Nursing diagnosis: risk for Infection
Risk factors may include
Inadequate primary defenses—broken skin, traumatized tissue, stasis of body fluids
Depression of the immune system, chronic disease, malnutrition, use of antimicrobial agents
Environmental exposure, invasive techniques
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Achieve timely healing of wounds or lesions.
Be afebrile and free of purulent drainage or secretions, and other signs of infectious conditions.
Identify and participate in behaviors to reduce risk of infection.
Nursing intervention with rationale:
1. Assess client knowledge and ability to maintain OI prophylactic regimen.
Rationale: Multiple medication regimen is difficult to maintain over a long period of time. Clients may adjust medication regimen based on side effects experienced, contributing to inadequate prophylaxis, active disease, and resistance. However, new medication regimens may increase adherence because they require less frequent dosing, fewer pills at each dose, and fewer side effects, thus maximizing quality of life and improving adherence to treatment.
2. Wash hands before and after all care contacts. Instruct client and SO to wash hands, as indicated.
Rationale: Reduces risk of cross-contamination.
3. Provide a clean, well-ventilated environment. Screen visitors and staff for signs of infection and maintain isolation precautions as indicated.
Rationale: Reduces number of pathogens presented to the immune system and reduces possibility of client contracting a nosocomial infection.
4. Discuss extent and rationale for isolation precautions and maintenance of personal hygiene.
Rationale: Promotes cooperation with regimen and may lessen feelings of isolation.
5. Monitor vital signs, including temperature.
Rationale: Provides information for baseline and data to track changes. Frequent temperature elevations or onset of new fever indicates that the body is responding to a new infectious process or that medications are not effectively controlling noncurable infections.
6. Assess respiratory rate and depth; note dry spasmodic cough on deep inspiration, changes in characteristics of sputum, and presence of wheezes or rhonchi. Initiate respiratory isolation when etiology of productive cough is unknown.
Rationale: Respiratory congestion and distress may indicate developing PCP—the most common opportunistic disease in clients with CD4 count below 200. However, TB is on the rise and other fungal, viral, and bacterial infections may occur that compromise the respiratory system. Note: CMV and PCP can reside together in the lungs and, if treatment is not effective for PCP, the addition of CMV therapy may be effective.
7. Investigate reports of headache, stiff neck, and altered vision. Note changes in mentation and behavior. Monitor for nuchal rigidity or seizure activity.
Rationale: Neurological abnormalities are common and may be related to HIV or secondary infections. Symptoms may vary from subtle changes in mood or sensorium (personality changes or depression) to hallucinations, memory loss, severe dementias, seizures, and loss of vision. Central nervous system (CNS) infections (encephalitis is the most common) may be caused by protozoal and helminthic organisms or fungus.
8. Examine skin and oral mucous membranes for white patches or lesions.
Rationale: Oral candidiasis, KS, herpes, CMV, and cryptococcosis are common opportunistic diseases affecting the cutaneous membranes.
9. Wear gloves and gowns during direct contact with secretions or excretions, or any time there is a break in skin of caregiver’s hands. Wear mask and protective eyewear to protect nose, mouth, and eyes from secretions during procedures (e.g., suctioning) or when splattering of blood may occur.
Rationale: Use of masks, gowns, and gloves is required by the Occupational Safety and Health Administration (OSHA, 1992) for direct contact with body fluids, such as sputum, blood or blood products, semen, or vaginal secretions.
10. Dispose of needles and sharps in rigid, puncture-resistant containers.
Rationale: Prevents accidental inoculation of caregivers. Use of needle cutters and recapping is not to be practiced. Note: Accidental needle sticks should be reported immediately, with follow-up evaluations done per protocol.