Risk for Infection

Kamis, 18 Juli 2013

At increased risk for being invaded by pathogenic organisms
Related Factors: See Risk Factors.
Risk Factors:

Invasive procedures;
insufficient knowledge regarding avoidance of exposure to pathogens;
trauma;
tissue destruction and increased environmental exposure;
rupture of amniotic membranes;
pharmaceutical agents (e.g., immunosuppressants);
malnutrition;
increased environmental exposure to pathogens;
immunosuppression;
inadequate acquired immunity;
inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response);
inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids,
change in pH secretions, altered peristalsis);
chronic disease
NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Immune Status
Knowledge: Infection Control
Risk Control
Risk Detection
Client Outcomes
Remains free from symptoms of infection
States symptoms of infection of which to be aware
Demonstrates appropriate care of infection-prone site
Maintains white blood cell count and differential within normal limits
Demonstrates appropriate hygienic measures such as hand washing, oral care, and perineal care
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Infection Control
Infection Protection
Nursing Interventions and Rationales
1. Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature.
With the onset of infection the immune system is activated and signs of infection appear.
2. Assess temperature of neutropenic clients every 4 hours; report a single temperature of >38.5 C or three
temperatures of >38 C in 24 hours.
Neutropenic clients do not produce an adequate inflammatory response; therefore fever is usually the first and often
the only sign of infection (Wujcik, 1993).
3. Use an electronic or mercury thermometer to assess temperature.
When temperature values have important consequences for treatment decisions, use mercury or electronic
thermometers with established accuracy (Erickson et al, 1996).
4. Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and

cultures).
Laboratory values are correlated with client's history and physical examination to provide a global view of the client's
immune function and nutritional status and develop an appropriate plan of care for the diagnosis (Lehmann, 1991).
5. Remove the granulocytopenic client from areas exposed to construction dust so that the client won't inhale fungal
spores. Remove all plants and flowers from client's room.
Aspergillus, an organism that can cause fungal pneumonia, is commonly found in soil, water, and decomposing
vegetation. This fungus can enter the hospital through an unfiltered air system, in dust stirred up during construction,
or in food or ornamental plants (Carlianno, 1999).
6. Assess skin for color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of changes.
Preventive skin assessment protocol, including documentation, assists in the prevention of skin breakdown. Intact
skin is nature's first line of defense against microorganisms entering the body (Kovach, 1995).
7. Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all at-risk surfaces.
Maintaining supple, moist skin is the best method of keeping skin intact. Dry skin can lead to inflammation,
excoriations, and possible infection episodes (Kovach, 1995) (see Risk for impaired Skin integrity).
8. Encourage a balanced diet, emphasizing proteins to feed the immune system.
Immune function is affected by protein intake (especially arginine); the balance between omega-6 and omega-3 fatty
acid intake; and adequate amounts of vitamins A, C, and E and the minerals zinc and iron. A deficiency of these
nutrients puts the client at an increased risk of infection (Lehmann, 1991).
9. Use strategies to prevent nosocomial pneumonia: assess lung sounds, sputum, and redness or drainage around
stoma sites; use sterile water rather than tap water for mouth care of immunosuppressed clients; provide a clean
manual resuscitation bag for each client; use sterile technique when suctioning; suction secretions above tracheal
tube before suctioning; drain accumulated condensation in ventilator tubing into a fluid trap or other collection device
before repositioning the client; assess patency and placement of nasogastric tubes; elevate the head of the client to
(30 to prevent gastric reflux of organisms in the lung; institute feeding as soon as possible; assess for signs of
feeding intoleranceno bowel sounds, abdominal distension, increased residual, emesis.
Hospital-acquired pneumonia is the second most common nosocomial infection but has the highest mortality (30%)
and morbidity rates. The strategies listed are used to prevent nosocomial pneumonia (Tasota et al, 1998).Once
treatment for pneumonia has begun, it must continue for 48 to 72 hours, the minimum time to evaluate a clinical
response (Ruiz et al, 2000).
10. Encourage fluid intake.
Fluid intake helps thin secretions and replace fluid lost during fever (Carlianno, 1999).
11. Encourage adequate rest to bolster the immune system.
Chronic disease and physical and emotional stress increase the client's need for rest (Potter, Perry, 1993).
12. Use proper hand washing techniques before and after giving care to client and any time hands become soiled,
even if gloves are worn: Wet hands under running water; dispense a minimum of 3 to 5 ml of soap or detergent and
thoroughly distribute it over all areas of both hands; vigorously wash all surfaces of hands and fingers for at least 10
to 15 seconds, including backs of hands and fingers and under nails; rinse to remove soap, and thoroughly dry
hands; use a dry paper towel to turn the faucet off.
Consistent and meticulous hand washing remains the most important contributing factor related to reduction of the
frequency of nosocomial infections in the intensive care unit (ICU). Hand washing significantly decreases the number
of pathogens on the skin and contributes to decreases in client's morbidity and mortality (Tasota et al, 1998). Ensure
that all hospital staff members follow precautions to prevent the spread of infection. In this study, a high percentage of
staff did not wash hands at appropriate times (Chandra, Milind, 2001). When soap is used, the mechanical action of
washing and drying removes most of the transient bacteria. Hands should remain in contact with the cleanser for 10
seconds, but 20 to 30 seconds is ideal (Gould, 1994a). Rinsing hands with tap water and drying them with towels can
reduce methicillin-resistant Staphylococcus aureus (MRSA) contamination by 95% (Sarver-Steffensen, 1999).
13. Hands should be thoroughly dried with paper towels after washing.
Bacterial transfer occurs more readily between wet surfaces than dry ones (Marples, Towers, 1979). More
microorganisms were removed with paper towels than with linen. After use of hot-air dryers, fecal organisms have
been recovered from hands, and bacterial counts are significantly higher than when paper towels are used (Gould,
1994b).
14. Follow Standard Precautions and wear gloves during any contact with blood, mucous membranes, nonintact skin,

