Last updated on December 28th, 2023

Sample Nursing Care Plan for Urinary Tract Infection (UTI)

In this post, we’ll formulate a comprehensive scenario-based sample nursing care plan for urinary tract infection (UTI). It includes three nursing diagnoses and nursing interventions with the rationales.

UTI – Case Scenario

An 81-year old female presents to the ED with fever, chills, frequent urination, urgency, and dysuria. The patient has a history of hypertension, hyperlipidemia, and diabetes. She was recently admitted 1 week ago for a fall and was discharged after 1 night in observation. 

Patient reports waking up 8-9 times overnight to urinate and feels that she is unable to fully empty her bladder. She experiences burning and pain when she attempts to urinate, and also notes an abnormal urine odor. 

Upon physical assessment, the nurse notes the patient’s temperature is 38.3 C, heart rate is 110 beats per minute, blood pressure is 95/60 (62) mmHg and oxygen saturation 97%. The patient is alert and oriented but appears to be restless and irritable. Her lung sounds are clear, bowel sounds are active, and pain is noted upon palpation of her abdomen.

On the patient’s urinalysis, WBC’s are elevated at 7 HPF, leukocyte esterase is noted in large quantities and nitrates are positive. Head, chest, and pelvic CT scan is negative for any acute process. 

The patient is admitted to the hospital for a Urinary Tract Infection

#1 Sample Nursing Care Plan for Urinary Tract Infection (UTI) – Impaired Urinary Elimination

Nursing Assessment

Subjective Data:

• Reports of urinary frequency and urgency
• Pain with urination
• A feeling of being unable to empty bladder

Objective Data:

• Elevated temperature of 38.3 C
• Elevated heart rate of 110 bpm
• Urinalysis with elevated WBC and positive for leukocytes

Nursing Diagnosis

Impaired urinary elimination related to urethra inflammation as evidenced by dysuria, frequency, and urgency.

Goal/Desired Outcome

Short-term goal: The patient will report an improvement in frequency by voiding no more than once every 2 hours by the end of shift.

Long-term goal: The patient will exhibit a normal urinary pattern as evidenced by an absence of frequency and no reports of dysuria or urgency.

Nursing Interventions and Rationales for Impaired Urinary Elimination

Nursing Interventions	Rationales
Assess urinary elimination by asking questions r/t feelings of pain, frequency, urgency and compare to previous/normal pattern of elimination	Awareness of baseline elimination patterns can help detect abnormalities
Perform a culture and sensitivity test to determine and prescribe the appropriate antibiotic	Antibiotics will treat the underlying infection
Perform a physical assessment to monitor for worsening abdominal pain or distention	Urinary retention is a potential complication which can lead to kidney injury
Encourage patient to keep a bladder diary to track patterns of urination and any accompanying reports of dysuria or urgency	A diary can help patients track and recall urinary symptoms
Educate client in the prevention of infection, such as wiping front to back or consuming a daily glass of cranberry juice	Wiping front to back can help prevent anal bacteria from spreading to the urethra, and cranberry juice has been shown to reduce occurrence of UTI’s

#2 Sample Nursing Care Plan for Urinary Tract Infection (UTI) – Acute Pain

Nursing Assessment

Subjective Data:

• The patient reports dysuria and pain with urination

Objective Data:

• Pain noted with palpation of abdomen
• The patient grimaces with urination

Nursing Diagnosis

Acute pain related to inflammation and infection of urinary tract as evidenced by dysuria, pain with abdominal palpation, and grimacing during urination.

Goal/Desired Outcome

Short-term goal: The patient will utilize pain relief strategies and report an improvement and reduction in pain by the end of the shift. 

Long-term goal: The patient will report 0/10 pain

Nursing Interventions and Rationales for Acute Pain

Nursing Interventions	Rationales
Administer medications as needed to control pain, such as analgesics or antispasmodics	Analgesics such as acetaminophen and antispasmodics such as phenazopyridine have been shown to decrease bladder irritability and pain
Utilize non-pharmacologic pain relief strategies such as heat application	Heating pads can relieve abdominal and back pain related to UTIs
Regularly assess pain on a pain scale	Tracking pain location and severity can help determine an improvement or worsening in infection
Encourage patient to increase fluid intake	Consuming more fluids helps to flush the bladder and decrease inflammation and irritation
Treat with appropriate antibiotics and educate the patient on taking the full course of medications, even if symptoms disappear	Antibiotics will treat the underlying infection, and taking the full course will ensure reinfection doesn’t occur

#3 Sample Nursing Care Plan for Urinary Tract Infection (UTI) – Disturbed Sleep Pattern

Nursing Assessment

Subjective Data:

• The patient reports waking up 8-9 times overnight
• The patient complains of feelings of frequency and urgency

Objective Data:

• The patient is restless and irritable

Nursing Diagnosis

Sleep pattern disturbance related to urinary tract infection as evidenced by frequency and urgency

Goal/Desired Outcome

Short-term goal: The patient will notice an improvement in frequency and ability to sleep by urinating no more than once every 2 hours by the end of the shift

Long-term goal: The patient will get high-quality sleep, remain asleep through the night, and report feelings of restfulness

Nursing Interventions and Rationales for Disturbed Sleep Pattern

Nursing Interventions	Rationales
Administer appropriate antibiotics	To treat the underlying infection and relieve symptoms of frequency and urgency
Assess current sleep pattern and compare to previous/normal sleep pattern	Awareness of the patient’s baseline sleep pattern can help return patient to their normal sleeping habits
Reduce noise and offer earplugs or eye covers if desired	Creating a positive sleep environment can promote high-quality sleep
Manage pain with both pharmacologic and nonpharmacologic measures	Pain reduction can help promote sleep
Educate patient about avoiding alcohol and caffeine before bed	Both alcohol and caffeine are diuretics. Alcohol interferes with deep sleep and caffeine is a stimulant which can make it difficult to fall asleep

Conclusion

Urinary tract infection (UTI) is a common problem among all age groups. Here, we’ve discussed a scenario-based sample nursing care plan for an elderly patient with a urinary tract infection (UTI). Also, included nursing interventions for urinary tract infection (UTI) with rationales.

Reference

Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing Diagnoses Handbook: An Evidence-based Guide to Planning Care (12th ed.). Elsevier.

Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.

Swearingen, P. (2016). ALL-IN-ONE CARE PLANNING RESOURCE (4th ed.). Elsevier/Mosby.