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, anergic or unable to muster a cellular immune
including weight, and serum response to pathogens and are therefore
albumin. susceptible to infection. [Gulanick, M. & Myers,
J. (2007). Nursing Care Plans: Nursing
Diagnosis and Interventions. 6th edition.p, 110].

Comfort Measures Comfort Measures

6. Understood the nurse’s role 6. The role of nurses in preventing the spread of
in identifying client at risk and severe sepsis is crucial because they are in the
preventive interventions; e.g., position to identify clients at the first signs of
hand disinfection, early developing sepsis. The sooner that treatment
removal of invasive tubes of sepsis begins, the less likely that it will
and catheter, 30-degree spread to involve organs and start a life-
head elevation for client on threatening cascade of events.[Doenges, M.,
ventilator, early nutrition. 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
7. Washed hands and facilitated microorganisms from hands. Washing between
other caregivers to wash procedures reduces the risk of transmitting
hands before contact with pathogens from one area of the body to
patients and between another. [Gulanick, M. & Myers, J. (2007).
procedures with the patient. Nursing Care Plans: Nursing Diagnosis and
Interventions. 6th edition.p, 111].
8. Reduces number of sites for entry of
8. Limited use of invasive opportunistic organism. [Doenges, M., et.al.
devices/procedures when (2006). Nursing Care Plans: Guidelines for
possible. Removed lines, Individualizing Client Care Across the Life
devices when infection is Span.7th ed.,p, 704].
present and replace if
necessary. 9. Use of aseptic technique decreases the
9. Maintained asepsis for chances of transmitting or spreading
dressing changes, catheter pathogens to the patient. [Gulanick, M. &
care and handling, and Myers, J. (2007). Nursing Care Plans: Nursing
peripheral IV and central Diagnosis and Interventions. 6th edition.p, 110].
venous access. 10. Good pulmonary toilet may reduce respiratory
10. Provided frequent position compromise. [Doenges, M., et.al. (2006).
changes. Nursing Care Plans: Guidelines for
Individualizing Client Care Across the Life
Span.7th ed.,p, 704].
 11. This maintains optimal nutritional status.
Teachings [Gulanick, M. & Myers, J. (2007). Nursing Care
11. Encouraged intake of protein Plans: Nursing Diagnosis and Interventions. 6th
and calorie-rich foods. edition.p, 111].
12. Hard-bristled toothbrushes may compromise
the integrity of the mucous membranes and
12. Recommended the use of provide a port of entry for pathogens.
soft-bristled toothbrush. [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
13. Taught the caregiver to wash surface pathogens; hand washing reduces
hands often, especially after these risks. [Gulanick, M. & Myers, J. (2007).
toileting, before meals, and Nursing Care Plans: Nursing Diagnosis and
before administering care. Interventions. 6th edition.p, 111].
14. Family members or others can spread
infections or colds to a susceptible patient
14. Teach S.O about protecting through direct contact, contaminated objects,
susceptible patients from or through air currents. [Gulanick, M. & Myers,
themselves and others with J. (2007). Nursing Care Plans: Nursing
infections or colds. Diagnosis and Interventions. 6th edition.p, 110].
15. Knowledge about isolation can help patients
and family members cooperate with specific
15. Taught family and caregivers precautions. [Gulanick, M. & Myers, J. (2007).
the purpose and proper Nursing Care Plans: Nursing Diagnosis and
technique for maintaining Interventions. 6th edition.p, 111].
isolation. 16. Bladder infection is more related to
overdistended bladder resulting from infrequent
16. Demonstrated and allow catheter than to use of clean versus sterile
return demonstration of all technique. [Gulanick, M. & Myers, J. (2007).
high risk procedures that the Nursing Care Plans: Nursing Diagnosis and
patient or caregiver will do Interventions. 6th edition.p, 111].
after discharge, such as
dressing changes; self-
catheterization (may use
clean technique).
NIC 2: Medication Management
Assessment: 1. To determine antibacterial effectiveness.
Another drug or different dosage may be
1. Monitored vital signs and required.[ Adams, M., et.al. (2007).
symptoms of infection 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
2. Monitored for hypersensitivity to 72 hours, and delayed after 2 hours. .
reaction. [ 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
3. Monitored IV site for signs Pathophysiological Approach. 2nd ed., p, 504.] immediately report
and symptoms of tissue rash, shortness of
irritation, severe pain, and breath, swelling, fever,
extravassation. loose stools.
4. To minimize the risk for developing infections. .
Comfort Measures: [ Broyles, B., et.al. (2007). Pharmacological
4. Implemented routine Aspects of Nursing Care. 7th ed., p, 197.]
handwashing between
clients, use of aseptic
technique, proper disposal of
infectious materials.

5. To avoid taking someone else’s medication, to

Teachings avoid using outdated medication, and to see
5. Adviced the caregiver to the primary care provider for an examination
contact the prescriber if and treatment rather than self medicating with
adverse reactions occurs. 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.
6. Instructed caregiver to report (2007). Pharmacology for Nurses: A
signs of and symptoms of Pathophysiological Approach. 2nd ed., p, 504.]
superinfection such as fever,
black hairy tongue, and loose 7. Certain food and beverages will interfere with
foul smelling stools. the medication’s effectiveness. .[ Adams, M.,
7. Instructed S.O regarding et.al. (2007). Pharmacology for Nurses: A
foods and beverages that 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: