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Prevent UTIs in the Elderly

Monday April 11, 2005
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Bedside caregivers lead the way in solving a common problem
Urinary tract infections (UTIs) are one of the most common nosocomial infections in the long-term care setting. They can cause severe pain and distress in the elderly and lead to serious conditions such as a kidney infection or sepsis. Yet there is disagreement about how to identify and treat these infections. Nurses at long-term care facilities (LTCFs) often have the responsibility of assessing and preventing UTIs. When assessing elderly patients, nurses need to focus on identifying typical symptoms and changes in residents' conditions that may signal a UTI.
Is it a UTI or not?
The three criteria considered indicative of UTIs in institutionalized elderly: bacteriuria, pyuria, and symptoms like urgency, frequency, and dysuria. But some researchers have proposed the presence of significant bacteria counts in the urine, even with pyuria, is not considered indicative of UTIs in the elderly nor the need for treatment.
Urgency, frequency, and dysuria can be present without bacteriuria. These are common complaints along with urge incontinence, spasmodic bladder, and urinary retention. All of these conditions can cause the urine to be malodorous and cloudy. Odor signifies the presence of bacteria in the urine. But according to some literature, although bacteria may cause malodorous urine, improved toileting may manage the problem better than antibiotics.
Hematuria is commonly thought to be a symptom of UTIs. Most cases of hematuria in the elderly are not caused by infection but are the side effect of medications like nonsteroidal antiinflammatory drugs, antibiotics, diuretics, and anticoagulants or the result of medical complications such as renal calculi, hypertension, cancer, cysts, trauma, and the use of indwelling catheters.
A unique UTI symptom for elderly patients living in LTCFs is a change in mental status or condition. In fact, a decline in general status has been described as sometimes the only certain indication of UTI in the elderly. Any report or observation of a change in behavior, mental status, or general condition in a patient should be considered a need for further evaluation.
Educating direct caregiver staff, including certified nursing assistants (CNAs) and licensed practical nurses, on what signs to look for increases the chances of detecting potential UTIs early. Bedside caregivers should report if they observe a patient crying out when urinating; an increase in incontinence; or a change in behavior, such as confusion, restlessness, or agitation.
Treating a UTI
Controversy notwithstanding, treatment of UTIs in older adults is recommended in the presence of fever, increased risk of sepsis, incontinence with the presence of pressure ulcers, and changes in mental status. A urine culture should be obtained to identify the causative organism and ensure that the antibiotic therapy ordered is appropriate. Antibiotics can be started once the culture is obtained, even when results are pending. In high-risk patients, even 72 hours can be critical in starting treatment; therapy can always be changed when results are verified.
Most UTIs in the long-term care population are caused by E. coli and staphyloccocus from skin and fecal contamination. These organisms respond very well to several drug regimens, including Bactrim DS, cephalexin, and ciprofloxacin (Cipro). Symptomatic treatment may also include Tylenol for fever and phenazopyridine HCl for bladder spasms and pain. Nursing staff should increase these patients' fluid intake (except for those on fluid restrictions) and observe them for signs of antibiotic side effects, like nausea, vomiting, diarrhea, and rash.
The proactive approach
Preventing UTIs is even more critical than assessing the infection. The National Association of Directors of Nursing Administrators in Long-Term Care recommends setting up hydration and toileting programs. Simple measures, such as keeping patients properly hydrated, helping them avoid becoming constipated, and employing a scheduled toileting plan, can significantly decrease the occurrence of UTIs in LTCFs. In LTCFs the risk of UTIs increases if patients have poor hygiene habits like cleansing improperly after bowel movements. Scheduled toileting and monitoring patients' hygiene habits can prevent infection and skin breakdown.
Vickie O'Quinn, director of nursing at Brian Center of Durham, N.C., takes a common sense, yet creative, approach to preventing UTIs in her facility. She recognizes CNAs carry the burden of care for residents and adding additional duties or expectations would lead to poor quality care. To relieve that burden, O'Quinn taps into other staff to make sure all appropriate measures are being taken to prevent UTIs.
"My rehabilitation aide had downtime each day between scheduled residents," says O'Quinn, "so now she makes hydration rounds instead of waiting for the next resident."
Some facilities use volunteers in this role or enlist dietary staff between meal preparation duties. Britthaven Corporation, a North Carolina-based long-term care provider, provides self-serve hydration and nutrition carts. These moveable carts hold a cooler of ice, water, containers of juice, small cans of diet soda, and snacks, such as graham crackers. Placement at the end of each wing makes the carts accessible to mobile residents and staff.
O'Quinn also motivates her LPN staff to assist CNAs in toileting residents and providing personal hygiene rounds. "The fostering of a team approach, as well as the closer monitoring of hygiene and skin by the nursing staff, is a win-win situation," says O'Quinn. "The staff feel appreciated, and my residents get better care."
Using daily bowel movement records and behavior sheets helps document and monitor potential risk factors for UTIs.
The key to preventing UTIs in the elderly is hydration, good hygiene with toileting, and accurate assessment. Educating staff also goes a long way in identifying and treating UTIs.
Editor's Note: For a bibliography, see the online version of this article at www.nursingspectrum.com.
Nanette Lavoie-Vaughan, ARNP-C, MSN, is an adult and geriatric nurse practitioner, professional speaker, and author. She is currently employed as a nurse practitioner in Raleigh, N.C. She may be reached at nursenan1@prodigy.net.