This article can help you determine what to consider when planning care for a patient who is at risk for infection. Patients at risk for infection are those whose immune system or natural defenses are compromised. These patients have inadequate protection from pathogenic organisms, and it is important to plan nursing interventions and care to provide additional protection and infection prevention.
In this article:
Risk for infection can be heightened by anything that interferes with the body’s ability to fight off pathogenic invasions. The following are common risk factors for infection:
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Care goals for risk for infection are focused on prevention of infection and patient education. Expected outcomes for a patient with a risk for infection diagnosis are the following:
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to risk for infection.
1. Assess the patient for risk factors or current injuries or treatments that could put the patient at risk for infection.
These represent a compromise of the body’s physical defenses and a potential source of infection
2. Review the patient’s medications to identify treatments that may cause immunosuppression.
These drugs reduce the body’s immune response and increase risk for infection.
3. Monitor for signs of infection.
Early identification of infection allows for prompt treatment.
4. Assess the patient’s weight, serum albumin, and nutritional status.
Malnutrition contributes to decreased immune capability and increased risk for infection.
5. Assess the patient’s hygiene practices.
The nurse should evaluate the individual’s hygiene practices, including hand hygiene, bathing, and oral care. Inadequate hygiene can contribute to the risk of infection.
6. Assess the patient’s vaccination status.
Patients who do not have up to date vaccines are also at increased risk of infection. This is doubly dangerous if the individual already has other risk factors for serious infections.
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a risk for infection.
1. Wash your hands and use aseptic technique for nursing tasks involving non-intact skin or invasive lines.
Hand washing and using aseptic technique reduces the likelihood of transmitting pathogens to the patient that can cause infection.
2. Limit visitors and/or use protective isolation for patients who are at risk for infection.
Reducing visitation reduces the chance of spreading pathogens to the patient. Protective isolation provides additional protection from the spread of pathogens for patients who are severely immunocompromised.
3. Teach the patient, family, and caregivers signs and symptoms of infection and when to contact a healthcare provider.
It is important to recognize signs of infection early in order to seek prompt treatment. Particularly if the patient is going home with a wound that needs care, the nurse must ensure the patient understands signs of a worsening infection.
4. Encourage the intake of calorically dense and protein rich foods.
The immune system is more responsive and effective when nutritional status is sufficient.
5. Ensure proper personal protective equipment is used.
Particularly for patients at risk of infection, the nurse should teach them about the importance of wearing a mask, particularly in high-risk situations. It is also important that the care team is diligent about wearing PPE around immunocompromised patients.
Nursing care plans for risk for infection should be focused on the patient’s specific risk factors and appropriate interventions. Some conditions associated with risk for infection are:
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for infection risk.
Risk for infection related to diminished immune response.
1. Assess the presence of the underlying cause of diminished immune system.
The patient may have an existing condition (e.g., neoplasm, autoimmune disorder, diabetes, liver or kidney failure, etc.) or treatment (steroid use, chemotherapy, radiotherapy) that weakens the immune response.
2. Check and notify the physician for any signs of infection. These include fever, redness, purulent discharge, etc.
Recognizing early signs of infection may help facilitate prompt treatment and prevent sepsis. Indicators for sepsis may include systemic manifestations such as changes in mental status, fever, chills, and hypotension.
3. Review laboratory values.
Increased WBC count may suggest infection. However, patients with neutropenia, or those with consistently low WBC count who present with fever, need emergency medical attention. Since their body cannot fight infections effectively, infection may quickly progress to sepsis without prompt treatment.
1. Place the very high-risk patient in protective isolation.
Protective isolation is suggested for patients with neutropenia (WBC less than 500 to 1000/mm3). Follow institutional protocols regarding the protective isolation of at-risk patients.
2. Limit visitors.
Restricting visitation decreases the risk of infection transmission. If visitors are allowed, ensure they are wearing proper personal protective equipment.
3. Observe proper hand hygiene. Wear gloves when appropriate to minimize contamination of hands, and discard them after each client. Wash hands after glove removal.
Hand hygiene is the single most effective way to prevent transmission of infection.
4. Instruct the patient and their families about proper hand hygiene.
Handwashing is the first-line defense against healthcare-associated infections (HAIs).
Risk for infection as evidenced by invasive procedure and surgical incision.
1. Monitor signs and symptoms of wound infection. Note foul-smelling purulent discharge, pain on the surgical site, warmth, swelling, or redness.
These signs and symptoms indicate surgical site infection. Signs of infection should be promptly reported to the care team.
2. Assess the knowledge of the patient and family about infection precautions.
Adequate knowledge could translate to proper health behavior to prevent infection, including hand hygiene.
3. Obtain appropriate tissue or fluid specimens for culture and sensitivities testing.
Culture and sensitivity tests will determine the antibiotic against the pathogen causing the surgical site infection.
1. Administer antimicrobials as indicated. The nurse should note the therapy response to determine the effectiveness of therapy and also the presence of side effects.
Antibiotic prophylaxis is often administered within an hour before incision until within 24 hours after the surgery. Individual protocols may differ between surgeon and site policy.
2. Instruct the patient and family on techniques of proper wound care.
Daily wound cleaning promotes the loosening of cellular debris from previous dressing. Proper technique includes the following:
If the patient is sent home with a dressing, it is essential that the nurse educates the patient on the signs of an infection and when they should contact their doctor.
3. Encourage intake of protein- and calorie-rich foods.
Optimal nutritional status enhances immune response.
4. Teach the patient the risk factors contributing to surgical wound infection.
Identifying risk factors for poor wound healing that are present in the patient will help them prioritize appropriate actions.
Shelly Caruso is a bachelor-prepared registered nurse in her fifth year of practice. She began her career as a nursing assistant and has worked in acute care for nearly eight years. In addition to her hospital and trauma center experience, Shelly has also worked in post-acute, long-term, and outpatient settings.
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