This guide is about Risk for Infection, Risk for Infection Nursing Assessment, Risk for Infection Nursing Interventions, and 2 for Risk of Infection Nursing Care Plan Examples. It can be used to create educational nursing care plans for risk of infection.
Risk for Infection
What is Risk for Infection?
Risk for infection is a NANDA nursing diagnosis that involves the alteration or disturbance in the body’s inflammatory response, which allows microorganisms to invade the body and cause infection. It is a common problem in people with low immune system. Preventing infection is a vital role of all healthcare professionals.
Infections occur when the natural defense mechanisms of an individual are inadequate to protect them. Microorganisms such as bacteria, viruses, fungus, and other parasites invade susceptible hosts through inevitable injuries and exposures. People have dedicated cells or tissues that deal with the threat of infection. These are known as the immune system.
The human immune system is crucial for survival in a world full of potentially deadly and harmful microbes. The serious impairment of this system can predispose to severe, even life-threatening, infections. Organs and tissues involved in the immune system include the thymus, bone marrow, lymph nodes, spleen, appendix, tonsils, and Peyer’s patches (in the small intestine). If the patient’s immune system cannot battle the invading microorganism sufficiently, an infection occurs.
Breaks in the integrity of the integument, mucous membranes, soft tissues, or even organs such as the kidneys and lungs can be sites for infections after trauma, invasive procedures, or invasion of pathogens through the bloodstream or lymphatic system.
A common means for infectious diseases to spread is by directly transferring bacteria, viruses, or other germs from one person to another. This can transpire via contact, airborne, sexual contact, or sharing of IV drug paraphernalia. Also, having inadequate resources, lack of knowledge, and being malnourished place an individual at high risk of developing an infection.
Infections prolong healing and can result in death if left untreated. Antimicrobials are widely used to treat infections when susceptibility is present. However, no antimicrobial is effective for some organisms, such as the human immunodeficiency virus (HIV). Another common medical intervention is called immunization. This is also universally used for those who are at high risk for infection. Handwashing is the best way to break the chain of infection.
Specific nursing interventions will depend on the nature and severity of the risk. Patients should be informed and well-educated by nurses on recognizing the signs of infection and how to reduce their risk. While many people are at risk for infection in the community, about 1.7 million patients acquire healthcare-associated or “nosocomial” infections, with a death record of 98,000 annually. A good understanding of the chain of infection helps in the early diagnosis and prevention of infection.
What are the Signs and Symptoms of Infection?
- Erythema – redness on the affected body part, region, or area
- Warmth and/or tenderness on the affected body part, region, or area
- Edema or swelling
- Fever and/or chills
- Aches and pains
- Night sweats
- Loss of appetite
- Weight loss
What is the Chain of Infection?
- Infectious agent (pathogen). A pathogen can be a bacterium, virus, fungus, parasite, or any other microorganisms.
- Reservoir. A reservoir is a place where the pathogen normally lives. It can include people, animals, soil, or any substance.
- Portal of exit from the reservoir. This refers to how the pathogen leaves the reservoir.
- Mode of transmission. This is the way the pathogen transfers from the reservoir to the host.
- Portal of entry into a host. This refers to how the pathogen gets into the host.
- Susceptible host. This is the final step in the chain of infection. When the pathogen reaches the host, the body fights off the microorganism. However, an infection can occur when the body is not strong enough to fight off the infection.
What Causes Infection?
Various health problems and conditions can create a favorable environment that would encourage the development of infections. Here are the common causes of infection and factors that place a patient at risk for infection:
- Inadequate primary defenses (e.g., break in skin integrity, tissue damage).
- Insufficient knowledge to avoid exposure to pathogens.
- Compromised host defenses (e.g., cancer, immunosuppression, AIDS, diabetes mellitus).
- Compromised circulation (e.g., obesity, lymphedema, peripheral vascular disease).
- A site for organism invasion (e.g., surgery, dialysis, invasive lines, intubation, enteral feedings).
