Risk for Infection NCP

Problem Identified: Risk for Infection

Nursing Diagnosis: 

• Risk for Infection related to inadequate primary defenses
• Risk for Infection related to invasive procedures
• Risk for Infection related to surgical incision

Cause Analysis:

ASSESSMENT	OBJECTIVES	INTERVENTION	RATIONALE
Subjective Cues: Objective Cues:	Short Term: After 8 hours of giving nursing interventions and health teachings, the client will be able to identify behaviors and practices to prevent and reduce the risk for infection. Long Term: After 3 days of giving nursing interventions, the client will achieve timely wound healing, free of signs of infection and inflammation, purulent drainage, erythema, and fever.	Independent: Stress and model proper hand-washing technique to client and caregivers.  Maintain aseptic technique with any procedures. Provide routine site care/wound care, as appropriate. Inspect dressings and wound; note characteristics of drainage.  Encourage frequent position changes and being out of bed or ambulation, as tolerated.  Provide routine catheter care and promote meticulous perianal care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible. Monitor vital signs.  Collaborative: Obtain drainage specimens, if indicated.  Administer antibiotics, as indicated.	Reduces risk of cross-contamination/bacterial colonization. Prevents entry of bacteria, reducing risk of nosocomial infections.  Early detection of developing infection provides opportunity for timely intervention and prevention of more serious complications. Limits stasis of body fluids, promotes optimal functioning of organ systems and GI tract.  Reduces bacterial colonization and risk of ascending UTI.  Temperature elevation and tachycardia may reflect developing sepsis.  Gram’s stain, culture, and sensitivity testing is useful in identifying causative organism and choice of therapy. Wide-spectrum antibiotics may be used prophylactically, or antibiotic therapy may be geared toward specific organisms.

Reference: Doenges, M. E., Moorehouse, M. F., Murr, A. C. (2009). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th ed. (p. 346-347, 651-652)