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Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Nursing Diagnosis: Risk for Infection
Universal Precautions; Standard Precautions; CDC Guidelines; OSHA

NOC Outcomes (Nursing Outcomes Classification)

  • Immune Status
  • Knowledge: Infection Control

NIC Interventions (Nursing Interventions Classification)

  • Infection Control
  • Infection Protection

NANDA Definition: At increased risk for being invaded by pathogenic organisms

Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. Infections occur when an organism (e.g., bacterium, virus, fungus, or other parasite) invades a susceptible host. Breaks in the integument, the body’s first line of defense, and/or the mucous membranes allow invasion by pathogens. If the host’s (patient’s) immune system cannot combat the invading organism adequately, an infection occurs. Open wounds, traumatic or surgical, can be sites for infection; soft tissues (cells, fat, muscle) and organs (kidneys, lungs) can also be sites for infection either after trauma, invasive procedures, or by invasion of pathogens carried through the bloodstream or lymphatic system. Infections can be transmitted, either by contact or through airborne transmission, sexual contact, or sharing of intravenous (IV) drug paraphernalia. Being malnourished, having inadequate resources for sanitary living conditions, and lacking knowledge about disease transmission place individuals at risk for infection. Health care workers, to protect themselves and others from disease transmission, must understand how to take precautions to prevent transmission. Because identification of infected individuals is not always apparent, standard precautions recommended by the Centers for Disease Control and Prevention (CDC) are widely practiced. In addition, the Occupational Safety and Health Administration (OSHA) has set forth the Blood Borne Pathogens Standard, developed to protect workers and the public from infection. Ease and increase in world travel has also increased opportunities for transmission of disease from abroad. Infections prolong healing, and can result in death if untreated. Antimicrobials are used to treat infections when susceptibility is present. Organisms may become resistant to antimicrobials, requiring multiple antimicrobial therapy. There are organisms for which no antimicrobial is effective, such as the human immunodeficiency virus (HIV).

    Risk Factors:
  • Inadequate primary defenses: broken skin, injured tissue, body fluid stasis
  • Inadequate secondary defenses: immunosuppression, leukopenia
  • Malnutrition
  • Intubation
  • Indwelling catheters, drains
  • Intravenous (IV) devices
  • Invasive procedures
  • Rupture of amniotic membranes
  • Chronic disease
  • Failure to avoid pathogens (exposure)
  • Inadequate acquired immunity
    Expected Outcomes
  • Patient remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.
  • Infection is recognized early to allow for prompt treatment.

Ongoing Assessment

  • Assess for presence, existence of, and history of risk factors such as open wounds and abrasions; in-dwelling catheters (Foley, peritoneal); wound drainage tubes (T-tubes, Penrose, Jackson-Pratt); endotracheal or tracheostomy tubes; venous or arterial access devices; and orthopedic fixator pins. Each of these examples represent a break in the body’s normal first lines of defense.
  • Monitor white blood count (WBC). Rising WBC indicates body’s efforts to combat pathogens; normal values: 4000 to 11,000 mm3. Very low WBC (neutropenia <1000 mm3) indicates severe risk for infection because patient does not have sufficient WBCs to fight infection. NOTE: In elderly patients, infection may be present without an increased WBC.
  • Monitor the following for signs of infection:
    • Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit sites of tubes, drains, or catheters Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified at culture.
    • Elevated temperature Fever of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, fever above 37.7° C (99.8° F) suggests infection; fever spikes that occur and subside are indicative of wound infection; very high fever accompanied by sweating and chills may indicate septicemia.
    • Color of respiratory secretions Yellow or yellow-green sputum is indicative of respiratory infection.
    • Appearance of urine Cloudy, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection.
  • Assess nutritional status, including weight, history of weight loss, and serum albumin. Patients with poor nutritional status may be anergic, or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection.
  • In pregnant patients, assess intactness of amniotic membranes. Prolonged rupture of amniotic membranes before delivery places the mother and infant at increased risk for infection.
  • Assess for exposure to individuals with active infections.
  • Assess for history of drug use or treatment modalities that may cause immunosuppression. Antineoplastic agents and corticosteroids reduce immunocompetence.
  • Assess immunization status. Elderly patients and those not raised in the United States may not have completed immunizations, and therefore not have sufficient acquired immunocompetence.

Therapeutic Interventions

  • Maintain or teach asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access management.
  • Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient. Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e.g., perineal care or central line care). Use of disposable gloves does not reduce the need for hand washing.
  • Limit visitors. This reduces the number of organisms in patient’s environment and restricts visitation by individuals with any type of infection to reduce the transmission of pathogens to the patient at risk for infection. The most common modes of transmission are by direct contact (touching) and by droplet (airborne).
  • Encourage intake of protein- and calorie-rich foods. This maintains optimal nutritional status.
  • Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).
  • Encourage coughing and deep breathing; consider use of incentive spirometer. These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.
  • Administer or teach use of antimicrobial (antibiotic) drugs as ordered. Antimicrobial drugs include antibacterial, antifungal, antiparasitic, and antiviral agents. All of these agents are either toxic to the pathogen or retard the pathogen’s growth. Ideally, the selection of the drug is based on cultures from the infected area; this is often impossible or impractical, and in these cases, empirical management usually is undertaken with a broad-spectrum drug.
  • Place patient in protective isolation if patient is at very high risk. Protective isolation is established if white blood cell counts indicate neutropenia (<500 to 1000 mm3). Institutional protocols may vary.
  • Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes.

Education/Continuity of Care

  • Teach patient or caregiver to wash hands often, especially after toileting, before meals, and before and after administering self-care. Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; hand washing reduces these risks.
  • Teach patient the importance of avoiding contact with those who have infections or colds.
  • Teach family members and caregivers about protecting susceptible patient from themselves and others with infections or colds.
  • Teach patient, family, and caregivers the purpose and proper technique for maintaining isolation.
  • Teach patient to take antibiotics as prescribed. Most antibiotics work best when a constant blood level is maintained; a constant blood level is maintained when medications are taken as prescribed. The absorption of some antibiotics is hindered by certain foods; patient should be instructed accordingly.
  • Teach patient and caregiver the signs and symptoms of infection, and when to report these to the physician or nurse.
  • Demonstrate and allow return demonstration of all high-risk procedures that patient or caregiver will do after discharge, such as dressing changes, peripheral or central IV site care, peritoneal dialysis, self-catheterization (may use clean technique). Bladder infection is more related to overdistended bladder resulting from infrequent catheterization than to use of clean versus sterile technique.

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