Charting: UTIs

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Specializes in Currently: Certified School Nurse.

We have a lot of UTIs on our unit. Please tell me what else is important to include in my note. THank you.

- temp

- charachter of urine (color, odor)

- dysuria?

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Specializes in LTC.

I work in LTC, and there are alot of behaviors noted with UTIs.

Usually confusion and mild combativeness in an otherwise A/O and compliant resident.

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Specializes in ER, Trauma.

In the ER I've frequently seen altered mentation or listlisness as the most pronounced symptom of a UTI, along with mild changes in vital signs. Foul urine in somebody with a catheter means an automatic catherter change if no contra-indications, some hospitals even wanting to culture the bladder end of the catheter. In the ER it seems that the pts with UTI's are often those who are least able to maintain their own hydration and other ADL's. More insight than actual charting suggestions, hope it helps.

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Specializes in Currently: Certified School Nurse.

I should also chart my interventions - -

- encouraged fluids

- refer to MD

- UA/CS ordered or pending results

- UA/CS results if they are in

- any ABX ordered

Correct?

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Usually include urinary frequency, urgency, color, odor, dysuria, hematuria, & temp.

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Specializes in Spinal Cord injuries, Emergency+EMS.
We have a lot of UTIs on our unit. Please tell me what else is important to include in my note. THank you.

- temp

- charachter of urine (color, odor)

- dysuria?

full set of obervations not just temperature

NPT dipstick result

when and what sort of urine samples are sent to the labs

if the patient is catheterised or not and when drainage devices are changed ...

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Specializes in LTC, Memory loss, PDN.

discomfort and is it addressed (Pyridium, Azo Standard)

any teaching

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Specializes in LTC.

I work in LTC. We have a UTI flowsheet we use for charting on someone with a UTI. It includes:

Temp

c/o increased urgency/frequency

c/o pain/burining with urination

color/clarity/odor of urine

increased incontinence

worsening functional/mental status

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Specializes in PICU, NICU, L&D, Public Health, Hospice.

All good suggestions...

the question that came immediately to my mind was...WHY?

Why so many UTI's? What are the risk factors of your patient population? Use the nursing process to discover if there are interventions that could reduce this risk.

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Specializes in ICU, CM, Geriatrics, Management.

S/s of adverse reactions to abt

Fluids encouraged

Resting

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Specializes in Pediatrics, Geriatrics, LTC.

VS, the name of the abx "for UTI". list any adverse effects of med or "no adverse effects noted". is the res eating and taking po fluids well,

example I would do

99.4, 122/64, 68, 22. Resident continues on Bactrim DS for UTI. No adverse effects of medication noted. (Or "resident c/o several episodes of loose stools with some abdominal cramping) No c/o dysuria or other distress offered. (Or, "resident c/o burning on urination") Resident is voiding Q-shift clear yellow urine with slight odor. Ate 50% of the evening meal. Is taking po fluids well, 360 cc's this shift. Will continue to monitor.

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Specializes in Currently: Certified School Nurse.

Thanks everyone for taking the time to respond.

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