Nursing Care Plan for Risk for Infection

Sample of nursing care plan for risk for infection

Nursing diagnosis: Risk for Infection

Definition of risk for infection | Nursing Care Plan for Risk for Infection

  • At increased risk for being invaded by pathogenic organisms

Risk Factors of risk for infection | Nursing Care Plan for Risk for Infection

  • Inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis)

  • Inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response) and immunosuppression

  • Inadequate acquired immunity; tissue destruction and increased environmental exposure; invasive procedures

  • Chronic disease, malnutrition, trauma

  • Pharmaceutical agents [including antibiotic therapy]

  • Rupture of amniotic membranes

  • Insufficient knowledge to avoid exposure to pathogens

NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes/Evaluation Criteria—Client Will:

  • Verbalize understanding of individual causative/risk factor(s).

  • Identify interventions to prevent/reduce risk of infection.

  • Demonstrate techniques, lifestyle changes to promote safe environment.

  • Achieve timely wound healing; be free of purulent drainage or erythema; be afebrile.

Nursing Interventions of risk for infection | Nursing Care Plan for Risk for Infection

NURSING PRIORITY NO. 1. To assess causative/contributing factors:

  • Note risk factors for occurrence of infection (e.g., compromised host, skin integrity, environmental exposure).

  • Observe for localized signs of infection at insertion sites of invasive lines, sutures, surgical incisions/wounds.

  • Assess and document skin conditions around insertions of pins, wires, and tongs, noting inflammation and drainage.

  • Note signs and symptoms of sepsis (systemic infection): fever, chills, diaphoresis, altered level of consciousness, positive blood cultures.

  • Obtain appropriate tissue/fluid specimens for observation and culture/sensitivities testing.

Nursing Interventions of risk for infection | Nursing Care Plan for Risk for Infection

NURSING PRIORITY NO. 2. To reduce/correct existing risk factors:

  • Stress proper handwashing techniques by all caregivers between therapies/clients. A first-line defense against nosocomial infections/cross-contamination.

  • Monitor visitors/caregivers to prevent exposure of client.

  • Provide for isolation as indicated (e.g., wound/skin, reverse). Reduces risk of cross-contamination.

  • Perform/instruct in preoperative body shower/scrubs when indicated (e.g., orthopedic, plastic surgery).

  • Maintain sterile technique for invasive procedures (e.g., IV, urinary catheter, pulmonary suctioning).

  • Cleanse incisions/insertion sites daily and prn with povidone iodine or other appropriate solution.

  • Change dressings as needed/indicated.

  • Separate touching surfaces when skin is excoriated, such as in herpes zoster. Use gloves when caring for open lesions to minimize autoinoculation/transmission of viral diseases (e.g., herpes simplex virus, hepatitis, AIDS).

  • Cover dressings/casts with plastic when using bedpan to prevent contamination when wound is in perineal/pelvic region.

  • Encourage early ambulation, deep breathing, coughing, position change for mobilization of respiratory secretions.

  • Monitor/assist with use of adjuncts (e.g., respiratory aids such as incentive spirometry) to prevent pneumonia.

  • Maintain adequate hydration, stand/sit to void, and catheterize if necessary to avoid bladder distention.

  • Provide regular catheter/perineal care. Reduces risk of ascending UTI.

  • Assist with medical procedures (e.g., wound/joint aspiration, incision and drainage of abscess, bronchoscopy) as indicated.

  • Administer/monitor medication regimen (e.g., antimicrobials, drip infusion into osteomyelitis, subeschar clysis, topical antibiotics) and note client’s response to determine effectiveness of therapy/presence of side effects.

  • Administer prophylactic antibiotics and immunizations as indicated.

Nursing Interventions of risk for infection | Nursing Care Plan for Risk for Infection

NURSING PRIORITY NO. 3. To promote wellness (Teaching/Discharge Considerations):

  • Review individual nutritional needs, appropriate exercise program, and need for rest.

  • Instruct client/SO(s) in techniques to protect the integrity of skin, care for lesions, and prevention of spread of infection.

  • Emphasize necessity of taking antibiotics as directed (e.g., dosage and length of therapy). Premature discontinuation of treatment when client begins to feel well may result in return of infection.

  • Discuss importance of not taking antibiotics/using “leftover” drugs unless specifically instructed by healthcare provider. Inappropriate use can lead to development of drug-resistant strains/secondary infections.

  • Discuss the role of smoking in respiratory infections.

  • Promote safer-sex practices and report sexual contacts of infected individuals to prevent the spread of sexually transmitted disease.

  • Involve in community education programs geared to increasing awareness of spread/prevention of communicable diseases.

  • Promote childhood immunization program. Encourage adults to update immunizations as appropriate.

  • Include information in preoperative teaching about ways to reduce potential for postoperative infection (e.g., respiratory measures to prevent pneumonia, wound/dressing care, avoidance of others with infection).

  • Review use of prophylactic antibiotics if appropriate (e.g., prior to dental work for clients with history of rheumatic fever).

  • Identify resources available to the individual (e.g., substance abuse/rehabilitation or needle exchange program as appropriate; available/free condoms, etc.).

  • Refer to NDs Disuse Syndrome, risk for; Home Maintenance, impaired; Health Maintenance, ineffective.

Documentation Focus | Nursing Care Plan for Risk for Infection

ASSESSMENT/REASSESSMENT| Nursing Care Plan for Risk for Infection

  • Individual risk factors that are present including recent/current antibiotic therapy.

  • Wound and/or insertion sites, character of drainage/body secretions.

  • Signs/symptoms of infectious process

PLANNING| Nursing Care Plan for Risk for Infection

  • Plan of care/interventions and who is involved in planning.

  • Teaching plan.

IMPLEMENTATION/EVALUATION| Nursing Care Plan for Risk for Infection

  • Responses to interventions/teaching and actions performed.

  • Attainment/progress toward desired outcome(s).

  • Modifications to plan of care.

DISCHARGE PLANNING| Nursing Care Plan for Risk for Infection

  • Discharge needs/referrals and who is responsible for actions to be taken.

  • Specific referrals made.

This is a sample of Nursing Care Plan for Risk for Infection: Nursing Diagnosis for Risk for Infection.