Nursing Diagnosis for Pneumonia | Risk for Infection

Nursing diagnosis: risk for infection

Risk factors may include

Inadequate primary defenses—decreased ciliary action, stasis of respiratory secretions

Inadequate secondary defenses—presence of existing infection, immunosuppression; chronic disease, malnutrition

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Infection Status

Achieve timely resolution of current infection without complications.

Knowledge: Infection Control

Identify interventions to prevent and reduce risk and spread of a secondary infection.

Nursing intervention with rationale:

1. Monitor vital signs closely, especially during initiation of therapy.

Rationale: During this period, potentially fatal complications, such as hypotension or shock, may develop.

2. Instruct client concerning the disposition of secretions (e.g., raising and expectorating versus swallowing) and reporting changes in color, amount, and odor of secretions.

Rationale: Although client may find expectoration offensive and attempt to limit or avoid it, it is essential that sputum be disposed of in a safe manner. Changes in characteristics of sputum

reflect resolution of pneumonia or development of secondary infection.

3. Demonstrate and encourage good hand-washing technique.

Rationale: Effective means of reducing spread or acquisition of infection.

4. Change position frequently and provide good pulmonary toilet.

Rationale: Promotes expectoration, clearing of infection.

5. Perform proper suctioning technique for ventilated clients as appropriate.

Rationale: Secretions that accumulate below and above the endotracheal (ET) tube cuff are an ideal growth medium for pathogens. The ET tube also prevents normal closure of the epiglottis,

resulting in an incomplete seal of the laryngeal structures that normally protect the lungs. This can contribute to aspiration and VAP (Pruitt & Jacobs, 2006).

6. Limit visitors as indicated.

Rationale: Reduces likelihood of exposure to other infectious pathogens.

7. Institute isolation precautions as individually appropriate.

Rationale: Depending on type of infection, response to antibiotics, client’s general health, and development of complications, isolation techniques may be instituted to prevent spread

and protect client from other infectious processes.

8. Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake.

Rationale: Facilitates healing process and enhances natural resistance.

9. Monitor effectiveness of antimicrobial therapy.

Rationale: Signs of improvement in condition should occur within 24 to 48 hours.

10. Investigate sudden changes or deterioration in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, and changes in sputum characteristics.

Rationale: Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection. Complications affecting any organ system include lung

abscess, empyema, bacteremia, pericarditis, endocarditis, meningitis, encephalitis, and superinfections.