Urinary tract infections (UTIs) result from pathogens invading the urethra, bladder, and/or kidneys. While any bacteria can cause UTIs, Escherichia coli is the bacteria typically responsible. UTIs are one of the most common hospital-acquired infections. When this type of infection occurs due to urinary catheterization, it is known as a catheter-associated urinary tract infection (CAUTI).
Outside of healthcare settings, UTIs are most common among women and older adults. Early identification and treatment of urinary tract infections is important to prevent complications like pyelonephritis.
In this article:
Nursing Process
While UTIs are easily treatable, if untreated or unrecognized, they can develop into life-threatening conditions such as sepsis. Nurses are vital in recognizing patients at risk for UTIs and educating them on preventing recurrent infections. Nurses administer antibiotics to treat UTIs, monitor for symptom resolution through urinalysis, and take special precautions in caring for patients with catheters to prevent CAUTI.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to urinary tract infection.
Review of Health History
1. Determine the patient’s general symptoms.
The most common UTI symptoms are urinary urgency and frequency, along with painful urination or burning sensations when urinating. Other signs of UTIs include the following:
- Cloudy urine
- Foul-smelling urine
- Blood in the urine
- Flank, back, or suprapubic pain or tenderness
- Incontinence
- Abdominal cramping
- Fever
- Chills
- Elevated white blood cell count
- Unexplained fatigue
- Changes in cognitive function (in older adults)
2. Investigate the underlying cause.
Interview the patient about their general and perineal hygiene. If the patient self-caths, ask the patient to demonstrate how they perform catheter care to assess their technique.
3. Identify the patient’s risk factors.
The following factors increase the risk of a urinary tract infection:
- Female gender (shorter urethra)
- Indwelling urinary catheter
- Anatomical urinary tract abnormalities
- History of a UTI
- Immunocompromised status
- Vesicoureteral reflux
- Enlarged prostate
- Diabetes mellitus
- Pregnancy
- Changes in pH or vaginal flora (menopause)
- Poor perineal hygiene
- Use of vaginal douches, sprays, and powders
4. Ask about sexual activity and birth control.
Patients who are sexually active should be asked about their hygiene practices after intercourse. Sexually transmitted diseases, spermicides, and diaphragms increase the risk of UTIs.
5. Pay attention to symptoms in older adults.
Older adults are particularly vulnerable to UTIs and may not display usual symptoms, like dysuria. Older adults who present with changes in behavior like agitation, lethargy, confusion, and falls should be assessed for UTI.
6. Assess the patient’s hydration status.
Dehydration can increase the risk of UTI. Assess if the patient is receiving enough water per day. Excessive intake of soda, sugary drinks, and alcohol can irritate the bladder.
Physical Assessment
1. Observe the urine characteristics.
Assess the urine’s volume, color, clarity, and odor. A diagnosis can’t be made through inspection but can identify abnormalities. The following characteristics typically demonstrate normal urine:
- Volume: 800– 2,000 mL/day
- Color: Yellow
- Clarity: Clear or translucent
- Odor: Mild
2. If the patient has a urinary catheter, assess its status.
A urinary catheter is a significant risk factor for UTIs. Patients with permanent indwelling catheters or suprapubic catheters may experience unclear symptoms (such as an increased WBC count and a low-grade fever). Most catheterized patients will have pyuria (pus in the urine) and high bacterial colony counts in their urine.
Diagnostic Procedures
1. Perform a urine dipstick.
Dipstick testing can be performed at the bedside. A urine dipstick measures the following values:
- pH
- Nitrites
- Leukocyte esterase
- Blood
2. Obtain urine analysis.
A complete urinalysis may be required if a diagnosis can’t be made through a urine dipstick. Urine should be sent to the lab immediately or refrigerated. Bacteria proliferate at room temperature, creating an overestimation of the severity of the infection.
3. Send a sample for culture and sensitivity.
Urine cultures are recommended due to rising drug resistance and to distinguish recurrent from relapsing infections. It is the gold standard for urine presenting with nitrites or leukocytes (greater than 10 colony-forming units (CFU) per milliliter). Urine should be cultured in the following patients:
- Men
- Patients with diabetes mellitus
- Patients who are immunocompromised
- Pregnant women
4. Prepare the patient for a possible imaging scan.
If the infection does not respond to treatment, the healthcare provider may order the following tests to look for disease or injury in the urinary system:
- Ultrasound
- Computed tomography (CT) scan or magnetic resonance imaging (MRI)
- Cystoscopy (endoscopy procedure to visualize the bladder through the urethra)
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with urinary tract infection.
Treat the Infection
1. Start antibiotic treatment immediately.
Adherence to the prescribed antibiotic treatment is necessary to kill the bacteria.
2. Promote increased fluid intake.
Hydration increases urination and flushes out the urinary tract. If not contraindicated, increase oral fluid intake.
3. Void frequently.
Encourage the patient to void frequently to excrete bacteria from the urinary system.
4. Administer antibiotics as prescribed.
The following antibiotics are used for the treatment of UTIs:
- Cephalosporins
- Nitrofurantoin
- Fluoroquinolones
- Fosfomycin
Prevent Further UTIs
1. Encourage regular and proper hygiene.
One of the most effective strategies to prevent UTIs and recurrent infections is by practicing personal hygiene.
- Advise female patients to always wipe from front to back after a bowel movement.
- Emphasize the need to change sanitary pads or tampons regularly during menstruation.
- Refrain from applying deodorants, powders, or perfumes to the vaginal area.
- Recommend showering instead of taking a bath.
2. Advise to urinate before and after sexual activity.
Sexual activities can introduce bacteria into the urethra. These bacteria can be flushed out by urinating before and after sex.
3. Discuss alternate birth control options.
Diaphragms carry an increased risk for UTIs. Discuss other birth control options if the patient experiences frequent UTIs.
4. Educate on estrogen creams.
For postmenopausal women, estrogen-containing vaginal cream may decrease the risk of UTIs by balancing the pH of the vagina.
5. Prevent moisture in the perineal area.
Tight-fitting clothing can produce a moist environment, which encourages bacterial growth. To avoid moisture around the urethra, wear loose-fitting clothing and cotton underwear.
6. Boost urogenital health.
Vitamin C supplements may make urine more acidic, limiting bacterial growth. In addition, patients may consider probiotics to balance the urogenital flora. Cranberry juice is controversial in the prevention of UTIs, with cranberry extract seeming to offer the most benefit.
7. Perform strict aseptic technique with catheters.
Avoid using urinary catheters when possible to reduce CAUTI rates. For patients who require catheters, implement sterile technique when inserting a catheter. For patients who require long-term catheterization, regular and thorough perineal care and catheter care are vital for infection prevention.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for urinary tract infection, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for urinary tract infection.
Acute Pain
Pain with a urinary tract infection is described as burning pain with the feeling of urgency or frequency.
Nursing Diagnosis: Acute Pain
Related to:
- Disease process
- Inflammatory process
- Infection
As evidenced by:
- Flank pain
- Pelvic pain
- Dysuria
- Urgency
- Frequency
- Burning with urination
Expected outcomes:
- Patient will report reduced flank or pelvic pain and relief from pain when urinating.
- Patient will verbalize two interventions to control pelvic pain with a UTI.
- Patient will report pain reduced to a 2 out of 10 or less.
Assessment:
1. Assess the patient’s pain characteristics.
Dysuria associated with a UTI is often described as a burning sensation when urinating. Pain may depend on the location of the infection. Pain in the flank or sides may indicate a kidney infection, while pain in the bladder may cause pelvic pressure or lower abdominal pain.
2. Assess the results of the patient’s urinalysis and urine culture.
A urinalysis with urine culture is indicated to help confirm the diagnosis of urinary tract infection and identify the causative agent so appropriate treatment and interventions can be initiated.
3. Assess for risk factors that contribute to the development of urinary tract infections.
Risk factors for urinary tract infection include previous UTI, catheter use, female gender, menopause, pregnancy, structural problems of the urinary tract, and poor hygiene practices. Understanding the risk factors that contribute to the development of UTI can help plan an appropriate approach to treating the underlying condition, resolving the current symptoms and infection, and preventing recurrence.
Interventions:
1. Apply a heating pad to the patient’s lower back or suprapubic area.
Heat therapy helps relieve pain and relax the muscles in patients with urinary tract infections.
2. Administer analgesics as indicated.
Medications like NSAIDs can help relieve the pain associated with UTIs. Phenazopyridine is another analgesic that alleviates the symptoms of dysuria, urgency, and frequency caused by UTIs.
3. Encourage the patient to avoid urinary tract irritants.
Coffee, spicy foods, sodas, and alcohol are urinary tract irritants and should be avoided while being treated for a UTI.
4. Encourage the patient to use a sitz bath.
A sitz bath is a warm and shallow bath that may help relieve discomfort and bladder spasms in patients with UTIs.
