Urinary Tract Infection NCLEX Review

This NCLEX review will discuss urinary tract infection (UTI).

As a nursing student, you must be familiar with urinary tract infections and how to care for patients who are experiencing a UTI.

These type of questions may be found on NCLEX and definitely on nursing lecture exams.

Don’t forget to take the urinary tract infection quiz.

You will learn the following from this NCLEX review:

• Definition of urinary tract infection
• Causes of UTI
• Defense systems of the urinary tract
• How it is diagnosed
• Treatment
• Nursing Interventions

NCLEX Lecture on Urinary Tract Infection

Urinary Tract Infection (UTI) NCLEX Review

What is a urinary tract infection (UTI)? It is an infection found within the urinary tract which can be caused by a bacteria (most common), virus, or fungus.

Urinary tract infections can be found anywhere throughout the urinary system such as:

Lower Urinary System:

• Urethra (Urethritis)
• Bladder (Cystitis)

Upper Urinary System:

• Ureters (Ureteritis)…usually associated with bladder or kidney infection
• Kidneys (Pyelonephritis)

*UTIs typically start in the urethra and spread upward to the bladder and can be found in both the lower or upper tract. If the infection is not treated promptly and correctly, it can spread to the ureters and kidneys. Pyelonephritis is extremely dangerous because the infection can enter the bloodstream and lead to sepsis….remember that we learned in the kidney and nephron anatomy video that the kidneys are very vascular and work closely with the heart.

When an infection exists in the urinary tract it leads to inflammation of the structure involved which leads to pain, spasms, dark/cloudy urine, etc.

Who is most at risk for urinary tract infections….women or men? Women!

Why? The female anatomy! The female urethra is shorter than the males which allows for easier migration of an infectious agent to the bladder AND the close proximity of the urethra and the rectum increases the chances of the bacteria in the GI tract infecting the urinary system (wiping incorrectly…back to front or wearing tight underwear or pants etc.).

Defense systems in place to help prevent Urinary Tract Infections

*If one of these defense systems becomes compromised, there is an increased risk of a UTI developing.

• Physiology of how urine flows downward: This keeps urine flowing out of the system and prevents the retention or back flow of urine into the kidneys (hence bacteria can be easily flushed out). What structures help with this?
  • Ureterovesical Valves: these are one- way valves that connect at the ureters and bladder to prevent the backflow of urine into the ureters from the bladder…in certain conditions like VUR (vesicoureteral reflux) these valves are defected.
  • Muscles of the Bladder: these muscles help squeeze the urine out of the bladder and prevent residual urine…sometimes these muscles become weak (diabetes, immobile patients who experience overextended bladder).
  • Pressure created by the urine in the bladder: this keeps the urine traveling downward.
• Urine itself: it is normally sterile and possesses antiseptic qualities that can prevent bacteria from sticking to the lining of the bladder. In addition, the acidic conditions of the pH and amount of urea concentration can play a role in preventing a UTI….however, in some conditions, like uncontrolled diabetes mellitus where there are high amounts of glucose in the urine, the urine can act as a medium for bacteria growth.
• Lining of the urinary system has immune cells that work to fight off infection…a suppressed immune system decreases the cells effectiveness.
• Prostate gland (males): it secretes a fluid that has antimicrobial properties to keep bacteria out…in men with enlarged prostates the amount of fluid secreted is decreased.
• Normal flora in women: present in and around the vagina are bacteria (lactobacilli) that keeps the area around the urethra acidic which prevents bacteria from migrating, especially E.coli from the rectum….however, if a woman experiences a hormonal change (pregnancy, menopause, birth control usage) the flora can be destroyed.

Causes of Urinary Tract Infection

“Hard to Void”

*The most common type of bacteria that causes a UTI is E. coli, which is usually from the GI system (rectum).

Hormone changes: pregnancy, menopause, birth control (changes the normal flora in the vagina that normally fights bad bacteria that can migrate into the urethra).

Antibiotics: changes the normal flora of the body

Renal Stones: cause blockage..urine stays in kidney and can’t drain

Diabetes: compromised circulation…immune system not able to work as strong as it should to fight the infection, high glucose in the urine: breeding ground for bacteria to flourish, bladder doesn’t empty as it should (urinary retention from nerve damage)

Toiletries: excessive bubble baths, powders, perfumes, especially scented tampons and sanitary napkins

Obstructive prostatic hypertrophy…seen in males with BPH: The urethra which is surrounded by the prostate gland becomes squeezed shut from the large prostate gland….urine stays in the bladder because the patient can NOT empty it completely, and the prostate gland isn’t able to properly secrete that fluid with antimicrobial properties.

