Urinary Tract Infections (UTIs)

▪ The urinary system, also known as the renal system or urinary tract, consists of the
kidneys, ureters, bladder, and the urethra.
▪ The purpose of the urinary system is to eliminate waste from the body, regulate blood
volume and blood pressure, control levels of electrolytes and metabolites, and regulate
blood pH.
The function of the kidneys
▪ Filter. Every day, the kidneys filter gallons of fluid from the bloodstream.
▪ Waste processing. The kidneys then process this filtrate, allowing wastes and excess ions
to leave the body in urine while returning needed substances to the blood in just the
right proportions.
▪ Elimination. Although the lungs and the skin also play roles in excretion, the kidneys
bear the major responsibility for eliminating nitrogenous wastes, toxins, and drugs from
the body.
▪ Regulation. The kidneys also regulate the blood’s volume and chemical makeup so that
the proper balance between water and salts and between acids and bases is
maintained.
▪ Other regulatory functions. By producing the enzyme renin, they help regulate blood
pressure, and their hormone erythropoietin stimulates red blood cell production in the
bone marrow.
▪ Conversion. Kidney cells also convert vitamin D to its active form.

The Kidneys
▪ The kidneys, which maintain the purity and constancy of our internal fluids, are perfect
examples of homeostatic organs.
▪ Location. These small, dark red organs with a kidney-bean shape lie against the dorsal
body wall in a retroperitoneal position (beneath the parietal peritoneum) in the superior
lumbar region; they extend from the T12 to the L3 vertebra, thus they receive
protection from the lower part of the rib cage.
▪ Positioning. Because it is crowded by the liver, the right kidney is positioned slightly
lower than the left.
▪ Size. An adult kidney is about 12 cm (5 inches) long, 6 cm (2.5 inches) wide, and 3 cm (1
inch) thick, about the size of a large bar of soap.
▪ Adrenal gland. Atop each kidney is an adrenal gland, which is part of the endocrine
system is a distinctly separate organ functionally.
▪ Fibrous capsule. A transparent fibrous capsule encloses each kidney and gives a fresh
kidney a glistening appearance.
▪ Perirenal fat capsule. A fatty mass, the perirenal fat capsule, surrounds each kidney and
acts to cushion it against blows.
 ▪ Renal fascia. The renal fascia, the outermost capsule, anchors the kidney and helps hold
it in place against the muscles of the trunk wall.
▪ Renal cortex. The outer region, which is light in color, is the renal cortex.
▪ Renal medulla. Deep to the cortex is a darker, reddish-brown area, the renal medulla.
▪ Renal pyramids. The medulla has many basically triangular regions with a striped
appearance, the renal, or medullary pyramids; the broader base of each pyramid faces
toward the cortex while its tip, the apex, points toward the inner region of the kidney.
▪ Renal columns. The pyramids are separated by extensions of cortex-like tissue, the renal
columns.
▪ Renal pelvis. Medial to the hilum is a flat, basinlike cavity, the renal pelvis, which is
continuous with the ureter leaving the hilum.
▪ Calyces. Extensions of the pelvis, calyces, form cup-shaped areas that enclose the tips of
the pyramid and collect urine, which continuously drains from the tips of the pyramids
into the renal pelvis.
▪ Renal artery. The arterial supply of each kidney is the renal artery, which divides into
segmental arteries as it approaches the hilum, and each segmental artery gives off
several branches called interlobar arteries.
▪ Arcuate arteries. At the cortex-medulla junction, interlobar arteries give off arcuate
arteries, which curve over the medullary pyramids.
▪ Cortical radiate arteries. Small cortical radiate arteries then branch off the arcuate
arteries and run outward to supply the cortical tissue.

Nephrons
▪ Nephrons are the structural and functional units of the kidneys.
▪ Nephrons. Each kidney contains over a million tiny structures called nephrons, and they
are responsible for forming urine.
▪ Glomerulus. One of the main structures of a nephron, a glomerulus is a knot of
capillaries.
▪ Renal tubule. Another one of the main structures in a nephron is the renal tubule.
 ▪ Bowman’s capsule. The closed end of the renal tubule is enlarged and cup-shaped and
completely surrounds the glomerulus, and it is called the glomerular or Bowman’s
capsule.
▪ Podocytes. The inner layer of the capsule is made up of highly modified octopus-like
cells called podocytes.
▪ Foot processes. Podocytes have long branching processes called foot processes that
intertwine with one another and cling to the glomerulus.
▪ Collecting duct. As the tubule extends from the glomerular capsule, it coils and twists
before forming a hairpin loop and then again becomes coiled and twisted before
entering a collecting tubule called the collecting duct, which receives urine from many
nephrons.
▪ Proximal convoluted tubule. This is the part of the tubule that is near to the glomerular
capsule.
▪ Loop of Henle. The loop of Henle is the hairpin loop following the proximal convoluted
tubule.
▪ Distal convoluted tubule. After the loop of Henle, the tubule continues to coil and twist
before the collecting duct, and this part is called the distal convoluted tubule.
▪ Cortical nephrons. Most nephrons are called cortical nephrons because they are located
almost entirely within the cortex.
▪ Juxtamedullary nephrons. In a few cases, the nephrons are called juxtamedullary
nephrons because they are situated next to the cortex-medullary junction, and their
loops of Henle dip deep into the medulla.
▪ Afferent arteriole. The afferent arteriole, which arises from a cortical radiate artery, is
the “feeder vessel”.
▪ Efferent arteriole. The efferent arteriole receives blood that has passed through the
glomerulus.
▪ Peritubular capillaries. They arise from the efferent arteriole that drains the glomerulus

Ureters
▪ The ureters do play an active role in urine transport.
▪ Size. The ureters are two slender tubes each 25 to 30 cm (10 to 12 inches) long and 6
mm (1/4 inch) in diameter.
▪ Location. Each ureter runs behind the peritoneum from the renal hilum to the posterior
aspect of the bladder, which it enters at a slight angle.
▪ Function. Essentially, the ureters are passageways that carry urine from the kidneys to
the bladder through contraction of the smooth muscle layers in their walls that propel
urine into the bladder by peristalsis and is prevented from flowing back by small valve-
like folds of bladder mucosa that flap over the ureter openings.

Urinary Bladder
▪ The urinary bladder is a smooth, collapsible, muscular sac that stores urine temporarily.
▪ Location. It is located retroperitoneally in the pelvis just posterior to the symphysis
pubis.
▪ Function. The detrusor muscles and the transitional epithelium both make the bladder
uniquely suited for its function of urine storage.
▪ Trigone. The smooth triangular region of the bladder base outlined by these three
openings is called the trigone, where infections tend to persist.
▪ Detrusor muscles. The bladder wall contains three layers of smooth muscle, collectively
called the detrusor muscle, and its mucosa is a special type of epithelium, transitional
epithelium.

Urethra
▪ The urethra is a thin-walled tube that carries urine by peristalsis from the bladder to the
outside of the body.
▪ Internal urethral sphincter. At the bladder-urethral junction, a thickening of the smooth
muscle forms the internal urethral sphincter, an involuntary sphincter that keeps the
urethra closed when the urine is not being passed.
 ▪ External urethral sphincter. A second sphincter, the external urethral sphincter, is
fashioned by skeletal muscle as the urethra passes through the pelvic floor and is
voluntarily controlled.
▪ Female urethra. The female urethra is about 3 to 4 cm (1 1/2 inches) long, and its
external orifice, or opening, lies anteriorly to the vaginal opening.
▪ Male urethra. In me, the urethra is approximately 20 cm (8 inches) long and has three
named regions: the prostatic, membranous, and spongy (penile) urethrae; it opens at
the tip of the penis after traveling down its length.
▪ Every day, the kidneys filter gallons of fluid from the bloodstream. The normal
physiology that takes place in the urinary system are as follows:
▪ Urine formation is a result of three processes:

Urine Formation

▪ Glomerular filtration. Water and solutes smaller than proteins are forced through the
capillary walls and pores of the glomerular capsule into the renal tubule.
▪ Tubular reabsorption. Water, glucose, amino acids, and needed ions are transported out
of the filtrate into the tubule cells and then enter the capillary blood.
▪ Tubular secretion. Hydrogen, potassium, creatinine, and drugs are removed from the
peritubular blood and secreted by the tubule cells into the filtrate.

Characteristics of Urine
▪ In 24 hours, the marvelously complex kidneys filter some 150 to 180 liters of blood
plasma through their glomeruli into the tubules.
▪ Daily volume. In 24 hours, only about 1.0 to 1.8 liters of urine are produced.
▪ Components. Urine contains nitrogenous wastes and unneeded substances.
▪ Color. Freshly voided urine is generally clear and pale to deep yellow.
▪ Odor. When formed, urine is sterile and slightly aromatic, but if allowed to stand, it
takes on an ammonia odor caused by the action of bacteria on the urine solutes.
▪ pH. Urine pH is usually slightly acidic (around 6), but changes in body metabolism and
certain foods may cause it to be much more acidic or basic.
▪ Specific gravity. Whereas the specific gravity of pure water is 1.0, the specific gravity of
urine usually ranges from 1.001 to 1.035.
▪ Solutes. Solutes normally found in urine include sodium and potassium ions, urea, uric
acid, creatinine, ammonia, bicarbonate ions, and various other ions.
Micturition
▪ Micturition or voiding is the act of emptying the bladder.
▪ Accumulation. Ordinarily, the bladder continues to collect urine until about 200 ml have
accumulated.
▪ Activation. At about this point, stretching of the bladder wall activates stretch receptors.
▪ Transmission. Impulses transmitted to the sacral region of the spinal cord and then back
to the bladder via the pelvic splanchnic nerves cause the bladder to go into reflex
contractions.
▪ Passage. As the contractions become stronger, stored urine is forced past the internal
urethral sphincter into the upper part of the urethra.
▪ External sphincter. Because the lower external sphincter is skeletal muscle and
voluntarily controlled, we can choose to keep it closed or it can be relaxed so that urine
is flushed from the body.
▪ Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary
tract.
▪ The normal urinary tract is sterile above the urethra.
▪ UTIs are infections involving the upper or lower urinary tract and can be uncomplicated
or complicated depending on other patient-related conditions.

Classification
UTIs are classified by location and are further classified according to other factors and
conditions.
▪ Lower UTIs. Lower UTIs include bacterial cystitis, prostatitis, and urethritis.
▪ Upper UTIs. Upper UTIs are much less common and include acute and chronic
pyelonephritis, interstitial nephritis, and renal nephritis.
▪ Uncomplicated Lower or Upper UTIs. Most uncomplicated UTIs are community acquired
and are common in young women but not usually recurrent.
▪ Complicated Lower or Upper UTIs. Complicated UTIs usually occur in people with
urologic abnormalities or recent catheterization and are often acquired during
hospitalization.

Pathophysiology
For infection to occur, bacteria must gain access to the system.
▪ Access. Infection occurs first as the bacteria gains access inside the urinary tract.
▪ Attachment. The bacteria attach to the epithelium of the urinary tract and colonize it to
avoid being washed out with voiding.
▪ Evasion. The defense mechanisms are then evaded by the host.
▪ Inflammation. As the defense mechanisms react to the bacteria, inflammation starts to
set in as well as other signs of infection.

Statistics & Epidemiology

Urinary tract infection cases are widespread around the world and affect both the young and the
old.
▪ UTI is the second most common infection in the body.
▪ Most cases of UTI occur among women; one out of five women in the United States will
develop UTI during her lifetime.
▪ The urinary tract is the most common site of infection, accounting for greater than 40%
of the total number reported by hospitals.
▪ UTI affects about 600, 000 patients each year.
▪ More than 250, 000 cases of acute pyelonephritis occur in the United States each year,
with 100, 000 requiring hospitalization.
▪ Approximately 11.3 million women are diagnosed with UTIs in the United States
annually.
▪ The expenditure in direct healthcare costs amounts to $1.6 billion.

Causes
UTIs are primarily caused by bacteria that have invaded the urinary tract.
 ▪ Inability or failure to empty the bladder completely. Stasis of urine inside the urinary
bladder attracts bacteria into entering the tract.
▪ Instrumentation of the urinary tract. Catheterization or cystoscopy procedures could
introduce bacteria into the urinary tract.
▪ Obstructed urinary flow. Abnormalities in the structure of the urinary tract could
obstruct the flow of the urine and result in inability to empty the bladder completely.
▪ Decreased natural host defenses. Immunosuppression or inability of the body to
produce the body’s defenses predisposes the patient to UTI.

Clinical Manifestations
A variety of signs and symptoms are associated with UTI.
▪ Burning on urination. The patient may feel pain during urinating and describe it as a
burning sensation.
▪ Frequency. The patient voids more than the usual every 3 hours.
▪ Nocturia. Awakening at night to urinate is also a sign of UTI.
▪ Suprapubic or pelvic pain. The patient may report pain at the suprapubic site or on the
pelvic area.
▪ Urgency. There is also a feeling that the patient would not be able to contain the urge
anymore and would rush just to excrete it.

Prevention
UTI is a preventable disease mainly focusing on the hygienic practices of the individual.
▪ Avoid bath tubs. Shower rather than bathe in a tub because bacteria in the bath water
may enter the urethra.
▪ Perineal hygiene. After each bowel movement, clean the perineum and urethral meatus
from front to back to reduce concentrations of pathogens at the urethral opening.
▪ Increase fluid intake. Drink liberal amounts of fluids daily to flush out bacteria.
▪ Avoid urinary tract irritants. Beverages such as coffee, tea, colas, alcohol, and others
contribute to UTI.
▪ Voiding habit. Void at least every 2 to 3 hours during the day and completely empty the
bladder.
▪ Medications. Take medications exactly as prescribed.

Complications
Early recognition of UTI and prompt treatment are essential to prevent recurrent infection and
the possibility of complications.
▪ Renal failure. UTIs that are not treated promptly could spread in the entire urinary
system and become the cause of renal failure.
▪ Urosepsis. The bacteria may invade the urinary system and result in sepsis.

Assessment and Diagnostic Findings

Results of various tests help confirm the diagnosis of UTI.
▪ Urine cultures. Urine cultures are useful in identifying the organism present and are the
definitive diagnostic test for UTI.
▪ STD tests. Tests for STDs may be performed because there are UTIs transmitted sexually.
▪ CT scan. A CT scan may detect pyelonephritis or abscesses.
▪ Ultrasonography. Ultrasound is extremely sensitive for detecting obstruction, abscesses,
tumors, and cysts.

Medical Management
Management of UTIs typically involves pharmacologic therapy and patient education.
▪ Acute pharmacologic therapy. The ideal medication for treatment of UTI is an
antibacterial agent that eradicates bacteria from the urinary tract with minimal effects
on fecal and vaginal flora.
▪ Long-term pharmacologic therapy. Reinfection with new bacteria is the reason for
recurrence, and these patients with recurrence are instructed to begin treatment on
their own whenever symptoms occur, to contact their physician only when symptoms
persist.
Nursing Management
Nursing care of the patient with UTI focuses on treating the underlying infection and preventing
its recurrence.

Nursing Assessment
A history of signs and symptoms related to UTI is obtained from the patient with a suspected
UTI.
▪ Assess changes in urinary pattern such as frequency, urgency, or hesitancy.
▪ Assess the patient’s knowledge about antimicrobials and preventive health care
measures.
▪ Assess the characteristics of the patient’s urine such as the color, concentration, odor,
volume, and cloudiness.

Nursing Diagnosis
Based on the assessment data, the nursing diagnoses may include the following:
▪ Acute pain related to infection within the urinary tract.
▪ Deficient knowledge related to lack of information regarding predisposing factors and
prevention of the disease.

Nursing Care Planning & Goals

Urinary Tract Infection Nursing Care Plans
Major goals for the patient may include:
▪ Relief of pain and discomfort.
▪ Increased knowledge of preventive measures and treatment modalities.
▪ Absence of complications.

Nursing Interventions
Nurses care for patients with urinary tract infection in all settings.
▪ Relieve pain. Antispasmodic agents may relieve bladder irritability and analgesics and
application of heat help relieve pain and spasm.
▪ Fluids. The nurse should encourage the patient to drink liberal amounts of fluids to
promote renal blood flow and to flush bacteria from the urinary tract.
▪ Voiding. Encourage frequent voiding every 2 to 3 hours to empty the bladder completely
because this can significantly lower urine bacterial counts, reduce urinary stasis, and
prevent reinfection.
▪ Irritants. Avoid urinary irritants such as coffee, tea, colas, and alcohol.

Evaluation
Expected outcomes may include:
▪ Experiences relief of pain.
▪ Explains UTI and their treatment.
▪ Experiences no complications.

Discharge and Home Care Guidelines

Care of the patient with UTI must continue until at home because it has a high recurrence rate.
▪ Personal hygiene. The nurse should instruct the female patient to wash the perineal
area from front to back and wear only cotton underwear.
▪ Fluid intake. Increase and fluid intake is the number one intervention that could stop
UTI from recurring.
▪ Therapy. Strictly adhere to the antibiotic regimen prescribed by the physician.

Documentation Guidelines
The focus of documentation should include:
▪ Individual assessment findings, including client’s description and response to pain,
expectations of pain management, and acceptable level of pain.
▪ Prior medication use.
▪ Plan of care and those involved in planning.
▪ Teaching plan.
▪ Response to interventions, teaching, and actions performed.
▪ Attainment or progress toward desired outcomes.
▪ Modifications to plan of care.