Nursing Diagnosis Risk for Infection: At increased risk for being invaded by pathogenic organisms
- 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)
- Increased environmental exposure to pathogens
- Inadequate acquired immunity
- Inadequate secondary defences (e.g. decreased haemoglobin)
- Chronic disease
• Contact transmitted
- Immune Status
- Knowledge: Infection Control
- Risk Control
- Risk Detection
- 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
- 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
• 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.