Nursing Diagnosis: Risk for infection:

NANDA Definition: At increased risk for being invaded by pathogenic organism. [Gulanick, M. & Myers, J. (2007). Nursing Care Plans: Nursing
Diagnosis and Interventions. 6th edition.p, 108].

Cause Analysis:

Defining Characteristics Interventions Rationale NOC

Subjective: NIC: Infection Control Knowledge: Infection

Assessment: Control
 Caregiver reported 1. Monitored the following for 1.
that there was signs of infection: Goals partially met
respiratory secretion  Color of respiratory  Yellow or yellow-green sputum is AEB S.O was able to
PTA. secretions indicative of respiratory infection. -verbalize the aseptic
[Gulanick, M. & myers, J. (2007). technique upon caring
Objective: Nursing Care Plans: Nursing Diagnosis for the patient
 T= and Interventions. 6th edition.p, 110]. -state the importance
 P= 2. Depression of immune system and use of of turning frequently
 R= 2. Inspected oral cavity for antibiotics increase risk of secondary -state the importance
 B= white plaques (thrush). infections, particularly yeast. [Doenges, M., of proper nutrition.
 GCS: et.al. (2006). Nursing Care Plans: Guidelines -respiratory secretions
for Individualizing Client Care Across the Life were still present.
 Color of urine:
Span.7th ed.,p, 705].
 Color of respiratory
secretion: yellowish-
3. Very low WBC (less than 1000 mm3) indicates
whitish
3. Monitored white blood cell severe risk for infection. [Gulanick, M. & Myers,
 WBC:
count J. (2007). Nursing Care Plans: Nursing
 With inserted IVF Diagnosis and Interventions. 6th edition.p, 110].
 Creatinine: 4. Older patients and those not raised in the
 Albumin: 4. Assessed immunization United States may not have completed
 Hgb: status immunizations and therefore may not have
 Hct: sufficient acquired immunocompetence.
 RBC: [Gulanick, M. & Myers, J. (2007). Nursing Care
 Segmenters: Plans: Nursing Diagnosis and Interventions. 6th
 Lymphocytes: edition.p, 110].
Monocytes:
 Weight – kg 5. Patients with poor nutritional status may be
 5. Assessed nutritional status,
including weight, and serum
albumin.
Comfort Measures
6. Understood the nurse’s role
in identifying client at risk and
preventive interventions; e.g.,
hand disinfection, early
removal of invasive tubes
and catheter, 30-degree
head elevation for client on
ventilator, early nutrition.
7. Washed hands and facilitated
other caregivers to wash
hands before contact with
patients and between
procedures with the patient.
8. Limited use of invasive
devices/procedures when
possible. Removed lines,
devices when infection is
present and replace if
necessary.
9. Maintained asepsis for
dressing changes, catheter
care and handling, and
peripheral IV and central
venous access.
10. Provided frequent position
changes.
anergic or unable to muster a cellular immune
response to pathogens and are therefore
susceptible to infection. [Gulanick, M. & Myers,
J. (2007). Nursing Care Plans: Nursing
Diagnosis and Interventions. 6th edition.p, 110].
Comfort Measures
6. The role of nurses in preventing the spread of
severe sepsis is crucial because they are in the
position to identify clients at the first signs of
developing sepsis. The sooner that treatment
of sepsis begins, the less likely that it will
spread to involve organs and start a life-
threatening cascade of events.[Doenges, M.,
et.al. (2006). Nursing Care Plans: Guidelines
for Individualizing Client Care Across the Life
Span.7th ed.,p, 705].
7. Friction and running water effectively remove
microorganisms from hands. Washing between
procedures reduces the risk of transmitting
pathogens from one area of the body to
another. [Gulanick, M. & Myers, J. (2007).
Nursing Care Plans: Nursing Diagnosis and
Interventions. 6th edition.p, 111].
8. Reduces number of sites for entry of
opportunistic organism. [Doenges, M., et.al.
(2006). Nursing Care Plans: Guidelines for
Individualizing Client Care Across the Life
Span.7th ed.,p, 704].
9. Use of aseptic technique decreases the
chances of transmitting or spreading
pathogens to the patient. [Gulanick, M. &
Myers, J. (2007). Nursing Care Plans: Nursing
Diagnosis and Interventions. 6th edition.p, 110].
10. Good pulmonary toilet may reduce respiratory
compromise. [Doenges, M., et.al. (2006).
Nursing Care Plans: Guidelines for
Individualizing Client Care Across the Life
Span.7th ed.,p, 704].

