Nursing diagnosis: risk for Infection
Risk factors may include
Depression of immunological defenses (secondary to uremia)
Invasive procedures or devices, such as urinary catheter
Changes in dietary intake, malnutrition
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Experience no signs or symptoms of infection.
Nursing intervention with rationale:
1. Promote good hand washing by client and staff.
Rationale: Reduces risk of cross-contamination.
2. Avoid invasive procedures, instrumentation, and manipulation of indwelling catheters whenever possible. Use aseptic technique when caring for IV and invasive lines. Change site and dressings per protocol. Note edema and purulent drainage.
Rationale: Limits introduction of bacteria into body. Early detection and treatment of developing infection may prevent sepsis.
3. Provide routine catheter care and promote meticulous perianal care. Keep urinary drainage system closed and remove indwelling catheter as soon as possible.
Rationale: Reduces bacterial colonization and risk of ascending UTI.
4. Encourage deep breathing, coughing, and frequent position changes.
Rationale: Prevents atelectasis and mobilizes secretions to reduce risk of pulmonary infections.
5. Assess skin integrity.
Rationale: Excoriations from scratching may become secondarily infected.
6. Monitor vital signs.
Rationale: Fever higher than 100.4°F (38.0°C) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response.
7. Monitor laboratory studies, such as WBC count with differential.
Rationale: Although elevated WBCs may indicate generalized infection, leukocytosis is commonly seen in ARF and may reflect inflammation or injury within the kidney. A shifting of the differential to the left is indicative of infection.
8. Obtain specimen(s) for culture and sensitivity and administer appropriate antibiotics, as indicated.
Rationale: Verification of infection and identification of specific organism aids in choice of the most effective treatment. Note: A number of anti-infective agents require adjustments of dose or time while renal clearance is impaired.