Risk of infection is a nursing diagnosis which is defined as “the state in which an individual is at risk to be invaded by an opportunistic or pathogenic agent (virus, fungus, bacteria, protozoa, or other parasite) from endogenous or exogenous sources and was approved by NANDA in 1986.
Although anyone can become infected by a pathogen, patients with this diagnosis are at an elevated risk and extra infection controls should be considered
Risk Factors of Risk for Infection
Altered immune function
Amniotic membrane rupture
Environmental exposure to pathogens
Lack of knowledge about causes of infection
Inadequate primary (such as skin) or secondary (such as inflammatory response) defenses
Nursing Diagnosis Risk for Infection | Assessment Focus
Nursing Diagnosis Risk for Infection | Nursing Interventions
Nursing Diagnosis Risk for Infection | Nursing Interventions of Risk for Infection
Nursing Interventions of Risk for Infection and Rationales
Monitor and record temperature after surgery at least every 4 hr; report elevations immediately as this may signal onset of pulmonary complications, wound infection or dehiscence, UTI, or thrombophlebitis
Monitor WBC count, as ordered. Report elevations or depressions. Elevated total WBC count indicates infection. Markedly decreased WBC count may indicate decreased production resulting from extreme debilitation or severe lack of vitamins and amino acids. Any damage to bone marrow may suppress WBC formation.
Monitor culture results of urine, respiratory secretions, wound drainage, or blood according to facility policy and physician’s order. This identifies pathogens and guides antibiotic therapy.
Perform hand hygiene before and after providing care, and direct patient to do this before and after meals and after using bathroom, bedpan, or urinal to avoid spread of pathogens; also, use strict sterile technique when handling would dressings to maintain asepsis.
Offer frequent oral hygiene to prevent colonization of bacteria and reduce risk of descending infection. Disease and malnutrition may reduce moisture in mucous membranes of mouth and lips.
Change intravenous tubing and give site care every 24–48 hr or as facility policy dictates to help keep pathogens from entering body. Rotate intravenous sites every 48–72 hr or as facility policy dictates to reduce chances of infection at individual sites.
Have patient cough and deep-breathe every 4 hr after surgery to help remove secretions and prevent pulmonary complications. Provide tissues to encourage expectoration and convenient disposal bags for expectorated sputum to reduce spread of infection.
Help patient turn every 2 hr. Provide skin care, particularly over bony prominences to help prevent venous stasis and skin breakdown.
Assist patient when necessary to ensure that perianal area is clean after elimination. Cleaning perineal area by wiping from the area of least contamination (urinary meatus) to the area of most contamination (anus) helps prevent genitourinary infections.
Use sterile water for humidification or nebulization of oxygen. This prevents drying and irritation of respiratory mucosa, impaired ciliary action, and thickening of secretions within respiratory tract.
Instruct patient to immediately report loose stools or diarrhea which may indicate need to discontinue or change antibiotic therapy; or to test for Clostridium difficile.
Instruct patient about good hand hygiene, factors that increase infection risk, and signs and symptoms of infection to encourage patient to participate in care and modify lifestyle to maintain optimum health.
Unless contraindicated, encourage fluid intake of 3,000–4,000 ml daily to help thin mucus secretions; and offer highprotein supplements to help stabilize weight, improve muscle tone and mass, and aid wound healing.
Arrange for protective isolation if patient has compromised immune system. Monitor flow and number of visitors. These measures protect patient from pathogens in environment.