Nursing Diagnosis: Risk for Infection

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

1. Immune Status

2. Knowledge: Infection Control

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

1. Infection Control

2. Infection Protection
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).
Risk Factors:
1. Inadequate primary defenses: broken skin, injured tissue, body fluid stasis
2. Inadequate secondary defenses: immunosuppression, leukopenia
3. Malnutrition
4. Intubation
5. Indwelling catheters, drains
6. Intravenous (IV) devices
7. Invasive procedures
8. Rupture of amniotic membranes
9. Chronic disease
10. Failure to avoid pathogens (exposure)
11. Inadequate acquired immunity
Expected Outcomes
1. Patient remains free of infection, as evidenced by normal vital signs and absence
of purulent drainage from wounds, incisions, and tubes.
2. Infection is recognized early to allow for prompt treatment.

Ongoing Assessment

• 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.

• Monitor white blood count (WBC). Rising WBC indicates

body’s efforts to combat pathogens; normal values: 4000 to
3 3
11,000 mm . Very low WBC (neutropenia <1000 mm )
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.

• 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.

• 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.

• 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.

• Assess for exposure to individuals with active infections.

• 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.
Therapeutic Interventions

• Maintain or teach asepsis for dressing changes and wound

care, catheter care and handling, and peripheral IV and central
venous access management.

• Wash hands and teach other caregivers to wash hands before

contact with patient and between procedures with patient.
Friction and running water effectively remove
microorganisms from hands. 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). Use of disposable gloves does not reduce the need
for hand washing.

• Limit visitors. This reduces the number of organisms in

patient’s environment and restricts visitation by individuals
with any type of infection to reduce the transmission of
pathogens to the patient at risk for infection. The most
common modes of transmission are by direct contact
(touching) and by droplet (airborne).

• Encourage intake of protein- and calorie-rich foods. This

maintains optimal nutritional status.

• Encourage fluid intake of 2000 ml to 3000 ml of water per day

(unless contraindicated). Fluids 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. Antimicrobial drugs include antibacterial,
antifungal, antiparasitic, and antiviral agents. All of these
agents are either toxic to the pathogen or retard the
pathogen’s growth. Ideally, the selection of the drug is
based on cultures from the infected area; this is often
impossible or impractical, and in these cases, empirical
management usually is undertaken with a broad-spectrum
drug.

• Place patient in protective isolation if patient is at very high

risk. Protective isolation is established if white blood cell
3
counts indicate neutropenia (<500 to 1000 mm ).
Institutional protocols may vary.

• Recommend the use of soft-bristled toothbrushes and stool

softeners to protect mucous membranes.
Education/Continuity of Care

• Teach patient or caregiver to wash hands often, especially

after toileting, before meals, and before and after administering
self-care. Patients and caregivers can spread infection from
one part of the body to another, as well as pick up surface
pathogens; hand washing reduces these risks.

• Teach patient the importance of avoiding contact with those

who have infections or colds.

• Teach family members and caregivers about protecting

susceptible patient from themselves and others with infections or
colds.

• Teach patient, family, and caregivers the purpose and proper

technique for maintaining isolation.

• Teach patient to take antibiotics as prescribed. Most

antibiotics work best when a constant blood level is
maintained; a constant blood level is maintained when
medications are taken as prescribed. The absorption of
some antibiotics is hindered by certain foods; patient
should be instructed accordingly.
 • Teach patient and caregiver the signs and symptoms of
infection, and when to report these to the physician or nurse.

• Demonstrate and allow return demonstration of all high-risk

procedures that patient or caregiver will do after discharge, such
as dressing changes, peripheral or central IV site care, peritoneal
dialysis, self-catheterization (may use clean technique). Bladder
infection is more related to overdistended bladder resulting
from infrequent catheterization than to use of clean versus
sterile technique.

Nursing Diagnosis: Ineffective airway clearance

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

1. Respiratory Status: Airway Patency

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

1. Cough Enhancement

2. Airway Management

3. Airway Suctioning
NANDA Definition: Inability to clear secretions or obstructions from the respiratory
tract to maintain airway patency
Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing
the airway. However, the cough may be ineffective in both normal and disease states
secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle
fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower
bronchioles and alveoli to maintain the airway include the mucociliary system,
macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect
function of the mucociliary system. Likewise, conditions that cause increased production
of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these
mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery)
or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem.
Elderly patients, who have an increased incidence of emphysema and a higher
prevalence of chronic cough or sputum production, are at high risk.
 Defining Characteristics:
1. Abnormal breath sounds (crackles, rhonchi, wheezes)
2. Changes in respiratory rate or depth
3. Cough
4. Hypoxemia/cyanosis
5. Dyspnea
6. Chest wheezing
7. Fever
8. Tachycardia
Related Factors:
1. Decreased energy and fatigue
2. Ineffective cough
3. Tracheobronchial infection
4. Tracheobronchial obstruction (including foreign body aspiration)
5. Copious tracheobronchial secretions
6. Perceptual/cognitive impairment
7. Impaired respiratory muscle function
8. Trauma
Expected Outcomes
1. Patient's secretions are mobilized and airway is maintained free of secretions, as
evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions
after treatments and deep breaths.

Ongoing Assessment

• Assess airway for patency. Maintaining the airway is

always the first priority, especially in cases of trauma,
acute neurological decompensation, or cardiac arrest.

• Auscultate lungs for presence of normal or adventitious breath

sounds, as in the following:
 Decreased or absent breath sounds These may indicate
presence of mucus plug or other major airway
obstruction.
 Wheezing These may indicate increasing airway
resistance.
 Coarse sounds These may indicate presence of fluid
along larger airways.

• Assess respirations; note quality, rate, pattern, depth, flaring

of nostrils, dyspnea on exertion, evidence of splinting, use of
accessory muscles, and position for breathing. Abnormality
indicates respiratory compromise.
 • Assess changes in mental status. Increasing lethargy,
confusion, restlessness, and/or irritability can be early
signs of cerebral hypoxia.

• Assess changes in vital signs and temperature. Tachycardia

and hypertension may be related to increased work of
breathing. Fever may develop in response to retained
secretions/atelectasis.

• Assess cough for effectiveness and productivity. Consider

possible causes for ineffective cough (e.g., respiratory
muscle fatigue, severe bronchospasm, or thick tenacious
secretions).

• Note presence of sputum; assess quality, color, amount, odor,

and consistency. This may be a result of infection, bronchitis,
chronic smoking, or other condition. A sign of infection is
discolored sputum (no longer clear or white); an odor may
be present.

Send a sputum specimen for culture and sensitivity as appropriate.

Respiratory infections increase the work of breathing;
antibiotic treatment is indicated.

• Monitor arterial blood gases (ABGs). Increasing PaCO2 and

decreasing PaO2 are signs of respiratory failure.

• Assess for pain. Postoperative pain can result in shallow

breathing and an ineffective cough.

• If patient is on mechanical ventilation, monitor for peak airway

pressures and airway resistance. Increases in these
parameters signal accumulation of secretions/ fluid and
possibility for ineffective ventilation.

• Assess patient’s knowledge of disease process. Patient

education will vary depending on the acute or chronic
disease state as well as the patient’s cognitive level.
Therapeutic Interventions

• Assist patient in performing coughing and breathing

maneuvers. These improve productivity of the cough.

• Instruct patient in the following:

 Optimal positioning (sitting position)
 Use of pillow or hand splints when coughing
  Use of abdominal muscles for more forceful cough
 Use of quad and huff techniques
 Use of incentive spirometry
 Importance of ambulation and frequent position changes
Directed coughing techniques help mobilize secretions from
smaller airways to larger airways because the coughing is
done at varying times. The sitting position and splinting the
abdomen promote more effective coughing by increasing
abdominal pressure and upward diaphragmatic movement.

• Use positioning (if tolerated, head of bed at 45 degrees; sitting

in chair, ambulation). These promote better lung expansion
and improved air exchange.

• If patient is bedridden, routinely check the patient’s position

so he or she does not slide down in bed. This may cause the
abdomen to compress the diaphragm, which would cause
respiratory embarrassment.