or any body substance except sweat. Use goggles, gloves, and gowns when appropriate.
Wearing gloves does not obviate the need for scrupulous hand washing. The purpose of wearing gloves is either to
protect the hands from becoming contaminated with dirt and microorganisms or to prevent the transfer of organisms
that are already present on the hands (Smock, Shiel, 1994). The first and most important tier of the new Centers for
Disease Control and Prevention (CDC) guidelines is Standard Precautions. Because client examination and medical
history cannot reliably identify every client with blood-borne pathogens, Standard Precautions apply to all clients. You
must assume all clients are carrying blood-borne pathogens such as human immunodeficiency virus (HIV) or
Hepatitis B or C (HBV or HCV). Standard Precautions exceed Universal Precautions. Transmission of blood-borne
pathogens takes place by parenteral, mucous membrane, or nonintact skin exposure to blood and other body
substances. You must take precautions whenever contact is likely with blood, mucous membranes, nonintact skin, or
any body substance except sweat (Medcom). This study indicates that when risk for infection is high, powder-free
gloves should be considered because powder may promote wound infection (Dave, Wilcox, Kellett, 1999).

15. Follow Transmission-Based Precautions for airborne-, droplet-, and contact-transmitted microorganisms:
Airborne: Isolate the client in a room with monitored negative air pressure, with the room door closed, and the client
remaining in the room. Always wear appropriate respiratory protection when you enter the room. For tuberculosis,
you should wear an approved particulate respirator mask. Limit the movement and transport of the client from the
room to essential purposes only. If at all possible, have the client wear a surgical mask during transport.
Droplet: Keep the client in a private room, if possible. If not possible, maintain a spatial separation of 3 feet from
other beds or visitors. The door may remain open. You should wear a mask when you must come within 3 feet of the
client. Some hospitals may choose to implement a mask requirement for droplet precautions for anyone entering the
room. Limit transport to essential purposes, and have the client wear a mask if possible.
Transmission: Place the client in a private room if possible or with someone who has an active infection from the
same microorganism. Wear clean, nonsterile gloves when entering the room. When providing care, change gloves
after contact with any infective material such as wound drainage. Remove the gloves and wash your hands before
leaving the room and take care not to touch any potentially infectious items or surfaces on the way out. Wear a gown
if you anticipate your clothing may have substantial contact with the client or other potentially infectious items.
Remove the gown before leaving the room. Limit the transport of the client to essential purposes and take care that
the client does not contact other environmental surfaces along the way. Dedicate the use of noncritical client care
equipment to a single client. If use of common equipment is unavoidable, adequately clean and disinfect equipment
before use with other clients.
Standard Precautions are based on the likely routes of transmission of pathogens. The second tier of the new CDC
guidelines is Transmission-Based Precautions. This replaces many old categories of isolation precautions and
disease-specific precautions with three simpler sets of precautions. These three sets of precautions are designed to
prevent airborne transmission, droplet transmission, and contact transmission (Medcom).
16. Sterile technique must be used when inserting urinary catheters. Catheters must be cared for at least every shift.
The genitourinary (GU) track is the most common site of nosocomial infections in the acute care setting.
Catheterization and instrumentation of the urinary tract are implicated as precipitating factors in approximately 80% of
cases (Tasota et al, 1998).
17. Use careful technique when changing and emptying urinary catheter bags; avoid cross-contamination.
Clients are most at risk for cross-infection during bag changing and emptying (Platt et al, 1983; Crow et al, 1993;
Roe, 1993).
18. Use alternatives to indwelling catheters whenever possible (external catheters, incontinence pads, bladder control
techniques).
The GU track is the most common site of nosocomial infections in the acute care setting. Catheterization and
instrumentation of the urinary tract are implicated as precipitating factors in approximately 80% of cases (Tasota et al,
1998).
19. Provide well-designed site care for all peripheral, central venous, and arterial catheters: standardize insertion
technique; select catheters with as few lumens as necessary; avoid use of femoral catheters in clients with fecal or
urinary incontinence; use aseptic technique for insertion and care; stabilize cannula and tubing; maintain a sterile
