Definition: At increased risk for being invaded by pathogenic organisms
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.
Nursing Interventions for Risk for Infection
1. Monitor the following for signs of infection:
- Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit sites of tubes, drains, or catheters Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified at culture.
- Elevated temperature Fever of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, fever above 37.7° C (99.8° F) suggests infection; fever spikes that occur and subside are indicative of wound infection; very high fever accompanied by sweating and chills may indicate septicemia.
- Color of respiratory secretions Yellow or yellow-green sputum is indicative of respiratory infection.
- Appearance of urine Cloudy, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection.
2. Monitor white blood count (WBC). Rising WBC indicates body’s efforts to combat pathogens; normal values: 4000 to 11,000 mm3. Very low WBC (neutropenia <1000 mm3) indicates severe risk for infection because patient does not have sufficient WBCs to fight infection.
NOTE: In elderly patients, infection may be present without an increased WBC.
3. Assess for presence, existence of, and history of risk factors such as open wounds and abrasions; in-dwelling catheters (Foley, peritoneal); wound drainage tubes (T-tubes, Penrose, Jackson-Pratt); endotracheal or tracheostomy tubes; venous or arterial access devices; and orthopedic fixator pins. Each of these examples represent a break in the body’s normal first lines of defense.
4. In pregnant patients, assess intactness of amniotic membranes. Prolonged rupture of amniotic membranes before delivery places the mother and infant at increased risk for infection.
5. Assess for history of drug use or treatment modalities that may cause immunosuppression. Antineoplastic agents and corticosteroids reduce immunocompetence.
6. 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.
7. 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.