URINARY TRACT Nursing Assessment Guideline

 

Whenever a resident has signs of a urinary tract infection (frequency, urgency, dysuria, hematuria, new incontinence) the following assessment should be completed before the decision is made to observe and treat with nursing measures and PRNs or to call the provider on call.

 

___________History:

 

1.      What are the specific signs and symptoms?

2.      How long have they been present?

3.      Does the resident have an indwelling foley catheter?

4.      Has the resident recently been hospitalized?

5.      Does the resident have a history of UTIs or urinary retention?

6.      When was the last UCS done? Results? Treated?

7.      Is the resident currently being treated for a UTI?

8.      Have fluids been increased since the start of these symptoms? Is the resident on dialysis?

9.      Is the resident allergic to any medication?

10.  Is the resident on Coumadin? If YES what is the most recent INR?

 

___________Physical:

11.  What are the current vital signs? (Accucheck if diabetic)

12.  Is the resident impacted? When was the last bowel movement?

13.  Is there flank pain, lower back pain, bladder distention?

14.  Note color, odor and characteristics of urine.

 

___________Response:

 

 

A.      If cause of symptoms is known and treatment in place continue with

medications and treatments as order.

B.       For resident who appears to be very ill or if there are significant mental status changes notify the on-call provider.

 

NOTIFICATION CATEGORIES:

 

Emergency: Worsening symptoms accompanied by hypotension,

hypertension, lethargy, decreased oral intake, chills.

 

Routine: Symptoms, not responding to nursing measures, present for at

least 12 hours.

 

Revised 2/04