Nursing Process Paper: UTI Care for an Elderly Patient

Client Profile and Initial Assessment

The patient is a white 80-year-old male whose religion is unknown. He was admitted on February 2, 2022, for a urinary tract infection (UTI), and care began on the day of admission. He is a father of three and a grandfather of five, living with his spouse. His socioeconomic status is low to middle class, and he had a career as a factory worker. The patient's full code status is noted, with a contrast dye allergy on record. Medical history reflects an altered mental state, dementia, frustration, hypertension, Gastroesophageal Reflux Disease (GERD), and Stage 4 chronic kidney disease. Blindness in the left eye was detected, but no challenges were observed with hearing. The patient denies any pain, can move with minimal assistance, has a good appetite, and has shown adjustment to aging — his primary hobby is spending time with his grandchildren.

The patient's respiratory rate was regular, with oxygen saturation levels of 96% in the morning and 97% in the afternoon. The patient expressed challenges with urination. Skin integrity was normal for his age; however, the patient required assistance with a bed bath and oral care. No sexual observations were noted, though the patient complained of penile discharge. Psychologically, the patient received no support from family but interacted well with hospital staff.

Laboratory results showed RBC clotting at 3.45 (normal range: 4.35–5.65), indicating a stroke risk. The autoimmune result was 1.8 (normal range: 14–17.5), and monocyte levels were 10.8 (normal range: 80–100,000). Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH), and Mean Platelet Volume (MPV) results all reflected normal conditions.

UTI Diagnosis and Pathophysiology

Urinary tract infection (UTI) is categorized as either complicated or uncomplicated and typically affects healthy individuals who do not have neurological or structural urinary tract abnormalities. Infections are further differentiated into lower or upper UTIs. UTI affects approximately 150 million people worldwide. Serious sequelae include recurrence of pyelonephritis with sepsis, preterm birth complications, frequent antimicrobial use, and renal damage at a young age. Prior infections, sexual activity, obesity, genetics, and genetic susceptibility are significant contributors to the high incidence of UTI cases (Kaufman et al., 2019). Complicated UTIs are associated with risk factors that compromise the urinary tract or host defense, including urinary retention, urinary obstructions, renal failure, pregnancy, renal transplantation, and foreign bodies in the urinary tract such as indwelling catheters.

The presence of indwelling catheters causes infections referred to as Catheter-Associated UTIs (CAUTIs), which are associated with high rates of mortality and morbidity and may result in secondary bloodstream infections. Prolonged catheterization, old age, diabetes, and female sex are risk factors for CAUTI development (Pujades-Rodriguez et al., 2019). UTIs are caused by Gram-negative and Gram-positive bacteria as well as fungi and yeast. The most common cause of both complicated and uncomplicated UTIs is uropathogenic Escherichia coli (UPEC). Uncomplicated UTIs also commonly involve Staphylococcus saprophyticus, Enterococcus faecalis, Klebsiella pneumoniae, Staphylococcus species, Group B Streptococcus (GBS), and Proteus mirabilis. Complicated UTIs are caused by agents such as Candida spp., S. aureus, K. pneumoniae, P. aeruginosa, P. mirabilis, Enterococcus spp., and GBS (Murgia et al., 2018). Complicated UTIs are further associated with urinary tract abnormalities, antibiotic exposure, and indwelling catheters.

Patients asymptomatically suffering from UTIs who are administered antibiotics may experience long-term alteration of the normal microbiota of the gastrointestinal tract, with the development of drug-resistant microorganisms (Chu & Lowder, 2018). Areas not affected by changes in microbiota face an increased risk of colonization by drug-resistant organisms. Pathogens in the urinary tract colonize and adapt to the bladder environment, persist and disseminate within the urinary tract, and evade immune system surveillance.

Adherence of pathogens is a core event at the initial stages of UTI pathogenesis. Infection typically begins with colonization of the periurethral area by a uropathogen originating from the gut or another contaminated source, such as a failing kidney, followed by colonization of the urethra and eventual migration to the bladder. Multiple bacterial adhesins recognize the bladder epithelium and initiate colonization (Gharbi et al., 2019). Because UPEC survives by invading the bladder epithelium, it produces proteases and toxins and synthesizes siderophores to obtain iron. After colonizing the bladder epithelium, pathogens subsequently advance into the kidneys, where they colonize the renal epithelium and produce tissue-damaging toxins.

