I need some advice - please help

[hensylee]

Some of you may know that my brother is in assisted living, is on coumadin to prevent stroke. He has only one kidney. Today the nurse called me to say he has a little blood in his urine (he knows to look and told her) and she thinks he might need a coumadin reduction today and tomorrow and she is going to do that. We really don't want to take him to ER - ours is very small and they don't do much for the patient, anyway. If they admit my bro, he becomes very upset - he's an awful patient anyway; always has been. He is due for his monthly checkup tomorrow (but we don't usually go on Sunday), we may wait til Mon morning to see if the reduction takes care of things, but I will call his cardio first thing Monday unless we have a crisis before then.

I just talked to him and he tells me the urine isn't as red as it was; I don't think it was a true red. The nurse tested it for infection, found none, but said it's the color of tea.

I had lunch w/bro yesterday and he ate a salad - something he has not done for years because he avoided ALL green things. He had another today. I told him not to eat anymore green things of any sort because he hasn't been doing it and this might be the cause.

He complains of some pain across the kidney but it isn't severe.

Any words of wisdom?

I will check in again soon. Thanks - and please.

 

[Blanche]

Ann:
I don't know how green things could cause blood in the urine. An elevated INR sometimes causes blood, and apparently the nurse thinks this is so because she is reducing his Coumadin. Since green things are full of vitamin K, eating them would tend to lower the INR. Al did have blood in his urine on a Sunday. The on-call physician told him he had the choice of emergency room or waiting one day. This doctor said that as long as the color remained light, there would be no problems. He waited...nothing happened..and they never figured out what caused the problem.

I hope this helps you worry a little less.

Blanche

 

[geebee]

The thing that worries me is the nurse said she was going to lower his coumadin dose but did not say anything about what his INR is. How can she make adjustments without testing?

Many things can cause blood in the urine besides high INR.

I would be worried about her changing his dose without testing his INR first.

 

[perkicar]

Tea colored urine can be caused by many things. Kidney function comes to mind, if he has a kidney stone, or kidney infection...reduced kidney function causing decreased urine output (usually darker, more concentrated)...Increased bilirubin in the urine (I had a patient last week whose urine looked almost orange, but not due to blood)....I guess I'd wonder about just assuming it is coumadin related, especially since we know how fast our INR's can drop when we don't take it or our doses change.
Did they do a urinalysis??? Even a dipstick test can tell them if there's Red blood cells present.

 

[hensylee]

the nurse did the dipstick and found no bacterial infection.

She did not do an INR. No way to do it there. The facility is small but a RN is on duty and on call 24/7.

Hope it's not a kidney stone - he's had them before and they were crushed in that tub thing. Then he had a tiny cancer in left one and it's been removed.

 

[DrAllan]

As described above by perkicar, change in urine color may be other things besides blood in the urine. Unless one is having frank bleeding and passage of pure blood versus bloody urine, it is not likely that one will go into shock from minimal hematuria.

Blood in the urine can be caused by many things. The most common would be kidney stones. As they move around in the kidney they scrap the linings and cause bleeding. Being on ATC prevents this from quickly stopping and you re more likely to see blood than if not on ACT.

Regardless of the cause, the bleeding needs to be investigated. Even with a history of previous stones as the most likely reason, one must rule out a tumor of the bladder first and the kidney second. Since he has already had a nephrectomy for a kidney cancer one must consider the possibility of him having a tumor in the remaining kidney

I would recommend against reducing his Coumadin. The chances of another stroke far outweigh the risk of bleeding. He does need a prompt urologic evaluation.

Best to you

 

[Karlynn]

I have the same concern. How can she reduce his Coumadin without knowing his INR. Sounds like she's asking for trouble. Even if it's a small facility, they should be able to get a "finger stick" unit.

