Nursing Diagnosis: Risk for Infection Application of NANDA, NOC, NIC

Nursing Diagnosis: Risk for Infection
Gail B. Ladwig

NANDA Definition: At increased risk for being invaded by pathogenic organisms
Related Factors: See Risk Factors.
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., immunosuppressants); malnutrition; increased environmental exposure to pathogens; immunosuppression; inadequate acquired immunity; inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); chronic disease

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         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-prone site

·         Maintains white blood cell count and differential within normal limits

·         Demonstrates appropriate hygienic measures such as hand washing, oral care, and perineal care

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Infection Control

·         Infection Protection

Nursing Interventions and Rationales

·         Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. With the onset of infection the immune system is activated and signs of infection appear.

·         Assess temperature of neutropenic clients every 4 hours; report a single temperature of >38.5° C or three temperatures of >38° C in 24 hours. Neutropenic clients do not produce an adequate inflammatory response; therefore fever is usually the first and often the only sign of infection (Wujcik, 1993).

·         Use an electronic or mercury thermometer to assess temperature. When temperature values have important consequences for treatment decisions, use mercury or electronic thermometers with established accuracy (Erickson et al, 1996).

·         Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures). Laboratory values are correlated with client's history and physical examination to provide a global view of the client's immune function and nutritional status and develop an appropriate plan of care for the diagnosis (Lehmann, 1991).

·         Remove the granulocytopenic client from areas exposed to construction dust so that the client won't inhale fungal spores. Remove all plants and flowers from client's room. Aspergillus, an organism that can cause fungal pneumonia, is commonly found in soil, water, and decomposing vegetation. This fungus can enter the hospital through an unfiltered air system, in dust stirred up during construction, or in food or ornamental plants (Carlianno, 1999).

·         Assess skin for color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of changes. Preventive skin assessment protocol, including documentation, assists in the prevention of skin breakdown. Intact skin is nature's first line of defense against microorganisms entering the body (Kovach, 1995).

·         Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all at-risk surfaces. Maintaining supple, moist skin is the best method of keeping skin intact. Dry skin can lead to inflammation, excoriations, and possible infection episodes (Kovach, 1995) (see Risk for impaired Skin integrity).

·         Encourage a balanced diet, emphasizing proteins to feed the immune system. Immune function is affected by protein intake (especially arginine); the balance between omega-6 and omega-3 fatty acid intake; and adequate amounts of vitamins A, C, and E and the minerals zinc and iron. A deficiency of these nutrients puts the client at an increased risk of infection (Lehmann, 1991).

·         Use strategies to prevent nosocomial pneumonia: assess lung sounds, sputum, and redness or drainage around stoma sites; use sterile water rather than tap water for mouth care of immunosuppressed clients; provide a clean manual resuscitation bag for each client; use sterile technique when suctioning; suction secretions above tracheal tube before suctioning; drain accumulated condensation in ventilator tubing into a fluid trap or other collection device before repositioning the client; assess patency and placement of nasogastric tubes; elevate the head of the client to (30° to prevent gastric reflux of organisms in the lung; institute feeding as soon as possible; assess for signs of feeding intolerance—no bowel sounds, abdominal distension, increased residual, emesis. Hospital-acquired pneumonia is the second most common nosocomial infection but has the highest mortality (30%) and morbidity rates. The strategies listed are used to prevent nosocomial pneumonia (Tasota et al, 1998).Once treatment for pneumonia has begun, it must continue for 48 to 72 hours, the minimum time to evaluate a clinical response (Ruiz et al, 2000).

·         Encourage fluid intake. Fluid intake helps thin secretions and replace fluid lost during fever (Carlianno, 1999).

·         Encourage adequate rest to bolster the immune system. Chronic disease and physical and emotional stress increase the client's need for rest (Potter, Perry, 1993).

