Friday, November 26, 2010

Risk for Infection

Risk for Infection

NANDA Definition
At increased risk for being invaded by pathogenic organisms.

Discussion of the Problem
Individuals normally have defenses that protect the body from infection. These defenses can be categorized as nonspecific and specific. Nonspecific defenses protect the person against all microorganisms, regardless of prior exposure. Specific (immune) defenses, by contrast, are directed against identifiable bacteria, viruses, fungi, or other infectious agents. Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and exposures that occur throughout the course of living. An infection happens when there is an invasion of body tissue by microorganisms and when they grow there. Such microorganism is called an infectious agent. If the microorganism produces no clinical evidence of disease, the infection is called asymptomatic or subclinical. Some subclinical infections can cause considerable damage. A detectable alteration in normal tissue function, however, is called disease. Infections can be transmitted, either by contact or through direct, indirect (vehicle-borne or vector-borne), airborne transmission, sexual contact, or sharing of intravenous (IV) drug paraphernalia. Patient who are in risk for infection are as follows: those who have break in the integument; those whose immune system cannot combat the invading organism adequately; those who have open, traumatic or surgical wounds; those who are malnourished, have inadequate resources for sanitary living conditions, lack knowledge about disease transmission; and those who have medical conditions such as AIDS, amputation, anemias, burns, COPD, cancer, asthma, craniocerebral trauma, diabetes mellitus, diabetic ketoacidosis, fractures, hepatitis, leukemias, pancreatitis, peritonitis, pneumonia, pulmonary tuberculosis, dialysis, sickle cell crisis, surgical interventions, total nutritional support (enteral feeding), transplantation, urinary diversions, and ventilatory assistance (mechanical). Antimicrobials are used to treat infections when susceptibility is present. Organisms may become resistant to antimicrobials, requiring multiple antimicrobial therapies. There are organisms for which no antimicrobial is effective, such as the human immunodeficiency virus (HIV). Health care workers must understand how to take precautions to prevent transmission to protect themselves and others from disease transmission. The aims of nursing management are to maintain or restore defenses, avoid the spread of infectious organisms, and reduce or alleviate problems associated with the infections.

Nursing Interventions Classification (NIC)
  • Infection Control
  • Infection Protection
  • Wound Care

Nursing Outcomes Classification (NOC)
  • Immune Status
  • Knowledge: Infection Control
  • Infection Status
  • Wound Healing

Goal and Objectives
  • Patient will attain timely healing of wounds or lesions.
  • Patient will exhibit methods, lifestyle changes to uphold safe environment.
  • Patient will keep a safe aseptic environment.
  • Patient will recognized Infection promptly to allow for early management.
  • Patient will remain free of infection, as manifested by normal vital signs and nonexistence of purulent drainage from wounds, incisions, and tubes.
  • Patient will take part in behaviors to decrease risk of infection.
  • Patient will verbalize awareness of individual causative or risk factors.

Subjective and Objective Data
[Not appropriate; existence of signs and symptoms ascertains an actual diagnosis.]

Risk Factors
  • Altered integrity of closed system (CSF leak)
  • Altered nutritional status
  • Antibiotic therapy
  • Chronic disease
  • Depression of the immune system
  • Failure to avoid pathogens (exposure)
  • Failure to recognize/treat infection and/or exercise proper preventive measures
  • Inadequate acquired immunity
  • Inadequate primary defenses: broken skin, injured tissue, body fluid stasis, decreased ciliary action
  • Inadequate secondary defenses: immunosuppression, leukopenia or decreased granulocytes (suppressed inflammatory response), decreased hemoglobin
  • Indwelling catheters, drains
  • Insufficient knowledge to avoid exposure to pathogens
  • Intravenous (IV) devices
  • Intubation
  • Invasive procedures; environmental exposure
  • Malnutrition
  • Rupture of amniotic membranes
  • Skeletal traction
  • Use of antimicrobial agents

Assessment (Dx)
  • Check for existence, presence of, and history of risk factors for instance open wounds and abrasions; in-dwelling catheters wound drainage tubes endotracheal or tracheostomy tubes; venous or arterial access devices; and orthopedic fixator pins. All of these examples represent a break in the body’s normal first lines of defense.

