Use of frequency volume charts and voiding diaries

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Use of frequency volume charts and voiding diaries

Transcript Of Use of frequency volume charts and voiding diaries

Nursing Practice Review Continence/urology

Keywords: Bladder/Assessment/ Diagnosis/Frequency volume charts
●This article has been double-blind peer reviewed

Frequency volume charts provide an objective measure of bladder function, which is essential to support the correct diagnosis and treatment of urological problems

Use of frequency volume charts and voiding diaries

In this article...
The different types of charts used to record bladder function How to interpret the results Case studies of how charts help with diagnosis

Author Wendy Colley OBE is a freelance writer and lecturer, and former continence nurse specialist. Abstract Colley W (2015) Use of frequency volume charts and voiding diaries. Nursing Times; 111: 5, 12-16, online version. Many people experience bladder and urinary problems and the reasons for them are manifold. Charting fluid intake and urinary output is an essential part of a continence and urology assessment, which will help practitioners diagnose problems and decide on treatment. This article describes the different charts in use; it also analyses and discusses examples of completed charts.
Urinary symptoms are common and may be due to conditions affecting the urinary tract or as a result of illness affecting other systems (for example, heart failure is associated with nocturia). Accurate diagnosis is essential to ensure prompt, effective treatment of the underlying cause.
Using charts to record the times urine is passed and the volumes voided over a period of time gives an objective measure of bladder performance. The charts are usually completed by patients after they have been taught how to do so by a health professional. They provide invaluable information and are used in the following circumstances: » As part of the initial assessment of
lower urinary tract symptoms (National Institute for Health and Care Excellence, 2010); » To aid diagnosis as part of a continence assessment (NICE, 2013); » As a baseline in planning a bladder training regime;

» To plan an individual toileting programme;
» To measure progress during treatment, for example for overactive bladder. The information that must be recorded
on the chart will be determined by the assessor and based on the capabilities of the patient, who must be able to safely void into a container, and measure and record the volume of fluid.
What is measured and when There are a variety of charts in use; this article follows the International Continence Society definitions (Abrams et al, 2002), which recognise three main types of recording: » Micturition time chart: records the times
of micturition during the day and night; » Frequency volume chart (FVC): records
the volumes voided as well as the time of each micturition, during the day and night; » Bladder diary: records the times of micturition and voided volumes, episodes of incontinence, pad use, other information such as the degree of urgency, degree of incontinence and fluid intake and type. Charts or diaries should be completed for a minimum of three days (NICE, 2013) although a period of 3-7 days is usually used; this is recommended by the European Association of Urology (Lucas et al, 2014). The patient should be asked to include work and leisure days where applicable as this may indicate exacerbating factors. Charts should include a time column covering each 24-hour period; this can be blank for the patient to insert times, but is often labelled at hourly intervals. A bladder diary is likely to be used as

5 key points
1 Charting bladder function and fluid intake is important for investigating symptoms and making a diagnosis
2It is important to understand what is being recorded and why
3Patients must be assessed to ensure they can record the information required
4Patients need to understand the importance of recording information accurately
5A completed chart forms the basis for further discussion with the continence/ urology team
The measuring jug used to measure voids should be used only for this purpose

Alamy

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part of a continence assessment to aid diagnosis and inform a treatment plan. It is an invaluable tool, giving a baseline against which progress can be monitored, which helps to motivate patients.
Preparation and instructions To ensure accurate, meaningful data is recorded, health professionals should help patients understand what is required and reinforce the importance of the chart in diagnosing and managing their condition.
Practitioners should: » Determine the information required
based on assessment; » Assess patients’ capabilities when
deciding what to record and ensure they are not at risk of falls when voiding into a container; » Confirm that the patient understands fluid measurements; » Provide a suitable chart for recording information. They should tell patients: » To use a jug to measure the volume of urine and record this on the chart against the time; » If patients do not use a jug, to measure the contents of any cups/glasses they use and make a note of these. Recording the volume of drinks is easier if the container volume is already known. Practitioners can do this for patients unable to do so; » To wash and dry the jug after each use, keeping it for this purpose only; » To start recording with the first void on rising; » That if they are unable to measure urine volumes – for example, when using a public toilet, or because they are opening their bowels at the same time – to place a tick in the column next to the time; » Record the time prescribed diuretic therapy is taken, as this will increase urine output; » Record times of going to bed and getting up.
Collating the results When a chart is returned, the assessor should collate the information for each day to identify: » Daytime frequency: the number of
voids recorded during waking hours, including the last void before sleep and the first void after rising in the morning; » Nocturia: the number of voids recorded during a night’s sleep, where each void was preceded and followed by sleep; » 24-hour frequency – the total number of daytime voids and episodes of