·         Use proper hand washing techniques before and after giving care to client and any time hands become soiled, even if gloves are worn: Wet hands under running water; dispense a minimum of 3 to 5 ml of soap or detergent and thoroughly distribute it over all areas of both hands; vigorously wash all surfaces of hands and fingers for at least 10 to 15 seconds, including backs of hands and fingers and under nails; rinse to remove soap, and thoroughly dry hands; use a dry paper towel to turn the faucet off. Consistent and meticulous hand washing remains the most important contributing factor related to reduction of the frequency of nosocomial infections in the intensive care unit (ICU). Hand washing significantly decreases the number of pathogens on the skin and contributes to decreases in client's morbidity and mortality (Tasota et al, 1998). Ensure that all hospital staff members follow precautions to prevent the spread of infection. In this study, a high percentage of staff did not wash hands at appropriate times (Chandra, Milind, 2001). When soap is used, the mechanical action of washing and drying removes most of the transient bacteria. Hands should remain in contact with the cleanser for 10 seconds, but 20 to 30 seconds is ideal (Gould, 1994a). Rinsing hands with tap water and drying them with towels can reduce methicillin-resistant Staphylococcus aureus (MRSA) contamination by 95% (Sarver-Steffensen, 1999).

·         Hands should be thoroughly dried with paper towels after washing. Bacterial transfer occurs more readily between wet surfaces than dry ones (Marples, Towers, 1979). More microorganisms were removed with paper towels than with linen. After use of hot-air dryers, fecal organisms have been recovered from hands, and bacterial counts are significantly higher than when paper towels are used (Gould, 1994b).

·         Follow Standard Precautions and wear gloves during any contact with blood, mucous membranes, nonintact skin, or any body substance except sweat. Use goggles, gloves, and gowns when appropriate. Wearing gloves does not obviate the need for scrupulous hand washing. The purpose of wearing gloves is either to protect the hands from becoming contaminated with dirt and microorganisms or to prevent the transfer of organisms that are already present on the hands (Smock, Shiel, 1994). The first and most important tier of the new Centers for Disease Control and Prevention (CDC) guidelines is Standard Precautions. Because client examination and medical history cannot reliably identify every client with blood-borne pathogens, Standard Precautions apply to all clients. You must assume all clients are carrying blood-borne pathogens such as human immunodeficiency virus (HIV) or Hepatitis B or C (HBV or HCV). Standard Precautions exceed Universal Precautions. Transmission of blood-borne pathogens takes place by parenteral, mucous membrane, or nonintact skin exposure to blood and other body substances. You must take precautions whenever contact is likely with blood, mucous membranes, nonintact skin, or any body substance except sweat (Medcom). This study indicates that when risk for infection is high, powder-free gloves should be considered because powder may promote wound infection (Dave, Wilcox, Kellett, 1999).

·         Follow Transmission-Based Precautions for airborne-, droplet-, and contact-transmitted microorganisms:

o Airborne: Isolate the client in a room with monitored negative air pressure, with the room door closed, and the client remaining in the room. Always wear appropriate respiratory protection when you enter the room. For tuberculosis, you should wear an approved particulate respirator mask. Limit the movement and transport of the client from the room to essential purposes only. If at all possible, have the client wear a surgical mask during transport.

o Droplet: Keep the client in a private room, if possible. If not possible, maintain a spatial separation of 3 feet from other beds or visitors. The door may remain open. You should wear a mask when you must come within 3 feet of the client. Some hospitals may choose to implement a mask requirement for droplet precautions for anyone entering the room. Limit transport to essential purposes, and have the client wear a mask if possible.

o Transmission: Place the client in a private room if possible or with someone who has an active infection from the same microorganism. Wear clean, nonsterile gloves when entering the room. When providing care, change gloves after contact with any infective material such as wound drainage. Remove the gloves and wash your hands before leaving the room and take care not to touch any potentially infectious items or surfaces on the way out. Wear a gown if you anticipate your clothing may have substantial contact with the client or other potentially infectious items. Remove the gown before leaving the room. Limit the transport of the client to essential purposes and take care that the client does not contact other environmental surfaces along the way. Dedicate the use of noncritical client care equipment to a single client. If use of common equipment is unavoidable, adequately clean and disinfect equipment before use with other clients.

Standard Precautions are based on the likely routes of transmission of pathogens. The second tier of the new CDC guidelines is Transmission-Based Precautions. This replaces many old categories of isolation precautions and disease-specific precautions with three simpler sets of precautions. These three sets of precautions are designed to prevent airborne transmission, droplet transmission, and contact transmission (Medcom).

