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NANDA Definition: At increased risk for being invaded by pathogenic organisms
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. Infections occur when an organism (e.g., bacterium, virus, fungus, or other parasite) invades a susceptible host. Breaks in the integument, the body’s first line of defense, and/or the mucous membranes allow invasion by pathogens. If the host’s (patient’s) immune system cannot combat the invading organism adequately, an infection occurs. Open wounds, traumatic or surgical, can be sites for infection; soft tissues (cells, fat, muscle) and organs (kidneys, lungs) can also be sites for infection either after trauma, invasive procedures, or by invasion of pathogens carried through the bloodstream or lymphatic system. Infections can be transmitted, either by contact or through airborne transmission, sexual contact, or sharing of intravenous (IV) drug paraphernalia. Being malnourished, having inadequate resources for sanitary living conditions, and lacking knowledge about disease transmission place individuals at risk for infection. Health care workers, to protect themselves and others from disease transmission, must understand how to take precautions to prevent transmission. Because identification of infected individuals is not always apparent, standard precautions recommended by the Centers for Disease Control and Prevention (CDC) are widely practiced. In addition, the Occupational Safety and Health Administration (OSHA) has set forth the Blood Borne Pathogens Standard, developed to protect workers and the public from infection. Ease and increase in world travel has also increased opportunities for transmission of disease from abroad. Infections prolong healing, and can result in death if untreated. Antimicrobials are used to treat infections when susceptibility is present. Organisms may become resistant to antimicrobials, requiring multiple antimicrobial therapy. There are organisms for which no antimicrobial is effective, such as the human immunodeficiency virus (HIV).
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
- Immune Status
- Knowledge: Infection Control
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
- Infection Control
- Infection Protection
Nursing Interventions :
- Observe and report signs of Infection.
- Assess temperature, Use an electronic or mercury thermometer to assess temperature.
- Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures).
- Assess skin for colour, moisture, texture, and turgor (elasticity).
- Carefully wash and pat dry skin, including skinfold area. Use hydration and moisturization on all at-risk surfaces.
- Encourage a balanced diet, emphasizing proteins to feed the immune system.
- Prevent nosocomial pneumonia.
- Encourage fluid intake and adequate rest to bolster the immune system.
- Before and after giving care to client use Proper hand washing techniques.
- Use goggles, gloves, and gowns when appropriate Follow Standard Precautions and wear gloves during any contact with blood, mucous membranes, nonintact skin, or any body substance.
- Transmission Based Precautions for
- Airborne
- Droplet
- Contact transmitted
- Sterile technique on catheterize.
- Use careful technique when changing and emptying urinary catheter bags; avoid cross contamination.
- Use careful sterile technique wherever there is a loss of skin integrity.
- Ensure client's appropriate hygienic care with hand washing; bathing; and hair, nail, and perinea care.
- Antibiotics.
