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RISK FOR INFECTION Nursing Care Plan

Risk for infection

NANDA-I Definition
At risk for being invaded by pathogenic organisms
Risk Factors
Related Factors
Various health problems and situations can create favorable conditions
that would encourage the development of infections.
Some common factors follow.
Pathophysiologic
Related to compromised host defenses secondary to:
Cancer
Altered or insufficient
leukocytes
Arthritis
Respiratory disorders
Periodontal disease
Renal failure
Hematologic disorders
Hepatic disorders
Diabetes mellitus*
Acquired immunodeficiency
syndrome (AIDS)
Alcoholism
Immunosuppression*
Immunodeficiency
secondary to: specify
Related to compromised circulation secondary to:
Lymphedema
Obesity*
Peripheral vascular disease
Treatment Related
Related to a site for organism invasion secondary to:
Surgery
Invasive lines
Dialysis
Intubation
Total parenteral nutrition
Enteral feedings
Related to compromised host defenses secondary to:
Radiation therapy
Organ transplant
Medication therapy (specify; e.g., chemotherapy,
immunosuppressants)
Situational (Personal, Environmental)
Related to compromised host defenses secondary to:
History of infections
Malnutrition*
Prolonged immobility
Stress
Increased hospital stay
Smoking
Related to a site for organism invasion secondary to:
Trauma (accidental, intentional)
Postpartum period
Bites (animal, insect, human)
Thermal injuries
Warm, moist, dark environment (skin folds, casts)

Related to contact with contagious agents (nosocomial or community
acquired)
Maturational
Newborns
Related to increased vulnerability of infant secondary to:
HIV positive mother
Lack of maternal antibodies (dependent on maternal exposures)
Lack of normal flora
Maternal substance addiction
Open wounds (umbilical, circumcision)
Immature immune system
Infant/Child
Related to lack of immunization
Adolescent
Related to lack of immunization
Related to multiple sex partners
Older Adult
Related to increased vulnerability secondary to:
Diminished immune response
Debilitated condition

Author's Notes
All people are at risk for infection. Secretion control, environmental
control, and hand washing before and after client care reduce the risk
of transmission of organisms. Included in the population of those at risk
for infection is a smaller group who are at high risk for infection. Risk
for Infection describes a person whose host defenses are compromised,
thus increasing susceptibility to environmental pathogens or his or her
own endogenous flora (e.g., a person with chronic liver dysfunction or
with an invasive line). Nursing interventions for such a person focus on
minimizing introduction of organisms and increasing resistance to infection
(e.g., improving nutritional status). For a person with an infection,
the situation is best described by the collaborative problem RC of Sepsis.
Risk for Infection Transmission describes a person at high risk for
transferring an infectious agent to others. Some people are at high risk
both for acquiring opportunistic agents and for transmitting infecting
organisms, warranting the use of both Risk for Infection and Risk for
Infection Transmission.

Goal
The person will report risk factors associated with infection and
precautions needed as evidenced by the following indicators:
• Demonstrate meticulous hand washing technique by the time
of discharge.
• Describe methods of transmission of infection.
• Describe the influence of nutrition on prevention of infection.

