Risk for Infection NCLEX Review Care Plans
Nursing Care Plans for Risk for Infection
Risk for infection is a NANDA nursing diagnosis that involves the alteration or disturbance in the body’s inflammatory response, which allows microorganisms to invade the body and cause infection.
It is a common problem in people with low immune system. Preventing infection is a vital role of all healthcare professionals.
Nursing Stat Facts 1
While many people are at risk for infection in the community, about 1.7 million patients acquire healthcare-associated or “nosocomial” infections, with a death record of 98,000 annually.
A good understanding of the chain of infection helps in the early diagnosis and prevention of infection.
Signs and Symptoms of Infection
- Erythema – redness on the affected body part, region, or area
- Warmth and/or tenderness on the affected body part, region, or area
- Edema or swelling
- Fever and/or chills
- Aches and pains
- Night sweats
- Loss of appetite
- Weight loss
Chain of Infection
- Infectious agent (pathogen). A pathogen can be a bacterium, virus, fungus, parasite, or any other microorganisms.
- Reservoir. A reservoir is a place where the pathogen normally lives. It can include people, animals, soil, or any substance.
- Portal of exit from the reservoir. This refers to how the pathogen leaves the reservoir.
- Mode of transmission. This is the way the pathogen transfers from the reservoir to the host.
- Portal of entry into a host. This refers to how the pathogen gets into the host.
- Susceptible host. This is the final step in the chain of infection. When the pathogen reaches the host, the body fights off the microorganism. However, an infection can occur when the body is not strong enough to fight off the infection.
Causes of Infection
The following are the common causes of infection:
- Inadequate primary defenses such as broken skin
- Lack of knowledge about pathogens
- Immunosuppression such as in people with cancer, recent organ donation and transplantation, AIDS, diabetes, and under radiation therapy.
- Contact with an infectious agent
- Lack of immunization
- Multiple sex partners
- Having chronic diseases
- Amniotic membrane rupture
Nursing Care Plans for Risk of Infection
Viral Infection Nursing Care Plan
Nursing Diagnosis: Risk for infection related to Viral illness and immunocompromised status (e.g. cancer, ongoing chemotherapy, diabetes, etc.)
Desired Outcome: The patient will demonstrate ways to prevent the spread of infection.
|Monitor the patient’s vital signs and signs of infection.||Vital signs are important markers of infection. Other signs of infection can help raise suspicion so tests can be conducted to confirm the presence of infection.|
|Educate patient to maintain respiratory isolation:|
Always keep tissues at the bedside or with the patient.
Cover mouth when coughing or sneezing
|Respiratory viral infection is transmitted through contact with contaminated articles or droplets when the patient sneezes or coughs.|
|Encourage hand hygiene and explain the importance of proper handwashing.||Handwashing is the single best way to prevent infection.|
|Explain the need to self-isolate for 14 days if any symptoms due to respiratory pandemic arise, or if patient tested positive.||Due to the limited knowledge of the disease, self-isolation is encouraged to prevent the transfer of infection to other people.|
|Educate the patient about the disease: its transmission, complications, and available help.||Educating the patient about the disease can raise confidence and understanding of the importance of sticking to the guidelines.|
|Educate the patient on the need for staff to use personal protective equipment when looking after them.||PPEs protect carers and prevent the transfer of infection to other people.|
|Give information regarding vaccinations.||The patient can make an informed choice about getting vaccinated when information is available.|
Tracheostomy Nursing Care Plan
Nursing Diagnosis: Risk for infection related to the presence of artificial airway (tracheostomy)
Desired Outcome: The patient will remain free from infection as evidenced by the absence of fever and clear stoma.
|Assess, monitor, and record the patient’s vital signs.||Vital signs monitoring including the patient’s temperature help in the monitoring of possible infections.|
|Regularly assess the patient’s stoma and surrounding skin for color, exudates, erythema, and crusting lesions.||The friction from the tracheostomy tube and mucus can irritate the stoma and surrounding skin making it a suitable site for infection.|
|Provide stoma care through the following steps:Clean the inner part of the stoma; if an inner cannula is used, replace it regularly with a new one.Keep the stoma clean and dry. Use barrier creams as needed.Secure the tracheostomy tube.||Regular stoma care prevents infection and helps maintain a clear, patent airway.|
|Encourage the patient to effectively cough out mucus.||Coughing is an effective method to expectorate mucus build up to prevent infection.|
|Keep a suction machine by the patient’s bedside.||Manual suctioning of the secretions may be necessary to avoid pooling of mucus in the airway if the patient is unable to independently cough it out.|
|Promote proper positioning or regular position changes.||An upright position and regular position changes prevent the pooling of mucus, therefore preventing infection.|
Tuberculosis Nursing Care Plan
Nursing Diagnosis: Risk for infection related to supressed inflammatory process
Desired Outcome: The patient will demonstrate lifestyle changes to promote a safe environment.
