Risk for Infection | Nursing Care Plan for Ventilatory Assistance

Nursing diagnosis: risk for Infection

Risk factors may include

Inadequate primary defenses—traumatized lung tissue, decreased ciliary action, stasis of body fluids

Inadequate secondary defenses—immunosuppression

Chronic disease, malnutrition

Invasive procedure—intubation

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Infection Control

Indicate understanding of individual risk factors.

Identify interventions to prevent or reduce risk of infection.

Demonstrate techniques to promote safe environment.

Nursing care plan intervention with rationale:

1. Note risk factors for occurrence of infection.

Rationale: Intubation interferes with the normal defense mechanisms that keep microorganisms out of the lungs. ET tubes, especially cuffed ones, interfere with the mucociliary transport system that helps clear airway secretions. Secretions that accumulate below and above the ET tube cuff are 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, which often leads to ventilator-associated pneumonia (VAP) (Pruitt & Jacobs, 2006). VAP is the primary cause of hospital-acquired pneumonia (HAP) reportedly occurring in 10% to 25% of individuals receiving mechanical ventilation (Byrd et al, 2006). Other factors include prolonged mechanical ventilation, trauma, general debilitation, malnutrition, age, and invasive procedures. Awareness of individual risk factors provides opportunity to limit effects and helps prevent VAP.

2. Observe color, odor, and characteristics of sputum. Note drainage around tracheostomy tube.

Rationale: Yellow or green, purulent odorous sputum is indicative of infection; thick, tenacious sputum suggests dehydration.

3. Engage in proper hand washing or alcohol-based hand rubs, wear gloves when handling respiratory secretions and equipment contaminated with respiratory secretions, maintain sterile suction techniques in open system, use closedsystem ET tube allowing for continuous removal of secretions, reduce the number of times the ventilator tubes are open, and provide clean nebulizer and tubing changes.

Rationale: These factors may be the simplest but are the most important keys to prevention of hospital-acquired infection. Note: The Centers for Disease Control and Prevention’s (CDC) (2005) guidelines recommend changing tubing no more often than every 48 hours. Research indicates that less frequent tubing changes (every 5 to 7 days) may be acceptable.

4. Encourage deep breathing, coughing, and frequent position changes.

Rationale: Maximizes lung expansion and mobilization of secretions to prevent or reduce atelectasis and accumulation of sticky, thick secretions.

5. Auscultate breath sounds.

Rationale: Presence of rhonchi and wheezes suggests retained secretions requiring expectoration or suctioning.

6. Provide or instruct client and SO in proper oral care and secretion disposal, such as disposing of tissues and soiled tracheostomy dressings.

Rationale: Reduces risk of pneumonia associated with aspiration of oral bacteria, as well as transmission of fluidborne organisms. Note: Chlorhexidine mouth rinse has been found to reduce

plaque and gingival inflammation as a means of preventing VAP.

7. Monitor and screen visitors. Avoid contact with persons with respiratory infections.

Rationale: Individual is already compromised and is at increased risk with exposure to infections.

8. Provide respiratory isolation when indicated.

Rationale: Depending on specific diagnosis, client may require protection from others or must prevent transmission of infection, for example, tuberculosis (TB) to others.

9. Maintain adequate hydration and nutrition. Encourage fluids to 2,500 mL/day within cardiac tolerance.

Rationale: Helps improve general resistance to disease and reduces risk of infection from static secretions.

10. Measure pH of gastric secretions, and monitor use of antacid medications, as indicated.

Rationale: Maintaining acid level of stomach about pH of 7.2 may help reduce risk of nosocomial infection and stress ulcers and contamination of respiratory tract by means of reflux and

aspiration.