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HOME NURSING CARE PLANS NURSING DIAGNOSIS RISK FOR INFECTION

NURSING CARE PLANS NURSING DIAGNOSIS

Risk for Infection

By Matt Vera, BSN, R.N. - Updated on March 20, 2019 1

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Risk for Infection – Nursing Diagnosis & Care Plan

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The NANDA nursing diagnosis Risk for Infection is

defined as at increased risk for being invaded by
pathogenic organisms. Use this nursing diagnosis guide
to create your Risk for Infection Care Plan.

Infections occur when the natural defense mechanisms

of an individual are inadequate to protect them.
Organisms such as bacterium, virus, 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,
and 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.

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Breaks in 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. And a common
means for infectious diseases to spread is through the
direct transfer of 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.

See Also: Nursing Diagnosis Complete List and Guide »

Infections prolong healing and can result in death if

treated inappropriately. Antimicrobials are widely used
to treat infections when susceptibility is present.
However, for some organisms such as the human
immunodeficiency virus (HIV), no antimicrobial is
effective. Another common medical intervention is
called the 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 how to recognize the
signs of infection and how to reduce their risk.

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1. Risk Factors
2. Goals and Outcomes
3. Nursing Care Plans for Risk for Infection
4. Nursing Assessment for Risk for Infection
5. Nursing Interventions for Risk for Infection
6. References and Sources

Risk Factors
Various health problems and conditions can create a
favorable environment that would encourage the
development of infections. Here are the common risk
factors for Risk for Infection that you can use after your
“related to” nursing diagnostic statement in your care
plan:

Inadequate primary defenses (e.g., broken 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)

Compromised host defenses

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

Goals and Outcomes

The patient should report risk factors associated with
infection and precautions needed. Here are the common
goals and outcomes for Risk for Infection that you can
use in your “short term” or “long term” goals in your
care plan:

Patient remains free of infection, as evidenced by

normal vital signs and absence of signs and
symptoms of infection.

Early recognition of infection to allow for prompt

treatment.

Patient will demonstrate meticulous hand washing

technique.

Nursing Care Plans for Risk for

Infection
Diseases, medical conditions, and related nursing care
plans for Risk for Infection nursing diagnosis:

Acute Glomerulonephritis

Acute Rheumatic Fever

Bronchopulmonary Dysplasia (BPD)

Congenital Heart Disease

Cryptorchidism

Diabetes Mellitus

Fracture

Geriatric Nursing

Hydrocephalus

Nephrotic Syndrome

Pneumonia

Spina Bifida

Surgery (Perioperative Client)

Vesicoureteral Reflux (VUR)

For the complete list, visit Risk for Infection.

Nursing Assessment for Risk for

Infection
Assessment is paramount in identifying risk factors for
Risk for Infection. Use the nursing assessment
guidelines below to identify your subjective data and
objective data for your risk for infection care plan:

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Assessment Rationales

Assess for the presence,

These represent a break
existence of, and history
in the body’s normal first
of risk factors (mentioned
line of defense.
above).
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
Monitor white blood cell
(WBC) count High: Above 11,000

Very low WBC count may

indicate a severe risk for
infection. In older
patients, infection may be
present without an
increased WBC count.

Patients with poor

nutritional status may be
Assess and monitor
anergic or unable to
nutritional status, weight,
muster a cellular immune
history of weight loss,
response to pathogens
and serum albumin.
making them susceptible
to infection.
Prolonged rupture of
amniotic membranes
For pregnant clients,
before delivery puts the
assess the intactness of
mother and neonate at
amniotic membranes.
increased risk for
infection.
Investigate the use of
medications or treatment Antineoplastic agents,
modalities that may corticosteroids, and so
cause on, can reduce immunity.
immunosuppression.
People with incomplete
Assess immunization immunizations may not
status and history. have sufficient acquired
active immunity.
Monitor the following signs of actual infection:
Redness, swelling, These are the classic
increased pain, signs of infection. Any
purulent discharge suspicious drainage
from incisions, injury, should be cultured;
and exit sites of tubes antibiotic therapy is
(IV tubings), drains, or determined by pathogens
catheters. identified.
Temperature of up to 38º
C (100.4º F) 48 hours
post-op is usually related
to surgical stress after 48
hours, temperature of
Elevated temperature. greater than 37.7º (99.8º
F) may indicate infection;
very high temperature
accompanied by sweating
and chills may indicate
septicemia.
Yellow or yellow-green
Color of respiratory
sputum is indicative of
secretions.
respiratory infection.
Cloudy, turbid, foul-
smelling urine with visible
Appearance of urine. sediment is indicative of
urinary tract or bladder
infection.

