This article can help you determine what to consider when planning care for a patient with 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.
Risk for infection can be heightened by anything that interferes with the body’s ability to fight off pathogenic invasions. One key risk factor is the 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.
Care Goals for Risk for Infection
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:
- The 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 Care Plans for Risk for Infection
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
- Invasive procedures
- Decrease in hemoglobin
- Open wounds
- Rupture of amniotic membranes
- Antibiotic therapy
- Altered pH of mucous secretions
Nursing Assessment for 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
These drugs reduce the body’s immune response and increase risk for infection.
3. Monitor for signs of infection.
- Increased white blood cell count
- 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.
Nursing Interventions for 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.
4. Encourage the intake of calorically dense and protein rich foods.
The immune system is more responsive and effective when nutritional status is sufficient.
References and Sources
- Doenges, Marilynn E., et al. Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care. F.A. Davis, 2005.
- Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier/Mosby, 2014.
- Herdman, T. Heather, and Shigemi Kamitsuru. Nursing Diagnoses: Definitions and Classification 2018-2020. Thieme, 2018.