Deficient Fluid Volume
Deficient fluid volume may be related to the cause of a urinary tract infection or a consequence of the patient’s symptoms.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Disease process
- Inflammatory process
- Urinary frequency
- Altered fluid intake
As evidenced by:
- Altered mental status
- Poor skin turgor
- Hypotension
- Decreased urine output
- Dry mucous membranes
- Increased body temperature
- Tachycardia
- Altered lab values
- Thirst
- Increased urine concentration
Expected outcomes:
- Patient will maintain blood pressure, temperature, pulse rate, and oxygen saturation within normal limits.
- Patient will exhibit a urine output of at least 0.5 ml/kg/hr.
Assessment:
1. Assess and monitor the patient for signs of hypovolemia and deficient fluid volume.
Changes in skin and mucous membranes are affected by hydration. Patients with UTIs who experience fluid deficiency can have dry skin, dry mucous membranes, poor skin turgor, alterations in mental status, and weight loss.
2. Assess the patient’s oral fluid intake.
Patients who do not consume enough fluids are at an increased risk of experiencing UTIs. If the patient is experiencing uncomfortable symptoms of UTIs like burning with urination, frequency, or urgency, they may drink less to avoid urinating, which only exacerbates the problem and leads to decreased fluid volume.
3. Assess the patient’s urine characteristics.
Patients with UTIs may exhibit hematuria and foul-smelling urine on inspection. Urine will likely be dark in color (concentrated) if dehydrated.
Interventions:
1. Encourage increased fluid intake, especially water.
Increased fluid intake helps dilute urine and allows more urine production to flush bacteria from the urinary system. Provide and encourage fresh water around the clock if not contraindicated.
2. Monitor the patient’s intake and output.
Accurate monitoring of the patient’s intake and output can help determine fluid deficits.
3. Advise to avoid caffeine and dark-colored drinks.
Coffee, alcohol, and caffeinated drinks can irritate the bladder. These beverages and liquids with high sugar content are not the best to rehydrate the patient.
4. Assess laboratory values.
A urinalysis may show a high urine specific gravity (greater than 1.030) and osmolality, indicating dehydration. Other serum lab values, like hematocrit, BUN, and creatinine, may be elevated with deficient fluid volumes.
Disturbed Sleep Pattern
Urinary tract infections cause a variety of uncomfortable urinary symptoms like dysuria, nocturia, and increased urinary urgency, which can disrupt sleep patterns.
Nursing Diagnosis: Disturbed Sleep Pattern
Related to:
- Impaired urinary elimination pattern
- Dysuria
- Urinary frequency
- Urinary hesitancy
- Urinary urgency
- Nocturia
- Urinary incontinence
- Urinary retention
As evidenced by:
- Nocturia
- Difficulty maintaining sleep state
- Expresses tiredness
- Expresses dissatisfaction with sleep
- Unintentional awakening
- Nonrestorative sleep-wake cycle
Expected outcomes:
- Patient will verbalize improved sleeping patterns and adequate rest and sleep.
- Patient will report not waking up to urinate more than once per night.
Assessment:
1. Assess the patient’s usual sleeping patterns and changes.
Identifying baseline sleeping patterns can help identify alterations and aid in planning an appropriate treatment regimen that will help the patient achieve restful sleep. Patients with an overactive bladder or incontinence frequently wake up during the night to urinate. Compare the patient’s usual sleep patterns to alterations caused by a UTI.
2. Assess factors that contribute to the patient’s disturbed sleeping pattern.
Factors like nocturia, noise, pain, poor sleep hygiene, large amounts of fluid intake, diuretics, urinary frequency, and anxiety affect how the patient sleeps and perceives current sleeping problems.
Interventions:
1. Instruct the patient to avoid drinking large amounts of fluid before bedtime.
Restrict fluids 2-4 hours before bedtime to prevent urinary urges while sleeping in patients with UTIs.
2. Instruct the patient to avoid alcohol and caffeine before sleeping.
Caffeine and alcoholic beverages are urinary tract irritants and induce diuresis, which can increase urinary frequency when the patient is sleeping. Caffeine is a stimulant that reduces the patient’s ability to fall asleep, while alcoholic beverages can interfere with REM sleep.
3. Encourage sleep hygiene practices.
Begin preparing for sleep several hours before bedtime by dimming lights, reducing noise, minimizing screen time, and setting the sleep environment to a comfortable temperature.
4. Schedule medication administration so it will not interrupt the patient’s sleep.
Diuretics should be taken at least six hours before bedtime, if possible. Proper timing and scheduling of certain medications can help promote uninterrupted sleep patterns.
