Risk for Infection | Nursing Care Plan for Pancreatitis

Nursing diagnosis: risk for Infection

Risk factors may include
Inadequate primary defenses: stasis of body fluids, altered peristalsis, change in pH of secretions
Immunosuppression
Nutritional deficiencies
Tissue destruction, chronic disease

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

Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Achieve timely healing; be free of signs of infection.
Be afebrile.
Risk Control
Participate in activities to reduce risk of infection.

Nursing intervention with rationale:
1. Use strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheters, tubes, or drains. Change soiled dressings promptly.
Rationale: Limits sources of infection, which can lead to sepsis in a compromised client.

2. Model and emphasize importance of good hand washing.
Rationale: Reduces risk of cross-contamination.

3. Observe rate and characteristics of respirations and breath sounds. Note occurrence of cough and sputum production.
Rationale: Pulmonary complications of pancreatitis include atelectasis, pleural effusion, pneumonia, and ARDS. Fluid accumulation and limited mobility predisposes client to respiratory infections and atelectasis. Accumulation of ascites fluid may cause elevated diaphragm and shallow abdominal breathing.

4. Encourage frequent position changes, deep breathing, and coughing. Assist with ambulation as soon as stable.
Rationale: Enhances ventilation of all lung segments and promotes mobilization of secretions.

5. Observe for signs of infection, such as the following: Fever and respiratory distress in conjunction with jaundice
Rationale: Cholestatic jaundice and decreased pulmonary function may be first sign of sepsis or ARDS.

6. Increased abdominal pain, rigidity and rebound tenderness, diminished or absent bowel sounds
Rationale: Suggestive of peritonitis.

7. Increased abdominal pain and tenderness, recurrent fever (higher than 101°F [38.3°C]), leukocytosis, hypotension, tachycardia, and chills
Rationale: Abscesses can occur 2 weeks or more after the onset of pancreatitis and should be suspected whenever client is deteriorating despite supportive measures.

8. Obtain culture specimens, such as blood, wound, urine, sputum, or pancreatic aspirate.
Rationale: Identifies presence of infection and causative organism.

9. Administer anti-infective therapies as indicated, such as imipenem/cilastatin (Primaxin), metronidazole (Flagyl), and levofloxacin (Levaquin); cephalosporins, such as cefoxitin sodium (Mefoxin); and aminoglycosides, such as gentamicin (Garamycin) and tobramycin (Nebcin).
Rationale: Broad-spectrum anti-infectives are generally recommended for pancreatitis sepsis; however, therapy will be based on the specific organisms cultured.

10. Prepare for surgical intervention, as necessary.
Rationale: Abscesses may be surgically drained with resection of necrotic tissue. Sump tubes may be inserted for antibiotic irrigation and drainage of pancreatic debris. Pseudocysts (persisting for several weeks) may be drained because of the risk and incidence of infection and rupture.