NURSING DIAGNOSIS: Risk for infection

  1. pneumonia related to stasis of secretions in the lungs (secretions provide a good medium for bacterial growth);
  2. urinary tract infection related to:
    1. increased growth and colonization of microorganisms associated with urinary stasis
    2. introduction of pathogens into the urinary tract associated with the presence of an indwelling catheter and/or difficulty maintaining good perineal hygiene during period of immobility.
Desired Outcome
The client will remain free of urinary tract infection as evidenced by:
  1. clear urine
  2. absence of frequency, urgency, and burning on urination
  3. absence of chills and fever
  4. fewer than 5 WBCs and absence of nitrites and bacteria in urine
  5. negative urine culture.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of urinary tract infection (e.g. cloudy urine; reports of frequency, urgency, or burning on urination; chills; elevated temperature; urinalysis showing a WBC count greater than 5 or the presence of nitrites or bacteria; positive urine culture).
  2. Implement measures to prevent urinary tract infection:
    1. perform actions to prevent urinary stasis (see Diagnosis 12, action B.1 in renal calculi complication)
    2. maintain a fluid intake of at least 2500 ml/day unless contraindicated to promote urine formation and subsequent voiding, which flushes pathogens from the urethra and bladder
    3. instruct female client to wipe from front to back after urinating or defecating
    4. assist client with perineal care routinely and after each bowel movement
    5. maintain sterile technique during urinary catheterization and irrigations
    6. if an indwelling urinary catheter is present:
      1. secure the catheter tubing to lower abdomen or thigh on males or to thigh on females to minimize risk of accidental traction on the catheter and subsequent trauma to the bladder and urethra; anchor tubing securely to reduce the amount of in-and-out movement of the catheter (this movement can result in introduction of pathogens into the urinary tract and cause tissue trauma, which can result in colonization of microorganisms)
      2. perform catheter care as often as needed to prevent accumulation of mucus around the meatus
      3. maintain a closed drainage system whenever possible to reduce the risk of introduction of pathogens into the urinary tract
      4. keep urine collection container below bladder level at all times to prevent reflux or stasis of urine
      5. change catheter according to hospital policy.
  3. If signs and symptoms of urinary tract infection occur, administer antimicrobials if ordered.