Complicated UTI infection begins when bacteria attach to a urinary catheter, a bladder stone, or a kidney stone, or when they are retained in the urinary tract due to physical obstruction. Pathogens such as P. aeruginosa, P. mirabilis, and Enterococcus spp. are common causes of complicated UTIs (Murgia et al., 2018). These uropathogens create a biofilm that is responsible for the persistence of colonization. Such pathogens initiate infection using pili to mediate adhesion to host environmental surfaces (Chu & Lowder, 2018), facilitating invasion of host tissue and promoting interbacterial interaction that supports biofilm formation. Gram-negative bacteria such as E. coli, Proteus spp., and Haemophilus spp. possess a conserved family of adhesive chaperone-usher pathway pili.

The biofilm forms after the type 1 pilus adhesin FimH binds mannosylated uroplakins, triggering actin rearrangement and bacterial internalization through the activation of RHO-family GTPases. UPEC can subvert host defenses within the host cell and resist antibacterial treatment. The host defense system's Toll-Like Receptor 4 (TLR4) triggers the production of lipopolysaccharide (LPS), which induces cyclic AMP (cAMP) (Pujades-Rodriguez et al., 2019). This mechanism results in exocytosis of UPEC through the apical plasma membrane. However, UPEC subverts this defense by moving into the cytoplasm, where it multiplies to form an Intracellular Bacterial Community (IBC) that establishes a cycle attacking new host cells.

The patient experienced small voiding that limited his ability to discharge urine whenever he felt the urge. Urinary tract infections were apparent in both the lower and upper tracts. Structural abnormalities, including infected cysts, renal abscesses, and calculi, were considered. Laboratory inspection of a urine sample was conducted to determine whether complicating factors — such as poorly controlled diabetes, chronic obstruction, indwelling urinary catheter, nephrolithiasis, chronic renal insufficiency, immunosuppression, or pregnancy — were present (Gharbi et al., 2019). Since no observable sexual activity was noted, infection via sexual activity was ruled out as the source. As an elderly patient with multiple comorbidities, complicating factors were considered a possible cause of infection. Blood cultures were required given the patient's dehydration and suspicion of pyelonephritis, as well as concerns that the patient may be immunocompromised due to his history of hypertension, GERD, and Stage 4 chronic kidney disease.

The patient also displayed signs of confusion and frustration; therefore, his responses could not be relied upon as the sole basis for determining a treatment plan. Laboratory results again confirmed RBC clotting at 3.45 (normal: 4.35–5.65), an autoimmune result of 1.8 (normal: 14–17.5), and monocyte levels of 10.8 (normal: 80–100,000). MCV, MCH, and MPV results reflected normal conditions. The history of kidney disease was identified as a likely source of infection, given its progression to antihypertensive management with increasing blood pressure.

In evaluating the patient's medication list, and in light of minimal urinary output — barely dripping — intermittent catheterization was recommended. This intervention was intended to reduce the risk of CAUTIs. Intermittent catheterization is considered the preferred long-term management strategy for preventing CAUTI development (Beahm et al., 2017). Given the patient's age and hypertension history, this intervention was designed to ensure post-void residuals greater than 300 mL and to facilitate scheduled voiding to prevent bladder overdistention. Prazosin, Flomax, Latanoprost, and Heparin were prescribed to lower blood pressure, relax the bladder, improve visibility in the left eye, and inhibit reactions resulting in blood clotting, respectively.

Nursing Process Application

The nursing process approach considers evidence from laboratory results alongside the patient's own understanding of their health. The nursing process aims to help the patient urinate on a schedule, eventually void independently, and achieve successful discharge (Ignatavicius et al., 2021). Following the five stages of the nursing process — assessment, diagnosis, planning, implementation, and evaluation — ensures that nursing responsibilities are addressed systematically (Pinkerton et al., 2020). This process is grounded in sharing scientific evidence and possible interventions with both the patient and family to establish an optimal care framework.

The patient was oriented to person and place (×3), calm and cooperative. Vital signs included a pulse rate of 80, respiration rate of 18, temperature of 36.6°C, SpO2 of 96%, and blood pressure of 121/59 mmHg. He denied a history of smoking; bilateral breath sounds were present. Oral mucous membranes were pink and moist. The Foley catheter was removed by the patient, resulting in incontinence. Bowel sounds were auscultated in all four quadrants with zero bowel movements noted. A small amount of bleeding was noted following catheter removal. Capillary refill was 1–2 seconds; no edema was noted. The patient was resting in a comfortable environment with an even respiratory rate. A positive range of motion was observed in both upper and lower extremities. No sputum, cough, nausea, or vomiting was noted. Left eye blindness was confirmed; adequate hearing was not noted. The patient was able to follow simple directional cues and reposition himself. He denied weakness but acknowledged needing minimal assistance with ambulation. The abdomen was soft. The patient required assistance with bed bath and oral care. No family support was noted, but he interacted appropriately with hospital staff. Fluid and electrolyte balance was maintained. The patient denied discomfort but required one-person assistance and repositioning every two hours. The bed was in a low, locked position with side rails up on three sides. No sexual observations were noted (see Appendix A).

