Nursing diagnosis: risk for Infection
Risk factors may include
Compromised immune system
Failure to recognize or treat infection and/or exercise proper preventive measures
Invasive procedures, environmental exposure (nosocomial)
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Achieve timely healing; be free of purulent secretions, drainage, or erythema; and be afebrile.
Nursing intervention with rationale:
1. Examine client for possible source of infection, such as sore throat, sinus pain, burning with urination, localized abdominal pain, burns, open wounds or cellulitis, presence of invasive catheters, or lines.
Rationale: Respiratory tract and urinary tract infection are the most frequent causes of sepsis, followed by abdominal and soft tissue infections. The use of intravascular devices is also a well-known cause of hospital-acquired sepsis.
2. Wash hands with antibacterial soap before and after each care activity, even when gloves are used.
Rationale: Hand washing and hand hygiene reduce the risk of crosscontamination. Note: Methicillin-resistant Staphylococcus aureus (MRSA) is most commonly transmitted via direct contact with healthcare workers who fail to wash hands between client contacts.
3. Provide isolation and monitor visitors, as indicated.
Rationale: BSI should be used for all infectious clients. Wound and linen isolation and hand washing may be all that is required for draining wounds. Clients with diseases transmitted through air may also need airborne and droplet precautions. Reverse isolation and restriction of visitors may be needed to protect the immunosuppressed client.
4. Encourage or provide frequent position changes, deep-breathing, and coughing exercises.
Rationale: Good pulmonary toilet may reduce respiratory compromise.
5. Encourage client to cover mouth and nose with tissue when coughing or sneezing. Place in private room if indicated. Wear mask when providing direct care as appropriate.
Rationale: Appropriate behaviors, personal protective equipment, and isolation prevent spread of infection via airborne droplets.
6. Limit use of invasive devices and procedures when possible. Remove lines and devices when infection is present and replace if necessary.
Rationale: Reduces number of possible entry sites for opportunistic organisms.
7. Inspect wounds and sites of invasive devices daily, paying particular attention to parenteral nutrition lines. Document signs of local inflammation and infection and changes in character of wound drainage, sputum, or urine.
Rationale: Catheter-related bloodstream infections (CR-BSIs) are increasing where central venous catheters are used in both acute and chronic care settings. Clinical signs, such as local inflammation or phlebitis, may provide a clue to portal of entry, type of primary infecting organism(s), as well as early identification of secondary infections.
8. Investigate reports of pain out of proportion to visible signs.
Rationale: Pressurelike pain over area of cellulitis may indicate development of necrotizing fasciitis due to group A beta hemolytic streptococci (GABS), necessitating prompt intervention.
9. Maintain sterile technique when changing dressings, suctioning, and providing site care, such as an invasive line or a urinary catheter.
Rationale: Medical asepsis prevents or limits introduction of bacteria and reduces the risk of nosocomial infection.
10. Administer medications, as indicated, for example: Anti-infective agents: broad-spectrum antibiotics, such as imipenem and cilastatin (Primaxin), meropenem (Merrem), ticarcillin and clavulanate (Timentin), piperacillin and tazobactam (Zosyn), clindamycin (Cleocin), vancomycin (Vancocin); aminoglycosides, such as tobramycin (Nebcin), gentamicin (Garamycin); cephalosporins, such as cefepime (Maxipime); fluoroquinolones, such as levofloxacin (Levaquin), ciprofloxin (Cipro); antifungals, such as fluconazole (Diflucan), caspofungin acetate (Cancidas)
Rationale: Specific antibiotics are determined by culture and sensitivity tests, but therapy is usually initiated before obtaining results, using broad-spectrum antibiotics and/or based on most likely infecting organisms. Antifungal therapy may be considered in client who has already been treated with antibiotics, who is neutropenic, receiving total parenteral nutrition (TPN), or who has central venous access in place.