- Inadequate primary defences: broken skin, injured tissue, body fluid stasis
- Inadequate secondary defenses: immunosuppression, leukopenia
- Malnutrition
- Intubation
- Indwelling catheters, drains
- Intravenous (IV) devices
- Invasive procedures
- Rupture of amniotic membranes
- Chronic disease
- Failure to avoid pathogens (exposure)
- Inadequate acquired immunity
Patient’s Diagnosis: –
Date:-
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- The patient will remains free of infection, as evidenced by: normal vital signs, and absence of purulent drainage from wounds, incisions, and tubes.
- Infection will be recognized early to allow for prompt treatment.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Assess for presence, existence of, and history of risk factors such as open wounds and abrasions; indwelling catheters; wound drainage tubes e.t.c. | Each of these examples represent a break in the body's normal first lines of defense. |
| Monitor white blood count (WBC). | Rising WBC indicates body's efforts to combat pathogens; normal values: 4000 to 11,000. |
| Assess nutritional status, including weight, history of weight loss, and serum albumin. | Patients with poor nutritional status may be anergic, or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection. |
| Assess for history of drug use or treatment modalities that may cause immunosuppression. | Antineoplastic agents and corticosteroids reduce immunocompetence. |
| Assess immunization status. | Elderly patients and those not raised in the United States may not have completed immunizations, and therefore not have sufficient acquired immunocompetence. |
| Wash hands and teach other caregivers to wash hands before contact with patient, and between procedures with patient. | Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e.g., perineal care or central line care). |
| Limit visitors. | To reduce the number of organisms in patient's environment and restrict visitation by individuals with any type of infection to reduce the transmission of pathogens to the patient at risk for infection. |
| Encourage intake of protein- and calorie-rich foods. | To maintain optimal nutritional status. |
| Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). | To promote diluted urine and frequent emptying of bladder; reducing stasis of urine in turn reduces risk of bladder infection or urinary tract infection (UTI). |
| Encourage coughing and deep breathing; consider use of incentive spirometer. | These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia. |
| Administer or teach use of antimicrobial (antibiotic) drugs as ordered. | Antibiotic agents are either toxic to the pathogen or retard the pathogen's growth. |
| Place patient in protective isolation if patient is at very high risk. | Protective isolation is established to protect the person at risk from pathogens. |
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