NURSING DIAGNOSIS: Risk for infection

related to:
  1. lowered natural resistance associated with:
    1. malnutrition
    2. chemotherapy-induced bone marrow suppression
    3. long-term treatment with corticosteroids (may be used in treatment of certain types of cancer)
    4. disruption in normal, endogenous microbial flora resulting from antimicrobial therapy
    5. impaired immune system functioning resulting from certain malignancies (e.g. Hodgkin's disease, lymphoma, multiple myeloma, leukemia);
  2. break in mucosal surfaces associated with delayed cellular renewal resulting from effects of cytotoxic agents;
  3. break in integrity of the skin associated with placement of a central venous catheter (e.g. Groshong), implanted infusion device (e.g. Port-a-Cath), or peritoneal catheter (e.g. Tenckhoff);
  4. stasis of secretions in lungs and urinary stasis if mobility is decreased.
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 heat, pain, redness, swelling, and unusual drainage in any area
  8. no reports of increased weakness and fatigue
  9. WBC and differential counts within normal range for client
  10. negative results of cultured specimens.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report:
    1. absolute neutrophil count (WBC count multiplied by the percentage of neutrophils) below 1000/mm3 (indicative of severely impaired immune function)
    2. signs and symptoms of infection (be alert to subtle changes in the client since the signs of infection may be minimal as a result of immunosuppression; also be aware that some signs and symptoms vary depending on the site of the infection, the causative organism, and the age of the client):
      1. increase in client's usual temperature
      2. chills
      3. increased pulse
      4. abnormal breath sounds
      5. development of or increased malaise
      6. lethargy, acute confusion
      7. further loss of appetite
      8. cough productive of purulent, green, or rust-colored sputum
      9. cloudy urine
      10. reports of frequency, urgency, or burning when urinating
      11. presence of bacteria, nitrites, or greater than 5 WBCs in urine
      12. heat, pain, redness, swelling, or unusual drainage in any area
      13. reports of increased weakness or fatigue
      14. increase in WBC count and/or significant change in differential
      15. positive results of cultured specimens (e.g. urine, vaginal drainage, mouth, sputum, stool, blood).
  2. Implement measures to reduce the risk for infection:
    1. protect client from others with infections and those who have recently been vaccinated (a person may have a subclinical infection after a vaccination)
    2. use good handwashing technique and encourage client to do the same
    3. adhere to the appropriate precautions established to prevent transmission of infection to the client (standard precautions, neutropenic precautions)
    4. maintain a fluid intake of at least 2500 ml/day unless contraindicated
    5. perform actions to promote an adequate nutritional status (see Diagnosis 2, action c)
    6. encourage a low-microbial diet (e.g. cooked foods, no unwashed fresh fruits and vegetables) if the client is likely to be immunosuppressed
    7. perform actions to prevent or reduce severity of stomatitis and relieve dryness of the oral mucous membrane (see Diagnosis 5, actions b and c)
    8. avoid invasive procedures (e.g. urinary catheterizations, arterial and venous punctures, injections) whenever possible; if such procedures are necessary, perform them using sterile technique
    9. change intravenous insertion sites according to hospital policy
    10. 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 the in-and-out movement of the tubing
    11. maintain a closed system for drains (e.g. urinary catheter) and intravenous infusions whenever possible
    12. change equipment, tubings, and solutions used for treatments such as intravenous infusions, respiratory care, irrigations, and enteral feedings according to hospital policy
    13. initiate measures to prevent constipation (e.g. offer client a daily fiber supplement such as a mixture of bran, applesauce, and prune juice; encourage a minimum fluid intake of 2500 ml/day; encourage increased intake of foods high in fiber; administer laxatives as ordered) in order to prevent damage to the bowel mucosa from hard stool
    14. avoid unnecessary rectal invasion (e.g. temperature taking, enemas, suppositories, rectal tube) to prevent trauma to rectal mucosa and possible abscess formation
    15. perform actions to reduce stress and discomfort (see Diagnoses 1, action b; 3, action d; 4, action c; and 5, actions b and c) in order to prevent an increase in the secretion of cortisol (cortisol interferes with some immune responses)
    16. perform actions to prevent stasis of respiratory secretions (e.g. assist client to turn, cough, and deep breathe; increase activity as tolerated)
    17. perform actions to prevent urinary retention (e.g. instruct client to void when the urge is first felt, promote relaxation during voiding attempts) in order to prevent urinary stasis
    18. instruct and assist client to perform good perineal care routinely and after every bowel movement
    19. instruct and assist client in proper care of the exit site of a central venous catheter or insertion site of an implanted infusion device or peritoneal catheter (see Diagnosis 12, actions i.1-3)
    20. administer the following as ordered:
      1. antimicrobial agents (usually initiated when the neutropenic client becomes febrile or may be administered prophylactically if the neutrophil count is less than 500/mm3)
      2. colony-stimulating factors (e.g. filgrastim) to stimulate granulocyte production.