Risk for Infection | Nursing Care Plan for Anemia

Nursing diagnosis: risk for Infection

Risk factors may include
Inadequate secondary defenses—decreased Hgb, leukopenia, or decreased granulocytes (suppressed inflammatory response)
Inadequate primary defenses—broken skin, stasis of body fluids, invasive procedures, chronic disease, malnutrition

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

Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Identify behaviors to prevent and reduce risk of infection.
Immune Status
Be free of signs of infection; achieve timely wound healing if present.

Nursing intervention with rationale:
1. Perform and promote meticulous hand washing by caregivers and client.
Rationale: Prevents cross-contamination or bacterial colonization. Note: Client with severe or aplastic anemia may be at risk from normal skin flora.

2. Maintain strict aseptic techniques with procedures and wound care.
Rationale: Reduces risk of bacterial colonization and infection.

3. Provide meticulous skin, oral, and perianal care.
Rationale: Reduces risk of skin or tissue breakdown and infection.

4. Encourage frequent position changes and ambulation, coughing, and deep-breathing exercises.
Rationale: Promotes ventilation of all lung segments and aids in mobilizing secretions to prevent pneumonia.

5. Promote adequate fluid intake.
Rationale: Assists in liquefying respiratory secretions to facilitate expectoration and prevent stasis of body fluids in lungs and bladder.

6. Emphasize need to monitor and limit visitors, as indicated. Provide protective isolation, if appropriate. Restrict live plants and cut flowers.
Rationale: Limits exposure to infectious agents. Protective isolation may be required in aplastic anemia, when immune response is most compromised.

7. Monitor temperature. Note presence of chills and tachycardia with or without fever.
Rationale: Reflective of inflammatory process or infection, requiring evaluation and treatment. Note: With bone marrow suppression, leukocytic failure may lead to fulminating infections.

8. Observe for wound erythema and drainage.
Rationale: Indicators of local infection. Note: Pus formation may be absent if granulocytes are depressed.

9. Obtain specimens for culture and sensitivity, as indicated.
Rationale: Verifies presence of infection, identifies specific pathogen, and influences choice of treatment.

10. Administer topical antiseptics and systemic antibiotics.
Rationale: May be used prophylactically to reduce colonization or used to treat specific infectious process.