• If cough is ineffective, use nasotracheal suctioning as needed:

 Explain procedure to patient.
 Use soft rubber catheters. This prevents trauma to
mucous membranes.
 Use curved-tip catheters and head positioning (if not
contraindicated). These facilitate secretion removal
from a specific side (right versus left lung).
 Instruct the patient to take several deep breaths before
and after each nasotracheal suctioning procedure and use
supplemental oxygen as appropriate. This prevents
suction-related hypoxia.
 Stop suctioning and provide supplemental oxygen (assisted
breaths by Ambu bag as needed) if the patient experiences
bradycardia, an increase in ventricular ectopy, and/or
desaturation.
 Use universal precautions: gloves, goggles, and mask as
appropriate. If sputum is purulent, precautions should
be instituted before receiving the culture and
sensitivity report.
Suctioning is indicated when patients are unable to remove
secretions from the airways by coughing because of
weakness, thick mucus plugs, or excessive mucus
production.

• Institute appropriate isolation precautions for positive cultures

(e.g., methicillin-resistant Staphylococcus aureus [MRSA] or
tuberculosis).
 • Use humidity (humidified oxygen or humidifier at bedside).
This loosens secretions.

• Encourage oral intake of fluids within the limits of cardiac

reserve. Increased fluid intake reduces the viscosity of
mucus produced by the goblet cells in the airways. It is
easier for the patient to mobilize thinner secretions with
coughing.

• Administer medications (e.g., antibiotics, mucolytic agents,

bronchodilators, expectorants) as ordered, noting effectiveness
and side effects.

• For patients with chronic problems with bronchoconstriction,

instruct in use of metered-dose inhaler (MDI) or nebulizer as
prescribed.

• Consult respiratory therapist for chest physiotherapy and

nebulizer treatments as indicated (hospital and home
care/rehabilitation environments). Chest physiotherapy
includes the techniques of postural drainage and chest
percussion to mobilize secretions in smaller airways that
cannot be removed by coughing or suctioning.

Coordinate optimal time for postural drainage and percussion (i.e.,

at least 1 hour after eating). This prevents aspiration.

• For patients with reduced energy, pace activities. Maintain

planned rest periods. Promote energy-conservation techniques.
Fatigue is a contributing factor to ineffective coughing.

• For acute problem, assist with bronchoscopy. This obtains

lavage samples for culture and sensitivity, and removes
mucus plugs.

• If secretions cannot be cleared, anticipate the need for an

artificial airway (intubation). After intubation:
 Institute suctioning of airway as determined by presence of
adventitious sounds.
 Use sterile saline instillations during suctioning. This helps
facilitate removal of tenacious sputum.

• For patients with complete airway obstruction, institute

cardiopulmonary resuscitation (CPR) maneuvers.
Education/Continuity of Care
• Demonstrate and teach coughing, deep breathing, and
splinting techniques. Patient will understand the rationale and
appropriate techniques to keep the airway clear of
secretions.

• Instruct patient on indications for, frequency, and side effects

of medications.

• Instruct patient how to use prescribed inhalers, as

appropriate.

• In home setting, instruct caregivers regarding cough

enhancement techniques and need for humidification.

• Instruct caregivers in suctioning techniques. Provide

opportunity for return demonstration. Adapt technique for home
setting.

• For patients with debilitating disease being cared for at home

(CVA, neuromuscular impairment, and others), instruct caregiver
in chest physiotherapy as appropriate. This may also be useful
for the patient with bronchiectasis who is ambulatory but
requires chest physiotherapy because of the volume of
secretions and the inability to adequately clear them.

• Teach patient about environmental factors that can precipitate

respiratory problems.

• Explain effects of smoking, including second-hand smoke.

Smoking contributes to bronchospasm and increased mucus
production in the airways.

• Refer patient and/or significant others to smoking-cessation

group, as appropriate, and discuss potential use of smoking-
cessation aids (e.g., Nicorette Gum, Nicoderm, or Habitrol) to
wean off the effects of nicotine.

• Instruct patient on warning signs of pending or recurring

pulmonary problems.

• Refer to pulmonary clinical nurse specialist, home health

nurse, or respiratory therapist as indicated.