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 50-75% 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
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 emptying
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 STD.
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.
N & V
Mental status changes in older adult clients.

14. Assess/Monitor Urinary output for color, volume, and odor Pain status
VS 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 clothes.
Avoid wearing pantyhose with slacks (jeans) 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. Nursing Interventions
Teach the client the need to take all of the prescribed antibiotics even if symptoms abate.
Fluoroquinolones (Ciprofloxacin), nitrofurantoin (Macrobid), or sulfonamides (Bactrim or Septra).
Advise the client that certain urinary analgesics such as Pyridium (sedural) 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

24. Pyelonephritis

25. Key points
An infection and inflammation of the renal pelvis, calyces, and medulla, usually begins in the LUT with organisms ascending into the renal pelvis.
Escherichia coli organisms are the cause of most acute cases of pyelonephritis.
Repeated infections create scarring that causes ischemia to the kidney, glomerulus, and tubular structure.
Filtration, reabsorption, and secretion are impaired, and there is a decrease in renal function.
Acute pyelonephritis is an active bacterial infection that can cause:
Interstitial inflammation.
Tubular cell necrosis.
Abscess formation in the capsule, cortex, or medulla.
Temporarily altered renal function, but this rarely progresses to renal failure.

26. Key points
Chronic pyelonephritis is the result of repeated infections that cause progressive inflammation and scarring.
Result in thickening of the calyces and postinflammatory fibrosis with permanent renal tissue scarring.
It is more common with obstructions, urinary anomaly, and vesicoureteral urine reflux.

27. Risk Factors Women over 65 years of age
Older men with prostate problems
Chronic urinary stone disorders
Spinal cord injury
Pregnancy
Congenital malformations
Bladder tumors
Chronic illness (DM, HTN, chronic cystitis)

28. Diagnostic Procedures and Nursing Interventions
Urinalysis and urine culture and sensitivity
Dark color, cloudy appearance, foul odor.
Bacturia, sediment, WBCs & RBCs.
Positive leukocyte esterase (85 to 90% specific).
Positive nitrate (95% specific).
WBC count and differential: White blood cell count at or above 10,000/mm3
Blood cultures will be positive for the presence of bacteria if a systemic infection is present.

29. Diagnostic Procedures and Nursing Interventions
Serum creatinine & BUN are elevated during acute episodes and consistently elevated with chronic infection.
C-reactive protein is elevated during exacerbating inflammatory processes.
ESR is elevated during acute or chronic inflammation.
X-ray (KUB) may demonstrate calculi or structural abnormalities.
Intravenous pyelogram (IVP) may demonstrate calculi, structural, or vascular abnormalities.
Assess renal function and allergy to contrast dye prior to the procedure.
Bowel preparation may be prescribed prior to the procedure for image clarity.
Hydration prior to the procedure and diuretic administration following the
procedure may be prescribed to reduce the risk of nephrotoxicity.
Gallium scan (nuclear) may indicate active pyelonephritis or abscesses

30. Therapeutic Procedures and Nursing Interventions
Surgical procedures may be needed to terminate the infectious process.
Pyelolithotomy – removal of a stone from the kidney
Nephrectomy – removal of the kidney
Ureteral diversion or re-implantation of the ureter to restore bladder drainage
Ureteroplasty – repair or revision of the ureter

31. Clinical picture Fever, tachycardia, tachypnea, hypertension Chills
Costovertebral tenderness
Flank and back pain
Colicky-type abdominal pain
N & V
Malaise, fatigue
Burning, urgency, and frequency with urination

32. S &Sx
Nocturia
Inability to concentrate urine or conserve sodium (chronic pyelonephritis)
Asymptomatic bacteremia
Assess:
I&O, F&E imbalance, pain, nutrition

33. Nsg Dx Acute pain Deficient knowledge Activity intolerance Anxiety
Impaired urinary elimination

34. Nsg Implementation Manage pain.
Narcotic analgesics
NSAIDs
AB (IV) after a specimen for urine C&S has been obtained.
Maintain AB schedules
Teach self-administration of prescribed medications.
Increase fluid intake to 2 to 3 L/day unless contraindicated.
Monitor temperature and administer antipyretic as needed.
Provide emotional support.
Assist with personal hygiene.

35. Complications and Nursing Implications
Septic Shock
Identify signs, such as hypotension, tachycardia, and fever.
Initiate life-support interventions as needed.
Renal Failure
Monitor intake and output.
Monitor renal function studies for elevations in BUN and creatinine.
Encourage increased fluid intake.
Hypertension
Monitor blood pressure for trends.
Report changes from baseline.

36. Thank you