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Sunday, June 27, 2010

Nursing Diagnosis Risk for Infection

Nursing Diagnosis Risk for Infection: At increased risk for being invaded by pathogenic organisms

Risk Factors

  • Invasive procedures
  • Insufficient knowledge regarding avoidance of exposure to pathogens
  • Trauma, Tissue destruction and increased environmental exposure, Rupture of amniotic membranes
  • Pharmaceutical agents (e.g. Immunosuppressant)
  • Malnutrition
  • Increased environmental exposure to pathogens
  • Inadequate acquired immunity
  • Inadequate secondary defences (e.g. decreased haemoglobin)
  • Chronic disease

Nursing Outcomes

  • Immune Status
  • Knowledge: Infection Control
  • Risk Control
  • Risk Detection

Client Outcomes

  • Remains free from symptoms of infection
  • States symptoms of infection of which to be aware
  • Demonstrates appropriate care of infection.
  • Maintains white blood cell count and differential within normal limits
  • Demonstrates appropriate hygienic measures such as hand washing, oral care, and perinea care

Nursing Interventions
Infection Control
Infection Protection

  • Observe and report signs of Infection.
  • Assess temperature, Use an electronic or mercury thermometer to assess temperature.
  • Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures).
  • Assess skin for colour, moisture, texture, and turgor (elasticity).
  • Carefully wash and pat dry skin, including skinfold area. Use hydration and moisturization on all at-risk surfaces.
  • Encourage a balanced diet, emphasizing proteins to feed the immune system.
  • Prevent nosocomial pneumonia.
  • Encourage fluid intake and adequate rest to bolster the immune system.
  • Before and after giving care to client use Proper hand washing techniques.
  • Use goggles, gloves, and gowns when appropriate Follow Standard Precautions and wear gloves during any contact with blood, mucous membranes, nonintact skin, or any body substance.
  • Transmission Based Precautions for

• Airborne
• Droplet
• Contact transmitted

  • Sterile technique on catheterize.
  • Use careful technique when changing and emptying urinary catheter bags; avoid cross contamination.
  • Use careful sterile technique wherever there is a loss of skin integrity.
  • Ensure client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perinea care.
  • Antibiotics.


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