Risk for Infection | Nursing Care Plan for Peritonitis

Nursing diagnosis: risk for Infection

Risk factors may include
Inadequate primary defenses—broken skin, traumatized tissue, altered peristalsis
Inadequate secondary defenses—immunosuppression
Invasive procedures

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

Desired Outcomes/Evaluation Criteria—Client Will
Infection Status
Achieve timely healing, be free of purulent drainage or erythema, and be afebrile.
Risk Control
Verbalize understanding of the individual causative or risk factor(s).

Nursing intervention with rationale:
1. Note individual risk factors: abdominal trauma, acute appendicitis, and peritoneal dialysis.
Rationale: Influences choice of interventions.

2. Assess vital signs frequently, noting unresolved or progressing hypotension, decreased pulse pressure, tachycardia, fever, and tachypnea.
Rationale: Signs of impending septic shock. Circulating endotoxins eventually produce vasodilation, shift of fluid from circulation, and a low cardiac output state. Note: These clients frequently are critically ill and medical or postsurgical intensive care is required.

3. Note changes in mental status, such as new onset confusion and stupor.
Rationale: Hypoxemia, hypotension, and acidosis can cause deteriorating mental status.

4. Note skin color, temperature, and moisture.
Rationale: Warm, flushed, dry skin is early sign of septicemia. Later manifestations include cool, clammy, pale skin and cyanosis as shock becomes refractory.

5. Monitor urine output.
Rationale: Oliguria develops as a result of decreased renal perfusion, circulating toxins, and effects of antibiotics.

6. Maintain strict aseptic technique in caring for abdominal drains, incisions or open wounds, dressings, and invasive sites. Cleanse with appropriate solution.
Rationale: Prevents access or limits spread of infecting organisms and cross-contamination.

7. Perform and model good hand-washing technique. Monitor staff and client compliance with hand washing.
Rationale: Reduces risk of cross-contamination and spread of infection.

8. Observe drainage from wounds or drains.
Rationale: Provides information about status of infection.

9. Maintain sterile technique when catheterizing client, provide catheter care, and encourage perineal cleansing on a routine basis.
Rationale: Prevents access and limits bacterial growth in urinary tract.

10. Monitor or restrict visitors and staff, as appropriate. Provide protective isolation if indicated.
Rationale: Reduces risk of exposure to, or acquisition of, secondary infection in immunosuppressed client.