RISK FOR INFECTION
At risk for being invaded by pathogenic organisms
• Altered immune function
• Pharmaceutical agents
• Amniotic membrane rupture
• Inadequate primary (such as
• Chronic disease
skin) or secondary (such as
• Environmental exposure to
• Invasive procedures
• Lack of knowledge about
• Tissue destruction
causes of infection
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Risk management
The patient will
• Have normal temperature, WBC count, and differential.
• Maintain good personal and oral hygiene.
• Have clear and odorless respiratory secretions.
• Have normal urine and be free from evidence of diarrhea.
• Exhibit wounds and incisions that show no signs of infection; and
intravenous sites with no signs of inﬂammation.
• Take ___ ml of ﬂuid and ___ g of protein daily.
• Identify infection risk factors, and signs and symptoms of infection.
SUGGESTED NOC OUTCOMES
Immune Status; Infection Status; Knowledge: Treatment Procedure(s),
and Infection Control; Nutritional Status; Risk Control; Risk Detec-
tion; Wound Healing: Primary Intention, and Secondary Intention
INTERVENTIONS AND RATIONALES
Determine: Monitor and record temperature after surgery at least
every 4 hr; report elevations immediately as this may signal onset of
pulmonary complications, wound infection or dehiscence, UTI, or
Monitor WBC count, as ordered. Report elevations or
depressions. Elevated total WBC count indicates infection. Markedly
decreased WBC count may indicate decreased production resulting
from extreme debilitation or severe lack of vitamins and amino
acids. Any damage to bone marrow may suppress WBC formation.
Monitor culture results of urine, respiratory secretions, wound
drainage, or blood according to facility policy and physician’s order.
This identiﬁes pathogens and guides antibiotic therapy.
Perform: Perform hand hygiene before and after providing care, and
direct patient to do this before and after meals and after using
bathroom, bedpan, or urinal to avoid spread of pathogens; also, use
strict sterile technique when handling would dressings to maintain
Offer frequent oral hygiene to prevent colonization of bacteria
and reduce risk of descending infection. Disease and malnutrition
may reduce moisture in mucous membranes of mouth and lips.
Change intravenous tubing and give site care every 24–48 hr or as
facility policy dictates to help keep pathogens from entering body.
Rotate intravenous sites every 48–72 hr or as facility policy dictates
to reduce chances of infection at individual sites.
Have patient cough and deep-breathe every 4 hr after surgery to
help remove secretions and prevent pulmonary complications. Pro-
vide tissues to encourage expectoration and convenient disposal bags
for expectorated sputum to reduce spread of infection.
Help patient turn every 2 hr. Provide skin care, particularly over
bony prominences to help prevent venous stasis and skin breakdown.
Assist patient when necessary to ensure that perianal area is clean
after elimination. Cleaning perineal area by wiping from the area of
least contamination (urinary meatus) to the area of most contamina-
tion (anus) helps prevent genitourinary infections.
Use sterile water for humidiﬁcation or nebulization of oxygen.
This prevents drying and irritation of respiratory mucosa, impaired
ciliary action, and thickening of secretions within respiratory tract.
Inform: Instruct patient to immediately report loose stools or
diarrhea which may indicate need to discontinue or change
antibiotic therapy; or to test for Clostridium difﬁcile.
Instruct patient about good hand hygiene, factors that increase infec-
tion risk, and signs and symptoms of infection to encourage patient
to participate in care and modify lifestyle to maintain optimum health.
Attend: Unless contraindicated, encourage ﬂuid intake of
3,000–4,000 ml daily to help thin mucus secretions; and offer high-
protein supplements to help stabilize weight, improve muscle tone
and mass, and aid wound healing.
Manage: Arrange for protective isolation if patient has compromised
immune system. Monitor ﬂow and number of visitors. These meas-
ures protect patient from pathogens in environment.
SUGGESTED NIC INTERVENTIONS
Incision Site Care; Infection Protection; Teaching: Procedure/Treatment;
Marrs, J. A. (2006, April). Care of patients with neutropenia. Clinical Journal
of Oncology Nursing, 10(2), 164–166.