Nursing Care and Pathophysiology of Urinary Tract Infection (UTI)
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Outline
Overview
- Infection anywhere within the urinary tract leading to inflammation
- Kidneys → Ureters → Bladder → Urethra
Pathophysiology: Infection occurring along the normally sterile track. This is usually caused by E.coli. The host has defense mechanisms to rid the bacteria but if unable to the bacteria will quickly overwhelm the host and reproduce rapidly. This patient will require antibiotics.
Nursing Points
General
- Urinary tract is sterile above the urethra
- Pathogens gain entrance via perineal area or via bloodstream
- Indwelling catheters – Catheter-Associated UTI (CAUTI) is a sentinel event per Medicare
- Females are more susceptible due to shorter urethra
- Older males more prone due to urinary stasis caused by enlarged prostate
Assessment
- Urine
- Cloudy, strong odor (pyuria)
- Burning with urination
- Urinary frequency and urgency
- Confusion (altered mental status) and lethargy, especially in older adults
- ↑ Temp, ↑ WBCs
- Urine cultures reveal bacteria
- Indwelling catheters – assess and clean around meatus and monitor output closely – CAUTI (Catheter-Associated UTI – sentinel event)
Therapeutic Management
- Urine and Blood cultures BEFORE antimicrobials
- Antimicrobials
- Start with broad spectrum until culture results are back
- Antispasmodics
- Oxybutynin
- Analgesics
- Pyridium specifically provides relief of pain and burning on urination
Nursing Concepts
- Fluid & Electrolytes
- Increase fluid intake > 3,000 mL/day
- Risk for intrarenal AKI
- Monitor UOP
- Monitor I&O
- Elimination
- Minimize the use of indwelling catheters
- Provide bladder training and potty plan
- Infection Control
- Provide adequate perineal care
- Hand hygiene
- Cultures before antibiotics
Patient Education
- Avoid caffeine, carbonation, alcohol
- Take the full course of antibiotics
- ↑ Fluid intake
- Avoid powders, sprays, and baths
- Proper perineal care/hygiene + handwashing
- Have a plan for frequent urination – bladder training
- Drink cranberry juice
- Signs of infection to report to provider
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Transcript
This lesson is going to cover Urinary Tract Infections or UTI’s. Chances are you have had one or know someone who has, but this is a big deal, especially when caring for patients in the hospital. So let’s dive in.
So, a urinary tract infection is an infection that can occur anywhere in the urinary tract from the kidneys through the ureters to the bladder and urethra. Keep in mind that the urinary tract as a whole is meant to be sterile above the urethra, so any time pathogens are introduced, it can cause a lot of problems. They could be introduced from the outside around the perineal area or through the bloodstream as those pathogens get filtered through the kidneys. Now, females are a higher risk for UTI’s because the urethra is shorter – so the bladder is physically closer to the outside than in a male whose urethra is much longer. However, as males age and their prostates enlarge, they experience urinary stasis, which can cause an increased risk of UTI’s. Now, one other major risk factor, which is especially important in our hospitalized patients, is the presence of any indwelling catheter. In fact, we call them CAUTI’s or Catheter Associated UTI’s. If your patient develops a UTI because of a foley catheter you put in them, that’s considered a sentinel event and the hospital will not be reimbursed by insurance for that patient’s care. It’s a very big deal, so we need to make sure we’re doing REALLY good foley care and getting those foleys out as soon as possible.
So when we are assessing a patient who may have a UTI, here’s what we might see. First and foremost, if you have a urine sample you’re gonna see it’s cloudy and maybe even dark and it will have a foul, sour odor. If the patient has a catheter, you’ll smell it when you’re emptying the bag. It really is nasty, like what you see here. Patients may also complain of burning with urination and urinary frequency or urgency. Another common sign we see, especially in older adults is confusion and altered mental status. In fact, in an elderly patient, if they present with confusion or altered mental status, there is a HUGE probability that they have some sort of infection somewhere! I used to laugh this off in nursing school like it was just another one of those supposedly common things but that I’d probably never see it. But y’all – these old folks just keep getting confused when they get infected!! Then, of course, we may see other signs of infection like increased HR, increased temp, etc., And we’ll see bacterial growth on urine cultures.
As far as management, the VERY first thing we want to do is obtain blood cultures and a urine specimen for culture. This needs to be obtained as sterile as possible, either through a legitimate clean catch after cleansing the perineum or through a straight cath. It should never be collected out of a urinal or bedpan – those are not sterile. Honestly, a true clean catch is hard for a normal person, getting this on a confused old lady is near impossible, so just plan to straight cath her for the culture. Then once we have our cultures we can start our antibiotics. We’ll usually start them on broad spectrum antibiotics until the cultures come back to tell us exactly what’s growing. We want to increase their fluid intake to upwards of 3L/day, unless it’s contraindicated. This will help flush the bacteria out of the kidneys and prevent any complications like kidney stones or acute kidney injury. And then we’ll address their pain with analgesics and antispasmodics like pyridium or oxybutynin. Those will help relieve the pain with urination and relax some of the bladder muscles.
Now, patient education is a MUST when it comes to UTI’s because they are largely preventable. We need to make sure they take their full course of antibiotics – this will make sure that ALL of the bacteria has been killed and isn’t just lying dormant, and it will help prevent drug resistance. Patients should increase their fluid intake like we talked about before, primarily with water and even cranberry juice. But they should avoid caffeine, carbonation, and alcohol. All of those things can affect our kidneys ability to process our urine well. We want them to avoid powders and sprays in the perineal area and to avoid baths. That standing water can harbor bacteria like crazy. And, of course they need to make sure they are doing proper perineal hygiene. Women should wipe front to back, men who aren’t circumcised should retract the foreskin and really make sure they’re keeping themselves clean. We also educate them about frequent urination. This is two fold – one is that they should expect it and have a plan for it when they DO have a UTI, the other is that holding your pee for too long can actually make you more prone to UTI’s. Us poor nurses will go 14 hours without going to the bathroom – it’s really not good for you.
Okay, so as you could probably guess, priority nursing concepts for a patient with a Urinary Tract Infection are infection control, fluid & electrolytes, and elimination. Make sure you check out the care plan attached to this lesson for more detailed nursing interventions and rationales.
So let’s recap. A UTI is an infection that occurs anywhere in the urinary tract. It can progress to sepsis if left untreated – in fact we call that urosepsis. So we need to identify this and treat it quickly. Patients will present with burning on urination and cloudy, smelly urine, plus elderly patients may present with confusion. We make sure we get our sterile urine cultures before we begin antibiotic therapy, and we always address their pain. We emphasize good patient education to make sure this infection is fully treated and that we decrease the risk of it happening again.
So that’s it for Urinary Tract Infections. Make sure you check out all the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!
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