Appearance of urine.
Cloudy, foul-smelling urine with visible sediment signifies urinary tract or bladder infection.
Character, odor of sputum.
Foul smelling, yellow, or greenish secretions implies the existence of pulmonary infection.
Elevated temperature
Fever of up to 38° C (100.4° F) for 48 hours after surgery is associated to surgical stress; after 48 hours, fever above 37.7° C (99.8° F) signifies infection; fever spikes that take place and subside are manifestations of wound infection; very high fever together sweating and chills may specify septicemia.
Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, and exit sites of tubes, drains, or catheters.
Any suspicious drainage must be cultured; antibiotic therapy is determined by pathogens recognized at culture.

Shaking chills and profuse diaphoresis.
Chills usually go before temperature spikes in incidence of generalized infection.

  • Assess intactness of amniotic membranes in pregnant patients. Protracted rupture of amniotic membranes before delivery places the mother and infant at higher risk for infection.

  • Check white blood count (WBC). Elevating WBC signifies body’s efforts to fight pathogens; normal values: 4000 to 11,000 mm3. Very low WBC (neutropenia <1000 mm3) suggests severe risk for infection because patient does not have adequate WBCs to fight infection. NOTE: In geriatric patients, infection may be existing without an elevated WBC.

  • Evaluate nutritional status, together with weight, history of weight loss, and serum albumin. Patients with poor nutritional state may be anergic, or not capable to gather a cellular immune response to pathogens and are consequently more prone to infection.

  • Evaluate patient awareness and aptitude to keep opportunistic infection prophylactic regimen. Manifold medication regimen is not easy to continue over a long period of time. Patients may modify medication regimen based on side effects experienced, adding to insufficient prophylaxis, active disease, and resistance.

  • Examine oral cavity for white plaques (oral thrush). Examine verbalization of vaginal or perineal itching or burning. Depression of immune system and use of antibiotics augments risk of secondary infections, especially yeast.

  • Examine site of invasive devices, checking for signs of local inflammation/infection. Assess also dressings and wound; observe characteristics of drainage. Prompt recognition of developing infection gives chance for timely intervention and avoidance of more serious complications.

  • Review for history of drug use or management modalities that may cause immunosuppression. Antineoplastic agents and corticosteroids decrease immunocompetence.

  • Review immunization status. Geriatric patients and those not raised in the urban areas may not have finished immunizations, and consequently not have adequate acquired immunocompetence.

Therapeutic Interventions (Tx)
  • Confirm sterility of all manufacturers’ items. Prepackaged items may come into view to be sterile; but, every item have to be examined for manufacturer’s statement of sterility, breaks in packaging, environmental effect on package, and delivery methods. Package sterilization and expiration dates, lot or serial numbers have to be documented on implant items for additional follow-up if needed

  • Get wound or drainage cultures and sensitivities as suitable. Determines existence of infection or specific organisms and proper therapy.

  • Give antimicrobial/antibiotic drugs as ordered. Antimicrobial drugs comprise antibacterial, antifungal, antiparasitic, and antiviral agents. Every of these agents are either toxic to the pathogen or retard the pathogen’s growth.

  • Give meticulous skin, oral, and perianal care. Lowers the risk of skin or tissue breakdown and infection.

  • Give perineal care. Preserve integrity of closed urinary drainage system if utilized. Lowers possibility for bacterial growth or ascending infection.

  • Grant for infection precautions or isolation as necessary. Lowers the risk of cross-contamination to staff, visitors, and other patients.

  • Help with medical procedures as indicated. Helps conclude causative factors for proper management and enhances recovery.

  • Keep asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access treatment. Reduces chance for introduction of bacteria.

  • Keep patency and regularly empty drainage device. Hemovac, Jackson-Pratt drains make possibles removal of drainage, enhancing wound healing and decreasing risk of infection.

