1. URINARY TRACT INFECTION UTI

2. كل شيء يولد مع الفجر الأقدار ، الأمل ، النجاح ، الطموح. قصة الأمس انتهت ، و قصة اليوم بدأت ، " اللهم إنا نسألك صباحاً يملأ الأجساد عافية، والروح فرحاً ، اللهم أرحنا من هموم الدنيا ، وارزقنا التوفيق في جميع أمورنا " الَلَهّمً اغُفُر لَنِآ ، وٌارحًمًنِآ ، وٌاغُفُر لَوٌالَدٍيَنِآ وٌلَلَمًسِلَمًيَنِ الَأحًيَاء مًنِهّمً وٌالَأمًوٌاتٌ. صباح الأمل والتفاؤل

4. Key Points  Urine is sterile  Presence of inflammatory cells or pathogens in urine indicate a urinary tract infection (UTI)  Urinary tract infection is the most common bacterial infection managed in general medical practice  Accounts for 1 ‐ 3% of consultations  Up to 50% of women will have a UTI at some point in their life  UTI uncommon in men except over the age of 60 when urinary tract obstruction due to prostatic hypertrophy may occur

5. Key Points  Urinary tract infection (UTI) refers to any portion of the lower urinary tract. This includes:  Cystitis.  Urethritis.  Prostatitis.  UUTI refers to conditions such as pyelonephritis.  UTIs are caused by Enterobacteriaceae MO (such as Klebsiella and Proteus), Pseudomonas, Serratia, and, most commonly, Escherichia coli.  Majority of infections are caused by bacteria, though some are fungal  Untreated UTIs may lead to urosepsis, which can lead to septic shock and death.

8. Risk factors/causes of UTI  Female gender  Anatomy  Decreased estrogen in aging women promotes atrophy of the urethral opening toward the rectum.  Sexual intercourse  Hygiene habits  Pregnancy  Women who are fitted poorly with diaphragms  Hormonal influences within the vaginal flora  Synthetic underwear and pantyhose

9. Risk factors/causes of UTI  Indwelling urinary catheters (significant source of infection in clients who are hospitalized)  Stool incontinence  Bladder distention  Incomplete urinary emtying  Urinary conditions (anomalies, stasis, calculi, and residual urine)  Possible genetic links  Immunosuppression  Disease (for example, diabetes mellitus)

10. Diagnostic Procedures and Nursing Interventions  Urinalysis and urine culture and sensitivity (clean voided midstream Sample)  Expected findings include: Bacteria, sediment, WBC, and RBCs. Positive leukocyte esterase (85 to 90% specific). Positive nitrate (95% specific).  WBC count and differential if urosepsis is suspected WBCs ≥10,000/mm3 with shift to the left (indicating an increased number of immature cells in response to infection).  Voiding cystoureterography or excretory urography is used for complicated UTIs.

11. Investigations to detect underlying factors  Dipstick examination of urine for blood, protein and glucose  Blood culture if fever, rigors or evidence of septic shock  Pelvic examination for women with recurrent UTI to rule out sexually transmitted diseases.  Cystoscopy if patients have suspected bladder lesion

13. Assessments  Clinical findings depend on the area of the urinary tract affected by the infecting organism. Expected client findings include:  Urinary frequency with voiding of small amounts: nocturia.  Dysuria, bladder cramping, or spasms.  Perineal itching.  Warm sensation during urination.  Urethral discharge.  Cloudy or foul-smelling urine.  Hematuria (tea- or cola-colored urine).  Lower back or lower abdominal discomfort and tenderness over the bladder  Fever.  Pyuria.  Nausea and vomiting.  Mental status changes in older adult clients.

14. Assess/Monitor  Urinary output for color, volume, and odor  Pain status  Temperature for fever  Systemic symptoms suggestive of pyelonephritis:  Fever above 38.3°C  Loin / flank pain  may be indication for hospitalization

15. NANDA Nursing Diagnoses  Acute pain  Impaired urinary elimination  Anxiety  Deficient knowledge

16. Nursing Interventions  Female clients should be instructed to:  Wipe the perineal area from front to back.  Urinate before and after intercourse.  Avoid the use of feminine products containing perfumes, bubble baths, and toilet paper containing perfumes.  Avoid sitting in wet bathing suits.  Avoid wearing pantyhose with slacks or tight clothing.  Encourage the client to increase fluid intake if not contraindicated.  Instruct the client regarding the proper collection of clean catch urine if specimens are required.  Collect the catheterized urine specimen using a sterile technique.  Provide perineal care to the client prior to the insertion of the urinary catheter.

17.  Teach the client the need to take all of the prescribed antibiotics even if symptoms abate.  Fluoroquinolones (Ciprofloxacin), nitrofurantoin (Macrobid), orsulfonamides (Bactrim or Septra).  Advise the client that certain urinary analgesics such as Pyridium will turn the urine orange.

18. Complications and Nursing Implications  Urethral obstruction, pyelonephritis, chronic renal failure, urosepsis, septic shock, and death.  Monitor/assess.  Report abnormal data promptly.  Maintain medication schedules to assure adequate medication blood levels to eradicate infection.

19. Measures to prevent UTIs  Keep clients hydrated (Fluid intake of at least 2litres per day)  Encourage regular complete emptying of the bladder  Good personal hygiene  For women, avoid feminine hygiene sprays  Encourage front to back cleansing  Showers preferable to baths  Cranberry juice maybe effective  Frequently change those who use incontinence pads  Set reminders/timers for those who are memory ‐ impaired to use the bathroom

21. Case Study  Ann is an 80 year old widow admitted to an elderly mentally ill (EMI) acute unit diagnosed with depression  She has been stable for a few weeks and is being considered for discharge  She wakes up this morning irritable and agitated and refuses her breakfast  As nurses try to calm her, she becomes aggressive, shouting that she wants to go home as her husband is waiting for her for his tea.  She barges into the ward doctor’s office, sits down and says she’s not leaving until the doctor says she can go home  A nurse comes in and talks calmly to her and persuades her to leave the office. As Ann gets up, she faints and has to be steadied, while the doctor notices that she wet herself while sitting down  She has never wet herself before and doesn’t normally need help with toileting  Ann is now sobbing uncontrollably

22. Questions from case study Please read these questions and try to answer them. 1. What action should be taken by the ward doctor?  2. What are the presenting features, signs and symptoms of UTI in older adults?  3. How do these differ from younger adults  4. What organisms usually cause UTI?  5. What are the management recommendations for UTI in older adults?  6. What general steps can be taken to reduce incidence of UTIs in hospital wards?

23. Answers to the case study questions  1. Urine dipstick of MSU sample  2. Agitation, confusion, urinary incontinence, can lead to delirium  3. Younger adults present with urinary urgency, dysuria, frequency of urination, abdominal pain  4. Most common organism is Escherichia Coli, though Klebsiella and some streptococci are also seen in hospital  5. Antibiotic therapy  6. Keeping patients hydrated, helping patients maintain good personal hygiene and encouraging bladder, general cleanliness on wards etc

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