Erik Erikson's eighth stage of human development — integrity versus despair — is applicable given the patient's age of 80 years (Gilleard, 2020). The core concern at this stage is whether the individual has led a satisfying life. The contrasting outcome involves egotism and denial of aging, while despair and wisdom serve as foundational determinants of psychological conflict. Since this stage begins at age 65, the patient confronts core life changes that reflect on the totality of his experience. The core virtue is wisdom: acceptance, a sense of wholeness, absence of regret, and inner peace (Gilleard, 2020). The patient had aspired to serve in the military but instead worked as a factory worker; however, his sense of wholeness is not limited to his career — he finds meaning in time with his grandchildren. The denial of hearing loss and the removal of the Foley catheter may reflect some degree of bitterness. Interventions to address this include patient education on the importance of keeping the catheter in place.

References

Chu, C., & Lowder, J. (2018). Diagnosis and treatment of urinary tract infections across age groups. American Journal of Obstetrics and Gynecology, 219(1), 40–51. https://doi.org/10.1016/j.ajog.2017.12.231

Gharbi, M., Drysdale, J., Lishman, H., Goudie, R., Molokhia, M., & Johnson, A., et al. (2019). Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all-cause mortality: Population-based cohort study. BMJ, l525.

Gilleard, C. (2020). The final stage of human development? Erikson's view of integrity and old age. International Journal of Ageing and Later Life, 1–24. https://doi.org/10.3384/ijal.1652-8670.1471

Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Medical-surgical nursing (10th ed.). Elsevier.

Kaufman, J., Temple-Smith, M., & Sanci, L. (2019). Urinary tract infections in children: An overview of diagnosis and management. BMJ Paediatrics Open, 3(1), e000487.

Murgia, L., Stalio, O., Arienzo, A., & Ferrante, V. (2018). Urinary tract infection — The result of the strength of the pathogen, or the weakness of the host. https://doi.org/10.5772/intechopen.68271

Murgia, L., Stalio, O., Arienzo, A., Ferrante, V., Cellitti, V., & Somma, S., et al. (2018). Management of urinary tract infections: Problems and possible solutions. Urinary Tract Infection — The Result of the Strength of the Pathogen, or the Weakness of the Host. https://doi.org/10.5772/intechopen.71588

Pinkerton, M., Bongu, J., James, A., Lowder, J., & Durkin, M. (2020). A qualitative analysis of diagnostic testing, antibiotic selection, and quality improvement interventions for uncomplicated urinary tract infections. PLOS ONE, 15(9), e0238453. https://doi.org/10.1371/journal.pone.0238453

Pujades-Rodriguez, M., West, R., Wilcox, M., & Sandoe, J. (2019). Lower urinary tract infections: Management, outcomes and risk factors for antibiotic re-prescription in primary care. eClinicalMedicine, 14, 23–31. https://doi.org/10.1016/j.eclinm.2019.07.012

Appendices

Age: 80 | Sex: M | Race: White | Code Status: Full Code | Allergies: Contrast Dye

Admitting Diagnosis: UTI | Past Medical History: Altered mental status, HTN, GERD, CKD Stage 4

Source of Information: Patient Chart | Surgical Procedures and Dates: Unknown

Treatments: IV #22 Jelco, Site: R Hand | O2 Sats monitored | Other O2 therapies: N/A | Dressings: N/A | Specialty bed: N/A

Cultural / Developmental Needs:

Caregiver/support persons: Spouse. Religion: Unknown. Socioeconomic level: Low to middle class. Payment source: Medicare. Work history: Factory worker. Hobbies: Spending time with grandchildren. Educational level: 12th grade. Erikson's Level: Integrity vs. Despair; adjustment to aging. Examples: Wanted to join the military; three children and five grandchildren.

