This article can help you determine what to consider when planning care for a patient who is at risk for infection. Patients at risk for infection are those whose immune system or natural defenses are compromised. These patients have inadequate protection from pathogenic organisms, and it is important to plan nursing interventions and care to provide additional protection and infection prevention.
In this article:
- Risk Factors (Related to)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Risk Factors (Related to)
Risk for infection can be heightened by anything that interferes with the body’s ability to fight off pathogenic invasions. The following are common risk factors for infection:
- Breakdown of the body’s physical defense mechanisms. This type of breakdown can be broken skin due to injury, surgery, or other invasive procedures. It can also take the form of altered peristalsis, swelling or stasis of body fluids, or damage to mucous membranes.
- Immunosuppression or immune impairment also increases risk for infection. This can be caused by conditions or medications that decrease the immune response. Chronic disease and malnutrition can also affect the body’s ability to fight off infections.
- Insufficient knowledge of infection preventing practices or high-risk behaviors, such as unprotected sex, can also put a person at increased risk for infection.
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected Outcomes
Care goals for risk for infection are focused on prevention of infection and patient education. Expected outcomes for a patient with a risk for infection diagnosis are the following:
- Patient is free of infection as evidenced by vital signs within normal range and lack of evidence of infection such as swelling, redness, and purulent drainage from non-intact areas of skin.
- Patient verbalizes understanding of behavioral and hygiene measures to prevent infection.
- Patient verbalizes recognition of signs of infection that need to be reported to a healthcare provider for treatment.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to risk for infection.
1. Assess the patient for risk factors or current injuries or treatments that could put the patient at risk for infection.
- Wounds, abrasions, or surgical sites
- Invasive lines (IVs, catheters, drains, intubation)
These represent a compromise of the body’s physical defenses and a potential source of infection
2. Review the patient’s medications to identify treatments that may cause immunosuppression.
- Antineoplastic agents
- Corticosteroids
These drugs reduce the body’s immune response and increase risk for infection.
3. Monitor for signs of infection.
- Increased white blood cell count
- Fever
- Redness, swelling, purulent drainage of areas of non-intact skin
- Changes in urine or sputum
Early identification of infection allows for prompt treatment.
4. Assess the patient’s weight, serum albumin, and nutritional status.
Malnutrition contributes to decreased immune capability and increased risk for infection.
5. Assess the patient’s hygiene practices.
The nurse should evaluate the individual’s hygiene practices, including hand hygiene, bathing, and oral care. Inadequate hygiene can contribute to the risk of infection.
6. Assess the patient’s vaccination status.
Patients who do not have up to date vaccines are also at increased risk of infection. This is doubly dangerous if the individual already has other risk factors for serious infections.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a risk for infection.
1. Wash your hands and use aseptic technique for nursing tasks involving non-intact skin or invasive lines.
- IV insertion and use
- Catheter insertion and catheter care
- Central and PICC dressing changes and use
- Wound or surgical site dressing changes
Hand washing and using aseptic technique reduces the likelihood of transmitting pathogens to the patient that can cause infection.
2. Limit visitors and/or use protective isolation for patients who are at risk for infection.
Reducing visitation reduces the chance of spreading pathogens to the patient. Protective isolation provides additional protection from the spread of pathogens for patients who are severely immunocompromised.
3. Teach the patient, family, and caregivers signs and symptoms of infection and when to contact a healthcare provider.
It is important to recognize signs of infection early in order to seek prompt treatment. Particularly if the patient is going home with a wound that needs care, the nurse must ensure the patient understands signs of a worsening infection.
4. Encourage the intake of calorically dense and protein rich foods.
The immune system is more responsive and effective when nutritional status is sufficient.
5. Ensure proper personal protective equipment is used.
Particularly for patients at risk of infection, the nurse should teach them about the importance of wearing a mask, particularly in high-risk situations. It is also important that the care team is diligent about wearing PPE around immunocompromised patients.
Nursing Care Plans
Nursing care plans for risk for infection should be focused on the patient’s specific risk factors and appropriate interventions. Some conditions associated with risk for infection are:
- Chronic illness
- Immunosuppression
- Invasive procedures
- Decrease in hemoglobin
- Leukopenia
- Open wounds
- Malnutrition
- Rupture of amniotic membranes
- Antibiotic therapy
- Altered pH of mucous secretions
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for infection risk.
