Use this nursing diagnosis guide to create your risk for infection nursing care plan individualized to your client. Show
Infections occur when the natural defense mechanisms of an individual are inadequate to protect them. Microorganisms such as bacteria, viruses, fungus, and other parasites invade susceptible hosts through inevitable injuries and exposures. People have dedicated cells or tissues that deal with the threat of infection. These are known as the immune system. The human immune system is crucial for survival in a world full of potentially deadly and harmful microbes. The serious impairment of this system can predispose to severe, even life-threatening, infections. Organs and tissues involved in the immune system include the thymus, bone marrow, lymph nodes, spleen, appendix, tonsils, and Peyer’s patches (in the small intestine). If the patient’s immune system cannot battle the invading microorganism sufficiently, an infection occurs. Breaks in the integrity of the integument, mucous membranes, soft tissues, or even organs such as the kidneys and lungs can be sites for infections after trauma, invasive procedures, or invasion of pathogens through the bloodstream or lymphatic system. A common means for infectious diseases to spread is by directly transferring bacteria, viruses, or other germs from one person to another. This can transpire via contact, airborne, sexual contact, or sharing of IV drug paraphernalia. Also, having inadequate resources, lack of knowledge, and being malnourished place an individual at high risk of developing an infection. SEE ALSO: Nursing Diagnosis Complete List and Guide » Infections prolong healing and can result in death if left untreated. Antimicrobials are widely used to treat infections when susceptibility is present. However, no antimicrobial is effective for some organisms, such as the human immunodeficiency virus (HIV). Another common medical intervention is called immunization. This is also universally used for those who are at high risk for infection. Handwashing is the best way to break the chain of infection. Specific nursing interventions will depend on the nature and severity of the risk. Patients should be informed and well-educated by nurses on recognizing the signs of infection and how to reduce their risk.
Causes of InfectionVarious health problems and conditions can create a favorable environment that would encourage the development of infections. Here are the common causes of infection and factors that place a patient at risk for infection:
Goals and OutcomesHere are some sample patient goals and expected outcomes for patients at risk for infection.
NOTE: This nursing care plan is recently updated with new content and a change in formatting. Nursing assessment and nursing interventions are listed in bold and followed by their specific rationale in the following line. Still, when writing nursing care plans, follow the format here. Diseases, medical conditions, and related nursing care plans for Risk for Infection nursing diagnosis:
Nursing Assessment for Risk for InfectionAssessment is paramount in identifying factors that may precipitate infection. Use the nursing assessment guidelines below to identify your subjective data and objective data for your risk for infection care plan: 1. Assess for the presence, existence, and history of the common causes of infection (listed above). 2.
Assess for the presence of local infectious processes in the skin or mucous membranes. 3. Monitor and report any signs and symptoms of infection. Signs and symptoms of infection vary according to the body area involved. Assess for the following signs and symptoms: 3.1. Redness, swelling, increased pain, purulent discharge from incisions, injury, and exit sites of tubes (IV tubings), drains, or catheters. 3.2. Elevated temperature. 3.3. Color of respiratory
secretions. 3.4. Appearance of urine. 4. Monitor white
blood cell (WBC) count.
5. Assess and monitor nutritional status, weight, history of weight loss, and serum albumin. 6. Investigate the use of medications or treatment modalities that may cause immunosuppression. 7. Assess immunization status and history. 8. Observe and report if an older client has a low-grade fever or new onset of confusion. 9. Obtain a travel history from clients. 10. For pregnant clients, assess the intactness of amniotic membranes. Nursing Interventions for Risk for InfectionThese nursing interventions help reduce the risk for infection, including implementing strategies to prevent infection. If the infection cannot be prevented, the goal is to prevent the spread of infection between individuals and treat the underlying infection. Use the nursing interventions below to help you create your nursing care plan for risk for infection: 1. Maintain strict asepsis for dressing changes, wound care, intravenous therapy, and catheter handling. 2. Ensure that any articles used are properly disinfected or sterilized before use. 3. Wash hands or perform hand hygiene before having contact with the patient. Also, impart these duties to the patient and their significant others and know the instances when to perform hand hygiene or “5 moments for hand hygiene”: Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another. Wash hands with antiseptic soap and water for at least 15 seconds, followed by an alcohol-based hand rub. If hands were not in contact with anyone or anything in the room, use an alcohol-based hand rub and rub until dry. Plain soap is good at reducing bacterial counts, but antimicrobial soap is better, and alcohol-based hand rubs are the best. 4. Educate clients and SO (significant other) about appropriate cleaning, disinfecting, and sterilizing items. 5. Encourage intake of protein-rich and
calorie-rich foods and encourage a balanced diet. SEE ALSO: Infection Control in Nursing » 6.
Perform measures to break the chain of infection and prevent infection.
7. Encourage increased fluid intake unless contraindicated (e.g., heart failure, kidney failure).
8. Encourage coughing and deep breathing exercises; frequent
position changes. 9. Recommend the use of soft-bristled toothbrushes and
stool softeners to protect mucous membranes. 10. Instruct client not to share personal care items (e.g., toothbrush, towels, etc.). 11. Promote nail care by keeping the client and the nurse‘s fingernails short and clean. 12. Limit visitors. 13. Encourage
sleep and rest. 14. Assist client to learn stress-reducing techniques. 15. Provide surgical masks to visitors who are coughing and provide the rationale to enforce usage. Instruct visitors to cover
mouth and nose (by using the elbows to cover) during coughing or sneezing; use tissues to contain respiratory secretions with immediate disposal to a no-touch receptacle; perform hand hygiene afterward. 16. Place the patient in protective isolation if the patient is at high risk of infection. 17. Initiate specific precautions for suspected agents as determined by CDC protocol.
18. Wear personal protective equipment (PPE) properly.
19. Teach the importance of avoiding contact with individuals who have infections or colds. Teach the importance of physical distancing. 20. Demonstrate and allow return demonstration of all high-risk procedures that the patient and/or SO will do after discharge, such as dressing changes, peripheral or central IV site care, and so on. 21. Teach the patient, family, and caregivers, the purpose and proper technique for maintaining isolation. 22. If infection occurs, teach the patient to take anti-infectives as prescribed. If taking antibiotics, instruct the patient to take the full course of antibiotics even if symptoms improve or disappear. Recommended ResourcesRecommended nursing diagnosis and nursing care plan books and resources. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.
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What should the nurse teach the client with neutropenia to avoid?These safety measures are called neutropenic precautions. Neutropenia is a blood condition involving low levels of neutrophils, a type of white blood cell.. raw or unwashed fruits and vegetables.. raw or undercooked meat, including beef, pork, chicken, and fish.. uncooked grains.. raw nuts and honey.. How soon should a client with multiple traumas receive treatment according to the five level emergency severity index ESI )?Multiple traumas are considered a level 2 on the emergency severity index (ESI) and require treatment within 10 minutes. Life-threatening and organ-threatening conditions such as cardiac arrest and severe respiratory distress need immediate treatment within 5 minutes.
Which action would the nurse perform first when prioritizing care for a hypertensive client?Which primary step should be followed by the nurse when prioritizing care for a hypertensive client? Assess for a severe headache.
Which step should the nurse take to alert the risk management system after notifying the primary health care provider of a client's fall?The nurse taking care of the client informs the primary healthcare provider. What step should the nurse take to alert the risk management system? The nurse should document the incident in the occurrence report tool.
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