NURSING PROCESS: THE PATIENT WITH LOWER URINARY TRACT INFECTION
Nursing care of the patient with lower UTI focuses on treating the underlying infection and preventing its recurrence.
A history of signs and symptoms related to UTI is obtained from the patient with a suspected UTI. The presence of pain, fre-quency, urgency, and hesitancy and changes in urine are assessed, documented, and reported. The patient’s usual pattern of void-ing is assessed to detect factors that may predispose him or her to UTI. Infrequent emptying of the bladder, the association of symptoms of UTI with sexual intercourse, contraceptive prac-tices, and personal hygiene are assessed. The patient’s knowledge about prescribed antimicrobial medications and preventive health care measures is also assessed. Additionally, the urine is assessed for volume, color, concentration, cloudiness, and odor, all of which are altered by bacteria in the urinary tract.
Based on the assessment data, the nursing diagnoses may include the following:
· Acute pain related to inflammation and infection of the ure-thra, bladder, and other urinary tract structures
· Deficient knowledge related to factors predisposing the pa-tient to infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy
Based on assessment data, the following complications may develop:
· Renal failure due to extensive damage of kidney
Major goals for the patient may include relief of pain and dis-comfort; increased knowledge of preventive measures and treat-ment modalities; and absence of complications.
The pain associated with UTI is quickly relieved once effective antimicrobial therapy is initiated. Antispasmodic agents may also be useful in relieving bladder irritability and pain. Aspirin and ap-plying heat to the perineum help relieve pain and spasm. The pa-tient is encouraged to drink liberal amounts of fluids (water is the best choice) to promote renal blood flow and to flush the bacte-ria from the urinary tract. Urinary tract irritants (eg, coffee, tea, citrus, spices, colas, alcohol) are avoided. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely be-cause this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection.
Early recognition of UTI and prompt treatment are essential to prevent recurrent infection and the possibility of complications, such as renal failure and sepsis. The goal of treatment is to pre-vent infection from progressing and causing permanent renal damage and renal failure. Thus, the patient must be taught to recognize early signs and symptoms, to test for bacteriuria, and to initiate treatment as prescribed. Appropriate antimicrobial ther-apy, liberal fluid intake, frequent voiding, and hygienic measures are commonly prescribed for managing UTI. The patient is in-structed to notify the physician if fatigue, nausea, vomiting, or pruritus occurs. Periodic monitoring of renal function (creatinine clearance, blood urea nitrogen [BUN], and serum creatinine levels) may be indicated for patients with repeated UTIs. If ex-tensive renal damage does occur, dialysis may be necessary.
Patients with UTI, especially catheter-associated infection, are at increased risk for Gram-negative sepsis. Indwelling catheters should be avoided if possible and removed at the earliest oppor-tunity (Thees & Dreblow, 1999). If an indwelling catheter is nec-essary, however, specific nursing interventions are initiated to prevent infection. These include the following:
· Using strict aseptic technique during insertion of the small-est catheter possible
· Securing the catheter with tape to prevent movement
· Frequently inspecting urine color, odor, and consistency
· Performing meticulous daily perineal care with soap and water
· Maintaining a closed system
· Using the catheter’s port to obtain urine specimens
Careful assessment of vital signs and level of consciousness may warn of impending sepsis. Blood cultures that are positive for in-fection and elevated WBC counts are reported to the physician. At the same time, appropriate antibiotic therapy and increased fluid intake are prescribed (intravenous antibiotic therapy and fluids may be required). Preventing sepsis is key because the mortality rate for Gram-negative sepsis is significant, especially in elderly patients.
In helping patients learn about and prevent or manage a recurrent UTI, the nurse needs to implement teaching that meets individ-ual patient needs. For a detailed discussion of patient teaching interventions, see Chart 45-4.
Expected patient outcomes may include:
1) Experiences relief of pain
a) Reports absence of pain, urgency, dysuria, or hesitancy on voiding
b) Takes analgesic and antibiotic agents as prescribed
2) Explains UTIs and their treatment
a) Demonstrates knowledge of preventive measures and prescribed treatments
b) Drinks 8 to 10 glasses of fluids daily
c) Voids every 2 to 3 hours
d) Voids urine that is clear and odorless
3) Experiences no complications
a) Reports no symptoms of infection (fever, dysuria, fre-quency) or renal failure (nausea, vomiting, fatigue, pruritus)
b) Has normal BUN and serum creatinine levels, negative urine and blood cultures
c) Exhibits normal vital signs and temperature; no signs or symptoms of sepsis
d) Maintains adequate urine output more than 30 mL per hour