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.
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.
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
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.
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
- Rash
- Fatigue
- Fever and/or chills
- Aches and pains
- Dyspnea
- Tachypnea
- Night sweats
- Loss of appetite
- Weight loss
Expected Outcomes for Risk for Infection
Avoidance of infection: The patient should be able to avoid acquiring an infection through appropriate hygiene practices, such as hand washing and avoiding contact with sick individuals.
Prevention of infection spread: If the patient already has an infection, the goal may be to prevent the spread of the infection to others through isolation precautions and appropriate use of personal protective equipment.
Early detection and treatment: The patient should be able to recognize the signs and symptoms of infection and seek prompt medical attention if necessary.
Improved immune function: The patient’s immune system should be strengthened through appropriate nutrition, rest, exercise, and medication management.
Education and empowerment: The patient should have a good understanding of infection prevention and management strategies and feel empowered to take an active role in their own care.
Nursing Assessment and Rationales
Patient History: Obtain information about the patient’s medical history. Rationale: This helps identify individuals who may be at a higher risk for infection.
Vital Signs: Monitor the patient’s vital signs. Rationale: Elevated vital signs can indicate an underlying infection.
Skin Assessment: Inspect the patient’s skin for any signs of redness, warmth, swelling, or breakdown. Rationale: These can be indications of an infection at the site or systemic infection.
Wound Assessment: Evaluate any surgical or traumatic wounds for signs of infection, such as redness, swelling, warmth, pain, or purulent drainage.
Laboratory Tests: Monitor appropriate laboratory tests, such as complete blood count (CBC), C-reactive protein (CRP), and cultures as needed. Rationale: To identify any signs of infection or an elevated inflammatory response.
Respiratory Assessment: Assess the patient’s respiratory system. Rationale: Changes in lung sounds, increased cough, or purulent sputum may indicate a respiratory infection.
Urinary Assessment: Monitor urinary output, assess the presence of urinary tract infection (UTI) symptoms (e.g., dysuria, urgency, frequency), and observe for any signs of catheter-associated infections.
GI Assessment: Observe for diarrhea, vomiting, or abdominal pain. Rationale: which can indicate gastrointestinal infections.
Nursing Interventions for Risk for Infection
Monitor the patient’s vital signs and signs of infection. Rationale: 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.
Encourage hand hygiene and explain the importance of proper handwashing. Rationale: Handwashing is the single best way to prevent infection.
Use of personal protective equipment (PPE). Rationale: Nurses should use appropriate PPE for patients with infectious diseases to prevent the spread of infection.
Implement appropriate isolation precautions. Rationale: To prevent the spread of infection.
Educate patients and their families about infection prevention strategies such as hand hygiene. Rationale: To reduce the risk of infection.
Ensure that patient care areas are kept clean and disinfected. Rationale: To prevent the spread of infection.
Risk of Infection Nursing Care Plan
Viral Infection
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.
Tracheostomy
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.
Tuberculosis
Nursing Diagnosis: Risk for infection related to supressed inflammatory process (TB)
Desired Outcome: The patient will demonstrate lifestyle changes to promote a safe environment.
Tonsillitis
Nursing Diagnosis: Risk for Infection related to inflammation of the tonsils. (Tonsillitis)
Desired Outcome: The patient will be able to avoid the development of worsening infection.
Varicella Infection
Nursing Diagnosis: 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.
Sample Nursing Test Questions for Risk for Infection
Question 1: A patient with diabetes mellitus is admitted to the hospital with a foot ulcer. Which nursing intervention is most important to include in the plan of care?
A) Administer pain medication as needed.
B) Provide diabetic education to the patient.
C) Keep the foot ulcer clean and properly dressed.
D) Encourage the patient to increase fluid intake.
Answer: C) Keep the foot ulcer clean and properly dressed.
Rationale: The most important nursing intervention for a patient with a foot ulcer is to maintain proper wound care. This reduces the risk of infection and promotes healing. Cleanliness and appropriate dressing help prevent the entry of microorganisms into the wound.
Question 2: Which of the following patients should the nurse identify as being at the highest risk for healthcare-associated infections?
A) A 35-year-old male with a history of asthma.
B) A 62-year-old female with a urinary catheter in place.
C) A 45-year-old female who underwent elective surgery.
D) A 20-year-old male with a mild upper respiratory tract infection.
Answer: B) A 62-year-old female with a urinary catheter in place.
Rationale: Patients with indwelling urinary catheters are at a higher risk of developing healthcare-associated urinary tract infections. The prolonged presence of a catheter increases the potential for bacterial colonization and subsequent infection.
Question 3: During the assessment of a postoperative patient, the nurse notes erythema, warmth, and purulent drainage at the surgical incision site. Which action should the nurse take first?
A) Notify the healthcare provider.
B) Administer prescribed antibiotics.
C) Document the findings in the patient’s chart.
D) Reinforce the dressing at the incision site.
Answer: A) Notify the healthcare provider.
Rationale: The presence of erythema, warmth, and purulent drainage at a surgical incision site indicates a probable infection. The nurse’s priority action is to notify the healthcare provider so that appropriate treatment can be initiated.
Question 4: A patient with a respiratory infection is placed in isolation. Which personal protective equipment (PPE) should the nurse wear when entering the patient’s room?
A) Gloves and gown
B) Gloves and mask
C) Mask and gown
D) Mask, gloves, and gown
Answer: D) Mask, gloves, and gown.
Rationale: For a patient with a respiratory infection, the nurse should wear a mask to protect against airborne droplets, gloves to prevent direct contact with infectious material, and a gown to prevent contamination of clothing.
Question 5: Which statement made by a nursing student indicates a need for further education about infection control?
A) “I should wash my hands for at least 20 seconds with soap and water.”
B) “I will use hand sanitizer if soap and water are not available.”
C) “I will always wear gloves when performing a sterile procedure.”
D) “I will clean the stethoscope between each patient use.”
Answer: C) “I will always wear gloves when performing a sterile procedure.”
Rationale: Gloves are not required for performing sterile procedures. Sterile technique involves maintaining asepsis using sterile instruments and supplies, not gloves alone. The student should be educated on the appropriate use of gloves for sterile procedures and when to don gloves for other aspects of patient care.
Nursing References
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.
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.
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.
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
Best Nursing Books and Resources
These are the nursing books and resources that we recommend.
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The Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care
This is an excellent reference for nurses and nursing students. While it is a great resource for writing nursing care plans and nursing diagnoses, it also helps guide the nurse to match the nursing diagnosis to the patient assessment and diagnosis.
This handbook has been updated with NANDA-I approved Nursing Diagnoses that incorporates NOC and NIC taxonomies and evidenced based nursing interventions and much more.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
All introductory chapters in this updated version of a ground-breaking text have been completely rewritten to give nurses the knowledge they require to appreciate assessment, its relationship to diagnosis and clinical reasoning, and the goal and use of taxonomic organization at the bedside.
Nursing Care Plans: Nursing Diagnosis and Intervention
It contains more than 200 care plans that adhere to the newest evidence-based recommendations.
Additionally, it distinguishes between nursing and collaborative approaches and highlights QSEN competencies.
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