Risk for Infection Nursing Diagnosis & Care Plan


Risk for infection nursing diagnosis and care plan

Risk Factors: 

  • Compromised defense mechanisms:
    • Broken skin 
    • Tissue injury 
    • Altered pH in secretions and skin 
    • Decreased ciliary function 
  • Medical equipment: 
    • Tubes and drains (chest tubes, foley catheters, endotracheal tubes, nasogastric tubes) 
    • IVs and central lines 
  • Invasive procedures 
  • Artificial airways (intubation, tracheostomy) 
  • Insufficient knowledge about preventing infection 
  • Chronic conditions (diabetes mellitus, autoimmune disease, obesity) 
  • Medical treatment:
    • Medications (medications high in lipids, such as TPN, propofol; immunosuppressants, steroids)
    • Invasive procedures (cardiac catheterizations, bronchoscopy, etc.) 
    • Surgery 

Expected Outcome: 

  • The patient will remain free of infectious processes, such as an elevated temperature, or drainage from surgical sites or access sites 
  • The patient will demonstrate measures to prevent infection, such as handwashing
  • The patient can name signs and symptoms of infection
  • The patient’s white blood cell count will remain within normal limits

Assessment 

Monitor for signs of infection such as redness, swelling, or drainage.

Any break in the skin or other compromise in the body’s first line of defense can lead to pathogens’ possible entrance into the body. Vulnerable areas such as fresh surgical incisions are especially prone to infection. Purulent drainage may be cultured. 

Review the past medical history and comorbidities. 

Certain diseases can increase a patient’s overall risk for infection. For example, some patients with diabetes mellitus might have poorly controlled blood glucose, which can pose a breeding ground for bacteria and make it easier to grow. It is crucial to monitor blood glucose during hospital stays closely. 

Review the patient’s medication history. 

Medications such as immunosuppressants, cancer treatment, or steroids can lower the patient’s ability to fight off infection.  

Monitor laboratory values that might indicate an infection, such as white blood cell count (WBC) and other values daily. 

White blood cell count 
Erythrocyte sedimentation rate 
Iron level 
Urine cultures 
Blood cultures 
Sputum culture 
Wound culture 

Any elevated value or presence of infectious microorganisms might be an indication of infection.

Monitor Sepsis and SIRS criteria. 
SIRS and sepsis criteria is a tool that allows for early recognition of infections that might have turned systemic. Monitor 

Temperature 
Heart rate 
Respiratory rate 
White Blood Cell count 
Lactate 

An elevated temperature of 38 degrees or 100.4 Fahrenheit should be of concern unless the patient underwent surgery within the past 48 hours. Even fever spikes warrant further investigation and might indicate the presence of infection. 

Monitor color and consistency of respiratory secretions. 

Thick, yellow, green, or tan colored sputum might indicate infection. A sputum culture may be indicated. 

Monitor the characteristics of urine. 

Color 
Clear or cloudy 
Presence of sediment 
Odor 

Dark and cloudy urine with a characteristic odor and sediment might be suspicious of an infection. 

Assess the patient’s nutritional status. Monitor weight and laboratory values such as serum albumin. 

Malnutrition affects the production of immune cells needed to fight infection. 

Ask about the patient’s immunization status. 

Patients may not be current on their vaccination schedule, which could put them at a higher risk of becoming sick.

Assess medical equipment such as tubes, drains, IV access sites frequently. 

Any equipment during the patient’s hospital stay can pose an access point for pathogens into the body. 

Nursing Interventions for Risk of Infection

Practice meticulous hand hygiene and teach patients about the importance of handwashing. 

The goal of frequent handwashing is to break the chain of infection. Clean hands and the use of aseptic techniques when managing a vulnerable area of entrance, such as changing a central line dressing, catheter care, or incision care, decrease the risk of introducing pathogens into the body. Hand hygiene is the number one practice to prevent infections such as central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). 

Use a proper handwashing technique before, in between, and after each patient. 

Current guidelines recommend washing hands for at least 15 seconds, covering all the hands, such as between fingers and fingertips. Hand washing between patients and even between procedures on the same patient prevents the transmission of harmful microorganisms to other body areas. 

Review appropriateness of lines and drains. Collaborate with the physician about possibly discontinuing lines and drains that are not necessary anymore. 

The earlier lines or drains can be removed, the better for the patient. Fewer invasive lines and devices pose a lesser risk of infection. 

Review appropriateness of lines and drains. Collaborate with the physician about possibly discontinuing lines and drains that are not necessary anymore. 

The earlier lines or drains can be removed, the better for the patient. Fewer invasive lines and devices pose a lesser risk of infection.

Ensure the patient receives daily baths. 

Bathing reduces the number of pathogens on the surface of the skin. Using lotion prevents the skin from breaking and helps keep skin intact. 

Encourage nutritional intake rich in calories and protein, vitamins, and carbohydrates. 

An adequate amount of calories helps the body use nutrients to build a strong immune system. Protein helps with wound healing. 

Encourage adequate fluid intake if not contraindicated. 

Aids in urine formation to flush the urinary tract system and promotes frequent bladder emptying

Thins secretions and facilitates expectoration of mucus

Helps to flush bacteria down the esophagus rather than sticking to the respiratory tract 

Lowers fever

Hydration has multiple benefits in reducing the risk of infection.

Encourage pulmonary hygiene. 