- Compromised host defenses (e.g., radiation therapy, organ transplant, medication therapy)
- Contact with contagious agents
- Increased vulnerability of infant (e.g., HIV-positive mother, lack of normal flora, lack of maternal antibodies).
- Lack of immunization
- Multiple sex partners
- Chronic diseases
- Rupture of amniotic membranes
What are the Goals and Outcomes of Nursing Diagnosis of Infection?
Here are some sample patient goals and expected outcomes for patients at risk for infection.
- Client will remain free of infection, as evidenced by normal vital signs and absence of signs and symptoms of infection.
- Client will maintain or restore defenses.
- Early recognition of infection to allow for prompt treatment.
- Patient will demonstrate a meticulous hand washing technique.
- Alleviate or reduce the problems related with the infection.
Risk for Infection Nursing Assessment
How do you assess for Infection?
Assessment is paramount in identifying factors that may precipitate infection. Use the nursing assessment guidelines below to identify your subjective data and objective data for your risk for infection care plan:
1. Assess for the presence, existence, and history of the common causes of infection (listed above).
These factors represent a break in the body’s normal first line of defense and may indicate an infection.
2. Assess for the presence of local infectious processes in the skin or mucous membranes.
Signs and symptoms include localized swelling, localized redness, pain or tenderness, loss of function in the affected area, palpable heat.
3. Monitor and report any signs and symptoms of infection. Signs and symptoms of infection vary according to the body area involved. Assess for the following signs and symptoms:
3.1. Redness, swelling, increased pain, purulent discharge from incisions, injury, and exit sites of tubes (IV tubings), drains, or catheters.
These are the classic signs of infection. Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified.
3.2. Elevated temperature.
Fever is often the first sign of an infection. A temperature of up to 38º C (100.4º F) 48 hours post-op is usually related to surgical stress after 48 hours. A temperature of greater than 37.7º (99.8º F) may indicate infection; a very high temperature accompanied by sweating and chills may indicate septicemia.
3.3. Color of respiratory secretions.
Yellow or yellow-green sputum is indicative of respiratory infection.
3.4. Appearance of urine.
Cloudy, turbid, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection.
4. Monitor white blood cell (WBC) count.
An increasing WBC count indicates the body’s efforts to combat pathogens. Rates are as follows:
- Low: below 4,500
- Normal: 4,500 – 11,000
- High: more than 11,000
- Very low WBC count may indicate a severe risk for infection. In older patients, the infection may be present without an increased WBC count. Additionally, WBC differential may show an increase and decrease in certain infections.
5. Assess and monitor nutritional status, weight, history of weight loss, and serum albumin.
Patients with inadequate nutrition may be anergic or unable to muster a cellular immune response to pathogens, making them susceptible to infection.
6. Investigate the use of medications or treatment modalities that may cause immunosuppression.
Antineoplastic agents, corticosteroids, and so on can suppress immune function.
7. Assess immunization status and history.
People with incomplete immunizations may not have sufficient acquired active immunity. You may ask patients during history taking when they were last immunized.
8. Observe and report if an older client has a low-grade fever or new onset of confusion.
Low-grade temperature elevation that appears in older clients must be reported as it could potentially be an infection.
9. Obtain a travel history from clients.
Integrating travel history in assessment can help stem possible outbreaks and help put infectious symptoms in context for the healthcare team.
10. For pregnant clients, assess the intactness of amniotic membranes.
Prolonged rupture of amniotic membranes before delivery puts the mother and neonate at increased risk for infection.
Risk for Infection Nursing Interventions
What are the Nursing Interventions for Infection?
These nursing interventions help reduce the risk for infection, including implementing strategies to prevent infection. If the infection cannot be prevented, the goal is to prevent the spread of infection between individuals and treat the underlying infection. Use the nursing interventions below to help you create your nursing care plan for risk for infection:
1. Maintain strict asepsis for dressing changes, wound care, intravenous therapy, and catheter handling.
Aseptic technique decreases the chances of transmitting or spreading pathogens to or between patients. Interrupting the chain of infection (see image above) is an effective way to prevent the spread of infection.
