Nursing Care Plan for Risk for Infection

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Do you need a guide for nursing diagnosis for infection?

As a nurse, you have a very important role when it comes to preventing infections. You are at the front line when it comes to delivering quality care so you need to be aware of what can and can’t compromise your patients’ health while they are in the hospital.

By having a clearer understanding of the chain of infection and with the right nursing diagnosis for infection, you’ll be able to intervene or stop an infection from happening.

Here’s a good example of a Nursing Care Plan for risk for infection.

Risk Factors

lack of immunization

A patient becomes at risk for infection if he is vulnerable to pathogenic organisms. It can be related to any of the following:

  • Invasive procedures
  • Pharmaceutical agents, like immunosuppressants
  • Increased exposure to pathogens
  • Compromised circulation
  • Break in the integrity of the skin
  • Chronic disease
  • Rupture of amniotic membrane
  • Lack of immunization
  • Inadequate primary defense, like tissue damage and broken skin
  • Inadequate secondary defenses, like decreased hemoglobin and suppressed
  • inflammatory response
  • Trauma
  • Insufficient knowledge regarding avoidance of pathogens

See Also: Nursing Care Plan for Pain Management

Desired Outcomes

With this nursing care plan, you can expect the patient to:

  • Remain free from signs of any infection
  • Demonstrate ability to perform hygienic measures, like proper oral care and handwashing

proper handwashing

  • Demonstrate ability to care for infection-prone site
  • Verbalize which symptoms of infection to watch out for
  • Show capability to recognize symptoms of infection

See Also: Nursing Care Plan for Hypertension

Nursing Interventions

Nursing Interventions Rationale
 Assess the skin for color, texture, elasticity, and moisture. Proper skin assessment and documentation facilitates prevention of the breakdown of skin breakdown which is the body’s first line of defense againts pathogens.
Routinely monitor the patient’s white blood cell count, serum protein, and serum albumin. These laboratory values are closely linked to the patient’s nutritional status and immune function.
Take note of the patient’s current medications, like corticosteroids and antineoplastic agents. Some medications and treatment modalities causes immunosuppression.
Check the patient’s immunization history. People with insufficient immunization may not have adequate acquired immunity.
Assess temperature of neutropenic clients every 4 hours. Neutropenic patients may not have adequate inflammatory response. In most cases, fever is the only symptom they’ll show.
Monitor the patient for any signs of swelling, purulent discharge or presence of pain from wounds, injuries, catheters or drains. These are the classic signs of infection.
Wash hands and encourage the patient to do the same. Dry hands with a paper towel after washing. Handwashing is an effective technique to prevent the spread of infection. Dry surfaces are better in preventing transfer of microorganisms.
Encourage patient to increase fluid intake if not contraindicated. It helps thin out secretions and replace fluid loss during fever. It also prevents stasis of urine by promoting diluted urine and frequent emptying of bladder.
Encourage adequate rest. It can reduce stress and boost the immune system.
Encourage patient to eat a balanced diet. A balanced intake of omega 3 and omega 6 fatty acids, protein, vitamins A, C and E, zinc and iron is essential in reducing risk of infection.
Help patient change positions frequently. It prevents stasis of secretions and pathogens in the lungs and bronchial tree.
Strictly observe sterile technique when inserting urinary catheter. Ensure that catheters are cared for every shift. The Genito-Urinary tract is one of the most common site for nosocomial infections.
Wear gloves during any contact with mucus, blood, and other body fluids. Use goggles when appropriate. It prevents the transfer of microorganisms that are already on the hands and to protect the hands from becoming contaminated.
 Limit the number of visitors allowed. This is to limit the risk of the patient being exposed to pathogens.
Strictly adhere to Transmission-Based Precautions:

Airborne

  • Isolate the patient in a monitored room with negative air pressure.
  • Wear respiratory protection before entering the room.
  • Limit the transfer of patient from one room to another.
  • Make sure the patient is wearing a surgical mask if transport is unavoidable.

Droplet

  • Let the patient stay in a private room.
  • Wear a mask if you’ll be within 3 feet from the patient.
  • Limit transport.
  • Encourage patient to wear a mask if possible.

Contact Transmission

  • Allow the patient to stay in a private room.
  • Always wear clean, non steril gloves when entering the patient’s room.
  • Wear a gown if exposure to contaminated items is expected.
  • Limit use of common equipment. If that isn’t possible, make sure to disinfect it before using on another patient.
They are essential in preventing the spread of infection.
Teach patient how to perform procedures at home, like dressing changes and assessing IV site for signs of infection. Patient and caregivers need to master these skills to make sure that they can continue preventing risk of infection even if they are already discharged.
Teach patient how to take antibiotics properly. Not completing or skipping the required dose of antibiotics can encourage antibiotic resistance.

 

Source:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis.

See Also: Nursing Care Plan for Diabetes

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