occlusive dressing (change every 72 hours per hospital policy); label insertion sites and all tubing with date and time
of insertion, inspect every 8 hours for signs of infection, record and report; replace peripheral catheters per hospital
policy (usually every 48 to 72 hours); when fever of unknown origin develops, obtain culture.
More than 40% of bloodstream infections in ICUs are associated with short-term use of central venous catheters.
Strict aseptic technique should be maintained. The risk of infection associated with use of triple-lumen catheters is as
much as three times greater than the risk associated with single-lumen catheters. Clients with unexplained fever and
signs of localized infection most likely have a catheter-related infection. The catheter should be removed and
samples obtained for microbial culture (Tasota et al, 1998). Care in selection of site and catheter is important. The

shortest catheter and smallest size should be used when possible. Accommodate the need to replace catheters
before they occlude (Schmid, 2000).
20. Use careful sterile technique wherever there is a loss of skin integrity.
Use of sterile technique prevents infection in at-risk clients (Wujcik, 1993).
21. Ensure client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perineal care performed
by either nurse or client.
Hygienic care is important to prevent infection in at-risk clients (Wujcik, 1993).
22. Recommend responsible use of antibiotics; use antibiotics sparingly.
Clients infected with resistant strains of bacteria are more likely than control clients to have received previous
antimicrobials, and hospital areas that have the highest prevalence of resistance also have the highest rates of
antibiotic use. For these reasons, programs to prevent or control the development of resistant organisms often focus
on the overuse or inappropriate use of antibiotics, for example, by restriction of widely used broad-spectrum
antibiotics (e.g., third-generation cephalosporins) and vancomycin. Other approaches are to rotate antibiotics used for
empiric therapy and to use combinations of drugs from different classes (Weber, Raasch, Rutala, 1999). Widespread
use of certain antibiotics, particularly third-generation cephalosporins, has been shown to foster development of
generalized beta-lactam resistance in previously susceptible bacterial populations. Reduction in the use of these
agents (as well as imipenem and vancomycin) and concomitant increases in the use of extended-spectrum penicillins
and combination therapy with aminoglycosides have been shown to restore bacterial susceptibility (Yates, 1999).
Geriatric
1. Recognize that geriatric clients may be seriously infected but have less obvious symptoms.
The immune system declines with aging. The elderly may present with atypical manifestations of infections
(Madhaven, 1994).
2. Suspect pneumonia when the client has symptoms of fatigue or confusion.
The only early indicators of pneumonia in an elderly client may be confusion and fatigue. An elderly client with
pneumonia may not have such classic signs and symptoms as fever, cough, or an increased white blood cell (WBC)
count, or lung consolidation may be masked by chronic pulmonary disease. Among all age groups, the elderly are at
greatest risk because aging can impair normal pulmonary defense mechanisms. Once an older client develops
pneumonia, his or her risk takes on deadly dimensions. Clients >65 years of age are five times more likely than those
in any other age group to die of a bacterial nosocomial pneumonia (Calianno, 1999).
3. Most clients develop nosocomial pneumonia by either aspirating contaminated substances or inhaling airborne
particles. Refer to care plan forRisk for Aspiration.
4. Foot care other than simple toenail cutting should be performed by a podiatrist.
5. Observe and report if client has a low-grade temperature or new onset of confusion.
The elderly can have infections with low-grade fevers. Be suspicious of any temperature rise or sudden confusion
these symptoms may be the only signs of infection (Madhaven, 1994).
6. During the peak of the influenza epidemic, limit visits by relatives and friends.
Hospital- and nursing home-acquired influenza A virus infection leads to high mortality in the elderly (Madhaven,
1994).
7. Recommend that the geriatric client receive an annual influenza immunization and one-time pneumococcal
vaccine.
Among the many infections to which the aged are susceptible, pneumonia and influenza combined are responsible
for the greatest mortality (Madhaven, 1994). Oseltamivir prophylaxis was very effective in protecting nursing home
residents from ILI and in halting an outbreak of influenza B. A comparable nursing home in this study that did not use
this treatment had double the cases (Parker, Loewen, Skowronski, 2001).
8. Recognize that chronically ill geriatric clients have an increased susceptibility to infection; practice meticulous care
of all invasive sites.
Home Care Interventions
1. Assess home care environment for appropriate disposal of used dressing materials.