Interventions
Identify Clients at High Risk for Nosocomial Infections (Owen &
Grier, 1987)
Use Appropriate Universal Precautions for All Body Fluids
• Wash hands before and after all contact with client or specimen.
• Handle the blood of all clients as potentially infectious.
• Wear gloves for potential contact with blood and body fluids.
• Handle all linen soiled with blood or body secretions as potentially
infectious.
• Process all laboratory specimens as potentially infectious.
• Place used syringes immediately in a nearby impermeable
container; do not recap or manipulate the needle in any way!
Use retractable needle syringes when possible.
• Wear protective eyewear and mask if splatter with blood or
body fluids is possible (e.g., bronchoscopy, oral surgery).
Consider Those With the Following Factors at High Risk for
Delayed Wound Healing:
• Malnourishment
• Tobacco use
• Obesity
• Anemia
• Diabetes
• Cancer
• Corticosteroid therapy
• Renal insufficiency
• Hypovolemia
• Hypoxia
• Surgery .3 hours
• Night or emergency surgery
• Zinc, copper, magnesium deficiency
• Immune system compromise
Use Universal Precautions
Reduce Client’s Susceptibility to Infection
• Encourage and maintain caloric and protein intake in diet (see
Imbalanced Nutrition).
• Assess client for adequate immunizations against childhood
diseases, bacterial infections (e.g., pneumonia, Haemophilus
influenzae), and other viral infections (e.g., influenza). (Refer
to Altered Health Maintenance on http://thePoint.lww.com/
CarpenitoHB14e.)
• Administer prescribed antimicrobial therapy within 15 minutes
of schedule.
• Minimize length of stay in hospital.
• Observe for superinfection in clients receiving antimicrobial
therapy.
Reduce Entry of Organisms into Clients (Owen & Grier, 1987)
Surgical Wound
• Monitor temperature every 4 hours; notify physician if
temperature
is greater than 100.8° F.
• Assess wound site every 24 hours and during dressing changes;
document any abnormal findings.
• Evaluate all abnormal laboratory findings, especially culture/
sensitivities and complete blood count (CBC).
• Assess nutritional status to provide adequate protein and
caloric intake for healing.
Urinary Tract
• Evaluate all abnormal laboratory findings, especially cultures/
sensitivities and CBC.
• Assess for abnormal signs and symptoms after any urologic
procedure, including frequency, urgency, burning, abnormal
color, and odor.
• Monitor client’s temperature at least every 24 hours for elevation;
notify physician if temperature is greater than 100.8° F.
• Encourage fluids when appropriate.
• Use aseptic technique when emptying any urinary drainage
device; keep bag off the floor, but below bladder or clamped
during transport.
• Reassess need for indwelling urinary catheter daily.
Circulatory
• Assess all invasive lines every 24 hours for redness, inflammation,
drainage, and tenderness.
• Monitor client’s temperature at least every 24 hours; notify
physician if greater than 100.8° F.
• Maintain aseptic technique for all invasive devices, changing
sites, dressings, tubing, and solutions per policy schedule.
• Evaluate all abnormal laboratory findings, especially cultures/
sensitivities and CBC.
• Assess client’s nutritional status.
Respiratory Tract
• Evaluate risk for infection after any instrumentation of the
respiratory tract for at least 48 hours after procedure.
• Monitor temperature at least every 8 hours and notify physician
if greater than 100.8° F.
• Evaluate sputum characteristics for frequency, purulence,
blood, and odor.
• Evaluate sputum and blood cultures, if done, for significant
findings.
• Assess lung sounds every 8 hours or PRN.
• If client has abdominal/thoracic surgery, instruct before surgery
on importance of coughing, turning, and deep breathing.
• Prompt to cough and deep breathe hourly.
• If client has had anesthesia, monitor for appropriate clearing of
secretions in lung fields.
• Evaluate need for suctioning if client cannot clear secretions
adequately.
• Assess for risk of aspiration, keeping head of bed elevated
30 degrees unless otherwise contraindicated.
• Ensure optimal pain management.
Protect the Client With Immune Deficiency From Infection
• Place client in private room.
• Instruct client to ask all visitors and personnel to wash their
hands before approaching.
• Limit visitors when appropriate.
• Screen all visitors for known infections or exposure to infections.
• Limit invasive devices to those that are necessary.
• Teach client and family members signs and symptoms of infection.
• Evaluate client’s personal hygiene habits.
Initiate Health Teaching and Referrals, as Indicated
• Instruct client and family regarding the causes, risks, and communicability
of the infection.
• Have family demonstrate use of equipment or treatment procedure.
• Collaborate with nurse epidemiologist on needs of client and
family.
Pediatric Interventions
• Monitor for signs of infection (e.g., lethargy, feeding difficulties,
vomiting, temperature instability, subtle color changes).
• Provide umbilical cord care. Teach cord care and signs of
infection (e.g., increased redness, purulent drainage).
• Teach signs of infection of circumcised area (e.g., bleeding,
increased redness, or unusual swelling).
Maternal Interventions
• Explain the increased vulnerability to infection during pregnancy.
• Teach how to prevent urinary tract infections during pregnancy:
• Drink at least eight 8-oz glasses of water.
• Void frequently.
• Void before and after intercourse (Reeder et al., 1997).
• Teach how to prevent infection postpartum:
• Wipe from front to back.
• Clean perineal area after voiding or defecating (e.g., sitz
bath, squirt bottle).
• Change perineal pads after each voiding.
• Teach proper breast care.
• Identify risk factors for postpartum infections:
• Anemia
• Poor nutrition
• Lack of prenatal care
• Obesity
• Intercourse after membrane rupture
• Immunosuppression
• Prolonged labor
• Prolonged membrane rupture
• Intrauterine fetal monitoring (in high-risk mothers)
• Bleeding
• Instruct on signs and symptoms of infection (e.g., fever,
purulent
drainage), and report promptly.
Geriatric Considerations
• Explain that the usual signs of infection may not be present
(e.g., fever, chills).
• Assess for anorexia, weakness, change in mental status, or
hypothermia.
• Monitor skin and urinary system for signs of fungal, viral, or
mycobacterial pathogens.

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