2. Ensure that any articles used are properly disinfected or sterilized before use.
This reduces or eliminates germs.
3. Wash hands or perform hand hygiene before having contact with the patient. Also, impart these duties to the patient and their significant others and know the instances when to perform hand hygiene or “5 moments for hand hygiene”:
1. Before touching a patient.
2. Before clean or aseptic procedure (wound dressing, starting an IV, etc.).
3. After body fluid exposure risk
4. After touching a patient
5. After touching the patient’s surroundings.
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. Wash hands with antiseptic soap and water for at least 15 seconds, followed by an alcohol-based hand rub. If hands were not in contact with anyone or anything in the room, use an alcohol-based hand rub and rub until dry. Plain soap is good at reducing bacterial counts, but antimicrobial soap is better, and alcohol-based hand rubs are the best.
4. Educate clients and SO (significant other) about appropriate cleaning, disinfecting, and sterilizing items.
Knowledge of ways to reduce or eliminate germs reduces the likelihood of transmission.
5. Encourage intake of protein-rich and calorie-rich foods and encourage a balanced diet.
Proper nutrition and a balanced diet support the immune systems’ responsiveness and enhance the health of all the body’s tissues. Adequate nutrition enables the body to maintain and rebuild tissues and helps keep the immune system functioning well.
6. Perform measures to break the chain of infection and prevent infection.
The following methods help break the chain of infection and prevent conditions that may be suitable for microbial growth:
- Change dressing and bandages that are soiled or wet.
- Assist clients in carrying out appropriate skin and oral hygiene.
- Dispose of soiled linens properly.
- Ensure all fluid containers are covered or capped.
- Avoid talking, coughing, or sneezing over open wounds or sterile fields.
- Wear gloves when handling patient secretions.
- Instruct clients to perform hand hygiene when handling food or eating.
7. Encourage increased fluid intake unless contraindicated (e.g., heart failure, kidney failure).
Fluids help promote diluted urine, frequent emptying of the bladder, and reducing the stasis of urine. This ultimately reduces the risk of bladder infection or urinary tract infection. Increased fluid intake also helps replace fluid lost during fever and helps thin secretions.
8. Encourage coughing and deep breathing exercises; frequent position changes.
Helps reduce the stasis of secretions in the lungs and bronchial tree. When stasis occurs, microbial infection of the respiratory tract occurs and may lead to pneumonia.
9. Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes.
Hard-bristled toothbrushes can compromise the integrity of the mucous membrane and provide a port of entry for pathogens.
10. Instruct client not to share personal care items (e.g., toothbrush, towels, etc.).
Explain to the client how infections can be transmitted from sharing personal items.
11. Promote nail care by keeping the client and the nurse‘s fingernails short and clean.
Rough edges or hangnails can harbor microorganisms.
12. Limit visitors.
Restricting visitation reduces the transmission of pathogens.
13. Encourage sleep and rest.
Adequate sleep is an essential modulator of immune responses. A lack of sleep can weaken immunity and increased susceptibility to infection. For instance, shorter sleep durations are associated with a rise in suffering from the common cold.
14. Assist client to learn stress-reducing techniques.
Excessive stress predisposes clients to infection.
15. Provide surgical masks to visitors who are coughing and provide the rationale to enforce usage. Instruct visitors to cover mouth and nose (by using the elbows to cover) during coughing or sneezing; use tissues to contain respiratory secretions with immediate disposal to a no-touch receptacle; perform hand hygiene afterward.
Educating visitors on the importance of preventing droplet transmission from themselves to others reduces the risk of infection.
16. Place the patient in protective isolation if the patient is at high risk of infection.
Protective isolation is set when the WBC indicates neutropenia.