Teachings
11. Encouraged intake of protein
and calorie-rich foods.
12. Recommended the use of
soft-bristled toothbrush.
13. Taught the caregiver to wash
hands often, especially after
toileting, before meals, and
before administering care.
14. Teach S.O about protecting
susceptible patients from
themselves and others with
infections or colds.
15. Taught family and caregivers
the purpose and proper
technique for maintaining
isolation.
16. Demonstrated and allow
return demonstration of all
high risk procedures that the
patient or caregiver will do
after discharge, such as
dressing changes; self-
catheterization (may use
clean technique).
11. This maintains optimal nutritional status.
[Gulanick, M. & Myers, J. (2007). Nursing Care
Plans: Nursing Diagnosis and Interventions. 6th
edition.p, 111].
12. Hard-bristled toothbrushes may compromise
the integrity of the mucous membranes and
provide a port of entry for pathogens.
[Gulanick, M. & Myers, J. (2007). Nursing Care
Plans: Nursing Diagnosis and Interventions. 6th
edition.p, 111].
13. Caregivers can spread infection from one part
of the body to another, as well as pick up
surface pathogens; hand washing reduces
these risks. [Gulanick, M. & Myers, J. (2007).
Nursing Care Plans: Nursing Diagnosis and
Interventions. 6th edition.p, 111].
14. Family members or others can spread
infections or colds to a susceptible patient
through direct contact, contaminated objects,
or through air currents. [Gulanick, M. & Myers,
J. (2007). Nursing Care Plans: Nursing
Diagnosis and Interventions. 6th edition.p, 110].
15. Knowledge about isolation can help patients
and family members cooperate with specific
precautions. [Gulanick, M. & Myers, J. (2007).
Nursing Care Plans: Nursing Diagnosis and
Interventions. 6th edition.p, 111].
16. Bladder infection is more related to
overdistended bladder resulting from infrequent
catheter than to use of clean versus sterile
technique. [Gulanick, M. & Myers, J. (2007).
Nursing Care Plans: Nursing Diagnosis and
Interventions. 6th edition.p, 111].
NIC 2: Medication Management
Assessment:
1. Monitored vital signs and
symptoms of infection
2. Monitored for hypersensitivity
reaction.
3. Monitored IV site for signs
and symptoms of tissue
irritation, severe pain, and
extravassation.
Comfort Measures:
4. Implemented routine
handwashing between
clients, use of aseptic
technique, proper disposal of
infectious materials.
Teachings
5. Adviced the caregiver to
contact the prescriber if
adverse reactions occurs.
6. Instructed caregiver to report
signs of and symptoms of
superinfection such as fever,
black hairy tongue, and loose
foul smelling stools.
7. Instructed S.O regarding
foods and beverages that
1. To determine antibacterial effectiveness.
Another drug or different dosage may be
required.[ Adams, M., et.al. (2007).
Pharmacology for Nurses: A
Pathophysiological Approach. 2nd ed., p, 504.]
2. Immediate hypersensitivity reaction may occur NOC2: regimen
within 2 to 3 minutes; accelerated occurs in 1 compliance
to 72 hours, and delayed after 2 hours. .
[ Adams, M., et.al. (2007). Pharmacology for
Nurses: A Pathophysiological Approach. 2nd Goal met AEB there
ed., p, 504.] was medication
3. These are signs of infiltration. .[ Adams, M., compliance and SO
et.al. (2007). Pharmacology for Nurses: A stated that she will
Pathophysiological Approach. 2nd ed., p, 504.] immediately report
rash, shortness of
breath, swelling, fever,
loose stools.
4. To minimize the risk for developing infections. .
[ Broyles, B., et.al. (2007). Pharmacological
Aspects of Nursing Care. 7th ed., p, 197.]
5. To avoid taking someone else’s medication, to
avoid using outdated medication, and to see
the primary care provider for an examination
and treatment rather than self medicating with
antimicrobial agents. .[ Broyles, B., et.al.
(2007). Pharmacological Aspects of Nursing
Care. 7th ed., p, 197.]
6. Increased risk for superinfections is due to
elimination of normal flora. .[ Adams, M., et.al.
(2007). Pharmacology for Nurses: A
Pathophysiological Approach. 2nd ed., p, 504.]
7. Certain food and beverages will interfere with
the medication’s effectiveness. .[ Adams, M.,
et.al. (2007). Pharmacology for Nurses: A
Pathophysiological Approach. 2nd ed., p, 504.]
 should be avoided with
specific antibiotic therapies
such as no acidic fruit juices,
no dairy/calcium products
with tetracyclines.
Care Plan Evaluation: