UTI (Urinary Tract Infection)

Outline

 OVERVIEW
 DEFINITION OF TERMS
 RISK FACTORS
 SIGN AND SYMPTOMS
 DIAGNOSIS, CLINICAL AND
LABORATORY EXAMINATION
 MANAGEMENT
 NURSING INTERVENTIONS
 NURSING CARE PLAN
 PATHOPHYSIOLOGY

Overview
A urinary tract infection (UTI) is an
infection in any part of your urinary system; your kidneys, ureters, bladder and urethra. Most infections
involve the lower urinary tract: the bladder and the urethra.
Women are at greater risk of developing a UTI than are men. They are more likely to get UTIs than boys
are because their urethra is shorter. Bacteria from the anus can more easily get into the vagina and
urethra.
Infection limited to your bladder can be painful and annoying. However, serious consequences can occur
if a UTI spreads to your kidneys.
Urinary tract infection (UTI) is one of the most common pediatric infections. It distresses the child,
concerns the parents, and may cause permanent kidney damage. Occurrences of a first-time symptomatic
UTI are highest in boys and girls during the first year of life and markedly decrease after that.
Febrile infants younger than 2 months constitute an important subset of children who may present
with fever without a localizing source. The workup of fever in these infants should always include
evaluation for UTI. The chart below details a treatment approach for febrile infants younger than 3
months who have a temperature higher than 38°C.
Types of urinary tract infections (UTIs)
UTIs are caused by micro-organisms or germs, usually bacteria. The different types of UTI can include:

 urethritis – infection of the urethra

 cystitis – infection of the bladder
 pyelonephritis – infection of the kidneys
 vaginitis – infection of the vagina.

What causes UTI?

Urinary tract infections are caused by microorganisms, usually bacteria, that enter the urethra and
bladder, causing inflammation and infection. Though a UTI most commonly happens in the urethra and
bladder, bacteria can also travel up the ureters and infect your kidneys.
Bacteria and other infection-causing microbes may enter the urinary tract when an infant has a dirty
diaper or when babies are wiped from back to front. Good hydration enabling frequent urination and
maintaining proper hygiene can help prevent UTIs.
A child gets infection when bacteria from their skin or poop get into the urinary tract and multiply. These
nasty germs can cause infections anywhere in the urinary tract, which is made up of the:

 Kidneys, which filter wastes and extra water out of the blood to make urine

 Ureters, which send urine from the kidneys into the bladder
 Bladder, which stores urine
 Urethra, which empties urine from the bladder out of the body
Some kids have a problem with their bladder or kidneys that makes them more likely to get UTIs.
Narrowing in the urinary tract can block urine flow and allow germs to multiply. A condition called
vesicoureteral reflux (VUR) can cause urine to back up from the bladder into the ureters and kidneys.
How does it forms?
When bacteria enter the urinary tract and multiply, they can cause a UTI. To infect the urinary system, a
micro-organism usually has to enter through the urethra or, rarely, through the bloodstream. The most
common bacterium to cause UTIs is Escherichia coli (E. coli).
Definition of Terms
Urinary System

 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.
Infection

 The invasion and growth of germs in the body. The germs may be bacteria, viruses, yeast, fungi,
or other microorganisms. Infections can begin anywhere in the body and may spread all through
it. An infection can cause fever and other health problems, depending on where it occurs in the
body.
Bacteria

 Bacteria are a type of biological cell. They constitute a large domain of prokaryotic
microorganisms. Typically a few micrometres in length, bacteria have a number of shapes,
ranging from spheres to rods and spirals. Bacteria were among the first life forms to appear on
Earth, and are present in most of its habitats.
Invasive Microorganism

 Invasive bacteria are pathogens that can invade parts of the body where bacteria are not normally
present, such as the bloodstream, soft tissues like muscle or fat, and the meninges.
Risk Factors of UTI
Over 50 percent of all women will experience at least one UTI during their lifetime, with 20 to 30 percent
experiencing recurrent UTIs. Pregnant women are not more likely to develop a UTI than other women,
but if one does occur, it is more likelyTrusted Source to travel up to the kidneys. This is because changes
in the body during pregnancy that affect the urinary tract.
As a UTI in pregnancy can prove dangerous for both maternal and infant health, most pregnant women
are tested for the presence of bacteria in their urine, even if there are no symptoms, and treated
with antibiotics to prevent spread.
People of any age and sex can develop a UTI. However, some people are more at risk than others. The
following factors can increase the likelihood of developing a UTI:

 sexual intercourse, especially if more frequent, intense, and with multiple or new partners
 diabetes
 poor personal hygiene
 problems emptying the bladder completely
 having a urinary catheter
 bowel incontinence
 blocked flow of urine
 kidney stones
 some forms of contraception
 pregnancy
 menopause
 procedures involving the urinary tract
 suppressed immune system
 immobility for a long period
 use of spermicides and tampons
 heavy use of antibiotics, which can disrupt the natural flora of the bowel and urinary tract
 babies – especially those born with physical problems (congenital abnormalities) of the urinary
system.
Urinary infections in children
A urinary infection in a child needs to be investigated as it may indicate a more serious condition. 
The most common urinary system condition is urinary reflux. With this condition, the bladder valve isn’t
working properly and allows urine to flow back to the kidneys, increasing the risk of a kidney infection. 
Urinary reflux and the associated infections can scar or permanently damage the kidney, and can also lead
to:

 high blood pressure 

 toxaemia in pregnancy 
 kidney failure. 
Urinary reflux tends to run in families, so it’s important to screen children as early as possible if a close
relative is known to have the problem.
Sign and Symptoms of UTI
The history and clinical course of a UTI vary with the patient's age and the specific diagnosis. No one
specific sign or symptom can be used to identify UTI in infants and children.
Children aged 0-2 months
Neonates and infants up to age 2 months who have pyelonephritis usually do not have symptoms
localized to the urinary tract. UTI is discovered as part of an evaluation for neonatal sepsis. Neonates with
UTI may display the following symptoms:

 Jaundice
 Fever
 Failure to thrive
 Poor feeding
 Vomiting
 Irritability
Infants and children aged 2 months to 2 years
Infants with UTI may display the following symptoms:

 Poor feeding
 Fever
 Vomiting
 Strong-smelling urine
 Abdominal pain
 Irritability
Children aged 2-6 years
Preschoolers with UTI can display the following symptoms:

 Vomiting
 Abdominal pain
 Fever
 Strong-smelling urine
 Enuresis
 Urinary symptoms (dysuria, urgency, frequency)
Children older than 6 years and adolescents
School-aged children with UTI can display the following symptoms:

 Fever
 Vomiting, abdominal pain
 Flank/back pain
 Strong-smelling urine
 Urinary symptoms (dysuria, urgency, frequency)
 Enuresis
 Incontinence
Physical examination findings in pediatric patients with UTI can be summarized as follows:

 Costovertebral angle tenderness

 Abdominal tenderness to palpation
 Suprapubic tenderness to palpation
 Palpable bladder
 Dribbling, poor stream, or straining to void
Diagnosis, Clinical and Laboratory Examinations
Diagnosis
The American Academy of Pediatrics (AAP) criteria for the diagnosis of UTI in children 2-24 months are
the presence of pyuria and/or bacteriuria on urinalysis and of at least 50,000 colony-forming units (CFU)
per mL of a uropathogen from the quantitative culture of a properly collected urine specimen. 
Urinalysis alone is not sufficient for diagnosing UTI. However, urinalysis can help in identifying febrile
children who should receive antibacterial treatment while culture results from a properly collected urine
specimen are pending. 

Urine specimen collection

 A midstream, clean-catch specimen may be obtained from children who have urinary control
 Suprapubic aspiration or urethral catheterization should be used in the infant or child unable to
void on request
Suprapubic aspiration is the method of choice for obtaining urine from the following patients:

 Uncircumcised boys with a redundant or tight foreskin

 Girls with tight labial adhesions,
 Children of either sex with clinically significant periurethral irritation
Culture of a urine specimen from a sterile bag attached to the perineal area has a false-positive rate too
high to be suitable for diagnosing UTI; however, a negative culture is strong evidence that UTI is absent. 
Laboratory studies

 Complete blood count (CBC) and basic metabolic panel (for children with a presumptive
diagnosis of pyelonephritis)
 Blood cultures (in patients with suspected bacteremia or urosepsis)
 Renal function studies (ie, serum creatinine and blood urea nitrogen [BUN] levels)
 Electrolyte levels
Imaging studies
Imaging studies are not indicated for infants and children with a first episode of cystitis or for those with a
first febrile UTI who meet the following criteria:

 Assured follow-up
 Prompt response to treatment (afebrile within 72 h)
 A normal voiding pattern (no dribbling)
  No abdominal mass
If imaging studies of the urinary tract are warranted, they should not be obtained until the diagnosis of
UTI is confirmed. Indications for renal and bladder ultrasonography are as follows:

 Febrile UTI in infants aged 2-24 months 

 Delayed or unsatisfactory response to treatment of a first febrile UTI
 An abdominal mass or abnormal voiding (dribbling of urine)
 Recurrence of febrile UTI after a satisfactory response to treatment
Voiding cystourethrography (VCUG) may be indicated after a first febrile UTI if renal and bladder
ultrasonography reveal hydronephrosis, scarring, obstructive uropathy, or masses or if complex medical
conditions are associated with the UTI. VCUG is recommended after a second episode of febrile UTI. 
Management of UTI
Patients with a nontoxic appearance may be treated with oral fluids and antibiotics. Outpatient care is
reasonable if the following criteria are met:

 A caregiver with appropriate observational and coping skills

 Telephone and automobile at home
 The ability to return to the hospital within 24 hours
 The patient has no need for oxygen therapy, intravenous fluids, or other inpatient measures
Hospitalization is necessary for the following patients with UTI:

 Patients who are toxemic or septic

 Patients with signs of urinary obstruction or significant underlying disease
 Patients who are unable to tolerate adequate oral fluids or medications
 Infants younger than 2 months with febrile UTI (presumed pyelonephritis)
 All infants younger than 1 month with suspected UTI, even if not febrile
Treat febrile UTI as pyelonephritis and consider parenteral antibiotics and hospital admission for
these patients.
Antibiotics for parenteral treatment are as follows:

 Ceftriaxone
 Cefotaxime
 Ampicillin
 Gentamicin
Patients aged 2 months to 2 years with a first febrile UTI.
If clinical findings indicate that immediate antibiotic therapy is indicated, a urine specimen for urinalysis
and culture should be obtained before treatment is started. Common choices for empiric oral treatment are
as follows:

 A second- or third-generation cephalosporin

 Amoxicillin/clavulanate, or sulfamethoxazole-trimethoprim (SMZ-TMP)
Children with cystitis
  Antibiotic therapy is started on the basis of clinical history and urinalysis results before the
diagnosis is documented
 A 4-day course of an oral antibiotic agent is recommended for the treatment of cystitis
 Nitrofurantoin can be given for 7 days or for 3 days after obtaining sterile urine
 If the clinical response is not satisfactory after 2-3 days, alter therapy on the basis of antibiotic
susceptibility
 Symptomatic relief for dysuria consists of increasing fluid intake (to enhance urine dilution and
output), acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs)
 If voiding symptoms are severe and persistent, add phenazopyridine hydrochloride (Pyridium) for
a maximum of 48 hours
Nursing Intervention
Major goals for the patient may include:

 Relief of pain and discomfort.

 Increased knowledge of preventive measures and treatment modalities.
 Absence of complications.
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.
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.
Nursing Care Plan
Diagnosis

Acute pain related to biological factors such as pain, irritability, strong smell of urine due to activity of
disease process

Assessment

Subjective
“My baby is crying for a period of time and he is always irritative and have temper behaviors” as
verbalized by the parents
Objective

 Facial grimace.
 Restlessness.
Vital signs follows:

 T: 37.3
 P: 82
 R: 19
Planning
After 8 hours of nursing interventions, the patient’s pain will be relieved or controlled.

 Assess pain, noting location, intensity (scale of 0 – 10), duration.

Rationale: Provides information to aid in determining choice or effectiveness of interventions.

 Administer Analgesic/Antipyretic as prescribed

Rationale: Alleviate fever and reduce pain felt by the patient

 Encourage increased fluid intake. Restrict milk feeding and put time interval.
Rationale: Increased hydration flushes bacteria and toxins.

 Investigate report of bladder fullness. Assess the weight of the diaper to assess volume of urine
Rationale: Urinary retention may develop, causing tissue distention ( bladder or kidney), and
potentiates risk for further infection.

 Observe for changes in mental status, behavior or level of consciousness.

Rationale: Accumulation of waste and having electrolyte imbalance is toxic to the body and should
be eliminated

 Provide comfort measure like back rub, helping patient assume, position of comfort. Suggest use
of relaxation technique such as providing quiet environment
Rationale: Promotes relaxation, refocuses attention, and may enhance coping abilities.
  Administer antibacterial as prescribed.
Rationale: Reduces bacteria present in urinary tract and those introduced by drainage system

 Teach proper hygiene care for the infant

Rationale: Promote hygiene care and prevent infection

Evaluation
Goal is met.

Pathophysiology