  • Monitor visitors or staff for signs of infection. Manage visitor adherence to protocol as necessary. This decreases the amount of organisms in patient’s surroundings and limits visitation by individuals with any kind of infection to decrease the transmission of pathogens to the patient at risk for infection. It also decreases potential of patient contracting a nosocomial infection. The most frequent modes of transmission are by means of direct contact and by droplet

  • Offer tissues and trash bag in a suitable location for sputum and other secretions. Educate patient in correct handling of secretions. Reduces spread of infection.

  • Put patient in defensive isolation if patient is at very high risk. Protective isolation is instituted if white blood cell counts signifies neutropenia (<500 to 1000 mm3).

  • Situate in private room. Forbid use of live plants or cut flowers. Limit fresh fruits and vegetables or make certain they are washed or peeled. Guard patient from possible sources of pathogens or infection. Note: Profound bone marrow suppression, neutropenia, and chemotherapy situate patient at higher risk for infection.

  • Stick to facility infection control, sterilization, and aseptic policies/measures. Standard mechanisms designed to avoid infection.

  • Talk about necessitate for sufficient nutritional intake. Malnutrition can affect over all health and decrease resistance to infection.

  • Uphold sufficient dietary and fluid intake. Helps in liquefying respiratory secretions to make possible the expectoration and avoid stasis of body fluids.

  • Uphold sufficient rest or exercise periods. Prevents fatigue, nevertheless promotes adequate movement to avoid stasis complications, for example, pneumonia, decubitus, and thrombus formation.

  • Utilize gowns, gloves, masks, and strict aseptic technique during direct wound care and offer sterile or freshly laundered bed linens or gowns. Avoids exposure to infectious organisms.

  • Wash hands and educate other caregivers to wash hands prior to contact with patient and between measures with patient. Friction and running water efficiently take away microorganisms from hands. Washing between procedures decreases the risk of transmitting pathogens from one area of the body to another. Utilization of disposable gloves does not lessen necessitate for hand washing. It also lowers risk of cross-contamination.

Educative (Edx)
  • Educate patient or caregiver to wash hands regularly, particularly after toileting, prior to meals, and prior to and after administering self-care. Patients and significant others can spread infection from one part of the body to another; hand washing diminishes this risk.

  • Educate patient to take antibiotics as ordered. The majority antibiotics work best when a constant blood level is sustained; a constant blood level is sustained when medications are taken as ordered. The absorption of some antibiotics is delayed by certain foods; patient must be educated therefore.

  • Persuade fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). Fluids promote diluted urine and regular emptying of bladder; decreasing stasis of urine, in turn, lessens risk of bladder infection or urinary tract infection (UTI).

  • Persuade increased intake of foods high in protein calorie-rich foods and fluids with ample fiber. Improves healing and avoids dehydration. Note: Constipation potentiates stasis of toxins and risk of rectalirritation or tissue injury.

  • Promote coughing and deep breathing; consider use of incentive spirometer. These measures decrease stasis of secretions in the lungs and bronchial tree. When stasis takes place, pathogens can root upper respiratory infections, together with pneumonia.

  • Promote proper oral hygiene. Advocate the use of soft-bristled toothbrushes to guard mucous membranes. Lessens risk of oral or gum disease.

  • Promote regular position changes and out of bed or ambulation as tolerated. Prevents stasis of body fluids, promotes maximal functioning of organ systems, GI tract.

  • Show and allow return demonstration of all high-risk measures that patient or caregiver will do after discharge, such as dressing changes, peripheral or central IV site care, peritoneal dialysis; self-catheterization. Bladder infection is more associated to over distended bladder resulting from irregular catheterization than to use of clean versus sterile technique.

  • Talk about extent and rationale for isolation precautions and continuation of personal hygiene. Upholds cooperation with treatment and may reduce feelings of isolation.

  • Teach patient or Significant Other(s) in methods to avoid spread of infection, keep the integrity of skin, and care for wounds or lesions. Self-care activities that may give protection for patient or others.

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