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.