Used dressing materials may contain or be a primary medium for growth of pathogens.
2. Role model all preventive behaviors in care of client (e.g., Universal Precautions). Do not visit client when you are
ill.
Demonstration is a more effective teaching strategy than verbalization.
3. Maintain the cleanliness of all irrigation and cleansing solutions. Change solutions when cleanliness has not been
maintaineddo not wait to finish bottle.
Solutions exposed to contaminants provide a medium for growth of pathogens.
4. Assess and teach clients about current medications and therapies that promote susceptibility to infection:
corticosteroids, immunosuppressants, chemotherapeutic agents, and radiation therapy.
Knowledge of risk factors promotes vigilance in assessment, prompt reporting, and early treatment.
5. Assess client for knowledge of infections that have been drug resistant.
6. Instruct client to complete any course of prophylactic antibiotic therapy unless experiencing adverse side effects.
Prophylactic antibiotic therapy decreases the risk of infection.
Client/Family Teaching
1. Teach client and family the symptoms of infection that should be promptly reported to a primary medical caregiver
(e.g., redness; warmth; swelling; tenderness or pain; new onset of drainage or change in drainage from wound;
increase in body temperature; hepatitis B virus [HBV]/acquired immunodeficiency syndrome [AIDS] symptoms:
malaise, abdominal pain, vomiting or diarrhea, enlarged glands, rash; tuberculosis symptoms: cough, night sweats,
dyspnea, changes in sputum, changes in breath sounds; insulin-dependent diabetes mellitus [IDDM] symptoms:
sores or wounds that do not heal).
A high prevalence of HBV/AIDS, an increasing incidence of tuberculosis, and the general risk of diabetes are related
to increased rate of infection.
2. Encourage high-risk persons, including health care workers, to have influenza vaccinations. Vaccinations help to
prevent viral nosocomial pneumonia (Carlianno, 1999).
3. Assess whether client and family know how to read a thermometer; provide instructions if necessary. Chemical dot
thermometers are easy to use and decrease risk of infection. Clients need to know that the instructions should be
followed carefully and that electronic or mercury thermometers may be the best choice for accuracy.
Chemical dot thermometers may underestimate the oral temperature by (0.4 C in about 50% of adults, thus lacking
the sensitivity to screen for fever and providing many false readings. Conversely, they may overestimate axillary
temperature by (0.4 C in about 50% of adults and some young children, thus lacking the specificity to rule out fever
and providing many false-positive readings (Erickson et al, 1996).
4. Instruct client and family about the need for good nutrition (especially protein) and proper rest to bolster immune
function.
5. If client has AIDS, discuss the continued need to practice safe sex, avoid unsterile needle use, and maintain a
healthy lifestyle to prevent infection.
6. Refer client and family to social services and community resources to obtain support in maintaining a lifestyle that
increases immune function (e.g., adequate nutrition and rest, freedom from excessive stress).
Diposkan oleh nic noc di 22.20
Label: Risk for Infection

