NR601 Standardized Procedure Worksheet

The selected disease is urinary tract infections (UTI) in facility-dwelling older adults. UTI is defined as an infection that affects the urinary system. It might affect the lower urinary tract only or the upper and lower urinary tracts (Kang et al., 2018). It is associated with various symptoms, including pain with urination, frequent urination, increased urge to urinate with the production of little urine, and vaginal discharge.

Pathophysiology

Urinary tract infections among facility-dwelling older adults are associated with various factors related to aging. T-cell dysfunction among the aging population disrupts the working mechanism of the acquired immunity. Normal defense mechanisms allow the body to void completely, eliminating all urine from the body (Godbole et al., 2020). Additionally, the mechanism is responsible for the immunoglobulin production and acidification of urine from organic acids. Thus, a compromised immune system increases the risk of UTIs among elderly adults. The risk of UTI is higher in women than men since women have a shorter urethra and highly-frequent vaginal colonization (Godbole et al., 2020). Estrogen deficiency in women causes urinary incontinence and vaginal prolapse, enhancing the ascending flow of bacteria to the urinary tract, and causing UTIs (Rodriguez-Mañas, 2020). Moreover, loss of pelvic floor muscle tone increases the risk of UTI in older women. Accumulation of comorbidities such as stroke and dementia also increases the risk of UTI in elderly women residing in indwelling facilities. These conditions lead to bowel and bladder incontinence and declined functional capacity, disrupting the body’s defense mechanisms. Lastly, physical limitation among women residing in indwelling settings increases the risk of UTIs.

Incidence and Prevalence

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Urinary tract infection (UTI) is highly prevalent among facility-dwelling older adults. According to Godbole et al. (2020), UTI is the second most frequent infection among elderly adults, residing in long-term care (LTC), representing more than a third of all nursing home-associated infections. Furthermore, UTI is the most prevalent infection among older adults, representing about 25% of all infections in this population (Godbole et al., 2020). A report by Medina and Castillo-Pino (2019) indicated that UTI is diagnosed in 50% – 60% of total adult women in their life. Additionally, UTI is the most prevalent cause of bacterial infection hospitalizations among geriatrics residing in long-term facilities.

The prevalence and incidence of UTIs are significantly high in older women than in men. This trend is associated with a relatively shorter urethra in women, allowing bacteria from the intestine to pass easily to the urinary tract system. According to Rodriguez-Mañas (2020), the overall incidence of UTI among postmenopausal community-dwelling women aged from 55 to 75 years was 7 cases per 100 person-years. This rate is relatively high, making UTI one of the most prevalent diagnoses in this population. Another study assessing the rate of UTI among men aged between 65 and 74 years residing in an indwelling facility indicated an incidence rate of 5 cases per 100 person-years (Rodriguez-Mañas, 2020). Therefore, the prevalence of UTIs among women residing in the indwelling facility exceeds that of men.

Assessment
Symptoms

Urinary tract infection among adult women residing in the indwelling facility is characterized by various symptoms of flank pain. Urinary frequency is another significant symptom of UTI in elderly women residing in indwelling facilities. The urination frequency among these individuals is more than 7 micturition incidents during waking hours (Czajkowski et al., 2021). Nocturia also characterizes UTIs in elderly women residing in indwelling facilities. Elderly patients with UTIs are interrupted from their sleep at least once due to the need to micturate. Sleep precedes and follows each sleep (Czajkowski et al., 2021). Lastly, UTI in this population is characterized by urinary urgency. Elderly adults with UTIs experience a compelling desire to pass urine that one cannot resist but ends up producing a little amount of urine (Czajkowski et al., 2021).

Physical Exam

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Physical examination of UTI aims at conforming to clinical manifestation reported by the client during a clinical interview. The physical examination in cases of suspected UTI targets the CVA, the suprapubic region, and general symptoms such as fever (Czajkowski et al., 2021).

Intended state of practice (Arizona) whether collaboration is required, if collaboration is required, describe the circumstances that would require physician collaboration

In Arizona, nurse practitioners (NPs) are allowed to practice independently. Nurses practicing in this state are not required to collaborate or be supervised by a physician during care delivery (American Medical Association, 2021). Thus, an NP practicing in Arizona can treat an adult woman who presented with UTI symptoms independently without collaborating or consulting a physician. However, the NP can refer the client to another health care professional if the presented symptoms exceed NP’s knowledge, skills, and experience. Referring the client to more competent and experienced healthcare providers would protect her health, welfare, and overall well-being.

Diagnostic tests
Testing

Analyzing of the urine sample: A freshly-collected urine sample is examined under a microscope to detect the presence of bacteria or white blood cells (WBC). According to Czajkowski et al. (2021), a count higher than 10 leuko-cytes/mm3 indicates an infection.

Urine culture: This test is conducted to determine if the infection is caused by bacteria or yeast present in the urine sample.

Expected results

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In an elderly patient with UTI, physical examination results should indicate a high or slightly high fever due to an infection. Additionally, in elderly women with UTIs, the suprapubic region is non-tender with touch. However, the suprapubic region becomes tender, or the client experiences signs of flank pain on deep abdominal palpation (Czajkowski et al., 2021). Furthermore, the CVA is tender on palpation or percussion. In addition to physical examinations, the number of white blood in an adult woman with a UTI is expected to be more than 10 cells/mm3 per high-power field (Czajkowski et al., 2021). Lastly, an adult woman with UTI has systemic inflammation, indicating increased WBC in the blood.

