Risk for infection means a client is more likely to be invaded by germs because of a weakened immune system, broken skin, invasive devices, or poor nutrition. There are no signs of infection yet, so your priorities are prevention, early detection, and teaching.
A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation
Each care plan below follows the nursing process (ADPIE).
CARE PLAN 1 · NURSING DIAGNOSIS
ASSESSMENT
Risk for Infection
Risk factors
PLANNING · EXPECTED OUTCOMES- Surgical wound or other break in the skin
- Invasive lines such as IVs and urinary catheters
- Weakened immune system from illness, chemotherapy, or steroids
- Poor nutrition
- Older age or chronic illness such as diabetes
Short-term goals
- Client stays free of signs of infection throughout the hospital stay
- Temperature stays below 38 °C (100.4 °F) each shift
Long-term goals
- Client and family practice infection prevention at home
- Client states signs of infection to report
- Temperature and other vital signs at least every 4 hours
- Wounds and IV or catheter sites for redness, warmth, swelling, or drainage
- WBC count and other labs as ordered
- Nutrition and fluid intake
| INTERVENTION | RATIONALE |
|---|---|
| Perform hand hygiene before and after every client contact | Clean hands are the most effective way to stop the spread of germs. |
| Use sterile technique for dressing changes and inserting invasive devices | Sterile technique keeps germs out of open areas and the body. |
| Remove lines and catheters as soon as they are no longer needed, per provider order | Each day a device stays in raises the risk of infection. |
| Encourage protein, calories, and fluids as allowed | Good nutrition supports healing and immune function. |
| Teach the client to report fever, chills, or wound changes | Early reporting allows early treatment. |
EVALUATION
- Client remains afebrile
- Wounds and line sites show no redness, swelling, or drainage
- WBC stays within normal limits
- Client states signs of infection to report
CARE PLAN 2 · NURSING DIAGNOSIS
ASSESSMENT
Risk for Infection (Neutropenia)
Risk factors
PLANNING · EXPECTED OUTCOMES- Low absolute neutrophil count from chemotherapy or bone marrow problems
- Mucous membrane damage
- Frequent exposure to others in the hospital
Short-term goals
- Client stays free of infection while the neutrophil count is low
- Client follows neutropenic precautions within 24 hours
Long-term goals
- Client's neutrophil count recovers without a serious infection
- Absolute neutrophil count (ANC) daily or as ordered
- Temperature, since fever may be the only sign
- Mouth, skin, and perineal area
- Lung sounds and urine
| INTERVENTION | RATIONALE |
|---|---|
| Place the client in a private room and follow neutropenic precautions per policy | Fewer exposures mean fewer chances of infection. |
| Report a temperature of 38 °C (100.4 °F) or higher right away | Clients with neutropenia may not show redness or pus, so fever may be the only clue. |
| Avoid fresh flowers, standing water, and visitors who are sick | These can carry harmful germs. |
| Avoid rectal temperatures, suppositories, and enemas | These can injure the tissue and let bacteria in. |
EVALUATION
- Client remains free of fever and infection
- Precautions are followed by staff, client, and visitors
- ANC returns toward normal
Practice this in Head-to-Toe
Run a full assessment and spot early signs of infection at wounds and line sites.
Play Head-to-ToeQuick answers
Why does a Risk for Infection diagnosis have no "as evidenced by" statement?
Because the problem has not happened yet. Risk diagnoses list risk factors only. If signs of infection appear, the diagnosis changes.
What is the single best way to prevent infection in the hospital?
Hand hygiene before and after every client contact.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.