known.
Notify the provider now
Red flagsThese are moments where the UA matters because the resident is changing in a way that can turn quickly. Use your assessment and facility protocol.
- Acute change in condition with abnormal vital signs.
- Concern for sepsis based on presentation and trend.
- New inability to void, suspected retention with decline, or severe suprapubic discomfort.
- Gross blood in urine or significant new hematuria pattern with symptoms.
- UA suggests infection pattern and the resident is clinically worsening.
Quick SBAR
Call readyWhen you call, you want to sound like you already put the puzzle together. Keep it short, factual, and tied to baseline.
Situation
Resident with acute change from baseline, UA results available, current vital signs obtained.
Background
Relevant history, recent antibiotics, prior culture history if known, hydration concerns, baseline cognition.
Assessment
Current assessment, symptom presence, intake trend, output trend if tracked, and whether the UA pattern matches the presentation.
Recommendation
Request guidance on culture, treatment plan, hydration plan, and monitoring parameters per provider direction.
SNF charting language
Copy friendlyChart like a nurse who assessed the resident and used the UA as supporting data. Keep it calm, factual, and tied to baseline.
- UA results reviewed and correlated with current assessment findings.
- Resident assessed with noted change from baseline. Vital signs obtained and trended.
- Oral fluids encouraged as tolerated. Intake monitored per plan of care.
- Specimen collection method documented. Sample handled and transported per facility process.
- Provider notified of change in condition and UA findings. New orders received and carried out.
- Resident monitored for fever, pain, urinary symptoms, and changes in mentation.
- Culture obtained per order and sent to lab. Resident tolerated collection without distress.
- Ongoing reassessment completed. Resident remains stable at this time.