Preventing UrinaryTract Infections

Nursing measures alonedramatically reducedUTI in a nursing home.

JOHN McCONNELL

The institutionalized elderly are atrisk for urinary tract infection, oneof their most common and distress­ing misfortunes. Inadequate hydra­tion, immobility, chronic disease,poor hygiene and toileting, and ure­thral catheters are among the con­tributing causes(l-3).

Most nursing personnel in long­term care recognize those facts .Yet some of the contributingcauses are potentiated rather thanminimized by institutional routinesor nursing procedures. Many anursing home resident reduces fluidintake to decrease urinary inconti­nence, unintentionally setting thestage for dehydration or a UTI.Many staff members assume thatfluids at mealtime and a bedsidepitcher of ice water will keep resi­dents hydrated.

But does the staff know whetherthe resident understands how muchto drink, is able to manipulate thepitcher and glass, or even if the res­ident will drink water?

Immobility is another problemwe quite unconsciously tend tomake worse. It's understandablydifficult to monitor the safety of 10to 13 confused adults wanderingthroughout a unit. This, combinedwith nurses' deep-felt distress if aresident falls, encourages the use ofgerichairs, Posey vests, and other

John McConnell, RN, MS, is director ofnurs ing at Her itage Healthcare Center. Ta­koma Park. MD.

devices that restrict activity andcontribute to further mobility prob­lems. Using bedpans and diaperingare also unwise because these prac­tices may introduce stool into theurinary tract.

Probably our worst error is to useindwelling urethral catheters as a"treatment" for incontinence. Ap­proximately 40 percent of noso­comial infections are UTIs, the ma­jority of them related to urethralcatheterization(3). The argumentfor placing catheters in the inconti­nent is usually the maintenance ofskin integrity. But adequate hydra­tion; individualized toileting, turn­ing. and repositioning; and goodhygiene will preserve skin integritywithout the use of catheters.

All of the situations describedabove respond favorably to nursingintervention. Since nursing mea­sures can minimize or eliminatefactors that contribute to UTI, theyshould prevent it and reduce therisk associated with advanced ageand institutionalization.

With this in mind, a combinationof nursing interventions was intro­duced at a proprietary, comprehen­sive care facility that providesskilled nursing and intermediatecare to 102 residents. Their agesranged from 60 to 100. Approxi­mately 66 percent were inconti­nent; 55 percent, confused.

The staff consisted of two regis­tered nurses, one licensed practicalnurse, two certified medicationaides, and 11 nurses' aides on days;one RN, LPN, and CMA, and 9NAs on evenings; one RN andLPN, and five NAs on night duty.Nursing hours averaged 2.6 perresident. The state minimum re­quirement is 2 hours. Staffing re­mained the same while the new

measures were being introducedand for the next six months.

Nursing Interventlons

The measures to prevent UTI in­cluded a hydration program, anambulation program, a toiletingprogram, and education of staffand residents . The goal was notonly to reduce UTI but to improvemobility, continence, hydration,bowel regularity, and self-esteem.

Increasing fluid intake helpsflush the lower urinary tract, keepsurine dilute, and helps preventstone formation(4). A total of1,400 milliliters of fluid were of­fered with daily meals. Ice waterwas kept at each resident's bedside,and fruit juices were served be­tween meals and at bedtime.

The purpose and importance ofthe increased fluid intake were ex­plained to nursing personnel, andthe amounts described in terms ofthe cups and containers they ordi­narily used, in order to help themrecord intake accurately.

A few residents complained thatthe staff was trying to "float themaway." And others, who had beenattempting to manage their incon­tinence by reducing fluids, were ag­itated at first by what they consid­ered an attempt to thwart their log­ical response to their problem. Sev­eral group sessions were held to ac­quaint residents with the reasonsfor increasing fluids. Individualsessions were arranged to reinforcewhat had been said in the groups.

Correct toileting encourages resi­dents to establish a consistent rou­tine, and allows for the privacy andposture that help prevent the volun­tary or involuntary retention ofurine or feces . The new toiletingprocedure discouraged the use ofbedpans and placed on an individu­al schedule every resident who wasunable to respond quickly enoughor appropriately to the urge to uri­nate or defecate. The individual­ized schedule was communicated toall staff members, who took eachperson to the toilet at his or herspecified times throughout the day .A disposable incontinent productwas provided for those residentswho had unavoidable accidents.

Geriatric Nursing November/December 1984361

Nursing measures to prevent urinary tract infections were implemented lully in December1982. By the end of June, the number of UTls acquired inhouse had dropped markedly.