Nursing Interventions for Risk for

Infection
The following therapeutic nursing interventions can help
reduce the Risk for Infection. Use these nursing
interventions for Risk for Infection in developing your
care plan:
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Interventions Rationales
Nursing Theories and
Theorists
Aseptic technique
Maintain or teach asepsis decreases the changes of
for dressing changes and transmitting or spreading Normal Lab Values
Reference Guide
wound care, peripheral IV pathogens to the patient.
and central venous Interrupting the
management, and transmission of infection Nursing Care Plans
(NCP): Ultimate Guide
catheter care and along the chain of and Database
handling. infection is an effective
way to prevent infection. Nursing Diagnosis List:
Complete Guide and
Wash hands and teach Examples
patient and SO to wash
NCLEX-RN Cram
hands before contact with
Sheet for Nursing
patients and between Exams (2019 Update)

procedures with the

Pharmacology Nursing
patient.Instances when to Mnemonics & Tips
wash hands:

Before putting on 40 Nursing Bullets:

gloves and after taking Friction and running Pediatric Nursing

Reviewer
them off. water effectively remove
microorganisms from 8-Step Guide to ABG
Before and after
hands. Washing between Analysis Tic-Tac-Toe
touching a patient, Method
procedures reduces
before handling an
the risk of transmitting 50+ IV Therapy Tips
invasive device (foley
pathogens from one area and Tricks: How to Hit
catheter, IV catheter, the Vein in One Shot
of the body to another.
and so on) regardless
Wash hands with 30 Nursing Life Hacks
of whether or not You Probably Didn’t
antiseptic soap and water
gloves are used. Know About
for at least 15 seconds
After contact with body followed by alcohol-based
fluids or excretions, hand rub. If hands were ADVERTISEMENTS

mucous membranes, not in contact with

nonintact skin, or anyone or anything in the
wound dressings.
Need a Cyber Plan?
room, use an alcohol-
Honeywell Cybersecurity
If moving from based hand rub and rub
Help better protect your data with
contaminated body site until dry.
real-time visibility into cyber
vulnerabilities
to another site during
Plain soap is good at
the care of the same
reducing bacterial counts
individual.
but antimicrobial soap is OPEN
After contact with better, and alcohol-based
inanimate surfaces and hand rubs are the best.
objects in the
immediate vicinity of
the patient.

After removing sterile

or nonsterile gloves.

Before handling
medications or
preparing food.

Encourage intake of Helps support the

protein-rich and calorie- immune system
rich foods. responsiveness.
Fluids promote diluted
urine and frequent
Encourage fluid intake of
emptying of bladder –
2,000 to 3,000 mL of
reducing the stasis of
water per day, unless
urine, in turn, reduces
contraindicated.
risk for bladder infection
or urinary tract infection.
Helps reduce stasis of
secretions in the lungs
Encourage coughing and and the bronchial tree.
deep breathing exercises; When stasis occurs,
frequent position pathogens can cause
changes. upper respiratory tract
infections and
pneumonia.
Recommend the use of These may compromise
soft-bristled toothbrushes the integrity of the
and stool softeners to mucous membranes and
protect mucous provide a port of entry for
membranes. pathogens.
Restricting visitation
Limit visitors. reduces the transmission
of pathogens.
Provide surgical mask to
visitors who are coughing
and provide
an explanation why.
Instruct:

Cover mouth and nose Educating visitors on the

during coughing or importance of preventing
sneezing. droplet transmission from
themselves to others can
Use tissues to contain
help reduce the risk of
respiratory secretions
infection.
with an immediate
disposal to a no-touch
receptacle; wash hands
with soap and water
afterward.

Place the patient in Protective isolation is set

protective isolation if the when WBC counts
patient is at very high indicate neutropenia (less
risk. than 500 mm3).
Initiate specific precautions for suspected
agents; follow infection prevention according to
institution or CDC protocol.
Meningitis Droplet, airborne
precautions
Rubella Airborne precautions
Contact, droplet
MRSA
precautions
Tuberculosis Airborne precautions
Wear personal protective equipment (PPE):
Wear gloves when
providing direct care;
Gloves wash hands with soap
and water after properly
disposing of gloves.
Use masks, goggles, or
face shields to protect the
mucous membrane of
your eyes, mouth, and
nose during procedures
and direct-care
Masks
activities (e.g., suctioning
oral secretions) that may
generate splashes or
sprays of blood, body
fluids, secretions, and
excretions.
Wear a gown for direct
contact with uncontained
secretions or excretions.
Remove gown and
Gowns perform hand hygiene
before leaving the
patient’s room or cubicle.
Do not reuse gowns even
with the same individual.
Teach the patient and/or
Patients and SO can
SO to wash hands often,
spread infection from one
especially after toileting,
part of the body to
before meals, and before
another – handwashing
and after administering
reduces these risks.
self-care.
Other people can spread
Teach the patient the
infections or colds to a
importance of avoiding
susceptible patient
contact with individuals
through direct contact,
who have infections or
contaminated objects, or
colds.
through air currents.
Demonstrate and allow
return demonstration of
all high-risk procedures
Patient and SO need
that the patient and/or
opportunities to master
SO will do after
new skills to reduce risk
discharge, such as
for infection.
dressing changes,
peripheral or central IV
site care, and so on.
Teach the patient, family, Knowledge about
and caregivers, the isolation can help patients
purpose and proper and family members
technique for maintaining cooperate with specific
isolation precautions.
Antibiotics work best
when a constant blood
If infection occurs, teach
level is maintained which
the patient to take
is done when medications
antibiotics as prescribed.
are taken as prescribed.
Instruct patient to take
Not completing the
the full course of
prescribed antibiotic
antibiotics even if
regimen can lead to drug
symptoms improve or
resistance in the
disappear.
pathogen and reactivation
of symptoms.

References and Sources

Recommended resources and reading materials for Risk
for Infection nursing diagnosis and care plan:

Group, H. L. (1999). Hand washing: a modest

measure—with big effects. BMJ: British Medical
Journal, 318(7185), 686. [Link]

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.
[Link]

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. [Link]

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.
[Link]