Appendices
20
Appendix B: Continued
A Assessment Input (check all boxes that apply)
Resident WITH indwelling
catheter
e criteria are met to initiate
antibiotics if one of the below
are selected
Resident WITHOUT indwelling catheter
Criteria are met if one of the three situations are
met
No Yes No Yes
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
Fever of 100°F (38°C)
or repeated temperatures
of 99°F (37°C)
a
New back or flank pain
Acute pain
Rigors /shaking chills
New dramatic change in
mental status
Hypotension (significant
change from baseline BP
or a systolic BP <90)
❑ ❑
1. Acute dysuria alone
— OR ———————————————
❑ ❑
2. Single temperature of 100°F (38°C)
and at least one new or worsening of
the following :
❑
urgency
❑
suprapubic pain
❑
frequency
❑
gross hematuria
❑
back or
flank pain
❑
urinary
incontinence
— OR ———————————————
❑ ❑
3. No fever, but two or more of the
following symptoms:
❑
urgency
❑
suprapubic pain
❑
frequency
❑
gross hematuria
❑
incontinence
Nurses: Please check box to indicate whether or not criteria are met
❑
Nursing home protocol criteria are met. Resident may require UA with C&S or
an antibiotic.
b
❑
Nursing home protocol criteria are NOT met. e resident does NOT need an
immediate prescription for an antibiotic but may need additional observation.
c
a
For residents that regularly run a lower temperature, use a temperature of 2°F (1°C) above the
baseline as a definition of a fever.
b
is is according to our understanding of best practices and our facility protocols. Minimum
criteria for a UTI must meet 1 of 3 criteria listed in box.
c
is is according to our understanding of best practices and our facility protocols. e information
is insufficient to indicate an active UTI infection.
