Nursing diagnosis – RISK FOR INFECTION

RISK  FOR  INFECTION

DEFINITION

At risk for being invaded by pathogenic organisms

RISK FACTORS

• Altered immune function

• Pharmaceutical agents

• Amniotic membrane rupture

• Inadequate primary (such as

• Chronic disease

skin) or secondary (such as

• Environmental exposure to

inflammatory response)

pathogens

defenses

• Invasive procedures

• Malnutrition

• Lack of knowledge about

• Tissue destruction

causes of infection

• Trauma

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid/electrolytes

• Risk management

• Neurocognition

• Sensation/perception

EXPECTED OUTCOMES

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

thrombophlebitis

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

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bathroom, bedpan, or urinal to avoid spread of pathogens; also, use

strict sterile technique when handling would dressings to maintain

asepsis.

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;

Wound Care

Reference

Marrs, J. A. (2006, April). Care of patients with neutropenia. Clinical Journal

of Oncology Nursing, 10(2), 164–166.

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