17. Initiate specific precautions for suspected agents as determined by CDC protocol.
- Meningitis: droplet, airborne precautions
- Rubella: airborne precautions
- MRSA: contact, droplet precautions
- COVID-19: droplet, airborne precautions
- Tuberculosis: airborne precautions.
18. Wear personal protective equipment (PPE) properly.
- Gloves. Wear gloves when providing direct care; perform hand hygiene after properly disposing gloves.
- Masks. Use masks, goggles, face shields to protect the mucous membranes of your eyes, mouth, and nose during procedures and in direct-care activities (e.g., suctioning secretions) that may generate splashes or sprays of blood, body fluids, secretions, and excretions.
- Gowns. Wear a gown for direct contact with uncontained secretions or excretions. Remove gown and perform hand hygiene before leaving the patient’s room or cubicle. Never reuse gowns even with the same individual.
19. Teach the importance of avoiding contact with individuals who have infections or colds. Teach the importance of physical distancing.
Other people can spread infections or colds to a susceptible patient (e.g., immunocompromised) through direct contact, contaminated objects, or air currents.
20. Demonstrate and allow return demonstration of all high-risk procedures that the patient and/or SO will do after discharge, such as dressing changes, peripheral or central IV site care, and so on.
Patient and SO need opportunities to master new skills to reduce susceptibility to infection.
21. Teach the patient, family, and caregivers, the purpose and proper technique for maintaining isolation.
Knowledge of isolation can help patients and family members cooperate with specific precautions.
22. If infection occurs, teach the patient to take anti-infectives as prescribed. If taking antibiotics, instruct the patient to take the full course of antibiotics even if symptoms improve or disappear.
Antibiotics work best when a constant blood level is maintained when medications are taken as prescribed. Not completing the prescribed antibiotic regimen can lead to drug resistance in the pathogen and reactivation of symptoms.
2 for Risk of Infection Nursing Care Plan Examples
What are Some of the Available Nursing Care Plans for Infection?
1. Viral Infection Nursing Care Plan
Nursing Diagnosis: Risk for infection related to Viral illness and immunocompromised status (e.g. cancer, ongoing chemotherapy, diabetes, etc.)
Desired Outcome: The patient will demonstrate ways to prevent the spread of infection.
|Monitor the patient’s vital signs and signs of infection.||Vital signs are important markers of infection. Other signs of infection can help raise suspicion so tests can be conducted to confirm the presence of infection.|
|Educate patient to maintain respiratory isolation:
Always keep tissues at the bedside or with the patient.
Cover mouth when coughing or sneezing
|Respiratory viral infection is transmitted through contact with contaminated articles or droplets when the patient sneezes or coughs.|
|Encourage hand hygiene and explain the importance of proper handwashing.||Handwashing is the single best way to prevent infection.|
|Explain the need to self-isolate for 14 days if any symptoms due to respiratory pandemic arise, or if patient tested positive.||Due to the limited knowledge of the disease, self-isolation is encouraged to prevent the transfer of infection to other people.|
|Educate the patient about the disease: its transmission, complications, and available help.||Educating the patient about the disease can raise confidence and understanding of the importance of sticking to the guidelines.|
|Educate the patient on the need for staff to use personal protective equipment when looking after them.||PPEs protect carers and prevent the transfer of infection to other people.|
|Give information regarding vaccinations.||The patient can make an informed choice about getting vaccinated when information is available.|
2. Tracheostomy Nursing Care Plan
Nursing Diagnosis: Risk for infection related to the presence of artificial airway (tracheostomy)
Desired Outcome: The patient will remain free from infection as evidenced by the absence of fever and clear stoma.