Oct 3, '08 by araujojr

Does my care plan look okay ? what do you all think? thanks

Subjective
I do not feel like eating
Objective
Solu-Cortef 100 mg IV Q8hr
RAC PICC
Foley Catheter
Wound L. Foot
Recent hx of UTI
Albumin 9/30/08 2.5 L
Unwillingness to eat
Wbc 9/30 8.4 and 10/02 10.7 normal
Hgb 9/30 11.3 L 10/02 9.7 L
Risk for Infection R/T inadequate secondary defenses, immunosuppression, invasive
procedures, and malnutrition.
GOAL:
Client will remain free of infection, as evidenced by normal WBC count, temp < 100 F,
and absence of purulent drainage from incisions. Or
1. Client will show no signs and symptoms of infection by discharge?
Note ( cannot teach pt) does not recall information
Assessment
1. Assess for presence, existence of, and history of risk factors of infection.
2. Monitor white blood count (WBC)
3. Observed/Monitor for signs and symptoms of infection.
4. Assess for nutritional status.
5. Assess immunization status.
Decrease stressors:
6. Stress proper hand washing technique by all caregivers between therapies.
7. Encourage deep breathing, coughing, and turning q 2hr.

8. Provide regular catheter/perineal care and proper foley care daily.

9. Obtain appropriate tissue/fluid specimens for observation and culture/sensitivities
testing.
Teaching/counseling/referrals:
10. Teach family members and caregivers about protecting susceptible patient from
themselves and others with infections or cold.
11. Teach patient and caregiver the signs and symptoms of infection, and when to
report to physician
12. Review individual nutritional needs, appropriate exercise program, and need for
rest.
Assessment
1. Assess clt at 1530 am. and clt has a Foley catheter present, wound on the L. heel,
PICC RAC and Hx of UTI as a risk factor.
2. Monitor WBC count, labs within normal parameters 9/30 (8.4) and 10/02 (10.7).
3. No signs and symptoms (redness, swelling, purulent drainage) at PICC, and Foley
clear yellow urine w/o visible sediment and Temp of 98.1 F
4. Albumin level of 2.5 L and unwillingness to eat, pt states I do not feel like eating.
and < 25% food eaten. Enjoys strawberry ice cream and hot chocolate, but drinks
Ensure chocolate.
5. No records of a pneumonax vaccine given. MD placed an ordered and SN
administered it.
Decrease stressors:
6. Washed hands before and after pt. contact between therapies. Staff is aware of
proper hand washing technique.
7. Taught patient to deep breath, cough and turn q hr, pt needs to be reminded.
8. Provided a total sponge bath on 10/02 at 1000, secured the foley catheter with tape
and reminded pt not to pull on catheter, and cleaned the skin around the catheter and
washed my hands before and after catheter care.
9. Obtain a Mersa swap at 1700 and results pending
Teaching/counseling/referrals:
10. Taught son preventive hygiene practices/ methods by return demonstration and to
gown up, wear a mask and glove if they have infection or cold.
11. Unable to teach patient the signs and symptoms of infection, pt has short term

memory loss, taught patients son the signs and symptoms of infection( fever >100 F,
foul smelly urine, confusion, redness, purulent drainage at the wound)
12. Advice the nurse the best way to treat this patient is to be placed on routine care,
provide enough rest and at sleep use BIPAP 35 %, and provided active and passive
ROM. Unable to let patient get out of bed due to high risk of injury.

Nursing Care Plan for Risk For Infection

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Nursing Care Plan for Risk for Infection is

used when a patient is at increased risk for being invaded by pathogenic
organisms.
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
asusceptible host. Breaks in the integument, the bodys first line of
defense, and/or the mucous membranes allow invasion by pathogens. If the
hosts (patients) 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)
drugparaphernalia. 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

Intubation

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:

OUTCOME

PLAN AND

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 bodys effort to combat

pathogens.

Normal values are 4,000 to 11,000 mm.

Very low WBC count

(less than 1,000 mm) 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;

spirometer.

consider use of incentive

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 pathogens 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 mm).