Care Plan #1
Diagnostic statement:
Risk for infection related to diminished immune response.
Expected outcomes:
- Patient will verbalize understanding of risk of infection.
- Patient will demonstrate precautionary measures to prevent infection.
Assessment:
1. Assess the presence of the underlying cause of diminished immune system.
The patient may have an existing condition (e.g., neoplasm, autoimmune disorder, diabetes, liver or kidney failure, etc.) or treatment (steroid use, chemotherapy, radiotherapy) that weakens the immune response.
2. Check and notify the physician for any signs of infection. These include fever, redness, purulent discharge, etc.
Recognizing early signs of infection may help facilitate prompt treatment and prevent sepsis. Indicators for sepsis may include systemic manifestations such as changes in mental status, fever, chills, and hypotension.
3. Review laboratory values.
Increased WBC count may suggest infection. However, patients with neutropenia, or those with consistently low WBC count who present with fever, need emergency medical attention. Since their body cannot fight infections effectively, infection may quickly progress to sepsis without prompt treatment.
Interventions:
1. Place the very high-risk patient in protective isolation.
Protective isolation is suggested for patients with neutropenia (WBC less than 500 to 1000/mm3). Follow institutional protocols regarding the protective isolation of at-risk patients.
2. Limit visitors.
Restricting visitation decreases the risk of infection transmission. If visitors are allowed, ensure they are wearing proper personal protective equipment.
3. Observe proper hand hygiene. Wear gloves when appropriate to minimize contamination of hands, and discard them after each client. Wash hands after glove removal.
Hand hygiene is the single most effective way to prevent transmission of infection.
4. Instruct the patient and their families about proper hand hygiene.
Handwashing is the first-line defense against healthcare-associated infections (HAIs).
Care Plan #2
Diagnostic statement:
Risk for infection as evidenced by invasive procedure and surgical incision.
Expected outcomes:
- Patient will have timely wound healing.
- Patient will be free from surgical site infection.
Assessment:
1. Monitor signs and symptoms of wound infection. Note foul-smelling purulent discharge, pain on the surgical site, warmth, swelling, or redness.
These signs and symptoms indicate surgical site infection. Signs of infection should be promptly reported to the care team.
2. Assess the knowledge of the patient and family about infection precautions.
Adequate knowledge could translate to proper health behavior to prevent infection, including hand hygiene.
3. Obtain appropriate tissue or fluid specimens for culture and sensitivities testing.
Culture and sensitivity tests will determine the antibiotic against the pathogen causing the surgical site infection.
Interventions:
1. Administer antimicrobials as indicated. The nurse should note the therapy response to determine the effectiveness of therapy and also the presence of side effects.
Antibiotic prophylaxis is often administered within an hour before incision until within 24 hours after the surgery. Individual protocols may differ between surgeon and site policy.
2. Instruct the patient and family on techniques of proper wound care.
Daily wound cleaning promotes the loosening of cellular debris from previous dressing. Proper technique includes the following:
- Wash hands before and after wound care.
- Observe sterile technique during wound care.
- Change dressings daily.
- Apply topical medications as indicated.
If the patient is sent home with a dressing, it is essential that the nurse educates the patient on the signs of an infection and when they should contact their doctor.
3. Encourage intake of protein- and calorie-rich foods.
Optimal nutritional status enhances immune response.
4. Teach the patient the risk factors contributing to surgical wound infection.
Identifying risk factors for poor wound healing that are present in the patient will help them prioritize appropriate actions.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Branch-Elliman, W., O’Brien, W, Strymish, J., Itani, K., Wyatt, C.,& Gupta, K. (2019). Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse Events. JAMA Surg, 154(7), 590–598. doi:10.1001/jamasurg.2019.0569
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Herdman, T. Heather, and Shigemi Kamitsuru. Nursing Diagnoses: Definitions and Classification 2018-2020. Thieme, 2018.
- Hobani, F.& Alhalal, E. (2022). Factors related to parents’ adherence to childhood immunization. BMC Public Health, 22, 819. https://doi.org/10.1186/s12889-022-13232-7