table 1. FVC: normal bladder function

Day 1

Day 2

Day 3

6am

500ml Got up

7am

450ml Got up

500ml Got up

8am

9am

150ml

10am

300ml

300ml

11am

200ml

12pm

1pm

200ml

2pm

250ml

150ml

3pm

4pm

5pm

350ml

250ml

6pm

300ml

7pm

8pm

250ml

9pm

200ml

10pm

450ml Bedtime

11pm

350ml Bedtime

450ml Bedtime

12am

1am

2am

3am

250ml

4am

5am

TOTAL

1,900ml

2,000ml

1,950ml

Summary

Number of voids each day

5-7

Number of voids each night

0-1

Total voids in 24 hours

6-7

Volume voided in 24 hours

1,900-2,000ml

Maximum void

500ml

nocturia during a specified 24-hour period (Abrams et al, 2002). An FVC or bladder diary must be used to determine the maximum voided volume (the largest volume of urine voided during a single micturition).
Interpreting the results Comparing the results with what is considered normal bladder function may indicate areas of dysfunction and be used to confirm a diagnosis.
It is important to remember that it is difficult to define a “normal” or healthy bladder function (Lukacz et al, 2011) as normal parameters depend on age and gender, as well as many other internal

and external factors such as fluid intake and type.
The International Continence Society defines urinary frequency as a complaint by a patient that they void too often during the day (Abrams et al, 2002), which shows that patients’ perception of their symptoms must also be considered.
As a guide, “normal” parameters of voiding volumes and frequency in adults of average weight and height are outlined in Table 1.
Daytime frequency Normal frequency is between five and eight voids in 24 hours. A high fluid intake may increase frequency.

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table 2. Bladder diary: stress urinary incontinence

Drinks

Urine output

Volume

Fluid type Volume

Leakage

7am Got up 200ml

Coffee

450ml

8am

200ml

Juice



9am

150ml

10am

150ml

Water

11am

150ml

Coffee

12pm

200ml

Water

300ml

1pm

200ml

Tea



3pm

200ml

4pm

200ml

Tea

6pm

200ml

Water

200ml



7pm



8pm

330ml

Cola

10pm

325ml



11pm Bedtime 150ml

Chocolate 100ml

3am

100ml

Water

200ml

Total

2,080ml

1,925ml

Summary

Fluid intake

Number of drinks in 24 hours

11

Volume in 24 hours

2,080ml

Caffeinated drinks

6

Urine output and incontinence

Number of voids each day

7

Number of voids each night

1

Volume voided in 24 hours

1,925ml

Maximum void

450ml

Incontinent episodes

5

Pad use

Product name

Panty liner

Number used in 24 hours

5

Pad changes Panty liner Panty liner
Panty liner
Panty liner Panty liner

Nocturia Rising during sleeping hours with the need to void once may be considered normal.
If nocturia is excessive, the practitioner should ensure the patient is awakening due to the desire to void and not for other primary reasons, such as pain, and simply voiding while awake.
The production of the antidiuretic hormone vasopressin decreases with age so older people may void more frequently at night. Nocturnal polyuria is present when an increased proportion of the 24-hour urine output occurs at night (normally during the hours while the patient is in bed). The precise definition is dependent

on age and is considered to be present when more than 20% (young adults) to 33% (over 65s) of urine is produced at night. Night-time urine output excludes the last void before sleep but includes the first void in the morning (van Kerrebroeck et al, 2002). Older people with nocturnal polyuria should be assessed to exclude underlying, undiagnosed heart conditions.
Maximum volume voided Normal functional bladder capacity in adults is approximately 300-400ml (Lukacz et al, 2011), although volumes of 500-600ml are often recorded. The largest void is usually on rising; during the day, the bladder is emptied at lower volumes.

Total volume voided The total volume voided depends on many factors but generally, in a healthy adult, should be 1,500-2,000ml. Patients who restrict fluid intake because they fear episodes of incontinence will have a low urine output, which can exacerbate symptoms as concentrated urine may both increase urgency and the patient’s risk of developing a urinary tract infection.
Low urine output that is not linked to low fluid intake should be investigated.
Fluid intake and type An average adult in good health will require a fluid intake of 30ml per kg of body weight in 24 hours (Kobriger, 2005). Using this calculation, an adult weighing 67kg should have a daily intake of approximately 2,010ml. The European Food Safety Authority (2010) recommends women have an overall intake of 2l and men 2.5l.
Caffeine is known to cause diuresis, urinary frequency and urgency at lower bladder volumes (Lohsiriwat et al, 2011). This is troublesome for some patients, who may benefit from advice about gradually reducing their intake of caffeinated drinks.
Case studies The fictitious case studies below indicate differing bladder function/dysfunction.
Normal bladder function Table 1 shows the FVC of Sarah Smith, a 38-year-old health professional with normal bladder function. Over three days, the chart shows: » Micturition frequency: 6-7 times in
24 hours; » Nocturia: up to once in 24 hours; » Total volume voided in 24 hours:
1,900-2,000ml; » Maximum void: 500ml.
Stress urinary incontinence Table 2 shows the bladder diary of 29-yearold Sue Green, who enjoys exercise and jogging. She has two children, the youngest of whom is nine months old. She has urine leakage on exertion and has no frequency or urgency. Over a single day the chart shows: » Daytime frequency: seven times in
24 hours; » Nocturia: once in 24 hours; » Total volume voided in 24 hours:
1,925ml; » Maximum void: 450ml; » Leakage on exertion: five times in
24 hours; » Continence aids: buying own panty
liners for leakage; » Fluid intake: 2,080ml in 24 hours.

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Mrs Green’s fluid intake and bladder function are within normal parameters, apart from episodes of leakage. Other investigations included urinalysis and physical examination. A diagnosis of stress urinary incontinence was then made and a treatment regimen of individualised pelvic floor muscle exercises commenced.
Overactive bladder Table 3 illustrates the bladder diary of George Emerton, a 48-year-old science teacher. He complains of urinary urgency, and leaks urine if he is unable to reach the toilet quickly. On one occasion, he had to take a white coat from the classroom to cover his clothes as he could not control his urgency on the way to the toilet. Since he was unable to measure his voids, he was asked to put a tick in the column each time he passed urine.
One day of three-day charting shows: » Daytime frequency: 12 times in 24
hours; » Nocturia: twice in 24 hours; » Total volume voided in 24 hours: not
recorded; » Maximum void: not recorded; » Leakage with urgency occurred once in
24 hours; » Continence aids: pads not used; » Fluid intake: 1,450ml, made up of six
cups of strong black coffee and a pint of lager. From Mr Emerton’s charting, the obvious causes for concern are the low fluid intake and the volume of strong black coffee. In addition, lager can irritate the bladder in some people. After urinalysis to exclude urinary tract infection and a full continence assessment, Mr Emerton was advised initially to gradually reduce his caffeinated drinks, replace these with noncaffeinated drinks and ensure his fluid intake was about 2l in 24 hours. He will be reviewed in four weeks for progress and further treatment, investigation and referral if required.
Interstitial cystitis Table 4 is the bladder diary of 55-year-old Jenny Carter. She complained of urinary frequency, urgency and leaks urine if unable to reach the toilet quickly. Lower abdominal pain occurs as her bladder fills. She is otherwise fit and active, but is very tired due to daytime frequency and nocturia occurring every hour.
One day of three-day charting shows: » Daytime frequency: 17 times in 24
hours; » Nocturia: seven times in 24 hours; » Total volume voided in 24 hours:

