Urinary tract infections (UTIs) are common in females, accounting for over 6 million client visits to healthcare providers per year in the United States. Forty percent of women will develop a UTI at some point in their lifetime, making this one of the most common infections in women.
UTI is defined as significant bacteriuria in the setting of symptoms of cystitis or pyelonephritis. These infections account for a significant number of emergency department (ED) visits, and 20% of women develop at least one UTI. Uncomplicated urinary tract infections, also known as cystitis or lower urinary tract infections, are bacterial infections of the bladder and associated structures. Complicated urinary tract infections occur in clients with structural abnormalities or comorbidities such as diabetes, old age, pregnancy, or immunocompromised status.
Asymptomatic bacteriuria. This is defined as two consecutive urine cultures growing more than 100,000 colony-forming units (CFU)/ml of a bacterial species in a client lacking symptoms of UTI.
Risk factors for UTIs may include the following.
- Pathogenic bacteria. Escherichia coli causes 70 to 95% of both upper and lower UTIs. Various organisms are responsible for the remainder of infections, including S. saprophyticus, Proteus species, Klebsiella species, Enterococcus faecalis, other Enterobacteriaceae, and yeast.
- Catheters. The most important risk factor for bacteriuria is the presence of a catheter. Eighty percent of nosocomial UTIs are related to urethral catheterization, while 5 to 10% are related to genitourinary manipulation. Catheters inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesion and causing mucosal irritation.
- Sexual intercourse. Sexual intercourse contributes to increased risk, as does the use of a diaphragm and/or spermicide.
- Renal transplantation. UTIs are the most common type of infection following renal transplantation. Susceptibility is especially high in the first two months following transplantation.
- Calculi. Calculi related to UTIs most commonly occur in women who experience recurrent UTIs with Proteus, Pseudomonas, and Providencia species.
The urinary tract is normally sterile. Uncomplicated UTI involves the urinary bladder in a host without underlying renal, metabolic, or neurologic diseases. Cystitis represents bladder mucosal invasion, most often by enteric coliform bacteria that inhabit the periurethral vaginal introitus and ascend into the bladder via the urethra. Bacteria that cause UTIs tend to have adhesins on their surface, which allow the organism to attach to the urothelial mucosal surface. In addition, a short urethra also makes it easier for the uropathogen to invade the urinary tract.
The classic symptoms of UTI in the adult are primarily dysuria with accompanying urinary urgency and frequency. A sensation of bladder fullness or lower abdominal discomfort is often present. Even a simple lower UTI may be accompanied by flank pain and costovertebral angle tenderness.
Management of UTIs today seeks to achieve good symptom control for uncomplicated acute cystitis while reducing antibiotic use. The following are nursing diagnoses associated with urinary tract infections.
- Impaired Urinary Elimination
- Acute Pain
- Urinary Retention
Urinary Tract Infection Nursing Care Plan
Below are sample nursing care plans for the problems identified above.
Impaired Urinary Elimination
Medical textbooks frequently cite incontinence as a symptom of urinary tract infection, presumably due to inflammation and irritability of the mucosa and smooth muscle of the bladder wall. Approximately 50% of women diagnosed with UTI experience urinary incontinence and other problems with urination, such as urgency and frequency. These two common conditions are associated in multiple, large, population-based studies, suggesting that women with a history of UTI are more likely to have incontinence and vice versa.
- Impaired Urinary Elimination
- Stimulation of the bladder by calculi
- Renal or ureteral irritation
- Urgency and frequency
- The client will void in normal amounts of greater than or equal to 30 ml/hour, and usual pattern.
- The client will experience no signs of obstruction.
|Monitor intake and output and characteristics of urine.||This provides information about kidney function and the presence of complications- infection and hemorrhage. Bleeding may also indicate increased irritation.|
|Determine the client’s normal voiding pattern.||Calculi may cause urinary tract nerve excitability, which causes sensations of an urgent need to void. Frequency and urgency usually increase as calculus nears the ureterovesical junction.|
|Assess reports of bladder fullness; palpate for suprapubic distention.||Urinary retention may develop, causing bladder, ureteral, and kidney distention, potentiating the risk of infection and renal failure.|
|Observe for changes in mental status, behavior, or level of consciousness.||Accumulation of uremic wastes and electrolyte imbalance may be toxic to the central nervous system.|
|Encourage increased fluid intake.||Increased hydration dilutes urine and flushes bacteria, blood, and debris and may facilitate stone passage, especially small stones. A study of 140 women with recurrent UTIs showed that increased fluid intake reduces the risk of repeated infections.|
|Promote intake of cranberry juice or tablets.||Drinking cranberry juice (10 oz/day) or taking cranberry tablets may offer some benefit in reducing recurrent UTIs and does not appear to be harmful. Cranberries contain type A proanthocyanidins. This compound and its urinary metabolites interfere with the adhesiveness of uropathogenic bacteria to the bladder epithelium.|
|Maintain patency of indwelling catheters- ureteral, urethral, or nephrostomy- when used.||This may be required to facilitate urine flow, preventing retention and corresponding complications.|
|Instruct the client to void immediately after sexual intercourse.||Sexually active women may attempt voiding immediately after intercourse to lessen the risk of coitus-related introduction of bacteria into the bladder. Some authors recommend large urinary flow volumes as a measure that will reduce the risk of UTI.|
|Administer antibiotics as prescribed.||The first-choice agents for the treatment of uncomplicated acute cystitis in women include nitrofurantoin monohydrate/macrocrystals, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin. Empiric antibiotic selection is determined in part by local resistance patterns.|
|Monitor urine culture and sensitivities.||This determines the presence of UTI, which may be causing or complicating the symptoms. This also determines appropriate antibiotic therapy.|
|Remove or replace the catheter as indicated.||In catheterized clients, removal of the catheter is essential for the clearance of funguria. If the catheter is still needed, it may be replaced.|
In a client with UTI, the bladder prompts the brain to urinate much more frequently, even when it feels empty. This is due to the bacteria that caused the infection irritating the delicate lining of the urinary tract. This irritation causes inflammation and a painful burning when the client urinates.
