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Risk of Infection — Nursing Care Plan
Nursing Diagnosis
Risk for infection related to (choose applicable) impaired skin integrity, invasive devices (e.g., IV, urinary catheter), immunosuppression, malnutrition, decreased mobility, recent surgery, or prolonged hospitalization.
Goal/Expected Outcomes
Short-term: The patient will remain free of signs and symptoms of infection (no fever, purulent drainage, increased WBC count, localized redness/warmth, or pain) during the shift/hospital stay.
Long-term: The patient will remain free from infection while in care and will demonstrate understanding of infection-prevention measures by discharge.
Assessment
Baseline data: vital signs (temperature, pulse, respirations), WBC count, wound appearance, presence/type of invasive devices, nutritional status, mobility, skin condition, and any immunosuppressive conditions or therapies.
Ongoing monitoring: Monitor temperature every 4–8 hours (more frequently if febrile), inspect wounds and insertion sites every shift, assess for signs/symptoms of systemic infection (rigors, tachycardia, hypotension, altered mental status), and review lab results (CBC, culture results if obtained).
Risk factors: note diabetes, steroid therapy, chemotherapy, neutropenia, chronic illness, poor hygiene, compromised circulation, or recent antibiotic use.
Nursing Interventions and Rationale
Hand hygiene
Intervention: Perform and encourage strict handwashing or use alcohol-based sanitizer before and after patient contact, wound care, and handling invasive devices.
Rationale: Hand hygiene is the single most effective method to prevent transmission of pathogens.
Aseptic technique
Intervention: Use sterile technique for invasive procedures, dressing changes, and when accessing central lines. Ensure sterile supplies and proper environment.
Rationale: Prevents introduction of microorganisms into sterile body sites.
Care of invasive devices
Intervention: Assess necessity of catheters, IV lines, or drains daily; remove as soon as no longer needed. Change dressings and tubing per facility protocol using aseptic technique.
Rationale: Duration of device placement is a major risk factor for device-associated infections.
Wound care
Intervention: Inspect wounds each shift, cleanse using prescribed solutions, apply appropriate dressings, and document odor, exudate, and tissue appearance.
Rationale: Early identification and proper wound management reduce bacterial proliferation and promote healing.
Personal protective equipment (PPE)
Intervention: Use gloves, gown, mask, and eye protection as indicated by standard and transmission-based precautions.
Rationale: PPE reduces exposure to infectious agents and protects both patient and staff.
Environmental cleanliness
Intervention: Ensure patient environment is clean, disinfect high-touch surfaces regularly, and manage linen and waste per protocol.
Rationale: Reduces environmental reservoirs of pathogens.
Respiratory hygiene/cough etiquette
Intervention: Encourage covering mouth/nose when coughing, provide tissues and masks if respiratory symptoms present, and place the patient on droplet/airborne precautions when indicated.
Rationale: Limits dispersal of respiratory pathogens.
Immunization and prophylaxis
Intervention: Verify immunization status; provide vaccines or prophylactic antibiotics per orders and guidelines.
Rationale: Immunization and prophylaxis reduce risk of specific infections.
Nutrition and hydration
Intervention: Assess nutritional status and collaborate with dietitian to provide adequate calories, protein, vitamins (A, C, E) and minerals (zinc) to support immune function. Encourage fluid intake unless contraindicated.
Rationale: Proper nutrition supports immune response and tissue repair.
Glycemic control
Intervention: Monitor blood glucose and manage hyperglycemia per protocol in diabetic or critically ill patients.
Rationale: Hyperglycemia impairs immune function and wound healing, increasing infection risk.
Patient and family education
Intervention: Teach infection prevention measures: hand hygiene, wound care instructions, signs/symptoms to report (fever, increased pain, redness, drainage), and safe device care if discharged with devices.
Rationale: Informed patients and caregivers help reduce risk and enable early detection.
Surveillance and early intervention
Intervention: Obtain cultures (blood, urine, wound) when infection suspected; notify provider promptly of abnormal findings; administer antibiotics or prescribed therapy timely and monitor response.
Rationale: Early identification and treatment reduces morbidity and prevents spread.
Isolation precautions
Intervention: Implement appropriate transmission-based precautions (contact, droplet, airborne) when indicated and follow facility policies for room placement and PPE.
Rationale: Prevents spread of contagious organisms to other patients and staff.
