Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. Infections occur when an organism (e.g., bacterium, virus, fungus, or other parasite) invades a susceptible host. Breaks in the integument, the body’s first line of defense, and/or the mucous membranes allow invasion by pathogens. If the host’s (patient’s) immune system cannot combat the invading organism adequately, an infection occurs. Open wounds, traumatic or surgical, can be sites for infection; soft tissues (cells, fat, muscle) and organs (kidneys, lungs) can also be sites for infection either after trauma, invasive procedures, or by invasion of pathogens carried through the bloodstream or lymphatic system. Infections can be transmitted, either by contact or through airborne transmission, sexual contact, or sharing of intravenous (IV) drug paraphernalia. Being malnourished, having inadequate resources for sanitary living conditions, and lacking knowledge about disease transmission place individuals at risk for infection.
Nursing Care Plan for Risk For Infection RELATED FACTORS
- Altered production of leukocytes
- Altered circulation
- Altered immune response
- Presence of favorable conditions for infection.
- Chronic disease
- Failure to avoid pathogens
AS EVIDENCED BY
- Inadequate secondary defenses: Bone marrow depression/immunosuppression, leukopenia
- Tracheostomy tubes
- Indwelling catheter, drains
- Nutritional deficiencies: Malnutrition
- IV devices – venous or arterial access devices
- Surgical/Invasive procedures: _____________________________
- Rupture of amniotic membranes
- History of infection
Nursing Care Plan for Risk For Infection: PLAN AND OUTCOME
The patient will:
- Remain infection free
- Demonstrate complete recovery from infection.
Nursing Care Plan for Risk For Infection: NURSING INTERVENTIONS
ON GOING ASSESSMENT
- Assess temperature every ___ hours. Temperature of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, temp. greater than 37.7° C (99.8° F) suggests infection.
- Assess for presence, existence of, and history of risk factors such as indwelling catheters (e.g. foley); open wounds and abrasion; wound drainage tubes (T-tubes, Jackson-Pratt, Penrose); venous or arterial access devices; ETT or tracheostomy tubes; orthopaedic fixator pins.
- Inspect and record signs of erythema, induration, foul smelling drainage, from or around wound, skin, invasive line, mouth/throat, exit sites of tubes, drains or catheters or other site every __ hours. Any suspicious drainage should be cultures; antibiotic therapy is determined by pathogens identified at culture.
- Assess nutritional status, including weight, history of weight loss and serum albumin. Patients with poor nutritional status may me anergic or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection.
- In pregnant patients, assess intactness of amniotic membranes. Prolonged rupture of amniotic membranes before delivery places the mother and the infant at increased risk for infection.
- Assess for exposure to individuals with active infections.
- Assess for history of drug use or treatment modalities. Antineoplastic agents and corticosteroids reduce immunocompetence.
- Assess immunization status. Older patients may not have completed immunizations and therefore may not have sufficient acquired immunocompetence.
- Report abnormal changes in WBC count and/or pathogenic growth on cultures. An increasing WBC count indicates the body’s effort to combat pathogens. Normal values are 4,000 to 11,000 mm³. Very low WBC count (less than 1,000 mm³) indicates severe risk for infection because the patient does not have sufficient WBCs to fight infection. NOTE: in older patients, infection may be present without an increased WBC count.
- Assess for cloudiness of urine every ___ hours.
Nursing Care Plan for Risk For Infection: THERAPEUTIC INTERVENTIONS
- Maintain or teach asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access management.
- Utilize good hand washing technique. Wash hands before contact with patients and between procedure with the patient. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e.g., perineal care or central line care). Alcohol-based hand sanitizers can be used between hand washing episodes if the hands are not visibly soiled. Use of disposable gloves does not reduce the need for hand washing.
- Limit visitors. Visitors and health care workers with active infection are to avoid contact with patient.
- Encourage high protein/high carbohydrate foods/fluids when indicated. This maintains optimal nutritional status.
- Encourage fluid intake of 2,000 to 3,000 mL of water per day (unless contraindicated). Fluids promote diluted urine and frequent emptying of the bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection.
- Encourage coughing and deep breathing; consider use of incentive spirometer. These measures reduce stasis of secretions in the lungs and bronchial tree.
- Explore with patient potential etiological factors which potentiate infection and include appropriate health teaching.
- Administer or teach use of antimicrobial (antibiotic drugs) as ordered. Antimicrobial drugs include antibacterial, antifungal, antiparasitic, and antiviral agents. All of these agents are either toxic to the pathogen or retard the pathogen’s growth.
- Place the patient in protective isolation/protective environment if he or she is at very high risk. Protective isolation is established when WBC counts indicate neutropenia (less than 500 to 1,000 mm³).
- Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes. Hard-bristled toothbrushes and constipation may compromise the integrity of the mucous membranes and provide a port of entry for pathogens.
Nursing Care Plan for Risk For Infection: EDUCATION / CONTINUITY OF CARE
- Teach the patient the importance of avoiding contact with those who have infections or colds. Teach family members and caregivers about protecting susceptible patients from themselves and others with infections and colds.
- Teach the patient, family, and caregivers the purpose and proper technique for maintaining isolation. Knowledge about isolation can help patients and family members cooperate with specific precautions.
- Teach the patient to take antibiotics as prescribed. Most antibiotics work best when a constant blood level is maintained; a constant blood level is maintained when medications are prescribed. The absorption of some medications is hindered by certain foods; patients should be instructed accordingly.
- Instruct the patient to take the full course of antibiotics even if symptoms improve or disappear. Not completing the entire course of the prescribed antibiotic regimen can lead to drug resistance in the pathogens and reactivation of symptoms.
- Teach the patient and caregiver the signs and symptoms of infection, and when to report these to the physician or nurse. Important signs and changes in condition need to be recognized so early treatment can be initiated.
- Demonstrate and allow return demonstration of all high-risk procedures that the patient or giver will do after discharge, such as dressing changes, peripheral or central IV site care, peritoneal dialysis, and self-catheterization (may use clean contact). Bladder infection is more related to over-distended bladder resulting from infrequent catheterization than to use of clean versus sterile technique.
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