Physical Assessment — Initial/General Impression:

Patient enjoys interacting with hospital staff; requires one-person assistance. Zero edema noted. Bowel sounds auscultated in all four quadrants. Foley catheter removed by patient; incontinence; zero bowel movements; last BM 2/5/2022. Vital signs at 07:32: BP 121/59, Pulse 80, RR 18, Temp 36.6°C, O2 96%. Assisted with feeding; no teeth noted. Patient reported left eye blindness. Patient alert and oriented ×3; comfortable environment; even respiratory rate noted.

Oxygenation/Ventilation: Denies history of smoking, cough, or shortness of breath. Respiratory rate: Morning 18, Lunch 18. Regular depth and quality. Breath sounds present bilaterally and clear. O2 sats: AM 96%, Lunch 97%. Capillary refill: 1–2 seconds. No sputum or cough noted.

Cardiac/Circulation: Denies any pain. Apical pulse regular. Pulse rate: Morning 80, Lunch 59. Blood pressure: Morning 121/59, Lunch 118/76. Capillary refill less than 3 seconds in extremities.

Nutrition/Fluids: Assisted with feeding at 08:10; tolerated well; consumed 100% liquid. Height: 5'3". Weight: 119 lbs; no weight loss noted. Mucous membranes: pink, not moist. No dentures; no difficulty swallowing. No nausea or vomiting. Therapeutic diet: Cardiac. Appetite: Good. Food consumed: breakfast 25%–50%, lunch 50%–70%.

Regulation (Neurological): Denies weakness; dementia/confusion noted. Temperature: Morning 36.6°C, Lunch 36.5°C. Blood glucose: Morning 110, Lunch 117. Alert and cooperative. Speech clear. Oriented to person and place; reoriented to time.

Stimulation: Left eye blindness reported. Denies hearing problems. Pupils equal and round. No drainage noted. Hearing: adequate hearing not confirmed.

Comfort/Pain: Denies any pain or discomfort. Pain scale: 0. No nonverbal pain signs. Patient able to follow simple directions and reposition self. Interventions: one-person assist; repositioned every 2 hours.

Activity/Rest: Patient states, "I can help." Active range of motion in all extremities. Ambulates with minimal assistance. Needs minimum assistance with ADLs. Total bed rest. Fall score noted.

Elimination: Denies constipation; last BM 2/5/2022. Failed indwelling Foley catheter 2/6/2022; catheter pulled out; small amount of bleeding noted. Urine: absent output. Urine color: clear. Genitalia: small amount of blood noted. Bowel sounds: present and active ×4 quadrants. Abdomen: soft. Bowel: incontinent. No stool described. Intake: 237 mL. Output: not noted.

Safety (Integumentary): One-person assist; side rails up ×3; bed in low, locked position. Skin temperature: warm. Skin turgor: normal for age. Skin integrity: no lesions or breakdown noted. No abnormal color or edema noted.

Hygiene: Assisted with bed bath and oral care. Requires assistance with ADLs.

Psychosocial: Zero family support noted. Patient interacts appropriately with hospital staff.

Sexual: No sexual observations noted. Penile discharge reported.

Teaching/Learning (Patient Identified): No teaching or learning opportunity voiced by patient.

Teaching/Learning (Nurse Identified): Maintain fluid and electrolyte balance; educate patient on the importance of keeping the Foley catheter in place.

Discharge Planning (Nurse Identified): Patient to be successful with Foley catheter and ultimately able to urinate independently.

Heparin 5,000 units | Classification: Anticoagulant | Dose: 1 mL | Route: SubQ | Frequency: Every 8 hours | Indication: Treatment of blood vessel, heart, and lung conditions | Action: Inhibits reactions leading to blood clotting and fibrin clot formation | Side Effects: Abdominal pain | Nursing Implications: Monitor for tightness of the throat.

Latanoprost 0.005% | Classification: Prostaglandin | Dose: One drop | Route: Ophthalmic | Frequency: Once daily | Indication: Treat glaucoma | Action: Increases intraocular pressure relief | Side Effects: Changes in eye color; increased pigmentation.

Lipitor | Classification: HMG-CoA Inhibitor | Dose: 40 mg | Route: PO | Frequency: Every bedtime (QHS) | Indication: Treat high cholesterol | Action: Decreases cholesterol | Side Effects: Joint pain | Nursing Implications: Monitor for chest pain.

Singulair | Classification: Leukotriene receptor antagonist | Dose: 10 mg | Route: PO | Frequency: QHS | Indication: Prevent asthma attacks | Action: Reduces risk of asthma flare-ups | Side Effects: Headache, cough | Nursing Implications: Take medication at the same time each day.

