NURSING DIAGNOSIS: Risk for infection

related to:
  1. stasis of pulmonary secretions associated with decreased mobility and weak cough effort (an increased risk with elderly clients);
  2. wound contamination associated with introduction of pathogens during or following surgery (risk is increased because of close proximity of wound to perineal area);
  3. decreased resistance to infection associated with factors such as an inadequate nutritional status and decreased effectiveness of immune system if client is elderly;
  4. increased growth and colonization of microorganisms in the urine associated with urinary stasis if mobility is decreased and introduction of pathogens if indwelling catheter is present.
Desired Outcome
The client will remain free of infection as evidenced by:
  1. absence of fever and chills
  2. pulse within normal limits
  3. normal breath sounds
  4. usual mental status
  5. cough productive of clear mucus only
  6. voiding clear urine without reports of frequency, urgency, and burning
  7. absence of redness, heat, and swelling around wound
  8. usual drainage from wound
  9. no new or increased discomfort in hip
  10. sedimentation rate and WBC and differential counts returning toward normal range
  11. negative results of cultured specimens.
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Postoperative Care Plan, Diagnosis 17, for measures related to assessment and prevention of infection.
  2. Assess for and report additional signs and symptoms that may be indicative of wound infection or osteomyelitis:
    1. elevated sedimentation rate
    2. reports of increased discomfort.
  3. Maintain patency of wound drainage system if present (e.g. prevent kinking of tubing, keep collection device below surgical wound, keep suction device compressed) to prevent the accumulation of drainage and subsequent colonization of pathogens in the surgical area.
  4. If signs and symptoms of wound infection or osteomyelitis occur:
    1. administer antimicrobials as ordered
    2. prepare client for drainage of wound if planned.