CHAPTER I

INTRODUCTION
1.1 Background
Urinary Tract Infection (UTI) is disease that is more common in
women. Up to 40% of women will develop UTI at least once during their
lives, and a significant number of these women will have recurrent urinary
tract infections (Gradwohl, 2016).
According to the WHO (2013), urinary tract infection (UTI) is the
second most common infectious disease in the body after infection of the
respiratory tract and as many as 8.3 million cases reported annually. The
infection is also more common in women than in men. Indonesia is the
fourth largest populous country after China, India and the United States.
According to estimates by the Ministry of Health of the Republic of
Indonesia, the number of patients with UTI in Indonesia is 90-100 cases per
100,000 population per year, or about 180,000 of its new case
(Depkesehatan Ri, 2014).
From that incident, it can be seen that the cases of UTI are still high.
Then the role of nurses was needed in health promotion about UTI, begin
from the definition until the nursing process.
1.2 Problem Formulation
How the nursing care plan of Urinary Tract Infection (UTI) ?
1.3 Purpose
The purpose of this paper is to explain nursing care plan for patient with
Urinary Tract Infection (UTI).

CHAPTER II
LITELATURE RIVIEW
2.1 Concept of Urinary Tract Infection
2.1.1 Definition
Urinary Tract Infection (UTI), a general term, refres to invasion
of the urinary tract by bacteria. Normally, the urinary tract is sterile
above the urethra. UTI is the second most common bacterial disease
and causes more than 100.000 people to be hospitalized each year. In
the hospital, UTIs are the most common hospital-acquired infection.
They are described by their location in the urinary tract. Lower urinary
tract infection inckude urethritis, prostatis, and cytitis. Upper urinary
tract infections include pyelonephritis and ureteritis. Infection may
result in chronic kidney disease, sepsis, or damage to the kidney
(Linda S William, 2011).
Urinary tract infections (UTIs) can be divided into upper tract
infections, which involve the kidneys ( pyelonephritis), and lower
tract infections, which involve the bladder ( cystitis), urethra
( urethritis), and prostate ( prostatitis). However, in practice, and
particularly in children, differentiating between the sites may be
difficult or impossible. Moreover, infection often spreads from one
area to the other. Although urethritis and prostatitis are infections that
involve the urinary tract, the term UTI usually refers to pyelonephritis
and cystitis (Imam, 2016).
2.1.2 Predisposing Factors for Urinary Tract Infection
UTIs are caused most often by an ascending infection, starting at
the external urinary meatus and progressing toward the bladder and
kidneys. Most UTIs are caused by the bacterium Escherichia coli,
which is commonly foundin feces. Predisposing factors for UTI
include the following (Linda S William, 2011) :
2.1.2.1Stasis of urine in the bladder can result from obstruction,
such as a clamped catheter or simply from not voiding
frequently enough. Urine over-distends the bladder, decreasing
the blood supply to the wall of the bladder. The standing urine
2

then serves as a culture medium for bacterial growth.

Incomplete emptying of the bladder prevent flushing out of the
bacteria and allows bacteria to ascend to higher structures.
2.1.2.2Contamination in the perianal and urethral areas can be
from fecal soiling, from sexual intercourse in which bacteria
are massaged into the urinary meatus, or from infection in the
area, such as vaginitis, epididymitis, or prostatitis.
2.1.2.3Instrumentation or having instruments or tubes inserted into
the urinary meatus can cause infection. The most common
cause if instrumentation infection is urinary catheterization.
Bacteria ascend around or within the catheter, causing
infection. Within 48 hours of catheter insertion, bacterial
colonization begins. Many patients develop a UTI within 2
weeks of placement of an indwelling catheter.
2.1.2.4Faulty valves that do not maintain one-way flow can cause
reflux of urine from the urethra to the bladder or the bladder to
the ureter. Reflux can be congenital or it may be acquired as a
result of previous infections.
2.1.2.5Previous UTIs are thought to provide a reservior of
persistent bacteria that cause reinfection.
2.1.2.6Women are more suspectible to UTIs than men due to the
short length of the female urethra and its proximity to the anus
and vagina. Pregnant women may have asymptomatic
bacteruria. Untreated 40% to 50% will develop pyelonephritis.
Pregnant woman may be prone to infection with group B
streptococci. Most commonly, infection occurs in the second
and third trimesters.
2.1.2.7Older adults have an increased incidenc of UTIs due to
diminished immune respone, diabetes, and neurogenic bladder.
Aging increases the risk of lower UTIs and may also mask the
symptoms. UTI is the most common cause of acute bacterial
sepsis in patients over age 65. Older men are predisposed to
infection because an enlarged prostate obstructs urine flow. In

older women, the decline in estrogen can contribute to the risk

of UTI.
2.1.3 Etiology
The bacteria that most often cause cystitis and pyelonephritis are the
following:

Enteric, usually gram-negative aerobic bacteria (most often)

Gram-positive bacteria (less often)

In normal GU tracts, strains of Escherichia coli with specific

attachment factors for transitional epithelium of the bladder and

ureters account for 75 to 95% of cases. The remaining gram-negative
urinary pathogens are usually other enterobacteria, typically
Klebsiella or Proteus mirabilis, and occasionally Pseudomonas
aeruginosa.

Among

gram-positive

bacteria,

Staphylococcus

saprophyticus is isolated in 5 to 10% of bacterial UTIs. Less common

gram-positive bacterial isolates are Enterococcus faecalis (group D
streptococci) and Streptococcus agalactiae (group B streptococci),
which may be contaminants, particularly if they were isolated from
patients with uncomplicated cystitis (Talha H Imam, 2016).
In hospitalized patients, E. coli accounts for about 50% of cases.
The

gram-negative

species

Klebsiella,

Proteus,

Enterobacter,

Pseudomonas, and Serratia account for about 40%, and the grampositive

bacterial

cocci,

E.

faecalis,

S.

saprophyticus,

and

Staphylococcus aureus account for the remainder (Talha H Imam,

2016).
2.1.4 Pathophysiology
The urinary tract, from the kidneys to the urethral meatus, is
normally sterile and resistant to bacterial colonization despite frequent
contamination of the distal urethra with colonic bacteria. The major

defense against UTI is complete emptying of the bladder during

urination. Other mechanisms that maintain the tracts sterility include
urine acidity, vesicoureteral valve, and various immunologic and
mucosal barriers (Talha H Imam, 2016).
About 95% of UTIs occur when bacteria ascend the urethra to
the bladder and, in the case of pyelonephritis, ascend the ureter to the
kidney. The remainder of UTIs are hematogenous. Systemic infection
can result from UTI, particularly in the elderly. About 6.5% of cases of
hospital-acquired bacteremia are attributable to UTI.
Uncomplicated UTI is usually considered to be cystitis or
pyelonephritis that occurs in premenopausal adult women with no
structural or functional abnormality of the urinary tract and who are
not pregnant and have no significant comorbidity that could lead to
more serious outcomes. Also, some experts consider UTIs to be
uncomplicated even if they affect postmenopausal women or patients
with well-controlled diabetes. In men, most UTIs occur in children or
elderly patients, are due to anatomic abnormalities or instrumentation,
and are considered complicated.
The rare UTIs that occur in men aged 15 to 50 yr are usually in
men who have unprotected anal intercourse or in those who have an
uncircumcised

penis,

and

they

are

generally

considered

uncomplicated. UTIs in men this age who do not have unprotected

anal intercourse or an uncircumcised penis are very rare and, although
also considered uncomplicated, warrant evaluation for urologic
abnormalities. (Talha H Imam, 2016)
2.1.5 Sign and Symptoms
UTIs are characterized by common symptoms of dysuria,
urgency, frequency, incontinence, nocturia, hematuria, back pain, and
cloudy, foul-smelling urine (Table 37.1). in the elderly, the most

common presenting symptom of UTI is generalized fatigue. The

elderly may experience atypical symptoms or present with a change in
cognitive functioning. Especially noted in patients without dementia.
A decline in mental status and fever in any patient with an indwelling
catheter meet the diagnostic criteria for a UTI (Linda S William, 2011).
Urinary Tract Infection
Sign and Symptoms

(Urethtritis, Cystitis, Pyelonephritis) Summary

Urinary urgency, frequency, dysuria
(Dysuria is burning, tingling, or
stinging of the urethra and meatus
associated with voiding.)
Flank Pain, fever, chills,
costovertebral, tenderness
Cloudy urine with casts, bacteria,
and WBCs

Complications

Urine positive for nitrites.

Pyelonephritis (is a potentially
serious kidney infection that can
spread to the blood, causing severe
illness.)
Urosepsis (is defined as sepsis
caused by infection of the urinary
tract and/or male or female genital
organs)

Priority Nursing Diagnoses

Chronic kidney disease

- Pain
- Impaired Urinary Elimination:
Frequency
- Ineffective Health Maintenance

2.1.6

Types of UTIs

2.1.6.1 Urethritis
Urethritis is an inflamation of the urethra that may result
from a chemical irritant, bacterial infection, trauma, or

exposure to a sexually transmitted disease. Post-traumatic

urethritis can occur with intermittent catheterization or
instrumentation of the urtehra. Bubble bath and bath salts are
common urethral irritants and should not be used by anyone
with a history of UTIs. Urethritis can also be caused by
spermicidal agents. Gonorrhea and chlamydiosis are sexually
transmitted disease that can cause urethritis in men. It is
common to have some degree of urethritis in association with
bladder or prostatic infections.
Symptoms of urethritis include urinary frequency,
urgency, and dysuria. The male patient may have discharge
from the penis. A urinalysis or urine culture is done to diagnose
urethritis.
The treatment of urethritis is removal of the cause if the
cause is a chemical irritant. If urethritis is caused by bacteria,
an antibiotic is prescribed based on results of a culture.
Possible organism include gram-negative rods, gram-positive
cocci, and Chlyamdia. Phenazopyridine (Pyridium), a urinary
analgesic, is often used to treat dysuria. The patient should be
forewarned that urine will turn orange while taking
phenazopyridine. If urethritis is sexually transmitted, it is
important that the sexual partner also be treated ( Linda S
William, 2011).
2.1.6.2 Cystitis
Cystitis is inflammation and infection of the bladder

wall. It can be caused by bacteria, viruses, fungi, or parasites.

Fungal infection can occur during long-term antibiotic therapy.
About 90% of UTIs are caused by Escherichia coli. In most
cases, the causative organisms first grow in the perineal area
and then ascend into the bladder. Catheters are the most
common predisposing factor for UTIs in the hospital setting.
Symptoms include dysuria, frequency, urgency, and
cloudy urine. Cystitis acquired outside the hopital is diagnosed
with a routine urinalysis collected as a midstream, clean-catch

specimen. Changes seen in the urinalysis include cloudy urine

and the presence of WBCs, bacteria, and some times red blood
cells (RBCs) in the specimen. Nitrites are usually positive.
Some laboratories also examine for leukocyte esterase, which
is positive if infection is present in the urine. In complicated
UTIs, such as one acquired in the hospital or a repeat infection,
a urine culture and sensitivityshould be done. Hospitalacquired UTIs are often caused by bacteria that are resistent to
the usual antibiotics used for UTIs. A sensitivity test can
identify which antibiotics will be effective againts the
offending organism.
Treatment of uncomplicated cystitis is most often a
combination of sulfa medication, such as sulfamethoxazole and
trimethropim (Bactrim, Septra). Complicated cystitis is often
treated with ciprofloxacin (Cipro). Other antibiotics may be
prescribed depending on the results of the urine culture and
sensitivity. Estrogen used as an intravaginal cream may
prevent recurrent UTIs in postmenopausal women. The patient
is told to finish all prescribed medication, force fluids unless
contraindicated, and retun for a follow-up urinalysis or culture
after the antibiotic course is complete to ensure that the
infection is gone (Linda S William, 2011).
2.1.6.3 Pyelonephritis
Pyelonephritis is infection of the renal pelvis, tubules,
and interstitial tissue of one or both kidneys. Pyelonephritis
usually begins with colonization and infection of the lower
urinary tract by means of the ascending urethral route. A
preexisting condition is usually present, such as obstruction,
strictures, stones, or vesicoureteral reflux. Risk factors include
urological surgery, lymphatic infection, urinary stasis, and
decreased immunity. Acute pyelonephritis begins in the renal
medula and spreads to the adjacent cortex.

Pathophysiology includes formation of small abscesses

throughout the kidney and gross elargement of the kidney. On
occasion, kidney infection is caused by bacteria spreading
from a distant site through the bloodstream and entering the
kidney through the glomerulus. Urosepsis is a systemic
infection arising from a source within the urinary system.
Prompt diagnosis and treatment are essential to prevent septic
shock and death. Urosepsis can occur in the elderly or persons
susceptible to infection.
Symptoms include fatigue, urgency, frequency, dysuria,
flank pain, fever and chills. Costovertebral tenderness on the
right or left side (tenderness posteriorly at angle where rib and
vertebrae join when struck gently with heel of examiners
closed first), which is associated with renal disease, is noted.
The urine is cloudly with increased WBCs, bacteria, casts,
RBCs, and positive nitrites. In contrast to cystitis, the patient
with pyelonephritis (Linda S William, 2011).
2.1.7 Medications
Medication Class/
Action
Antibiotics
Effective against
Escherichia coli,

Example

Aztreonam

Route

IV

(Azactam)

Nursing

Side Effects

Headache,

Considerations
-

Contraindicate

diarrhea,

d in patients

Klebsiella,

nausea,

allergic

Serratia

blurred

penicillins and

vision

clearance
less

to
is
than

30mL/min.
-

Check

BUN

and creatinine
Effective against
E. coli and
Enterococcus

Fosfomycin
(Monurol)

PO

Headache,

before

diarrhea,
nausea

administration.
-

Dissolve
9

faecalis

packet in 3-4
oz

Effective against

Nitrofurantoi

PO

Headache,

of

cold

water.

E.coli,

anorexia,

enterococci,

(Macrobid)

diarrhea,

or

nausea

full glass of

Staphylococcus

aureus,
-

Enterobacter.
Fluoroquinolones
E. coli,

milk

and

water.

Klebsiella, and

Effective against

Give with food

Avoid
antacids.

Ciprofloxacin

Absorption
may

diarrhea,

decreased

photosensiti

given within 2

and other

vity,

hr

organisms.

increased

aluminum

risk of

antacids.

Pseudomonas,

IV

Nausea,
headache,

Klebsiella,

(Cipro)

PO

Levofloxacin
(Levaquin)

tendinitis

be
if
of

Give

with

and tendon

large amounts

rupture

of water.
-

Teach to avoid
sunlight
report

and
tendon

aches
promptly.
Sulfonamides
Effective against

Trimethoprim

PO

Photosensitiv

Teach to avoid

E. coli and

ity, GI

pseudomonas.

sulfametho

upset,

Used for

xazole

hemolytic,

large amounts

uncomplicated

(Bactrim,

anemia,

of water.

UTIs.

Septra)

rash
Severe

sunlight.
-

Give with

Contraindicate
d in serve renal

10

hypersensiti

or liver

vity

disease.

erythema
multiforme
or
exfoliative
dermatitis
(StephensJohnson
syndrome)
Urinary
Antiseptic

PO

Antibacterial action Cinoxacin

in the urine; not

Photosensitiv

Teach to avoid

ity, GI

(Cinobac)

upset, rash

systemic.

sunlight.
Encourage fluids.
May discolor urine.

Effective against

Absorption may be

E. coli,

decreased if given

Klebsiella, and

within 2 hr of

other gram-

aluminum or

negative

magnesium

organisms.
Urinary

antacids.

Antiseptic, AntiInfective
Effective against

Methenamine

PO

Nausea,

gram-negative

(Mandelami

vomiting,

with sulfa

and gram-positive

ne)

rash

drugs because

organisms, E.

may cause

coli.
Urinary Analgesic
Topical analgesic.
Relieves pain
urgency and

Do not use

crystalluria.
Phenazopyrid

PO

GI upset,

Urine color

ine

rash, and

changes to red-

(Pyridium)

blue to

orange.

11

frequency

purple skin

associated with

discoloratio

UTI

n
Nephrotoxic
and

Avoid in renal
insufficiency.

Changes urine
glucose
testing.

hepatotoxic
2.1.8 Complications
Repeated kidney infections can result in scarring and loss of
kidney function, leading to chronic kidney disease. Septicemia may
occur from bacteria invading the bloodstream. When septicemia
results from a urinary cause, it is called urosepsis. In the elderly,
urosepsis can be the cause of new-onset confusion. The elderly or
immunocompromised patient may develop septic shock from infection
in the urinary tract that has invaded the bloodstream, which may result
in death (Linda S William, 2011).
2.1.9 Diagnostic Examination
a) Urine Analysis
In the first step of microscopic evaluation, 10 ml of urine sample
was centrifuged at 2500 - 3000 rpm for 5 minutes. After centrifuge
supernatant was removed. Then one drop of sediment was placed
onto the microscope slide, covered and examined using light
microscope under 40x magnifications. Any bacteria (0 - 4) was
defined as bacteriuria and leukocyte more than 3 - 5 in one high
power field (hpf) was defined as pyuria. (CHENARI , MOHSEN R.
2012)

b) Urine Culture
Urine sample was taken with calibrated sterile inoculating loops
and fractioned on the surface of two plates; a blood agar base and
a McConkey agar by streak method. Plates were incubated for
approximately 24 hours at 35C - 37C. If there were no growth
occurred after first time incubation they were further incubated 24
hours. Therefore, no growth after 48 hours was reported as
negative. A culture with growth of potentially pathogenic bacteria

12

was normally considered positive if the number of colony-forming

units per milliliter (CFU/mL) was more than 105 . Then, grown
colonies were counted, morphologically examined and identified
by using biochemical tests. Type and subtype of bacteria was
identified and confirmed using standard methods. (CHENARI ,
MOHSEN R. 2012)

2.2 Nursing Care Plan

First, it is important to listen to the patients concerns about the
diagnosis. The patient is asked about pain on urination, flank pain, or
general symptoms of infection, such as fever, chills, and malaise. The
patients usual pattern of voiding is assessed. Urinary frequency, burning, or
pain on urination is noted. Assess the patient for pain in the lower abdomen,
flank, or costovertebral angle. The presence of a catheter, recent
instrumentation, surgery, or other predisposing factor is determined. The
urine is examined for volume, color concentration, cloudiness, blood, or
odor. Urinalysis and culture results are examined. And this is step for
making nursing process with urinary tract infection.
2.2.1 Assessment
a. Identity of client : Mostly woman who get UTI.
b. History of Illness
- Main complaint : Dysuria, polyuria, painful, fever.
- Present medical history : Fever, painful in lower abdomen,
-

cloudy urine.
Past medical history : Patients had been hospitalized with a catheter for 2

weeks.
- Family medical history : There is no family with UTI.
c. Physical Examination
a) Concusion level : Limp
b) Vital Sign
Blood pressure
: increased (120/100mmHg)
Pulse rate
: increased (100 bpm)
Respiratory rate
: increased (24 bpm)
Temperature
: increased (37 C)
c) Head to toe physical examination
1. Hair : Normal (nothing changes, hair color black)
2. Eyes : Normal (pink eyes conjunctiva, white sclera )
3. Nose : Normal (there are no nostrils)
4. Ears : Normal (nothing changes)
5. Mouth : Dry mouth mucosa, because
13

6. Neck : Normal (no swelling on the jugular vein)

7. Thorax : Normal (symmetries)
8. Abdomen
Inspection
= Normal (the stomach look flat)
Auscultation = There is bowel sound
Palpation
= There is tenderness in the lower
abdomen
Percusion
= Filled with air
9. Extremity
: no skin turgor
d) Diagnostic examination
Laboratory examination
1. Urinalysis : Any bacteria (0 - 4) was defined as bacteriuria
and leukocyte more than 3 - 5 in one high power field (hpf).
2. Urine culture : there is bacteria in the urine such as E. coli.
2.2.2 Nursing Diagnoses
a. Acute Pain related to Inflammation of the Urethra, Bladder, and Other
Urinary Structures
b. Impaired Urinary Elimination Related to Frequency, Nocturia, Dysuria,
and Incontinence
c. Risk for Injury Related to Sepsis, Kidney Disease, or Kidney Injury
2.2.3 Nursing Outcome and Intervention
a. Acute Pain related to Inflammation of the Urethra, Bladder, and
Other Urinary Structures
NOC
Expected Outcome:
-

NIC
Encourage fluids at 2 to 3 L per

The patient will report

day

relief

urinary tract and promote renal

from

pain

and

discomfort.

to

flush

bacteria

from

blood flow.
Give antimicrobial therapy as
ordered to relieve pain and
discomfort from inflammation

and infection.
Teach patient
prescribed

to

finish

medications

all
to

prevent recurrent infection.

Give antispasmodic agents as
ordered

to

relieve

bladder

14

irritability and pain.

Administer
antipyretics
relieve

fever,

pain,

to
and

discomfort.
Encourage voiding every 3 hours
to empty the bladder, lower
bacterial counts, reduce stasis,

and prevent reinfection.

Teach patient to avoid cola,
coffee, tea, and alcohol because

they are urinary irritants.

Suggest consuming cranberry
juice or capsules to prevent
bacteria from sticking on the

walls of the bladder.

Apply heat to suprapubic area to

relieve discomfort.
Instruct patient to empty bladder
as soon as urge is felt and after
sexual

intercourse

to

flush

bacteria out of the body.

Avoid substances such as bubble
bath and scented toilet paper,

which can be irritating.

Teach patient to practice good
perineal hygiene and to wipe
front to back to reduce risk of

reinfection
Teach patient to wear cotton
underwear to reduce perineal
moisture.

b. Impaired Urinary Elimination Related to Frequency, Nocturia,

Dysuria, and Incontinence
15

NOC
Expected Outcome:
-

NIC
Monitor urinary

elimination,

The patient will return to

including frequency, consistency,

previous voiding patterns.

volume, and color, to identify

signs and symptoms of UTI.

Administer antimicrobial drugs
as

ordered

to

symptoms

eliminate

produced

by

microbial growth.
Teach patient to recognize signs
and symptoms of UTI to monitor
effectiveness of treatment and

detect recurrence.
Encourage adequate fluids to
prevent

infection

and

dehydration.
Encourage women to void after
sexual

intercourse

to

flush

bacteria out of the urethra.

c. Risk for Injury Related to Sepsis, Kidney Disease, or Kidney Injury
NOC
Expected Outcome: The patient

NIC
Administer antimicrobial drugs as

will be free from injury due to

prescribed to prevent recurrent

sepsis or recurrent infection.

infection or complications.
Teach signs and symptoms of UTI

so patient can detect recurrence or

complications.

Clean

the

environment

appropriately after each patient

use

Use intermittent catheterization to

reduce the incidence of bladder

16

infection

Teach

patient and family about

signs and symptoms of infection

and when to report them to the
health care provider
2.2.4 Evaluation
a. The patient does not feel pain or reduced pain
b. The patient return to normal voiding pattern
c. The patient do not experience injury due to sepsis or recurrent
infection againja5

17

CHAPTER III
CONCLUSION

Urinary Tract Infection (UTI), a general term, refres to invasion of the

urinary tract by bacteria. Normally, the urinary tract is sterile above the urethra.
UTIs are caused most often by an ascending infection, starting at the external
urinary meatus and progressingtoward the bladder and kidneys. Most UTIs are
caused by the bacterium Escherichia coli, which is commonly found in feces.
Types of UTIs is urethritis, cystitis and pyelonephritis.

18

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Access on : Thursday, November 17th 2016. Time. 15.50
Imam, Talha H. 2016. Journal Bacterial Urinary Tract Infection (UTI). MSD
MANUAL Access on : Thursday, November 17th 2016. Time : 13.31
William, Linda S. 2011. Understanding Medical Surgical Nursing.
Philadelphia. Davis Company. Access on : Friday, November 18th, 2016. Time :
11.55.
Depkes RI. 2014. Survei Demografi dan Kesehatan Indonesia. Jakarta:
Depkes RI. Access on : Friday, November 18th, 2016. Time : 09.00.
WHO. 2013. Kesehatan Reproduksi Wanita ISK. Jakarta: Salemba Medika
Access on : Friday, November 18th, 2016. Time : 10.45.
THOMAS C. MICHELS, MD, MPH, is a faculty physician in the Family
Medicine Residency at Madigan Army Medical Center, Tacoma. Access on :
Friday, November 18th, 2016. Time : 11.45.
JARRET E. SANDS, DO, South Sound Family Medicine Clinic of the
Madigan Healthcare System, Olympia, Washington. Access on : Friday,
November 18th, 2016. Time : 12.05.
CHENARI , MOHSEN R. 2012. Assessment of Urine Analysis Diagnostic
Role: A Cross Sectional Study in South Eastern of Iran. Iran. Access on :
Monday, November 21th, 2016. Time 11.32

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