NURSING DIAGNOSIS: Risk for infection

  1. pneumonia related to stasis of pulmonary secretions associated with decreased activity; depressed ciliary function resulting from the effect of anesthesia; and a poor cough effort resulting from weakness, surgical site pain, and fear of dislodging chest tube;
  2. wound infection and mediastinitis related to:
    1. wound contamination associated with introduction of pathogens during or following surgery
    2. decreased resistance to infection associated with factors such as inadequate nutritional status and diminished tissue perfusion to wound area (an increased risk if client is elderly or has diabetes or if on cardiopulmonary bypass a prolonged time or cardiac output is low for a prolonged time).
Desired Outcome
The client will not develop pneumonia (see Standardized Postoperative Care Plan, Diagnosis 17, for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Postoperative Care Plan, Diagnosis 17, for measures related to assessment, prevention, and treatment of pneumonia.
  2. Implement additional measures to reduce the risk for pneumonia:
    1. perform actions to maintain adequate respiratory function (see Postoperative Diagnosis 2, action b)
    2. have client splint chest incision with a pillow when turning, coughing, and deep breathing in order to increase client's willingness to move, cough, and deep breathe.