Cough and deep breath 
Use of incentive spirometer 
Use of flutter valve 

These measures promote the clearing of old secretions and prevent pathogens from settling in the respiratory tract, possibly causing pneumonia. For the intubated patient, use the inline suction periodically to remove secretions. 

Provide routine oral care. 

Using toothbrushes and sponges that are soaked in antibacterial mouth wash and paste reduces bacterial growth in the mouth. It therefore reduces the risk of bacteria entering the respiratory tract causing pneumonia. 

Administer anti-infective agents as ordered. 

Antibiotic treatment might start with an empiric approach until the culture results can further narrow down the appropriate antimicrobial therapy. Management may include antibacterial, antifungal, antiviral, or antiparasitic, and antipyretic treatment. 

Collect culture samples as ordered. 

Blood cultures, sputum cultures, stool samples, urine samples, and wound cultures can guide appropriate treatment. 

Use evidence-based practices when performing care. 

Evidence-based practice guidelines and best practice bundles, such as the ventilator bundle, reduce infection risk by following proven steps that ensure the best patient outcome possible. 

Place the patient on appropriate isolation precautions. 

Contact:
Wear clean, non-sterile gloves and gown upon entering the room. Treat the entire room as if pathogens could be anywhere in the room, meaning wearing gloves at all times and changing them after coming in direct contact with the source of infection. Use dedicated equipment for the patient. 
Droplet: 
Wear a surgical mask, gown, gloves, and a face shield when entering the room. Have the patient wear a mask when transporting. If a private room is not available, there must be a 3 feet distance between patients. Place patients with the same illness and or pathogen in one room. 
Airborne: 
Wear an N95 respirator, face shield, gown, gloves, and hair protection when entering the room. Group tasks as much as possible to limit contact. Place the patient in a private room with negative pressure abilities. Keep the door closed at all times and limit transport. 
Neutropenic precautions: 
These precautions will be implemented for patients with a very low white blood cell count. The patient is placed on “reverse isolation” to protect the patient from staff carrying potential germs. Limit visitors and wear mask, gown, and gloves when entering the room. 

Encourage appropriate immunizations. 

The CDC recommends certain immunizations for different patient populations. For example, children should receive immunizations for measles, mumps, rubella, and chickenpox, among others. Adults should receive boosters of the Tdap and yearly flu vaccine. The older population should receive the pneumococcal vaccine, according to the CDC.

For the Critically Ill Patient

Elevate the head of the bed at least 30 degrees at all times. 

Intubated patients have a decreased ability to handle their secretions. Elevation of the head helps manage secretions and prevents aspiration, which could lead to respiratory infection. Often intubated patients are tube-fed continuously. In that case, the elevation of the head is imperative and prevents aspiration pneumonia.

Turn the patient at least every two hours. 

Frequent repositioning helps prevent skin breakdown and therefore prevents pathogens from entering the body and causing infection. 

Patient Teaching 

Teach the patient, family, and caregiver to wash hands before and after using the bathroom, before meals, and before and after self-care and wound care. 

Hand hygiene between these tasks reduces the risk of transmitting pathogens from one area to another and possibly introducing germs into the body. 

Educate about the risk factors of infection. 

Chronic diseases  (e.g., heart failure, COPD) 
Occupation (homeless, unemployed) 
Travel (Viruses) Nutrition (Obesity, anorexia) 
High-risk lifestyle (substance abuse, diseases) 

Knowledge about factors that increase infection risk strengthens awareness and helps the patient, caregivers, and family improve care. Diseases such as diabetes mellitus or autoimmune diseases such as systemic lupus erythematosus (SLE) can increase infection risk. 

Teach about the signs and symptoms of infection. 

At the site:
Redness 
Heat 
Purulent drainage 
Pain 
Swelling 
Immobility 
Systemic:
Fever or fever spikes 
Chills 

Recognizing signs of infection early ensures early treatment and improves the patient’s outcome. 

Teach about the importance of the influenza vaccine and other vaccines appropriate for each patient. 

Staying current on vaccinations may help the patient reduce the need for hospitalizations.

Teach patient and caregiver procedures necessary to continue after discharge. 

This might be wound care, administering medication intravenously, or giving shots. Demonstrations and return-back demonstrations might be helpful to ensure competency in performing procedures. Knowing how to properly perform a procedure, especially if it needs to be sterile, reduces infection risk and promotes patient safety. 

Teach about the importance of taking antibiotics at the right times and completing them. 

The patient needs to know to complete the entire course of antibiotics even after symptoms subsided and the patient feels better. Most antibiotics need to be taken at a specific time to maintain a certain blood level.

Teach the patient and caregiver how to take a temperature and encourage them to take the patient’s temperature at least once daily. 

Monitoring a trend and noting temperature spikes might identify early signs of infection. 

More Care Plans:

Activity Intolerance Nursing Diagnosis & Care Plan

Impaired Physical Mobility Nursing Diagnosis & Care Plan

Knowledge Deficit [Care Plan]

Ineffective Coping

Gastritis Nursing Diagnosis & Care Plan

References: 

SIRS, Sepsis, and Septic Shock Criteria – MDCalc. (2021). https://www.mdcalc.com/sirs-sepsis-septic-shock-criteria

Show Me the Science | Hand Hygiene | CDC. (2021). https://www.cdc.gov/handhygiene/science/index.html

Immunization Schedules | CDC. (2021). https://www.cdc.gov/vaccines/schedules/index.html

Potter, P., & Perry, A. (2013). Fundamentals of nursing. Saint-Louis (Mo): Elsevier.

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