Risk for Infection | Nursing Care Plan for Leukemia

Nursing diagnosis: risk for Infection

Risk factors may include
Inadequate secondary defenses—alterations in mature WBCs with low granulocyte and abnormal lymphocyte count, increased number of immature lymphocytes; immunosuppression, bone marrow suppression (effects of therapy, transplant)
Inadequate primary defenses—stasis of body fluids, traumatized tissue
Invasive procedures
Malnutrition; chronic disease

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

Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Infection Control
Identify actions to prevent or reduce risk of infection.
Demonstrate techniques or lifestyle changes to promote safe environment and achieve timely healing.

Nursing intervention with rationale:
1. Place in private room. Screen and limit visitors, as indicated. Prohibit use of live plants or cut flowers. Restrict fresh fruits and vegetables or make sure they are washed or peeled.
Rationale: Protect client from potential sources of pathogens and infection. Note: Profound bone marrow suppression, neutropenia, and chemotherapy place client at great risk for infection.

2. Model and require good hand-washing protocol for all personnel and visitors.
Rationale: Prevents cross-contamination and reduces risk of infection.

3. Monitor temperature. Note correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, and subtle mental changes.
Rationale: Although fever may accompany some forms of chemotherapy, progressive hyperthermia occurs in some types of infections, and fever unrelated to drugs or blood products occurs in most leukemia clients. Note: Septicemia may occur without fever.

4. Prevent chilling. Force fluids and administer tepid sponge bath.
Rationale: Helps reduce fever, which contributes to fluid imbalance, discomfort, and central nervous system (CNS) complications.

5. Encourage frequent turning and deep breathing.
Rationale: Prevents stasis of respiratory secretions, reducing risk of atelectasis and pneumonia.

6. Auscultate breath sounds, noting crackles and rhonchi; inspect secretions for changes in characteristics, such as increased sputum production or change in sputum color. Observe urine for signs of infection: cloudy, foul-smelling, or presence of urgency or burning with voids.
Rationale: Early intervention is essential to prevent sepsis or septicemia in immunosuppressed person.

7. Handle client gently. Keep linens dry and wrinkle free.
Rationale: Prevents sheet burns and skin excoriation.

8. Inspect skin for tender, erythematous areas and open wounds. Cleanse skin with antibacterial solutions.
Rationale: May indicate local infection. Note: Open wounds may not produce pus because of insufficient number of granulocytes.

9. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care.
Rationale: The oral cavity is an excellent medium for growth of organisms and is susceptible to ulceration and bleeding.

10. Promote good perianal hygiene. Examine perianal area at least daily during acute illness. Provide sitz baths, using Betadine or Hibiclens, if indicated. Avoid rectal temperatures and use of suppositories.
Rationale: Promotes cleanliness, reducing risk of perianal abscess; enhances circulation and healing. Note: Perianal abscess can contribute to septicemia and death in immunosuppressed clients.