|Regularly assess for signs of infection.||Treatment can be started as soon as an infection is identified.|
|Educate patient on the signs of infection such as the following:|
Changes in cough or having a new cough
Shortness of breath
|Involving the patient in the early identification of the presence of an infection can improve the success of treatment once started.|
|Instruct patient on the following:Cough or expectorate onto a tissue and dispose of after use.Do not reuse tissues.Gel or wash hands after coughing or expectorating.Encourage spitting onto a tissue and discarding the tissues immediately. Refrain from spitting on the ground.||These are behaviors necessary to prevent the spread of infection.|
|Educate the patient with easy-to-understand words on the pathology of tuberculosis.||This information will help the patient understand the importance of lifestyle changes to avoid secondary infection and the spread of infection to others.|
|Place the patient under airborne precaution isolation.||There are two purposes in isolating a person with tuberculosis: protect the patient and protect others. The infectious agent in tuberculosis is airborne. Putting the patient in isolation reduces the risk of others contracting it. On the other hand, isolation also protects the patient from possible cross-contamination from carers, family, friends, or healthcare staff. People with tuberculosis have reduced immune system response.|
|Encourage the use of separate utensils for eating.||Using separate eating utensils from the rest of the household will prevent cross-contamination.|
|Encourage proper hygiene.||Proper hygiene promotes wellness and prevents further infection.|
Tonsillitis Nursing Care Plan
Nursing Diagnosis: Risk for Infection related to inflammation of the tonsils
Desired Outcome: The patient will be able to avoid the development of worsening infection.
|Assess vital signs and observe for any signs of infection as well as for any signs of respiratory distress.||To assess for the evidence of ongoing infection. Tonsillitis may cause blockage of airways, which may lead to respiratory distress.|
|Perform a focused assessment on the oropharyngeal region, particularly checking for any collection of abscess.||Tonsillitis can lead to peritonsillar abscess. The infection can cause pus production which then collects behind the tonsils.|
|Prepare the patient for tonsillectomy.||Surgery can be the treatment of choice if the tonsillitis is causing difficult to manage complications such as apnea, swallowing difficulty, and abscess formation.|
|Teach the patient how to perform proper hand hygiene.||To maintain patient safety and reduce the risk for cross contamination.|
|Administer antibiotics as prescribed.||To treat the underlying infection with broad spectrum antibiotics, then switch with the type of antibiotics to which the causative bacteria are sensitive. This is also done to prevent the risk of developing further infection in a patient with bacterial tonsillitis.|
Varicella Infection Nursing Care Plan
Risk for Infection related to contagious skin infection
Desired Outcome: The patient will prevent spread of infection to the rest of the body, as well as cross-contamination to other people by following treatment regimen for varicella infection.
|Assess the patient’s skin on his/her whole body.||To determine the severity of varicella infection and any affected areas that require special attention or skin care.|
|Isolate the patient in his/her room ideally during the first 48 hours since the appearance of blisters.||Varicella infection is an infectious/ communicable skin disease to people who have not had chickenpox before. It is also harmful for pregnant women as it can affect the unborn baby.|
|Administer antiviral medication as prescribed. Ensure that the patient finishes the course of antibiotic prescribed by the physician.||Varicella infection is generally treated using antiviral therapy. If the rash leads to other skin breakdown which then gets infected, antibiotics is prescribed. Application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection.|
|Educate the patient and carer about proper wound hygiene through washing the rash with soap and water.||It is important to maintain the cleanliness of the affected areas by washing with mild soap and water. The rash may cause mild itching, but it is advisable to prevent the child from scratching the affected areas to prevent worsening and spread of the infection.|
|Trim the patient’s fingernails and ensure frequent hand hygiene. Advise the patient and carer to prevent scratching the affected areas.||Long fingernails tend to contain more bacteria. Scratching the infected skin areas will allow the bacteria to transfer into the fingernails and onto the fingerpads. When the patient touches other people or objects with infected hands, the infection will likely spread.|
|Teach the patient/ carer the proper application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection.||Proper application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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