Management

Treating urinary tract infection (UTI) for the elderly is the same as treating UTI in young women. The treatment plan consists of pharmacological and non-pharmacological interventions. First-line medications and second-line medications can be used in treating UTIs in elderly patients.

First-line medications

Antibiotics are recommended as the first-line treatment for UTIs in elderly patients. According to Chu and Lowder (2018), trimethoprim-sulfamethoxazole 800/160mg is one of the first-line medications and should be taken for three days, and the patient should take them twice a day. Also, nitrofurantoin monohydrate/macrocrystals 100 mg is recommended and should be taken for five days where the patient needs to take it twice a day too. However, these medications are more viable if the local resistant rates are less than 20 percent. For instance, E. Coli bacteria have low nitrofurantoin resistance rates compared to other bacteria like Enterobacteraciae species, which are commonly experienced in the elderly, thus posing a higher probability of nitrofurantoin resistance (Durkin et al., 2018). Nitrofurantoin is also contraindicated for chronic kidney disease patients that are common in the elderly. Hence, the most preferred first-line medication for UTI in the elderly is trimethoprim-sulfamethoxazole though clinicians should assess local resistance rates to influence their empiric antibiotic choices.

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Second-line medications

When intervening for UTIs in the elderly, the second-line treatment involves Beta-lactam antibiotics, which include amoxicillin-clavulanate and cefaclor. These antibiotics are only essential if the other treatments have failed to intervene in the patient’s conditions and should be used within three to seven days (Durkin et al., 2018). However, the healthcare providers should use the second-line treatment sparingly to avoid further implicating the patients’ health.

c. Other treatments

Non-pharmacological interventions are also used to treat UTIs in elderly patients. First, the client will be prescribed cranberry products. According to Rodriguez-Mañas (2020), cranberry products effectively treat UTI symptoms in women. Secondly, the client is advised to increase fluid intake, which will flush excess bacteria from the urinary tract system. The client is also advised to void regularly and ensure that the bladder is completely emptied to prevent the accumulation of bacteria in the urinary tract system.

d. Follow-Up Care

The treatment plan for elderly patients with UTIs includes follow-up care. The client is advised to visit the health care clinic after 2 weeks. Follow-up care allows the healthcare provider to monitor how the client is responding to the prescribed medication, including drug-related side effects. According to Gharbi et al. (2019), antibiotics used in treating UTIs in women increase the risk of bloodstream infection. If the prescribed medication has been effective in treating the presented symptoms, the healthcare provider educates the client about maintaining a high level of hygiene and drinking a lot of fluids to avoid recurrence. On the contrary, if the client reports initial symptoms or slight improvement in the initial symptoms during follow-up care, an alternative treatment plan is developed. Alternative treatment should also be prescribed if the client reports adverse drug reactions during the follow-up care.

Referral

The client might be referred to a gynecologist for further examination if the symptoms persist even after completing the prescribed dosage. Additionally, a client might be referred to a gynecologist if other symptoms such as vaginal bleeding, lower back pain, or a mass in the pelvic region are reported. In such cases, the client requires further medical check-ups to rule out other obstetric cases associated with such symptoms.

References

American Medical Association (AMA). (2021). State law chart: Nurse Practitioner Practice Authority. AMA. https://www.ama-assn.org/system/files/2020-02/ama-chart-np-practice-authority.pdf

Chu, C. M., & Lowder, J. L. (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

Czajkowski, K., Broś-Konopielko, M. & Teliga-Czajkowska, J. (2021). Urinary tract infection in women. Menopausal Review; 20(1):40-47. DOI:10.5114/pm.2021.105382

Durkin, M. J., Keller, M., Butler, A. M., Kwon, J. H., Dubberke, E. R., Miller, A. C., … & Olsen, M. A. (2018, September). An assessment of inappropriate antibiotic use and guideline adherence for uncomplicated urinary tract infections. In Open forum infectious diseases (Vol. 5, No. 9, p. ofy198). US: Oxford University Press. https://doi.org/10.1093/ofid/ofy198

Gharbi, M., Drysdale, J. H., Lishman, H., Goudie, R., Molokhia, M., Johnson, A. P., … & Aylin, P. (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, 364. DOI: https://doi.org/10.1136/bmj.l525

Godbole, G. P., Cerruto, N., & Chavada, R. (2020). Principles of assessment and management of urinary tract infections in older adults. Journal of Pharmacy Practice and Research, 50(3), 276-283. https://doi.org/10.1002/jppr.1650

Kang, C. I., Kim, J., Park, D. W., Kim, B. N., Ha, U. S., Lee, S. J., … & Wie, S. H. (2018). Clinical practice guidelines for the antibiotic treatment of community-acquired urinary tract infections. Infection & chemotherapy, 50(1), 67. DOI: 10.3947/ic.2018.50.1.67

Medina, M., & Castillo-Pino, E. (2019). An introduction to the epidemiology and burden of urinary tract infections. Therapeutic advances in urology, 11, 1756287219832172. https://doi.org/10.1177/1756287219832172

Rodriguez-Mañas, L. (2020). Urinary tract infections in the elderly: a review of disease characteristics and current treatment options. Drugs in context, 9. Doi: 10.7573/dic.2020-4-13