Evaluation
Risk of Infection — Nursing Care Plan
Nursing Diagnosis
Risk for infection related to (choose applicable) impaired skin integrity, invasive devices (e.g., IV, urinary catheter), immunosuppression, malnutrition, decreased mobility, recent surgery, or prolonged hospitalization.
Goal/Expected Outcomes
Short-term: The patient will remain free of signs and symptoms of infection (no fever, purulent drainage, increased WBC count, localized redness/warmth, or pain) during the shift/hospital stay.
Long-term: The patient will remain free from infection while in care and will demonstrate understanding of infection-prevention measures by discharge.
Assessment
Baseline data: vital signs (temperature, pulse, respirations), WBC count, wound appearance, presence/type of invasive devices, nutritional status, mobility, skin condition, and any immunosuppressive conditions or therapies.
Ongoing monitoring: Monitor temperature every 4–8 hours (more frequently if febrile), inspect wounds and insertion sites every shift, assess for signs/symptoms of systemic infection (rigors, tachycardia, hypotension, altered mental status), and review lab results (CBC, culture results if obtained).
Risk factors: note diabetes, steroid therapy, chemotherapy, neutropenia, chronic illness, poor hygiene, compromised circulation, or recent antibiotic use.
Nursing Interventions and Rationale
Hand hygiene
Intervention: Perform and encourage strict handwashing or use alcohol-based sanitizer before and after patient contact, wound care, and handling invasive devices.
Rationale: Hand hygiene is the single most effective method to prevent transmission of pathogens.
Aseptic technique
Intervention: Use sterile technique for invasive procedures, dressing changes, and when accessing central lines. Ensure sterile supplies and proper environment.
Rationale: Prevents introduction of microorganisms into sterile body sites.
Care of invasive devices
Intervention: Assess necessity of catheters, IV lines, or drains daily; remove as soon as no longer needed. Change dressings and tubing per facility protocol using aseptic technique.
Rationale: Duration of device placement is a major risk factor for device-associated infections.
Wound care
Intervention: Inspect wounds each shift, cleanse using prescribed solutions, apply appropriate dressings, and document odor, exudate, and tissue appearance.
Rationale: Early identification and proper wound management reduce bacterial proliferation and promote healing.
Personal protective equipment (PPE)
Intervention: Use gloves, gown, mask, and eye protection as indicated by standard and transmission-based precautions.
Rationale: PPE reduces exposure to infectious agents and protects both patient and staff.
Environmental cleanliness
Intervention: Ensure patient environment is clean, disinfect high-touch surfaces regularly, and manage linen and waste per protocol.
Rationale: Reduces environmental reservoirs of pathogens.
Respiratory hygiene/cough etiquette
Intervention: Encourage covering mouth/nose when coughing, provide tissues and masks if respiratory symptoms present, and place the patient on droplet/airborne precautions when indicated.
Rationale: Limits dispersal of respiratory pathogens.
Immunization and prophylaxis
Intervention: Verify immunization status; provide vaccines or prophylactic antibiotics per orders and guidelines.
Rationale: Immunization and prophylaxis reduce risk of specific infections.
Nutrition and hydration
Intervention: Assess nutritional status and collaborate with dietitian to provide adequate calories, protein, vitamins (A, C, E) and minerals (zinc) to support immune function. Encourage fluid intake unless contraindicated.
Rationale: Proper nutrition supports immune response and tissue repair.
Glycemic control
Intervention: Monitor blood glucose and manage hyperglycemia per protocol in diabetic or critically ill patients.
Rationale: Hyperglycemia impairs immune function and wound healing, increasing infection risk.
Patient and family education
Intervention: Teach infection prevention measures: hand hygiene, wound care instructions, signs/symptoms to report (fever, increased pain, redness, drainage), and safe device care if discharged with devices.
Rationale: Informed patients and caregivers help reduce risk and enable early detection.
Surveillance and early intervention
Intervention: Obtain cultures (blood, urine, wound) when infection suspected; notify provider promptly of abnormal findings; administer antibiotics or prescribed therapy timely and monitor response.
Rationale: Early identification and treatment reduces morbidity and prevents spread.
Isolation precautions
Intervention: Implement appropriate transmission-based precautions (contact, droplet, airborne) when indicated and follow facility policies for room placement and PPE.
Rationale: Prevents spread of contagious organisms to other patients and staff.
Evaluation