·         Sterile technique must be used when inserting urinary catheters. Catheters must be cared for at least every shift. The genitourinary (GU) track is the most common site of nosocomial infections in the acute care setting. Catheterization and instrumentation of the urinary tract are implicated as precipitating factors in approximately 80% of cases (Tasota et al, 1998).

·         Use careful technique when changing and emptying urinary catheter bags; avoid cross-contamination. Clients are most at risk for cross-infection during bag changing and emptying (Platt et al, 1983; Crow et al, 1993; Roe, 1993).

·         Use alternatives to indwelling catheters whenever possible (external catheters, incontinence pads, bladder control techniques). The GU track is the most common site of nosocomial infections in the acute care setting. Catheterization and instrumentation of the urinary tract are implicated as precipitating factors in approximately 80% of cases (Tasota et al, 1998).

·         Provide well-designed site care for all peripheral, central venous, and arterial catheters: standardize insertion technique; select catheters with as few lumens as necessary; avoid use of femoral catheters in clients with fecal or urinary incontinence; use aseptic technique for insertion and care; stabilize cannula and tubing; maintain a sterile occlusive dressing (change every 72 hours per hospital policy); label insertion sites and all tubing with date and time of insertion, inspect every 8 hours for signs of infection, record and report; replace peripheral catheters per hospital policy (usually every 48 to 72 hours); when fever of unknown origin develops, obtain culture. More than 40% of bloodstream infections in ICUs are associated with short-term use of central venous catheters. Strict aseptic technique should be maintained. The risk of infection associated with use of triple-lumen catheters is as much as three times greater than the risk associated with single-lumen catheters. Clients with unexplained fever and signs of localized infection most likely have a catheter-related infection. The catheter should be removed and samples obtained for microbial culture (Tasota et al, 1998). Care in selection of site and catheter is important. The shortest catheter and smallest size should be used when possible. Accommodate the need to replace catheters before they occlude (Schmid, 2000).

·         Use careful sterile technique wherever there is a loss of skin integrity. Use of sterile technique prevents infection in at-risk clients (Wujcik, 1993).

·         Ensure client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perineal care performed by either nurse or client. Hygienic care is important to prevent infection in at-risk clients (Wujcik, 1993).

·         Recommend responsible use of antibiotics; use antibiotics sparingly. Clients infected with resistant strains of bacteria are more likely than control clients to have received previous antimicrobials, and hospital areas that have the highest prevalence of resistance also have the highest rates of antibiotic use. For these reasons, programs to prevent or control the development of resistant organisms often focus on the overuse or inappropriate use of antibiotics, for example, by restriction of widely used broad-spectrum antibiotics (e.g., third-generation cephalosporins) and vancomycin. Other approaches are to rotate antibiotics used for empiric therapy and to use combinations of drugs from different classes (Weber, Raasch, Rutala, 1999). Widespread use of certain antibiotics, particularly third-generation cephalosporins, has been shown to foster development of generalized beta-lactam resistance in previously susceptible bacterial populations. Reduction in the use of these agents (as well as imipenem and vancomycin) and concomitant increases in the use of extended-spectrum penicillins and combination therapy with aminoglycosides have been shown to restore bacterial susceptibility (Yates, 1999).

Geriatric

·         Recognize that geriatric clients may be seriously infected but have less obvious symptoms. The immune system declines with aging. The elderly may present with atypical manifestations of infections (Madhaven, 1994).

·         Suspect pneumonia when the client has symptoms of fatigue or confusion. The only early indicators of pneumonia in an elderly client may be confusion and fatigue. An elderly client with pneumonia may not have such classic signs and symptoms as fever, cough, or an increased white blood cell (WBC) count, or lung consolidation may be masked by chronic pulmonary disease. Among all age groups, the elderly are at greatest risk because aging can impair normal pulmonary defense mechanisms. Once an older client develops pneumonia, his or her risk takes on deadly dimensions. Clients >65 years of age are five times more likely than those in any other age group to die of a bacterial nosocomial pneumonia (Calianno, 1999).