 

[hensylee]

Thank you all. I have to think very seriously that it's probably a kidney stone because he's had them before. Last night he complained of some pain at the top of the kidney. I will get in touch with the nurse first thing and tell her not to stop his coumadin - he has no history of stroke but with all the things going on in his body, the coumadin is preventative for possible stroke - he has a-flutter always and sometimes it becomes a-fib and that's the worry for stroke. He has been dxed w/dysautonomia (system failure). He has that heart/bp thing where he might pass out when he stands up; pheripheral neuropathy; he has Parkinson-like symptoms and is on Parkinson medicines plus heart meds and a bp med.

I will check on him as soon as he's awake to find out about his night and to decide the next step. We will be on it ASAP and will keep you all posted.

I'll talk to his cardio about getting a finger stick unit for him so the facility can do it - or I can. I don't know if any other resident is on coumadin but my guess is that there's bound to be somebody else on it; a finger stick unit on premises would be a good thing. The facility houses less than a hundred people. Maybe 60 or 70, and that's stretching it a bit, I think. That many residents should be enough for a unit to be on hand.

I really appreciate all your help. It is wonderful to speak to you who can calm our fears and anxieties, while giving us your expert knowledge. I can't thank you enough. Blessins.....

 

[Ross]

Ann if you have to fight her about stopping the Coumadin, do it. No stopping without an INR check first!!!!

 

[Nancy]

I think they should be doing a culture on his urine or blood. The reason I think this is because he is also complaining of kidney area pain. Cultures take a few days to develop. So they are different from the dipstick stuff.

Have they also done any bloodwork on his kidney function? And of course, his INR should have been checked before reducing his dosage.

Right now Joe is in the hospital for the third time from what started out as a bladder infection with chronic and acute kidney failure. I don't want to hijack your thread. I will be posting on this on separate thread in a day or so when I have more info.

Just wanted to express my concerns that they need to investigate further. In older folks, many things can happen that defy a cursory "off the cuff" diagnosis.

 

[hensylee]

Ross, I have already talked with the senior staff member and told her to have that nurse put him back on his coumadin right away. Her response: "She can't take him off without doctor's orders" - Mine to her "Well, she did". There may be trouble before this is over because it will travel on up to the administrator who is, herself, a nurse. In any case, he'll get his coumadin today.

Nancy, we will begin first thing tomorrow with our local doctor and the lab with his INR (which is due anyway). Our doctor will run the gamut of tests and refer us where he needs to go if they find something.

He is still haveing tea colored urine but not dark. His pain is light and travels to both sides of his back just above the kidney area. He only has one so I can't figure out why he's got a little pain on the other side. Nothing severe.

I am on it, believe me. He and I have been through so much since my dear Joe died (there was about a week from Joe's death til we started with my brother) and that's been 9 years ago. We'll just keep on keeping on.

Thanks for your caring.

Nancy, best to Joe. I'll watch for your post.

 

[Ross]

Sounds like a stone passing to me.

 

[geebee]

I agree with Ross. It sounds just like the pain and problems I had with my kidney stone. The talk of pain cinched it.

 

[bvdr]

Ann, if he is medically able to do so then also encourage him to drink lots of fluids. It works to flush out the plumbing and dilute the urine. Sometimes a concentrated urine looks tea-like without blood being present and infection/inflammation, and even a stone, can be a secondary condition that sets in when the condition of concentrated stagnant urine exists especially in the elderly or in those with pre-existing urinary tract problems.

My mom has Parkinson's and for years we had to really watch that she got enough fluids. It was such a hassle for her to get to the bathroom that she reduced fluids to keep her from having to make the trip more than necessary. On several occasions she developed infections that first made themselves known by her mental status really slipping. Now when she gets really agitated or combative they check her right away for a UTI (urinary tract infection). She too has had stones in the past which do create some scarring that can in itself make one more prone to infections. My mom's condition has deteriorated to the point she no longer has trips to the bathroom but we still make sure she gets plenty of fluids.

Nancy, I don't know what to say except I am so sorry that Joe needed to have yet another hospitalization. What a balancing act for everyone involved. You all frequently are in my prayers and now will be more so as well as Ann & her brother as well.

I wish you all well.

 

[hpuehler]

No orders?

No orders?

I am a nurse and when I started reading the thread I was wondering, "Where is the Dr. order"? Nurses cannot just decide to change medication dosages. This equals practicing as a Physician without a license, a serious offense. The nurse should report new blood in the urine to the physician immediately in a situation where the client has this history and anytime for that matter.
My concern is not so much with the urine, but the possibility that a nurse that would alter meds without an order is working with your loved one.

I hope all is well and I will add you to my prayer list.

Heather

 

[hensylee]

Heather, this nurse is fairly new. She may not last too long when the administrator gets into the situation. As to reporting to the doctor, they don't. This is assisted living, nor nursing home, so they report to the family, which she did. She called me yesterday shortly before I posted here - to tell me what's going on. After talking with her, we decided to watch it overnight and wait til Monday if possible - and we are waiting because so far he seems pretty much as usual.

Betty - he does drink water, but I will encourage him to drink more. He tries to keep a bottle handy most of the time.

Thanks....

I sure miss my sister, Jackie, right now......... sigh.....

 

[EVELYN]

Hens

Just read your thread about your brother......I'm putting him on my prayer list immediately. My gut also went to kidney stones before high inr.....please keep us posted.

My cousin's urologist said that for kidney stones not to just drink water, but to drink water flavored with lemon/lemonade....don't know how much that does, but flush, flush, flush.

Love ya, girlfriend.

Evelyn

 

[DrAllan]

Welcome to the world of medical myth, single case reports, and unproven but possibly good theories. First of all there are several types of kidney stones, calcium, oxalate, cystine, uric acid stones, and combinations of the previous chemicals Except for drinking 10-12 glasses of water a day and voiding frequently to try and keep the concentration of salts down so that they do not precipitate as stones, there is not documentd proven method to either prevent stone formation or to ?flush? out already formed stones.

The lemon theory has some interesting chemical facts to support it but no proof. The recommendation, nevertheless are for the consumption of 1/2 cup of pure lemon juice per day. The idea is that the citrate ?may? protect against calcium stone. However, 8 oz of grapefruit juice increases the risk of stone formation. Orange juice while it contains citrate dies not lower calcium levels and raises oxalate levels.

I could go on and on with the paucity of good scientific evidence to support dietary control of kidney stones. My personal prejudice is that the problem of stones long precedes the surgical methods we have to deal with stones and nobody by trial or error has found s reliable dietary cure.

Best to you

 

[hensylee]

DrAllan, as I recall, brother's urologist didn't even put a great deal of faith in the water treatment, either. He did suggest maybe not as much milk as Richard had been drinking, tho.

This morning the urine was clearer, but it was still a strong color - like after we take a bunch of vitamins. I took him to the lab and got a Urinalysis and his INR done, but we didn't hear from anybody. The nurse at the 'home' is in touch with his cardiologist, however. She spoke to his office this morning and expected to again before the day was out. OUr local dr didn't call - he was doing surgery this morning which made his afternoon caseload extremely heavy, especially it being Monday. They would have called me, tho, if there was anything to worry about. We are VERY long time patients and they take good care of us.

Richard has taken to bed the last couple of days and that's not his usual routine. He's very good about his PT and walks every day around the facility. He was really not mentally ok today; he was very weak and I attribute it to his lying around, but will pay close attention to it tomorrow because I am always afraid it might be something to be seen to. He has days like that now and then so it isn't that unusual, but it was a strange day. He saw a few things that weren't there. I never try to convince him otherwise. He sees it, it must be there for him. Mostly he is very aware like the rest of us, uses his computer daily, etc..... I just stay concerned for him all the time.

 

[geebee]

Ann,

Hope things continue to improve for your brother. I hope it is merely a small stone that passes without any more problems.

I understand what you mean about the seeing things. When my mom was alive and just starting with Alzheimer's she was seeing a lot of things that "weren't there for us". She was so convinced of seeing the stuff that my sister and I began to think we were the ones with the problem. Once we just went along with Mom, things got a lot easier for all of us. We even played with the kitten that kept showing up (even tho it wasn't there). Or was it???????

Who really knows for sure?