Prazosin | Classification: Alpha-blocker | Dose: 2 mg | Route: PO | Frequency: QHS | Indication: Treat hypertension | Action: Lowers blood pressure | Side Effects: Headache, nausea/vomiting | Nursing Implications: Monitor blood pressure and pulse rate.

Seroquel | Classification: Atypical antipsychotic | Dose: 25 mg | Route: PO | Frequency: Three times daily (TID) | Indication: Restore balance in the brain | Action: Decreases hallucinations | Side Effects: Weight gain, dry mouth | Nursing Implications: Monitor for severe CNS depression.

Flomax | Classification: Alpha-blocker | Dose: 0.8 mg | Route: PO | Frequency: With every meal | Indication: Improve urination | Action: Relaxes muscles in the prostate and bladder | Side Effects: Problems with ejaculation | Nursing Implications: Instruct patient to rise slowly from sitting or lying position.

Valproic Acid 500 mg | Classification: Anticonvulsant | Dose: 10 mL | Route: PO | Frequency: Twice daily (BID) | Indication: Mental/mood disorders; treat seizures | Action: Stabilizes mood and reduces seizure activity | Side Effects: Diarrhea, hair loss | Nursing Implications: Monitor for clotting defects.

Cipro | Classification: Fluoroquinolone | Dose: 500 mg | Route: PO | Frequency: BID | Indication: Treat bacterial infections | Action: Inhibits DNA replication | Side Effects: Nausea/vomiting, pale skin | Nursing Implications: Avoid use in breastfeeding patients.

Amlodipine | Classification: Calcium channel blocker | Dose: 2.5 mg | Route: PO | Frequency: Once daily (QD) | Indication: Treat hypertension | Action: Increases blood supply to the heart | Side Effects: Upset stomach, headache | Nursing Implications: Report increased arrhythmias.

Dutasteride | Classification: 5-alpha-reductase inhibitor | Dose: 0.5 mg | Route: PO | Frequency: QD | Indication: Treat benign prostatic hyperplasia (BPH) | Action: Reduces DHT levels | Side Effects: Headache, problems with ejaculation | Nursing Implications: Monitor voiding patterns.

RBC | Finding: Clotting | Client Result: 3.45 | Normal Range: 4.35–5.65 | Reason for Abnormality: Hypertension (HTN)

Hgb | Finding: Clotting | Client Result: 10.8 | Normal Range: M = 13–17, F = 12–15 | Reason for Abnormality: HTN

Hct | Finding: Clotting, stroke risk | Client Result: 32.7 | Normal Range: M = 40%–52%, F = 36%–47% | Reason for Abnormality: HTN

MCV | Finding: Normal | Client Result: 94.8 | Normal Range: 80–100 | Reason: Within normal range

MCH | Finding: Normal | Client Result: 31.3 | Normal Range: 27–31 | Reason: Within normal range

MPV | Finding: Normal | Client Result: 10.7 | Normal Range: 7–12 | Reason: Within normal range

Immature Auto (Imm. Auto) | Finding: Stroke risk | Client Result: 1.8 | Normal Range: 14–17.5 | Reason for Abnormality: CKD Stage 4

Monocyte Auto (Mono Auto) | Finding: Stroke risk | Client Result: 10.2 | Normal Range: 80–100,000 | Reason for Abnormality: CKD Stage 4

Chloride | Finding: Dehydration | Client Result: 108 | Normal Range: 95–105 | Reason for Abnormality: UTI

BUN | Finding: Dehydration | Client Result: 28 | Normal Range: 10–20 | Reason for Abnormality: GERD

Calcium | Finding: Antacid use | Client Result: 8.4 | Normal Range: 8.5–10.2 | Reason for Abnormality: GERD

Disorder: Urinary Tract Infection (UTI)

Pathophysiology: Abnormalities of UTI involve both the lower and upper urinary tracts. Structural abnormalities include calculi, infected cysts, and renal or bladder abscesses.

Etiology/Cause: Bacteria enter through the urethra and begin to multiply in the bladder. Common causative pathogens include uropathogenic E. coli as well as yeast organisms.

Risk Factors: When the patient is unable to urinate independently or has neurological problems that affect bladder control, a urinary catheter may be indicated.

Signs and Symptoms: Burning or irritation with urination; inflammation of the ureters causing pain.

Diagnostics: Laboratory analysis of a urine sample, including assessment of WBC and RBC counts.