table 3. Bladder diary: overactive bladder

Drinks

Urine output

Pad changes

Volume

Type of fluid

Volume* Leakage

6am Got up

150ml

Coffee



7am

150ml

Coffee

9am



11am

150ml

Coffee



1pm

150ml

Coffee



2pm





3pm

200ml

Coffee

4pm



5pm



7pm

500ml

Lager



11pm



12am Bedtime 150ml

Coffee

1am



TOTAL

1,450ml

Summary

Fluid intake

Number of drinks in 24 hours

7

Volume in 24 hours

1,450ml

Caffeinated drinks

6

Alcohol

1

Urine output and incontinence

Number of voids each day

12

Number of voids each night

2

Maximum void

Not known

Incontinent episodes

1

Pad use

Product name

None

Number used in 24 hours

0

*Because of workplace arrangements, the patient was unable to record volume

1,665ml plus leakage; » Maximum void: 90ml; » Leakage with severe urgency: five times
in 24 hours; » Continence aids: three rectangular
pads used; » Fluid intake: 2,150ml.
The bladder diary confirmed the severity of Ms Carter’s symptoms. Urinalysis and vaginal examination did not show any abnormality, and constipation was excluded. A post-void ultrasound scan showed her bladder was completely emptying. Referral to a urologist led to urodynamic studies; these showed a significant increase in bladder pressure during filling, resulting in severe urgency with high pressure and leakage at 90ml. A cystoscopy and

biopsy confirmed interstitial cystitis as the cause of the symptoms. This can be a difficult condition to manage and Ms Carter is discussing the options with the urologist.
Conclusion Charting bladder function and fluid intake gives invaluable information to the assessor, but the importance of the chart and the need for accuracy must be explained to the patient completing it.
Although these charts are only a part of an assessment of bladder symptoms, no assessment is complete without them. Symptoms explained verbally can easily be misinterpreted, so an objective measure of bladder function is essential to support correct diagnosis and treatment. NT

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table 4. Bladder diary: interstitial cystitis

Drinks

Urine output

Record when applying new pad

Volume

Type of fluid

Volume

6am Got up

100ml

Water

90ml

7am

150ml

Tea

60ml

8am

250ml

Tea and Juice

75ml

9am

60ml

10am

200ml

Coffee

90ml

11am

60ml

12pm

250ml

Soup

60ml

1pm

150ml

Water

60ml

2pm

150ml

Coffee

75ml

3pm

90ml

4pm

200ml

Tea

75ml

5pm

60ml

6pm

150ml

Water

60ml

7pm

90ml

8pm

200ml

Wine

60ml

9pm

60ml

10pm

200ml

Tea (decaffeinated) 75ml

11pm Bedtime

100ml

Water

90ml

12am

60ml

1am

60ml

2am

60ml

3am

50ml

Water

60ml

4am

75ml

5am

60ml

TOTAL

2,150ml

1,665ml

Summary

Fluid intake

Number of drinks in 24 hours (volume)

13 (2,150ml)

Caffeinated drinks

5

Alcohol

1

Urine output and incontinence

Number of voids each day

17

Number of voids each night

7

Maximum void

90ml

Incontinent episodes

5

Pad use

Product name (number used in 24 hours)

Rectangular pad (3)

Leakage ✓ ✓ ✓ ✓ ✓
5

Pad changes Rectangular pad
Rectangular pad Rectangular pad 3

References Abrams P et al (2002) The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics; 21: 2, 167-178. European Food Safety Authority (2010) Scientific opinion on dietary reference values for water. EFSA Journal; 8: 3, 1459. tinyurl.com/ EuropeWaterValues Kobriger AM (2005) Hydration: Maintenance:

Dehydration, Laboratory Values, and Clinical Alterations. Chilton, WI: Kobriger Presents. Lohsiriwat S et al (2011) Effect of caffeine on bladder function in patients with overactive bladder symptoms. Urology Annals; 3: 1, 14-18. Lucas MG et al (2014) Guidelines on Urinary Incontinence. European Association of Urology. tinyurl.com/GuideUI Lukacz ES et al (2011) A healthy bladder: a consensus statement. International Journal of Clinical Practice; 65: 10, 1026-1036.

16 Nursing Times 28.01.15 / Vol 111 No 5 / www.nursingtimes.net

National Institute for Health and Care Excellence (2013) The Management of Urinary Incontinence in Women. nice.org.uk/cg171 National Institute for Health and Care Excellence (2010) The Management of Lower Urinary Tract Symptoms in Men. nice.org.uk/cg97 van Kerrebroeck P et al (2002) The standardisation of terminology in nocturia: report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics; 21: 2, 179-183.
VoidVolumeFrequencyFluid IntakeCharts