Risk for Infection – Nursing Diagnosis & Care Plan

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Risk for infection NCP ND

Risk for infection is one of the common problems of an individual wherein there is an alteration or disturbance in the immune defenses which causes microorganisms to enter and invade the body which later one causes different kinds of infections. These infections can be caused by viruses, bacteria, fungi and other microorganisms.

These microbes will invade and attack the body and thereby causing specific infections that need urgent interventions to prevent its worsening.

Nanda-I Definition: Risk For Infection

Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health.

Related Factors (Risk For Infection Related to…)

  • Lack of knowledge on the different microorganisms which cause infections
  • Diminished immune response or defense
  • Break in the skin and tissue integrity
  • Immunocompromised individuals
  • Persons who had undergone surgical operations
  • Persons with underlying diseases such as cancer and AIDS
  • Lack of or incomplete immunization
  • Polygamous individuals

Defining Characteristics

  • Verbalization of lack of knowledge on the different infections, its treatment and prevention
  • Presence of underlying diseases which suppress the immune function of the body
  • White Blood Cells (WBC) level of the blood is decreases or below the normal range
  • Reported case of being a polygamous individual
  • Presence of delayed healing at the surgical incision site
  • Reported lack or no immunization being administered
  • Presence of open wounds or cuts in the skin

Nursing Assessment

Assessment Rationale
1. assess the patient for any signs of possible infection (fever, redness, swelling, pain, purulent discharges) ·       It determines the presence of infection and will let the nurse provide immediate and appropriate nursing interventions
2. Assess and monitor patient’s nutritional status by checking signs of weight loss ·       Weight loss is one of the possible effects of an underlying infection
3. ask for the immunization status of the patient if needed ·       It will determine any lack of or missed vaccines prescribed
4. ask patient if taking medications that can suppress the immune system function ·       Some medications may lower the immune function as its side effects. It will let the nurse be guided on the medications that should be avoided or taken with limit

 

Desired Outcomes:

  • Increase in the knowledge on the prevention of infection
  • No signs and symptoms of infection
  • Normal temperature, respiratory rate, pulse rate, and blood pressure
  • Demonstrate the proper handwashing technique as a means of preventing transmission of infections

Nursing Interventions/Rationale:

Nursing Interventions Rationale
1. educate the patient on the ways of preventing infection such as the proper handwashing technique ·       It will limit or reduce transmission of infections through proper handwashing
2. always perform the proper handwashing technique before and after any procedure done to the patient ·       It will prevent transmission and acquisition of infection by both the nurse and the patient
3. encourage the patient to eat healthy foods that can enhance the immune function and take necessary vitamins needed ·       It enhances the immune function of the body
4. increase oral fluid intake ·       It will let the patient urinate frequently so as to flush the microorganisms present in the body
5. limit visitors if the patient is immunocompromised and render reverse isolation ·       It will prevent transmission of pathogens from visitors which may aggravate the infection
6. wear mask, gloves and gown if necessary ·       It will limit further transmission of microorganisms to and from the patient
Collaborative
1. check the presence of elevated temperature and give paracetamol as prescribed ·       Fever is one sign of infection and it needs immediate interventions to prevent worsening of the illness
2. administer antibiotics as prescribed ·       It will treat an infection caused by a bacteria
3. administer antiviral medications as prescribed ·       It will treat viral infection
4. refer the patient to the attending physician if there is worsening of the patient’s health condition ·       It signals presence of complications which needs immediate interventions

 

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