N o s o c o m lc a l U ri nary T ra ct Inl c tionsJun 1982 to July 1983

10

9 ....--8

7

6

5 ,--- -4 ....-- ....--

3 .-- .--2 .-- .-- ..-- ..--

1 nJune July S pi OCI. ov Dec Jan . Fe ar. Apr ay Jun

The toi!eting program took muchof the nursing assistants' time untilit became routine and more resi­dents began to walk again.

A third nursing intervention wasto encourage ambulation. Mobilityis essential to prevent urinary sta­sis, which promotes bacterial colon­ization in the bladder(5) . Impairedmobility also increases calciumloss, which predisposes to the for­mation of renal calculi.

The ambulation guidelines statedthat every resident who had nomedical reason for immobilitywould be assisted in walking to tol­erance twice a day. At first, thismeant two or three steps for some,but progress was seen almost im­mediately. ' A poster showing eachresident's name and accomplish­ments kept staff informed and en­couraged the residents.

Physicians were glad to discon­tinue all unnecessary catheters.Their willingness may indicate thatmanaging incontinence with ure­thral catheters had been a nursingrather than a medical preference.When residents had catheters onadmission from the hospital, thephysicians were asked to discontin­ue the Foley catheters after the res­idents had a short period of bladdertraining. Again, the physicianswere very cooperative.

Six months after the nursing in­terventions were in complete effect,a retrospective survey of the entire12 months was done. All UTIs ac­quired in the facility were traced,from , pharmacy, lab, and medicalrecords. August 1982 was excludedbecause the information for thatmonth was incomplete.

UTI Decreased

The numbers of nosocomialUTIs appear in the graph. Thenumber of UTIs acquired inhousepeaked in September 1982. Afterthe complete implementation of thenursing interventions in December,the number of inhouse-acquiredUTIs decreased from an average offive a month to an average of two,

These results indicate that thenursing interventions, which in­cluded ensuring the absence of in­dwelling urethral catheters, re-

duced the incidence of infection.The cost of UTI both in quality

of life and in dollars is enormouswhen one considers the discomfort,complications: and even death theycause, not to mention the relateddrugs, equipment, and frequenthospitalization. .

Several measures were intro­duced at the same time, so it is im­possible to determine the weight ofeach measure. However, each in­tervention was therapeutic dense inthat it helped prevent not only UTIbut also pneumonia, constipation,dehydration, immobility, and con­tractures; and promoted self-es­teem and continence.

Staff and residents have experi­enced benefits in addition to theprevention of urinary tract infec­tions, most notably an environment

. free of urine odors. The urine is di­lute because of the residents' im­proved hydration, and the toi!etingprogram prevents avoidable acci­dents. The number of ambulatoryresidents has risen. This decreasesthe potential for skin problems andcontractures. It also decreases the ­amount of heavy lifting to be doneby nursing assistants. Laxative usehas declined over the past six -toeight months, and care is providedmore consistently,

The professional staff is noworiented to prevention because theyrealize they can improve residentcare without medicines and beforean acute illness occurs.

It may be impossible to eliminate

UTIs from the institutional setting,but nursing 'measures to preventthem should become the standardin long-term care. In some geronto­logical texts, the first nursing ac­tion related to urinary tractinfec­tion is observation for its symp­toms, then the steps to take once itis established. Perhaps nursing'sdeep roots in acute care are whatmake us more comfortable dealingwith acute illness than taking ac­tion to prevent it.

In long-term care, nurses havethe advantage of knowing-most res­idents very well . That knowledge,our opportunities for health teach­ing, and considerable control overenvironment and procedure can en­able us to look beyond simply inter­vening during episodes of illness.

If the incidence of urinary tractinfection were cut in half in thelong-term care facilities across thenation, the impact on health careand health-care costs would bestaggering. The potential is there.It's up to nursing to do it.

ReferencesI. Carnevali, D. L., and Patrick, M ., eds. Nurs­

ing Managem ent for the Elderly. Philadel ­phia, J.B. Lippincott Co., 1979, p. 344 .

2. Eliopoulos, C. K. Gerontological Nursing.Philadelphia, J.R. Lippincott Co., 1979 .

3. Reese, R. E., and Douglas, R. G. A PracticalApproach to Infe ctious Diseases. Boston. Lit.tie, Brown & Co., 1983 , p. 491.

4. Hart, Mon ica, and Adamek, Constance. Doincresed fluids decreaseurin ary stone forma­tion? Geriatr .Nurs . 5:245-248, J uly-Au g.1984 .

5. Dontas, A. S.• and others. Bacteriuria andsurvival in old age. N .Engl.J .Med. 304:939­943, Apr. 16, 1981.

362 Geri atric Nursing November/December 1984