Vesicoureteral reflux (VUR): most common in pediatric patients and is when urine from the bladder backflows into the kidneys. It is usually a congenital defect to the ureterovesical valves that are found between the bladder and ureters. They don’t close properly and there is a backflow of urine into the ureters.

Overextended bladder: bladder is full for long periods of time and the bladder muscles become weak which leads to urinary retention. Patients who are immobile are at risk for this.

Indwelling catheters, invasive procedures, intercourse (especially with the usage of spermicides), incontinence of the bowel

Decreased immune system…can’t fight germs (immunosuppressed) and majorly at risk for UTIs that are fungal and viral in origin.

How is a UTI Diagnosed?

Urinalysis (U/A): assesses for bacteria or WBCs in urine

• Nurse’s role: properly collecting urine sample and educating the patient how to do this….WHY? to prevent contamination to the specimen
  • It is best to collect the urine when the bladder has been full for about 2-3 hours. It will be more concentrated….don’t want diluted urine.
    • First wipe with an antiseptic wipe
    • Void small amount into the toilet
    • Then collect the urine (midstream) and fill cup halfway
    • Keep the cup a few inches away from the urethra

• How to collect out of a Foley catheter? Use access port (found at the top of the tubing…never collect from the Foley collection bag)…..clean access port with antiseptic and use needless sterile syringe to withdraw urine.

Urine culture: to assess what bacteria is causing the UTI…so antibiotics can be ordered correctly

Cystoscopy: assesses the inside of the urethra and bladder (ordered for recurrent infections)

Signs and Symptoms of Urinary Tract Infection

• Pain when voiding (burning)
• Persistent need to void but not a lot is voided or can’t void
• Strong odor to urine that is dark and cloudy (can have blood)
• Cramping in abdomen or pain at the costovertebral angle
  • Costovertebral angle is found under the 12th rib and between the spine (please watch video above for a demonstration). Lay non-dominate hand flat over the angle and make a fist with the dominate hand and firmly thump the fist onto the flat hand….if pain is experienced a kidney infection may be present (pyelonephritis).

• Spasms of the bladder or urethra
• Fever
• Increased WBC on U/A

NOTE: In the geriatric population, confusion, sudden increase in falling, and agitation are typically seen rather than the typical signs and symptoms above…they are less likely to have a fever or pain.

Nursing Interventions for Urinary Tract Infection

Assess for signs and symptoms of UTI (catch it before it becomes complicated….many patients in the hospital setting are at risk for a UTI)

Maintain fluid status (intake and output) and monitor that urinary output is at least 30 cc/hr

Control pain with nonpharmacological and pharmacology methods:

• Warm sitz bath or heating pad
• Tylenol, NSAIDs, or Pyridium per MD order
  • Pyridium “Phenazopyridine”: analgesic that will coat bladder wall and urethra to decrease spasms and help with urinary frequency/burning. However, that patient will void ORANGE-COLORED urine…this is a normal side effect…educate patient about this.

Monitor for complications (sepsis, renal failure)

Administer antibiotic medications per MD order… Sulfonamide “Bactrim” (educate patient about consuming 2.5 to 3 L of fluid/day to keep urine diluted due to crystalluria )…give antibiotic at same time every day to keep blood level constant because a decrease in blood levels can decrease the effectiveness of the medication.

• If antibiotics are ordered for treatment along with urine culture…COLLECT URINE CULTURE BEFORE starting the first dose of antibiotics

Encourage the patient to take in 2.5 to 3L of fluid per day. WHY?  This keeps the urine diluted and helps the system flush out the infection. In addition, if the urine becomes concentrated this increases the risk of crystalluria in patients taking sulfonamides like Bactrim.

Encourage frequent voiding at least every 2-3 hours.

Remove indwelling catheter if present per MD order (remember a major cause of UTI)

Patient Education for UTI:

• Take all the antibiotics
• Wipe front to back
• Urinate immediately after intercourse
• Avoid tight pants or underwear (wear cotton underwear that is loose fitting)
• Avoid bubble bath, powders, and perfumes in the genital area
• Change sanitary pads often and avoid tampons
• Avoid caffeine and alcohol…irritate bladder
• Every 2-3 hours void

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