Care Plan for Urinary Tract Infection (UTI)

Category / Primary Body System

• Genitourinary System

Problem

• Patient is at risk for complications due to urinary tract infection (UTI).

Goal

• Patient’s UTI will resolve within 30 days.

Plan/Approach

1. Medication Management

   • Administer antibiotics as ordered

2. Hydration and Nutrition

   • Encourage fluids unless contraindicated

3. Monitoring and Assessment

   • Monitor temperature every shift while on antibiotics
   • Monitor for behavioral changes and notify MD if present
   • Follow up with urine analysis (UA) and culture and sensitivity (C+S) if ordered by MD

4. Patient and Family Education

   • Educate patient and family on the importance of medication adherence and adequate fluid intake

Rationale

1. Medication Management

   • Administering prescribed antibiotics is essential to effectively treat the UTI and prevent complications.

2. Hydration and Nutrition

   • Adequate fluid intake helps flush bacteria from the urinary tract, aiding in the resolution of the infection.

3. Monitoring and Assessment

   • Regular temperature checks help detect persistent or worsening infection.
   • Monitoring for behavioral changes can identify early signs of complications, especially in elderly patients.
   • Follow-up urine tests ensure the infection is resolving and guide any necessary adjustments to treatment.

4. Patient and Family Education

   • Educating the patient and family enhances adherence to the treatment plan and promotes practices that support recovery.

Actions

1. Medication Management

   • Administer antibiotics as per the prescribed schedule, monitoring for side effects and therapeutic response.

2. Hydration and Nutrition

   • Encourage the patient to drink plenty of fluids, such as water and clear fluids, unless contraindicated by other medical conditions.

3. Monitoring and Assessment

   • Check and document the patient’s temperature every shift while they are on antibiotics, reporting any spikes or persistent fever to the MD.
   • Observe for any behavioral changes such as confusion, agitation, or lethargy, and notify the MD immediately if these are present.
   • Collect follow-up urine samples for UA and C+S as ordered by the MD to monitor the resolution of the infection.

4. Patient and Family Education

   • Provide education on the importance of completing the full course of antibiotics and the benefits of adequate hydration.
   • Explain the signs and symptoms of UTI and when to seek medical attention.
   • Offer written and verbal instructions on maintaining urinary tract health and preventing future infections.