NURSING DIAGNOSIS: Risk for infection

  1. wound infection related to:
    1. wound contamination associated with introduction of pathogens during or following surgery (especially with a perineal approach because incision is close to the anus)
    2. delayed wound healing associated with factors such as diminished tissue perfusion of wound area (especially if client received external radiation therapy prior to surgery) and decreased nutritional status (if present);
  2. urinary tract infection related to:
    1. introduction of pathogens associated with presence of indwelling catheter
    2. increased growth and colonization of microorganisms associated with urinary stasis (can occur with decreased activity and catheter obstruction).
Desired Outcome
The client will remain free of wound infection (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 and prevention of wound infection.
  2. If a perineal approach was used, implement additional measures to prevent wound infection:
    1. instruct and assist client to perform good perineal care immediately after bowel movements
    2. use a double-tailed T-binder, scrotal support, or jockey shorts to secure perineal dressings (movement of loose dressings can cause skin irritation and subsequent breakdown).
Desired Outcome
The client will remain free of urinary tract infection as evidenced by:
  1. clear urine
  2. absence of chills and fever
  3. fewer than 5 WBCs and absence of nitrites and bacteria in urine
  4. 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, 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 retention and subsequent stasis of urine (see Postoperative Diagnosis 2, action b)
    2. maintain a fluid intake of at least 2500 ml/day unless contraindicated to promote urine formation and subsequent flushing of pathogens from the bladder
    3. maintain sterile technique during bladder irrigations if performed
    4. perform catheter care as often as needed to prevent accumulation of mucus and blood around the meatus
    5. keep urine collection container below bladder level at all times to prevent reflux or stasis of urine
    6. anchor tubing securely to reduce the amount of in-and-out movement of the catheter (this movement can result in the introduction of pathogens into the urinary tract and can cause tissue trauma, which can result in colonization of microorganisms)
    7. if frequent bladder irrigations are necessary, consult physician about initiation of continuous, closed system irrigation (frequent intermittent irrigations increase the risk of introduction of pathogens)
    8. increase activity as allowed and tolerated to decrease urinary stasis.
  3. If signs and symptoms of urinary tract infection are present, administer antimicrobials as ordered.