Risk for Infection | Nursing Care Plan for Craniocerebral Trauma

Nursing diagnosis: risk for Infection

Risk factors may include

Traumatized tissues, broken skin, invasive procedures

Decreased ciliary action, stasis of body fluids

Nutritional deficits

Suppressed inflammatory response—steroid use

Altered integrity of closed system—CSF leak

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Immune Status

Maintain normothermia, free of signs of infection.

Achieve timely wound healing when present.

Nursing intervention with rationale:

1. Provide meticulous, clean, or aseptic care; maintain good hand-washing techniques.

Rationale: First-line defense against nosocomial infections.

2. Observe areas of impaired skin integrity (wounds, suture lines, invasive line insertion sites), noting drainage characteristics and presence of inflammation.

Rationale: Early identification of developing infection permits prompt intervention and prevention of further complications.

3. Monitor temperature routinely. Note presence of chills, diaphoresis, and changes in mentation.

Rationale: May indicate developing sepsis requiring further evaluation and intervention.

4. Encourage deep breathing and aggressive pulmonary toilet. Observe sputum characteristics.

Rationale: Enhances mobilization and clearing of pulmonary secretions to reduce risk of pneumonia and atelectasis. Note: Postural drainage should be used with caution if risk of increased ICP exists.

5. Provide perineal care. Maintain integrity of closed urinary drainage system if used. Encourage adequate fluid intake.

Rationale: Reduces potential for bacterial growth and ascending infection.

6. Observe color and clarity of urine. Note presence of foul odor.

Rationale: Indicators of developing urinary tract infection (UTI) requiring prompt intervention.

7. Screen and restrict access of visitors or caregivers with upper respiratory infections (URIs).

Rationale: Reduces exposure of “compromised host.”

8. Obtain specimens, as indicated.

Rationale: Culture with sensitivities may be done to verify presence of infection and identify causative organism and appropriate treatment choices.