Risk for Infection | Nursing Care Plan Total Nutritional Support

Nursing diagnosis: risk for infection

Risk factors may include
Invasive procedures—insertion of venous catheter, surgically placed gastrostomy or jejunostomy feeding tube
Malnutrition, chronic disease
Environmental exposure—access devices in place for extended periods; improper preparation and handling or contamination of the feeding solution

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

Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Experience no fever or chills.
Demonstrate clean catheter insertion sites, free of drainage and erythema or edema.

Nursing intervention with rationale:
1. Stress and model proper hand-washing technique.
Rationale: Reduces risk of cross-contamination.

2. Maintain sterile technique for invasive procedures. Provide routine site care, as appropriate.
Rationale: Prevents entry of bacteria, reducing risk of nosocomial infections.

3. Encourage frequent position changes and being out of bed or ambulation, as tolerated.
Rationale: Limits stasis of body fluids, promotes optimal functioning of organ systems and GI tract.

4. Screen visitors and care providers for infectious processes, especially upper respiratory infection (URI).
Rationale: Reduces risk of transmission of viruses that are difficult to treat.

5. Monitor and assist with respiratory exercises and use of adjuncts, such as incentive spirometer. Auscultate lungs for adventitious sounds.
Rationale: Promotes deep breathing to clear airways and reduce risk of pneumonia. Presence of wheezes suggests retained secretions and potential complications requiring intervention.

6. Assess vital signs, including temperature, per protocol.
Rationale: A rise in pulse and temperature may provide warning of infectious process unless client’s immune system is too compromised to respond.

7. Maintain an optimal aseptic environment during bedside insertion of central venous catheters and during changes of TPN bottles and administration tubing.
Rationale: Catheter-related sepsis may result from entry of pathogenic microorganisms through skin insertion tract or from touch contamination during manipulations of TPN system.

8. Secure external portion of catheter and administration tubing to dressing with tape. Note intactness of skin suture.
Rationale: Manipulation of catheter in and out of insertion site can result in tissue trauma or coring and potentiate entry of skin organisms into catheter tract.

9. Maintain a sterile occlusive dressing over catheter insertion site. Perform central or peripheral venous catheter dressing care per protocol.
Rationale: Protects catheter insertion sites from potential sources of contamination. Note: Central venous catheter sites can easily become contaminated from tracheotomy or endotracheal secretions, or from wounds of the head, neck, and chest.

10. Inspect insertion site of catheter for erythema, induration, drainage, and tenderness.
Rationale: The catheter is a potential irritant to the surrounding skin and subcutaneous skin tract, and extended use may result in insertion site irritation and infection.