Recommend the use of soft-bristled toothbrushes and stool softeners to

protect mucousmembranes.

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 selfcatheterization (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.
We have more Examples of Nursing Care Plans

Radical Nephrectomy with Inferior Vena Cava (IVC)

Thrombectomy: Implications for Post-Operative Nursing Care.
Authors:
1

Klipfel, Janee
2
Jacobson, Therese M.
3
Havel, Michelle
Source:
Urologic Nursing. Nov/Dec2010, Vol. 30 Issue 6, p347-352. 6p. 1 Color Photograph, 1 Chart.
Document Type:
Article
Subject Terms:
*POSTOPERATIVE pain -- Treatment
*VENA cava inferior -- Surgery
*RENAL cell carcinoma
*FLUID therapy
*GASTROINTESTINAL motility
*KIDNEYS -- Surgery
*OPERATING room nursing
*POSTOPERATIVE care

*RESPIRATORY therapy
*SURGICAL complications
*THROMBOSIS -- Surgery
*URINARY organs
*UROLOGICAL nursing
*PATIENT discharge instructions
*SURGICAL site
*ANATOMY
*HISTOLOGY
*SYMPTOMS
Author-Supplied
Keywords:
Renal cell carcinoma
tumor thrombus
A
b
s
t
r
a
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t
:
The article discusses the implications of radical nephrectomy with inferior vena cava (IVC) thrombectomy for
post-operative nursing care. An overview of the radical nephrectomy with IVC thrombectomy is provided,
along with the components of post-operative nursing care such as pain management and respiratory
management. Also explored are post-operative complications associated with the surgical procedure.

Infection, Risk for Universal Precautions; Standard

Precautions; CDC Guidelines; OSHA
Audrey Klopp, RN, PhD, ET, CS, NHA

NANDA: The state in which an individual is at increased risk for being

invaded by pathogenic organisms
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 (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. Health care workers, to protect
themselves and others from disease transmission, must understand how to take precautions
to prevent transmission. Because identification of infected individuals is not always

apparent, standard precautions recommended by the Centers for Disease Control and
Prevention (CDC) are widely practiced. In addition, the Occupational Safety and Health
Administration (OSHA) has set forth the Blood Borne Pathogens Standard, developed to
protect workers and the public from infection. Ease and increase in world travel has also
increased opportunities for transmission of disease from abroad. Infections prolong healing,
and can result in dealth if untreated. Antimicrobials are used to treat infections when
susceptibility is present. Organisms may become resistant to antimicrobials, requiring
multiple antimicrobial therapy. There are organisms for which no antimicrobial is effective,
such as the human immunodeficiency virus (HIV).
Risk Factors

Inadequate primary defenses: broken skin, injured tissue, body fluid stasis
Inadequate secondary defenses: immunosuppression, leukopenia
Malnutrition
Intubation
Indwelling catheters, drains
Intravenous (IV) devices
Invasive procedures
Rupture of amniotic membranes
Chronic disease
Failure to avoid pathogens (exposure)
Inadequate acquired immunity

Expected Outcomes

Patient remains free of infection, as evidenced by normal vital signs, and absence of
purulent drainage from wounds, incisions, and tubes.
Infection is recognized early to allow for prompt treatment.

Ongoing Assessment
Actions/Interventions/Rationale
Key:

(i) independent
(c) collaborative
(i) Assess for presence, existence of, and history of risk factors such as open
wounds and abrasions; indwelling catheters (Foley, peritoneal); wound drainage
tubes (T-tubes, Penrose, Jackson-Pratt); endotracheal or tracheostomy tubes;
venous or arterial access devices; and orthopedic fixator pins.
Each of these examples represent a break in the body's normal first lines of defense.
(c) Monitor white blood count (WBC).
Rising WBC indicates body's efforts to combat pathogens; normal values: 4000 to
11,000. Very low WBC (neutropenia <1000) indicates severe risk for infection
because patient does not have sufficient WBCs to fight infection. NOTE: In the
elderly, infection may be present without an increased WBC.

