NURSING DIAGNOSIS: Risk for infection: extrapulmonary (e.g. bacteremia, pericarditis, endocarditis, meningitis, septic arthritis) and/or superinfection (e.g. candidiasis)

related to:
  1. spread of infecting organism into the blood and to other sites associated with inadequate host defenses and resistance to antimicrobial agents;
  2. interruption in the balance of usual endogenous microbial flora associated with the administration of antimicrobial agents.
Desired Outcome
The client will not develop an extrapulmonary infection or a superinfection as evidenced by:
  1. gradual return of vital signs to normal
  2. usual mental status
  3. absence of a pericardial friction rub, precordial pain, and a pathologic murmur
  4. absence of joint pain and swelling
  5. absence of unusual drainage from any body cavity
  6. absence of white patches and ulcerations in mouth
  7. absence of stiff neck and headache
  8. WBC and differential counts returning toward normal range for client.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of an extrapulmonary infection or a superinfection:
    1. increase in temperature and pulse above previous levels
    2. change in mental status
    3. pericardial friction rub, precordial pain, or development of a pathologic murmur
    4. swollen, red, painful joints
    5. unusual color, amount, and odor of vaginal drainage; perineal itching; white patches or ulcerated areas in the mouth (fungal infections are common superinfections with antimicrobial therapy)
    6. stiff neck, headache
    7. increase in WBC count above previous levels and/or significant change in differential.
  2. Implement measures to prevent an extrapulmonary infection and/or a superinfection:
    1. perform actions to resolve the infectious process (see Diagnosis 6, action b.1)
    2. use good handwashing technique and encourage client to do the same
    3. maintain sterile technique during all invasive procedures (e.g. urinary catheterizations, venous and arterial punctures, injections)
    4. change peripheral intravenous line sites according to hospital policy
    5. protect client from others with infection
    6. anchor catheters/tubings (e.g. urinary, intravenous) securely in order to reduce trauma to the tissues and the risk for introduction of pathogens associated with in-and-out movement of the tubing
    7. change equipment, tubings, and solutions used for treatments such as intravenous infusions and respiratory care according to hospital policy
    8. maintain a closed system for drains (e.g. urinary catheter) and intravenous infusions whenever possible
    9. instruct and assist client to perform good perineal care routinely and after each bowel movement
    10. reinforce importance of frequent oral hygiene.
  3. If signs and symptoms of an extrapulmonary infection or a superinfection occur:
    1. prepare client for and/or assist with diagnostic tests (e.g. lumbar puncture, cultures, joint aspiration) if planned
    2. implement appropriate comfort measures for symptoms experienced
    3. administer antimicrobials as ordered.