- Acute Pain
- Increased frequency and force of ureteral contractions
- Tissue trauma or inflammation
- Reports of pain
- Guarding or distraction behaviors
- Restlessness, self-focusing
- Facial mask of pain, muscle tension
- Autonomic responses
- The client will report pain is relieved.
- The client will appear relaxed and be able to sleep and rest appropriately.
|Assess location, duration, intensity, and radiation.||Clients with acute cystitis may demonstrate dome suprapubic tenderness to palpation or suprapubic or low back pain. Flank pain suggests that stones are in the kidney area, upper ureter. Sudden, severe pain may precipitate apprehension, restlessness, and severe anxiety.|
|Note reports of increased or persistent abdominal pain.||Complete obstruction of the ureter can cause perforation and extravasation of urine into the perirenal space. This represents an acute surgical emergency.|
|Explain the cause of pain and the importance of notifying caregivers of changes in pain occurrence or characteristics.||This provides an opportunity for the timely administration of analgesics and alerts the caregivers to developing complications.|
|Provide comfort measures such as back rub and a restful environment.||This promotes relaxation, reduces muscle tension, and enhances the client’s coping skills.|
|Apply warm compresses to the back.||A warm compress may relieve muscle tension and reduce reflex spasms.|
|Promote the use of focused breathing, guided imagery, and diversional activities.||These interventions redirect the client’s attention and aids in muscle relaxation.|
|Encourage increased fluid intake.||Hydration to accentuate unidirectional clearance of bacteriuria is recommended, especially if an obstruction was relieved recently.|
|Administer urinary analgesics as indicated.||These agents relieve pain, discomfort, and spasms of the bladder. Phenazopyridine is an azo dye excreted in the urine, where it exerts a topical analgesic effect on the urinary tract mucosa. It is compatible with antibacterial therapy and can help relieve pain and discomfort before antibacterial therapy controls infection.|
|Maintain the patency of catheters when used.||This prevents urinary stasis or retention and reduces the risk of increased renal pressure and infection.|
A urinary tract infection can cause swelling of the urethra or weakness of the bladder, both of which can cause urinary retention. Urinary retention is a condition where the bladder does not empty completely when the client urinates.
- Urinary Retention
- Tissue trauma
- Presence of local tissue edema
- Bladder weakness
- Sensation of bladder fullness, urgency
- Small, frequent voiding
- Absence or urinary output
- Overflow incontinence
- Bladder distention
- The client will empty bladder regularly and completely.
|Note voiding pattern and monitor urinary output.||This may indicate urinary retention if voiding frequently in small insufficient amounts of less than 100 ml.|
|Palpate the bladder. Investigate reports of discomfort, fullness, and inability to void.||Perception of bladder fullness and distention of a bladder above the symphysis pubis indicates urinary retention.|
|Assess urine characteristics, noting color, clarity, and odor.||Urinary retention, vaginal discharge, and the possible presence of intermittent or indwelling catheters increase the risk of infections especially if the client has perineal sutures.|
|Observe the urinary stream, noting size and force.||This is useful in evaluating the degree of obstruction and choice of interventions.|
|Provide routine voiding measures, such as privacy, normal position, running water in the sink, and pouring warm water over the perineum.||This promotes the relaxation of perineal muscles and may facilitate voiding efforts.|
|Encourage the client to void every 2 to 4 hours and when the urge is noted.||This may minimize urinary retention and overdistention of the bladder.|
|Encourage good perineal cleansing and catheter care when present.||This promotes cleanliness, therefore reducing the risk of ascending urinary tract infection.|
|Keep drainage tubing free from kinks.||This promotes free drainage of urine, thereby reducing the risk of urinary stasis or retention and infection.|
|Instruct the client to document the time and amount of each voiding.||Urinary retention increases pressure within the ureters and kidneys, which may cause renal insufficiency. Any deficit in blood flow to the kidney impairs its ability to filter and concentrate substances.|
|Recommend sitz bath as indicated.||This promotes muscle relaxation, decreases edema, and may enhance voiding effort.|
|Catheterize when indicated per protocol if the client is unable to void or is uncomfortable.||Edema or interference with nerve supply may cause bladder atony or urinary retention requiring decompression of the bladder.|
|Check residual urine volume after voiding, as indicated.||The client may not be emptying the bladder completely. Retention of urine increases the possibility of infection and is uncomfortable, even painful.|
- Ackerman, L. (2022, November 28). Urinary Tract Infection – StatPearls. NCBI. Retrieved January 15, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK470195/
- Brusch, J. L., & Stuart, M. (2020, January 2). Urinary Tract Infection (UTI) and Cystitis (Bladder Infection) in Females: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved January 15, 2023, from https://emedicine.medscape.com/article/233101-overview#a2
- Cleveland Clinic. (2021, January 10). Urinary Retention: Causes, Diagnosis & Treatment. Cleveland Clinic. Retrieved January 15, 2023, from https://my.clevelandclinic.org/health/diseases/15427-urinary-retention
- Moore, E. E., Jackson, S. L., Boyko, E. J., Scholes, D., & Fihn, S. D. (2008, February). Urinary Incontinence and Urinary Tract Infection. Obstetrics and Gynecology. 10.1097/AOG.0b013e318160d64a