Hyperthermia
Urinary tract infections may cause an elevated temperature, resulting in chills and shivering.
Nursing Diagnosis: Hyperthermia
Related to:
- Disease process
- Inflammatory process
- Infectious process
- Dehydration
As evidenced by:
- Flushed skin
- Lethargy
- Skin warm to touch
- Tachycardia
- Tachypnea
- Chills
- Temperature over 38.0 C (100.4 F)
Expected outcomes:
- Patient will maintain body temperature within normal limits.
- Patient will be free from any complications of increased body temperature, like dehydration, chills, and seizures.
Assessment:
1. Assess and monitor the patient’s temperature.
Assessing and monitoring the temperature in patients with UTIs is necessary to determine a worsening in condition and to evaluate the effectiveness of the treatment regimen.
2. Assess the patient’s laboratory values.
Various factors can contribute to the increase of the patient’s temperature. Assessing laboratory values, including complete blood count, urinalysis, and urine culture, can monitor the patient’s condition and prevent deterioration and complications like sepsis.
3. Monitor the patient’s vital signs.
Other parameters of the patient’s vitals will also be affected as the patient’s temperature increases. With hyperthermia, dehydration can occur, which can exhibit as tachycardia, hypotension, and tachypnea.
Interventions:
1. Administer antibiotic therapy as indicated.
Antibiotic therapy is necessary to treat the infection and resolve the associated hyperthermia. It is important to instruct the patient on proper adherence to medication timing and duration to prevent the recurrence of infection.
2. Administer antipyretics as indicated.
Acetaminophen and other antipyretic medications can quickly reduce the patient’s increased body temperature.
3. Encourage the patient to increase fluid intake.
Increasing fluid intake can help prevent dehydration caused by hyperthermia.
4. Provide nonpharmacologic cooling measures.
A tepid sponge bath can help reduce hyperthermia as this allows moist air circulation to help release heat from the body through convection. Offer cool rags to the forehead and axilla area. Decrease the room temperature or use a circulating fan.
Impaired Urinary Elimination
Urinary tract infections cause impaired urinary elimination patterns like urinary retention, frequency, urgency, and nocturia.
Nursing Diagnosis: Impaired Urinary Elimination
Related to:
- Disease process
- Inflammatory process
- Infectious process
- Dehydration
- Anatomical dysfunction
- Urinary catheter
As evidenced by:
- Dysuria
- Urinary frequency
- Urinary hesitancy
- Urinary urgency
- Nocturia
- Urinary incontinence
- Urinary retention
Expected outcomes:
- Patient will report the ability to void without pain, hesitancy, and urgency.
- Patient will exhibit normal urine output volume and characteristics.
- Patient will not void more frequently than every 2 hours.
Assessment:
1. Assess the patient’s urinary elimination patterns.
Assessing the patient’s urinary elimination patterns can help determine the signs and symptoms of UTI associated with altered urinary elimination. UTI commonly causes the patient to avoid voiding due to pain or burning or void frequently from a sense of urgency. Compare the patient’s current symptoms to their baseline level of functioning.
2. Assess and review the patient’s medical history affecting the patient’s urinary elimination patterns.
Urinary tract injury, overactive bladder, strictures, benign prostatic hyperplasia (BPH), prolapse, and neurogenic bladder can also cause impaired urinary elimination patterns like dysuria, retention, frequency, and incontinence.
3. Assess and monitor the patient’s urine output.
Urine output is closely affected by the patient’s urinary elimination patterns. Patients with UTIs often experience dysuria and decreased urine output due to infection, inflammation, pain with voiding, and possibly urinary tract blockage.
Interventions:
1. Instruct not to ignore the urge to void.
Some patients may ignore the urge to void due to dysuria or frequency. This can worsen the infection from the stasis of urine.
2. Instruct the patient to void every 2 to 3 hours.
Proactive voiding and bladder training will help prevent the accumulation of urine and bacteria in the bladder. This can also reduce urinary incontinence and retention in patients with UTIs.
3. Monitor the use of catheters.
Some patients with a neurogenic bladder may require intermittent catheterization to void adequately. Instruct on proper techniques to prevent introducing bacteria into the bladder.
4. Encourage intake of cranberry products or probiotics.
Cranberry extract may be useful in some patients to prevent UTI recurrence, as it can produce an acidic environment that will make it difficult for bacteria to grow. Probiotics may be prescribed for urogenital health.
References
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