|Assess, monitor, and record the patient’s vital signs.||Vital signs monitoring including the patient’s temperature help in the monitoring of possible infections.|
|Regularly assess the patient’s stoma and surrounding skin for color, exudates, erythema, and crusting lesions.||The friction from the tracheostomy tube and mucus can irritate the stoma and surrounding skin making it a suitable site for infection.|
|Provide stoma care through the following steps: Clean the inner part of the stoma; if an inner cannula is used, replace it regularly with a new one. Keep the stoma clean and dry. Use barrier creams as needed. Secure the tracheostomy tube.||Regular stoma care prevents infection and helps maintain a clear, patent airway.|
|Encourage the patient to effectively cough out mucus.||Coughing is an effective method to expectorate mucus build up to prevent infection.|
|Keep a suction machine by the patient’s bedside.||Manual suctioning of the secretions may be necessary to avoid pooling of mucus in the airway if the patient is unable to independently cough it out.|
|Promote proper positioning or regular position changes.||An upright position and regular position changes prevent the pooling of mucus, therefore preventing infection.|
References and Sources
Recommended resources and reading materials for risk for infection nursing diagnosis and care plan:
- Allegranzi, B., & Pittet, D. (2009). Role of hand hygiene in healthcare-associated infection prevention. Journal of hospital infection, 73(4), 305-315.
- Arrowsmith, V. A., Maunder, J. A., & Taylor, R. (2001). Removal of nail polish and finger rings to prevent surgical infection. Cochrane database of systematic reviews, (1).
- Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., … & Parker, B. (2014). Kozier & Erb’s Fundamentals of Nursing Australian Edition (Vol. 3). Pearson Higher Education AU.
- Guppy, M. P., Mickan, S. M., Del Mar, C. B., Thorning, S., & Rack, A. (2011). Advising patients to increase fluid intake for treating acute respiratory infections. Cochrane Database of Systematic Reviews, (2).
- Group, H. L. (1999). Hand washing: a modest measure—with big effects. BMJ: British Medical Journal, 318(7185), 686.
- Ibarra-Coronado, E. G., Pantaleón-Martínez, A. M., Velazquéz-Moctezuma, J., Prospéro-García, O., Méndez-Díaz, M., Pérez-Tapia, M., … & Morales-Montor, J. (2015). The bidirectional relationship between sleep and immunity against infections. Journal of immunology research, 2015.
- Ivanov, A. V., Bartosch, B., & Isaguliants, M. G. (2017). Oxidative stress in infection and consequent disease.
- Jane Ward, D. (2007). Hand adornment and infection control. British journal of nursing, 16(11), 654-656.
- Kong, W., & Agarwal, P. P. (2020). Chest imaging appearance of COVID-19 infection. Radiology: Cardiothoracic Imaging, 2(1), e200028.
- Laws, T., & Hillman, E. (2015). Infection prevention and control. Pearson Australia.
- Pittet, D. (2000). Improving compliance with hand hygiene in hospitals. Infection Control & Hospital Epidemiology, 21(6), 381-386.
- Price, V. A., Smith, R. A., Douthwaite, S., Thomas, S., Almond, D. S., Miller, A. R., … & Beadsworth, M. B. (2011). General physicians do not take adequate travel histories. Journal of travel medicine, 18(4), 271-274.
- Reime, M. H., Harris, A., Aksnes, J., & Mikkelsen, J. (2008). The most successful method in teaching nursing students infection control–E-learning or lecture?. Nurse Education Today, 28(7), 798-806.
- Robson MC, Stenberg BD, Heggers JP. Wound healing alterations caused by infection. Clin Plast Surg. 1990;17(3):485-492.
- Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J., & Pittet, D. (2007). ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection, 67(1), 9-21.
- Voss, A., & Widmer, A. F. (1997). No time for handwashing!? Handwashing versus alcoholic rub can we afford 100% compliance?. Infection Control & Hospital Epidemiology, 18(3), 205-208.
- Zimmerman, S., Gruber‐Baldini, A. L., Hebel, J. R., Sloane, P. D., & Magaziner, J. (2002). Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors. Journal of the American Geriatrics Society, 50(12), 1987-1995.