(i) Monitor for the following signs of infection:

Redness, swelling, increased pain, or purulent drainage at incisions, injured sites,

exit sites of tubes, drains, or catheters.
o Any suspicious drainage should be cultured; antibiotic therapy is determined
by pathogens identified at culture.
Elevated temperature.
o Fever of up to 38 degrees C (100.4 degrees F) for 48 hours after surgery is
related to surgical stress; after 48 hours, fever above 37.7 degrees C (99.8
degrees F) suggests infection; fever spikes that occur and subside are
indicative of wound infection; very high fever accompanied by sweating and
chills may indicate septicemia.
Color of respiratory secretions.
o Yellow or yellow-green sputum is indicative of respiratory infection.
Appearance of urine.
o Cloudy, foul-smelling urine with visible sediment is indicative of urinary tract
or bladder infection.

(i) Assess nutritional status, including weight, history of weight loss, and serum
albumin.
Patients with poor nutritional status may be anergic, or unable to muster a cellular
immune response to pathogens and are therefore more susceptible to infection.
(i) In pregnant patients, assess intactness of amniotic membranes.
Prolonged rupture of amniotic membranes before delivery places the mother and
infant at increased risk for infection.
(i) Assess for exposure to individuals with active infections.
(i) Assess for history of drug use or treatment modalities that may cause
immunosuppression.
Antineoplastic agents and corticosteroids reduce immunocompetence.
(i) Assess immunization status.
Elderly patients and those not raised in the United States may not have completed
immunizations, and therefore not have sufficient acquired immunocompetence.

Therapeutic Interventions
Actions/Interventions/Rationale
Key:

(i) independent
(c) collaborative

(i) Maintain or teach asepsis for dressing changes and wound care, catheter care
and handling, and peripheral IV and central venous access management.
(i) Wash hands and teach other caregivers to wash hands before contact with
patient, and between procedures with patient.
Friction and running water effectively remove microorganisms from hands. 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). Use of disposable gloves
does not reduce the need for handwashing.
(i) Limit visitors.
To reduce the number of organisms in patient's environment and restrict visitation
by individuals with any type of infection to reduce the transmission of pathogens to
the patient at risk for infection. The most common modes of transmission are by
direct contact (touching) and by droplet (airborne).
(i) Encourage intake of protein- and calorie-rich foods.
To maintain optimal nutritional status.
(i) Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless
contraindicated).
To promote diluted urine and frequent emptying of bladder; reducing stasis of urine
in turn reduces risk of bladder infection or urinary tract infection (UTI).
(i) Encourage coughing and deep breathing; consider use of incentive spirometer.
These measures reduce stasis of secretions in the lungs and bronchial tree. When
stasis occurs, pathogens can cause upper respiratory infections, including
pneumonia.
(c) Administer or teach use of antimicrobial (antibiotic) drugs as ordered.
Antimicrobial drugs include antibacterial, antifungal, antiparasitic, and antiviral
agents. Ideally, the selection of the drug is based on cultures from the infected area;
this is often impossible or impractical, and in these cases, empirical management
usually with a broad-spectrum drug is undertaken. All of these agents are either
toxic to the pathogen or retard the pathogen's growth.
(c) Place patient in protective isolation if patient is at very high risk.
Protective isolation is established to protect the person at risk from pathogens.
(i) Recommend the use of soft-bristled toothbrushes and stool softeners to protect
mucous membranes.

Education/Continuity of Care
Actions/Interventions/Rationale
Key:

(i) independent
(c) collaborative
(i) Teach patient or caregiver to wash hands often, especially after toileting,
before meals, and before and after administering self-care.
Patients and caregivers can spread infection from one part of the body to another, as
well as pick up surface pathogens; handwashing reduces these risks.
(i) Teach patient the importance of avoiding contact with those who have
infections, colds, or other things.
(i) Teach family members and caregivers about protecting susceptible patient
from themselves and others with infections or colds.
(i) Teach patient, family, and caregivers the purpose and proper technique for
maintaining isolation.
(i) Teach 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 taken as prescribed. The absorption
of some antibiotics is hindered by certain foods; patient should be instructed
accordingly.
(i) Teach patient and caregiver the signs and symptoms of infection, and when to
report these to the physician or nurse.
(i) Demonstrate and allow return demonstration of all high-risk procedures that
patient or caregiver will do after discharge, such as dressing changes, peripheral
or central IV site care, peritoneal dialysis, self-catheterization (may use clean
technique).
Bladder infection more related to overdistended bladder resulting from infrequent
catheterization than to use of clean versus sterile technique.