·         Most clients develop nosocomial pneumonia by either aspirating contaminated substances or inhaling airborne particles. Refer to care plan for Risk for Aspiration.

·         Foot care other than simple toenail cutting should be performed by a podiatrist.

·         Observe and report if client has a low-grade temperature or new onset of confusion. The elderly can have infections with low-grade fevers. Be suspicious of any temperature rise or sudden confusion—these symptoms may be the only signs of infection (Madhaven, 1994).

·         During the peak of the influenza epidemic, limit visits by relatives and friends. Hospital- and nursing home-acquired influenza A virus infection leads to high mortality in the elderly (Madhaven, 1994).

·         Recommend that the geriatric client receive an annual influenza immunization and one-time pneumococcal vaccine. Among the many infections to which the aged are susceptible, pneumonia and influenza combined are responsible for the greatest mortality (Madhaven, 1994). Oseltamivir prophylaxis was very effective in protecting nursing home residents from ILI and in halting an outbreak of influenza B. A comparable nursing home in this study that did not use this treatment had double the cases (Parker, Loewen, Skowronski, 2001).

·         Recognize that chronically ill geriatric clients have an increased susceptibility to infection; practice meticulous care of all invasive sites.

Home Care Interventions

·         Assess home care environment for appropriate disposal of used dressing materials. Used dressing materials may contain or be a primary medium for growth of pathogens.

·         Role model all preventive behaviors in care of client (e.g., Universal Precautions). Do not visit client when you are ill. Demonstration is a more effective teaching strategy than verbalization.

·         Maintain the cleanliness of all irrigation and cleansing solutions. Change solutions when cleanliness has not been maintained—do not wait to finish bottle. Solutions exposed to contaminants provide a medium for growth of pathogens.

·         Assess and teach clients about current medications and therapies that promote susceptibility to infection: corticosteroids, immunosuppressants, chemotherapeutic agents, and radiation therapy. Knowledge of risk factors promotes vigilance in assessment, prompt reporting, and early treatment.

·         Assess client for knowledge of infections that have been drug resistant.

·         Instruct client to complete any course of prophylactic antibiotic therapy unless experiencing adverse side effects. Prophylactic antibiotic therapy decreases the risk of infection.

Client/Family Teaching

·         Teach client and family the symptoms of infection that should be promptly reported to a primary medical caregiver (e.g., redness; warmth; swelling; tenderness or pain; new onset of drainage or change in drainage from wound; increase in body temperature; hepatitis B virus [HBV]/acquired immunodeficiency syndrome [AIDS] symptoms: malaise, abdominal pain, vomiting or diarrhea, enlarged glands, rash; tuberculosis symptoms: cough, night sweats, dyspnea, changes in sputum, changes in breath sounds; insulin-dependent diabetes mellitus [IDDM] symptoms: sores or wounds that do not heal). A high prevalence of HBV/AIDS, an increasing incidence of tuberculosis, and the general risk of diabetes are related to increased rate of infection.

·         Encourage high-risk persons, including health care workers, to have influenza vaccinations. Vaccinations help to prevent viral nosocomial pneumonia (Carlianno, 1999).

·         Assess whether client and family know how to read a thermometer; provide instructions if necessary. Chemical dot thermometers are easy to use and decrease risk of infection. Clients need to know that the instructions should be followed carefully and that electronic or mercury thermometers may be the best choice for accuracy. Chemical dot thermometers may underestimate the oral temperature by (0.4° C in about 50% of adults, thus lacking the sensitivity to screen for fever and providing many false readings. Conversely, they may overestimate axillary temperature by (0.4° C in about 50% of adults and some young children, thus lacking the specificity to rule out fever and providing many false-positive readings (Erickson et al, 1996).

·         Instruct client and family about the need for good nutrition (especially protein) and proper rest to bolster immune function.

·         If client has AIDS, discuss the continued need to practice safe sex, avoid unsterile needle use, and maintain a healthy lifestyle to prevent infection.

·         Refer client and family to social services and community resources to obtain support in maintaining a lifestyle that increases immune function (e.g., adequate nutrition and rest, freedom from excessive stress).