Nursing Diagnosis Risk for Infection - Urinary Tract Infections

Nursing Diagnosis for Infection Risk-A Student’s Guide

Introduction

Infection is a type of disease that can be caused by either bacteria or viruses. Common types of infections are skin infections, respiratory tract infections, and urinary tract infections. The diagnosis for infection risk is about assessing the potential for an individual to have an infection based on their exposure to infectious agents such as viruses or bacteria. It also includes determining if the person is at risk from their environment, exposure to smoke, drugs, and other hazardous materials.

Healthcare providers have one goal: to provide the best quality care for their patients while minimizing any potential risks to themselves and others. To do so, hospitals and other providers need to follow strict safety protocol guidelines, including patient isolation, hand hygiene, personal protective equipment (PPE), and waste disposal procedures, among others. The more stringent these rules are, the less likely any infections will spread.

Healthcare providers also need to be aware of what is happening with their patients and recognize signs of infection early on. This could help minimize further risks, prevent worsening patients’ conditions, and possibly even save lives. Having good communication skills is vital in finding out what kind of risk your patients are at.

This post will cover how nurses can identify patients at high risk for developing infections and what they should do if they have one.

As you read, keep in mind that our top writers are ready to help in case you get stuck or cannot complete your nursing assignment due to other reasons such as a busy schedule. All you need to is place an order with us!

Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

What is an Infection?

Infection is a type of disease that either bacteria or viruses can cause. Common types of infections are skin, respiratory tract, and urinary tract infections. The signs and symptoms include fever, chills, fatigue, loss of appetite, enlarged lymph nodes, and joint pain.

When people are infected with viruses or bacteria, they are being exposed to an infectious agent. The goal of infection control is to monitor patients’ conditions and environment and reduce any potential risk for them to become infected. Patients whose immune systems are low such as those with chronic diseases (e.g., cancer, diabetes, HIV-Aids), are at a higher risk of infection.

What is Infection Risk?

Infection risk is the chance that an individual may become infected by contact. It is also known as the probability of transmission or likelihood of acquiring an infection from exposure to another person’s bodily fluids (blood, saliva, mucus) containing infectious organisms (bacteria or viruses). When assessing this probability, age and immune system health are considered alongside other environmental factors such as the type of organism present.

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What Are Nosocomial Infections?

Infections are acquired while a patient is in the hospital. Infection can travel throughout the body by being spread from one part of your body to another, or it may enter your bloodstream and travel throughout your entire body.

The nursing care plan for nosocomial infections addresses how to prevent these infections from happening and what interventions are required if the diseases do develop.

A patient can get infected in a hospital for many different reasons. The most common way is from an invasive device such as a catheter, IV, or surgical wound to transmit bacteria into the area where it wasn’t present before. Nosocomial infections are often resistant to antibiotics, so nurses must monitor patients and report concerns about illness or inflammation.

The most important thing you can do to avoid getting bacteria in a hospital is to wash your hands frequently. Make sure all wounds are cleaned regularly with soap and water or antiseptic wipes.  If someone has an open sore on their skin (for example, a large ulcer or a weeping wound), they must be careful to prevent the bacteria from coming in contact with other parts of their body.

If you are working near other patients, wash your hands before and after touching another patient. When changing dressings on wounds or handling catheters, wash hands afterward. Take care not to touch the dressing or the catheter as you move your patient.  If blood gets on the outside of gloves, remove them and wash hands. This reduces the risk of transmitting pathogenic organisms from one person to another.

No matter how much care you take to avoid infection, it can still happen. Some signs that infection is starting include fever, chills, cough or shortness of breath for a long time, skin redness or rash, pus from a wound, or a surgical incision that doesn’t heal within days or weeks. In addition, if you have an injury that gets worse rather than better, or if you are treated for an infection, and you feel worse over the next few days, report this to your doctor or nurse right away.

If you develop an infection in a hospital, tell your nurse or doctor right away. Keeping track of infections is essential so that hospitals can figure out how to better prevent them from happening. Hospitals also need to know how many people get infections to monitor trends and research the best ways to handle nosocomial infections.

Risk Factors of Infection Risk

Patients at high risk for infections include:

  • People with unstable health status (e.g., recent surgery, severe burns, or trauma)
  • Patients who have an overall poor health status, i.e., heart disease or cancer
  • Those on immunosuppressive medications/steroids 
  • Patients who are otherwise debilitated from conditions such as dementia, dementia-related behaviors, or traumatic brain injury
  • Patients with infection or other diseases in a place where the skin or mucous membrane is damaged
  • Patients at low risk for infections include:
  • Those who are younger and have a healthy immune system (young children) 
  • Those whose immune systems have been stimulated, i.e., those who have received immunizations or are on corticosteroids
  • Those who have had a recent surgery that required a prolonged hospital stay and were exposed to many other patients
  • People whose immune systems are not suppressed because they are taking antibiotics as directed or HIV medications as prescribed
  • Those who have limited exposure to visitors, including those with household pets (limited exposure to people who also have a weakened immune system)

Once an infection develops, it is essential to do what you can to get better. The best way to avoid infections getting worse in the hospital is to keep your immune system strong through exercise and healthy eating.

Ask your doctor or nurse if there are any restrictions on activities that can help you get stronger and recover as soon as possible. Some actions may include:

  • Exercising a little every day 
  • Taking part in physical therapy or other recovery programs directed by your doctor 
  • Follow all instructions about taking medications correctly. This includes warning about medication side effects (especially if the agent is an antibiotic)
  • Trying to get your loved one out of bed and moving several times a day. (This does not apply if your doctor or nurse has recommended that they remain in bed.) 
  • Stay hydrated by drinking large amounts of water.  A general rule is to drink at least 4 ounces every hour when you are awake. This reduces the risk of dehydration to a patient.

Taking all these steps helps reduce the risk of getting an infection. It also reduces the length of time you may be sick if one develops. Moreover, staying healthy supports your efforts to recover from your injury or illness.

What Are the Causes of Risk for Infection?

Generally, infections occur when a person’s immune system is either damaged or suppressed by the infection itself (secondary infection), other disease processes, or chronic drug therapy. Infections can be caused by exposure to an infectious agent from another person who has an infection or from the person’s environment.

  • Infectious agents are the leading cause of infection risk. Infectious agents are microorganisms, such as bacteria or viruses, which invade the body.

Infectious agents are easily spread if they contact the body of a susceptible individual and enter the body through breaks or damaged tissue in the skin, mouth, nose, and genitals. This can happen when an infectious agent is inhaled (through sneezing or coughing), ingested (most commonly through food or water that is contaminated), or through direct contact with an ill person.

We are constantly exposed to infectious agents, and generally, the immune system can keep their numbers at manageable and safe levels without any consequence.  However, when a person’s immune system is damaged or suppressed, infections can occur.

  • Another common cause of infection risk in healthcare settings is due to improperly washed hands.

Diseases are spread through two primary routes: direct and indirect contact transmission.

Direct contact transmission means that an individual touches a contaminated surface and then touches their mouth or nose, leading to infection.

Indirect contact transmission occurs when infectious agents in the environment are transmitted from one person to another through contaminated objects such as bed linens, clothing, soiled equipment, food, or beverages. Many sources of indirect contact transmission include:

  • Environmental surfaces and reservoirs (i.e., soil/water and food) are infectious agents’ sources. Some infectious agents can live in the environment for extended periods (ex: norovirus, HepA) 
  • Droplets are expelled into the air while talking, sneezing, or coughing (i.e., influenza virus). Although most respiratory droplets from a person with the flu do not land on another individual, when an ill person sneezes or coughs near someone who is not infectious, the droplets may spread 3 feet to 6 feet.
  • Human carriers of infections can spread the infection to others if they touch a susceptible host.

What Helps Fight Infection in the Body?

Your body has several natural defenses to help fight infectious agents and protect yourself from infection. These include:

  • Skin, which acts as a barrier against invasion by toxic substances and microorganisms; however, when the skin is damaged, it can be easy for germs to enter the body
  • Mucous membranes that line areas of the body exposed to the environment, such as the mouth and nose. These membranes are designed to trap germs that enter this route and flush them out of the body every time you blow your nose or swallow.
  • Germ-eating enzymes (ex: lysozyme in milk), which can eat bacteria found in food 
  • Hair helps sweep particles away from the body and prevents them from settling on other parts of the body.
  • Breathing is an essential factor in preventing respiratory infections by circulating fresh air to filter out germs and pollutants that may enter the body through the nose or mouth.

What is the Immune System?

The immune system includes blood cells such as white blood cells and antibodies that fight infection. Antibodies are specialized proteins produced by white blood cells to help destroy or inactivate foreign substances (i.e., bacteria, viruses) in the body.

The immune system is comprised of several different types of tissues that work together to protect your body from disease-causing germs. The first line of defense, which forms the outer layer of protection against infection, is your skin and mucous membranes. 

When exposed to a foreign invader, they alert the next layer of defense—white blood cells or leukocytes. These cells help fight off any potentially harmful agents that enter your body through breaks in the skin or during mucous membrane exposure.

They do this by directly killing invading bacteria or viruses or producing antibodies, marking the invasion for destruction, and recruiting other parts of the immune system to help destroy it.

Natural killer cells recognize germ-infected cells that have escaped detection by the body’s immune defenses and destroy them. An example of a lymphocyte, a white blood cell type, is the T-cell.  These cells have receptors on their surface that help them sense when germs are present in your body, and they can respond quickly to fight off infections.

The complement system consists of proteins called “complement,” which coat the surfaces of bacteria, destroying them and creating an inhospitable environment for the bacteria to grow.

Antibody-producing cells (B cells) are a type of white blood cell that produce antibodies to identify and neutralize germs or substances that may be harmful to the body, such as viruses, bacteria, or toxins. Antigens are the parts of bacteria or viruses that cause your immune system to react. 

Each kind of antibody produced is specific—or, in other words, customized—to only one antigen. Antibodies are the major players involved in allergic reactions like hives because they often don’t recognize a particular substance as harmful and trigger an immune response.

  • Natural killer cells (NK cells) kill infected body cells and destroy cancer cells.
  • Macrophages eat bacteria and use them to create more antibodies, which then attack the germ
  • T lymphocytes (or “T cells”) produce biochemical, including interferons that attack viruses and other pathogens. This helps limit infection size and spread within the body. T cells are activated in the lymph nodes and spleen (two crucial components of your immune system), located in the center of the body.

T-cells can be divided into two groups:

  • Helper T-cells have receptors activated by human leukocyte antigens (HLA), a large family of proteins predominantly found on the surface of cells.  To activate, these T-cells must contact a specific HLA molecule on the surface of an infected cell to produce interferon that will help fight off infection.
  • Suppressor T-cells act like “brakes” or “toll booths.”  These receptors are activated when they contact cytokines, proteins that play a role in the immune response.  Suppressor T-cells can limit the immune response if it becomes too large and troublesome or harmful to your body (like during an allergic reaction).

How Can Risk for Infection Be Prevented in Healthcare Settings?

The spread of infectious diseases can be prevented by implementing barrier precautions, hand hygiene and isolation. Use of personal protective equipment (PPE) is also be needed to protect healthcare workers from exposure to infectious materials.

  • Hand Hygiene:

Wash hands properly between each patient or before leaving the patient’s bedside. This is essential in preventing the spread of infection and minimizing the risk of infection in the hospital. Hand hygiene is the single most important means of preventing the transmission of infectious agents from one patient to another and between healthcare workers and patients.

  • Barrier Precautions:

Barrier precautions are an additional, potentially necessary means of preventing the spread of infection. They include durable medical equipment (durable medical equipment is any item used on a patient that cannot be cleaned and disinfected), the use of gowns, gloves, masks, and eye protection by healthcare workers.

  • Isolation:

Infection control and isolation of patients at high risk for infection and have the potential to spread infections. Isolation is usually performed in a negative pressure room or cubicle with airlocks and mechanical ventilation systems to ensure no air exchange between the isolation room and other areas.

The following are signs and symptoms of infections that may indicate a need for isolation precautions:

  • Fever (temperature greater than 1000F),
  • Abdominal pain or tenderness
  • Difficulty breathing (dyspnea),
  • Shaking chills
  • Extensive bruising (fracture may be present)
  • Cough
  • Congestion or shortness of breath (pulmonary infiltrate) and diarrhea.

Other ways for prevention of infection include;

  • Prevention of water pollution from hospital waste
  • Safe ways to dispose of sharps (needles are disposed of with gloves still on)
  • Ensuring equipment used is non-contaminated or released after decontamination
  • Disinfecting rooms and materials in contact with patients after a while where they are not occupied
  • Healthcare workers monitor their health status and teach themselves about the signs, symptoms, and treatment options for potential infectious diseases.
  • Educating and working with patients to follow good hygiene practices when near or around other people. – Isolation of patients in specialized areas using private rooms
  • Patient’s “barriered” or protected by a barrier agent that doesn’t compromise their skin integrity. In addition, the use of gloves and other protective clothing is mandatory for all patients who have a known infectious risk. As an extra precaution, disposable items such as gowns, masks, IV tubing, and other equipment should be used to prevent cross-contamination.
  • Heat

Heat kills germs. This is why the temperature must remain constant, even when it is cold outside. Adequate heat inpatient rooms and isolation rooms can also reduce the risk of infection. An additional preventive measure is running fresh water through plumbing that gets hot or boiling water. This is done to decrease the number of bacteria that can grow on surfaces in the home, school, or workplace and travel to your system when you breathe.

  • Identifying nearby health hazards

Hazards in the healthcare setup are anything that can compromise barriers or harm skin. For example, safety pins poking through a gown, exposed areas of skin under a mask, glove, or bandage. An IV needle sticking out of the arm during transport, exposed staples attached to a surgical dressing, etc. If possible, find out the hazard’s source and report it immediately to supervisors responsible for patient safety!

When Do PPEs Need to be Used?

PPE is recommended when you need close contact with patients, students, or patients with infections (or students and patients suspected of having an infectious disease). PPE may also be required to protect yourself from exposure to blood and/or other body fluids and certain chemicals.

Consider the following questions:

If I am a school nurse and know that a student has the flu, should I use PPE?

If I suspect a student has chickenpox, can I talk with the parent and send the child back to class?

No. Children who have active chickenpox should be kept home from school until all blisters have fully formed crusts (about five days) and no longer have a fever. If you contact an ill person who may have chickenpox, it is imperative to use PPEs. No matter how mild the illness seems, because you cannot see the blisters on your skin, do not take any chances.

What Are the Three Categories of PPEs?

A, B & C.

Category A: Gloves, gowns, and masks should always be worn in rooms where secretions from infected patients can quickly get onto surfaces such as bed rails or light switches — i.e., patients with highly infectious diseases such as tuberculosis, hepatitis, and HIV/AIDS.

Category B: Gloves only should be worn when dealing with blood or body fluids (such as stool) from patients who are not infected with those diseases — i.e., accidental cuts or nose bleeds of non-TB, non-HIV/AIDS patients.

Category C: Masks should only be worn when there is a very low risk of transmission, such as outpatient surgery.

What Are the Guidelines on Use of PPE?

  • Wear PPE correctly and consistently, including during patient transport.
  • Remove PPE before entering non-sterile areas.
  • Do not perform patient care tasks unless your hands and body are clean and free from breaks in the skin (such as sores, cuts, or other wounds).
  • Properly dispose of PPE after use by placing it on a designated cart or in an appropriate container for dirty linen.
  • Wash hands with soap and running water immediately after removing gloves, gowns, or masks.
  • If you are going to remove your PPE in a patient’s room or care area, ensure that the patient is not contagious. Before leaving the room, perform hand hygiene as described previously.

What is Infection Risk Assessment?

Infection risk assessment is a systematic process used in health care settings to identify people who might be experiencing an infection (e.g., fever, cough) to receive appropriate treatment. This process should occur without delay once the presence of a potential pathogen has been identified through the laboratory.

How Infection Risk can be Assessed in Healthcare Settings

The primary way to know if you are at risk for infection is to get a baseline set of laboratory tests that includes: complete blood count (CBC), liver enzymes and electrolytes, kidney function tests, HIV screening, hepatitis screening, chest X-ray, and urine analysis. Additional tests, as appropriate, can be ordered by your physician.

Nursing Diagnosis Risk for Infection – Skin Infection

This diagnosis is used when a patient’s risk of acquiring an infection on the skin (due to wounds, during invasive procedures, etc.) is greater than the average person.

Signs and Symptoms

  • Open sores (infections) on the skin
  • Skin that appears damaged or more fragile than usual (e.g., weakened by surgery or chemotherapy)
  • Damage to the skin (e.g., due to radiation, burns)

Underlying Causes:

  • Being in a healthcare setting with many patients who are ill and have weakened immune systems.
  • Having cancer or other medical conditions that put you at risk of having compromised skin integrity.

Skin Infection Nursing Care Plan:

  • If you develop a wound on the skin, immediately report it to your provider.
  • When undergoing surgery or other invasive procedures, discuss with your medical team when to receive an antibiotic (if not already prescribed) and do not leave the hospital until you have received the antibiotic as ordered. Afterward, continue taking antibiotics as per your physician’s orders until the antibiotic course has been completed.
  • Report any surgical wound infections to your provider right away.

What Are the Nursing Interventions?

If your skin appears damaged, avoid exposure to sick patients and do not go to work until it heals.

Put on clean protective clothing and gown before entering the room of a contagious patient. Remove these items upon leaving the room.

Ensure that you are wearing PPE before performing invasive procedures.

Limit visitors: It is essential to reduce the number of visitors until the infection has been fully treated.

Take extra precautions with wounds in body areas, such as the groin and perineum. Ask a health care provider if you are unsure whether an area on your skin is at risk for infection.

Nursing Diagnosis Risk for Respiratory Tract Infections

This diagnosis is used when a patient’s risk of contracting respiratory tract infections (e.g., colds, the flu) is significantly greater than the average person.

Signs and Symptoms:

Underlying Causes:

Being in a healthcare setting with many patients who are ill and have weakened immune systems

Having cancer or other medical conditions that put you at risk of having weakened respiratory tissues.

Respiratory Tract Infections Nursing Care Plans

Practice good hygiene by washing your hands frequently and using hand sanitizer when soap and water are not available.

Use a facemask or surgical mask when exposed to anyone who is contagious (e.g., the patient has pneumonia, influenza, gastroenteritis).

Limit visitors: It is essential to reduce the number of visitors. Respiratory infection may be spread by people coughing and sneezing.

What Are Primary Nursing Interventions?

In a healthcare setting, avoid exposure to sick patients and do not work when you have symptoms of infection (e.g., sore throat, fever, or body aches). If possible, wear a surgical mask in the hospital while caring for a patient with respiratory tract infections.

Wash your hands thoroughly before touching the patient, even if you usually wear gloves. Gloves should be worn when providing care for an infectious patient.

Wear PPE that covers the mouth and nose while you are providing care to a contagious patient. Remove these items upon leaving the room.

Treatment

Consider giving the patient an antibiotic if they have a fever. They should not leave the hospital without an antibiotic.

Keep the patient hydrated with oral fluids and watch for signs of dehydration.

Nursing Diagnosis Risk for Infection – Urinary Tract Infections

This diagnosis is used when a patient’s risk of acquiring a urinary tract infection (e.g., a bladder or kidney infection, UTI) is significantly greater than the average person’s risk.

Urinary Tract Infections can be caused by: Bladder catheterization, poorly controlled diabetes mellitus, urinary stents, and some medications such as antibiotics and anti-seizure medications. They may also be caused by unhygienic practices and patients having insufficient knowledge of the disease.

Signs and Symptoms:

  • Burning sensation during urination
  • Difficulty urinating
  • Frequent urge to urinate
  • Painful or difficult urination, blood in urine
  • Rupture of amniotic membranes for pregnant women.

Underlying Causes:

 Having a urinary tract catheter (Catheter is a thin tube inserted into the bladder to drain urine)

Having an indwelling tube (e.g., urethral catheter) to collect urine from a narrowed kidney artery

Having a spinal cord injury that makes it difficult to empty the bladder

Using drugs that impair bladder function. These drugs may include antispasmodics, diuretics, tranquilizers, or anticholinergics. These are drugs that block dopamine. Dopamine is a neurotransmitter involved in passing messages from the brain to the bladder).

 In men: having prostate trouble such as benign enlargement of the prostate gland

 Having diabetes and not being well controlled. This causes glucose (sugar) to be present in the urine.

 Uncontrolled hypertension (high blood pressure).

Infection with an indwelling catheter may cause a UTI:

The presence of the bacterium in the urinary tract can cause infection if bacteria from the patient’s skin enter their bladder through a catheter tube.

If the catheter causes an obstruction or ureteral damage.

The presence of bacteria caused by using a contaminated instrument (e.g., a bladder catheter).

Urinary Tract Infections Nursing Care Plan

Use sterile technique: scrub hands, wear gloves and use sterile instruments when inserting catheters in patients:

Choose a urinary catheter that is the shortest possible length to minimize risks for infection.

Use broad-spectrum antibiotics to reduce the risk of infection from bacteria.

Change any indwelling urinary catheters as soon as possible after a urine sample has been obtained.

Healthy kidney function helps prevent urinary tract infections (e.g., diabetes, hypertension).

Stop using any drugs that damage the kidneys and bladder until the infection is cleared up. Drugs to avoid include anticholinergics, antihistamines, and tranquilizers.

Nursing Interventions

Caring for the patient’s catheter according to hospital protocol is required.

Change the catheter bag or place a new one on the IV tree every time you empty it, and hang it high so that no urine drips into the tubing.

Wash your hands before touching the patient, even if you usually wear gloves.

Gloves should be worn when providing care for an infectious patient.

Wear PPE that covers the mouth and nose while you are providing care to a contagious patient. Remove these items upon leaving the room.

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Nursing Diagnosis Risk for infection-Gastro intestinal Tract Infections

This diagnosis is used when a patient’s risk of gastroenteritis (inflammation of gastrointestinal tract) is significantly greater than the average person.

Signs and Symptoms:

  • Diarrhea, fever, nausea, vomiting-can be accompanied by abdominal pain or cramps

Underlying Causes:

Being in a healthcare setting with many patients who are ill and have weakened immune systems

Risk for Gastrointestinal Tract Infections Nursing Care Plan

This plan addresses common causes of vomiting in surgical patients: pain and excessive amounts of anesthesia that lead to nausea. Vomiting can also interfere with breathing if it is so forceful that it forces the stomach contents into the trachea.

Goals for care include minimizing nausea, vomiting, and aches to improve a patient’s ability to protect their airway.

What Are Primary Nursing Interventions for this Diagnosis?

Primary interventions include using pain management techniques. This includes giving the patient nonsteroidal anti-inflammatory drugs (NSAIDs). The nurse should provide intravenous morphine injections for pain relief and administer antiemetic (anti-nausea) medications as required.

NPO Order: Allowing patients to eat or drink nothing by mouth after surgery is a standard practice intended to decrease the risk of vomiting and aspiration. This order focuses on healing instead of digestion while the patient recovers from surgery, particularly abdominal wounds and intestinal surgery.

Promote a healthy diet and exercise to prevent weight gain, which can contribute to the risk of pulmonary aspiration in patients with increased intra-abdominal pressure, such as those with morbid obesity or pregnant women.

Treatment Modalities for Gastrointestinal Tract Infections

  • Antibiotics are given to treat the infection.
  • Parenteral feeding (feeding into a vein) for patients unable to eat or drink normally.
  • IV hydration and electrolyte replacement may be prescribed, especially if a patient has suffered vomiting, diarrhea, dehydration, fever, or abdominal pain for an extended period.
  • Surgery may be suggested if a patient’s condition does not improve or worsens despite treatment.

You may also check our article on Gastrointestinal bleeding

Nursing Diagnosis Risk for infection-Urinary Retention or Incomplete Urination

Urinary retention or incomplete urination occurs when a person cannot empty all of their urine. This can be caused by an inability to get to a toilet in time (urinary retention) or obstruction of the urethra.

Signs and Symptoms

  • Difficulty getting started with urination, Feeling that you are unable to empty your bladder, Uncomfortable sensation in the bladder area

Underlying Causes:

Being in a healthcare setting with many patients who are ill and have weakened immune systems, Diabetes mellitus

Nursing Care Plan for Risk of Urinary Retention or Incomplete Urination in Patients with Non-Organic Causes.

Patient Outcomes: The patient will consistently empty the bladder without discomfort and assistance.

Goal: The patient will empty the bladder several times a day without discomfort.

Rationale: In the absence of infection or obstruction, the volume of urine excreted by the voiding phase should be greater than 400 ccs per 24 hours in adults.

Nursing Interventions:

Provide anticholinergic agents. These are drugs that block the function of the parasympathetic nervous system by blocking muscarinic receptors) are commonly prescribed for non-infectious or obstructive urinary retention.

Keep the patient’s bladder empty as often as possible to prevent urinary tract infections.

Maintain the patient’s privacy in using the toilet.

Teach patients to report pain or burning with urination as well as any blood in their urine.

Ensure that the patient’s bed linens are always dry.

Maintain room temperature at a comfortable level and not too cold or hot.

Assist in getting out of bed – Reduce the number of call lights to maintain privacy – Ensure that often used toilets are easily accessible and placed in easy view from the bedside.

The nurse needs to make sure that the patient is well hydrated since dehydration affects the function of all body systems. The nurse needs to ensure the patient uses the restroom when necessary and empties their bladder as much as possible. 

The nurses should advocate for the patient’s care in case of falls. The nurses can talk to the family and other caregivers, who may not know that self-care is limited.

Treatment Modalities for Urinary Retention or Incomplete Urination

  • The patient should be given a clear liquid diet (milkshakes, ice chips)
  • IV hydration with fluids to restore volume and correct dehydration. Avoid coffee, tea, stimulants, and alcohol while treating acute hypotension
  • Diuretics for a fluid overloaded patient
  • Hemodialysis (for renal failure).

Nursing Diagnosis Risk for Infection-Meningitis

Meningitis is an infection of the lining around the brain and spinal cord that may cause meningeal irritation.

Signs and Symptoms:

  • A headache, neck pain, feeling feverish or cold, a stiff neck, unusual sensitivity to light, decreased level of awareness

Underlying Causes:

Having a weakened immune system

What Are Primary Nursing Interventions?

Wear gloves to reduce the spread and risk of infection.

Minimize patient’s movement, as excessive motion may cause discomfort and aggravation of symptoms.

Limit visitors: It is crucial to reduce the number of visitors. Respiratory infection may be spread by people coughing and sneezing.

Keep the patient’s room as quiet and dark as possible so that the patient can rest.

Isolate a patient in a single room to prevent spreading disease, but make sure they get needed attention from health care providers and family members.

The nurse should inform the physician of any changes in the patient’s condition, especially if they are consistent.

Encourage patients to drink plenty of fluids and water to prevent dehydration.

Educate patients on symptoms that require immediate attention, such as confusion and headache; seizures or convulsions; nausea; vomiting; severe neck pain; inability to speak or move arms and legs.

Use side rails with caution, as they may irritate the skin or pin patients’ arms and cause tingling in the hands.

Teach the patient about medications, as many antihistamines can make patients drowsier.

Nursing Interventions

Wash your hands before touching the patient, even if you usually wear gloves. Gloves should be worn when providing care for an infectious patient.

Secure the airway with an endotracheal tube if the patient is severe enough to need one.

Wear PPE that covers the mouth and nose while you are providing care to a contagious patient. Remove these items upon leaving the room.

Treatment

Medication to reduce fever and treat the infection. These include antibiotics, antihistamines to relieve itching and pain

Nursing Diagnosis Risk for Infection-Measles

A variety of factors can cause the risk of infection. Measles is a contagious viral infection that causes fever, rash, and inflammation of the mucous membranes.

Signs and Symptoms:  

  • High fever, red eyes, sensitivity to light, rash on face and body, feeling miserable or cranky, headache 

Underlying Causes:

Being unvaccinated, recent exposure to a person who has the measles

Nursing Interventions

The nurse must wear gloves at all times during the patient’s care to prevent the spread of the disease.   

Ensure that you wash your hands before and after caring for each patient.  

Do not share utensils/gadgets with other patients to reduce the spread of infection.

The nurse must stay up to date and ask the patient about their vaccination history. 

If the patient was not vaccinated, do not let that person leave your care room until they are no longer infectious (check with the doctor). If the patient were not vaccinated, they would receive a booster vaccine. 

Teach patients about other preventative measures such as frequent hand washing.

Treatment Modalities for this Nursing Diagnosis:

Observe and record the patient’s temperature every four hours. A fever of 39 degrees C or greater should be treated with antipyretics.

Antipyretics may include ibuprofen, acetaminophen, aspirin, or Tylenol.     

Do not give medications to children under 16 years old without consulting the doctor.

The nurse may need to watch for other signs of infection such as rashes on the skin, swollen glands, or an earache. 

Nursing Diagnosis Risk of infection-Tuberculosis (TB)

A variety of factors can cause the risk of infection. Tuberculosis (TB) is an infectious, transmissible disease that affects the lungs.

Signs and Symptoms:  

  • Wheezing or coughing, chest pains, low-grade fever, weight loss (if TB has spread to other organs), night sweats, fatigue, weakness

Underlying Causes:  

The patient’s age (children under five years old are at higher risk), whether or not the person is immunocompromised, recent exposure to a contagious individual, or smoking.

Care Plan:  

Teach the patient about their condition and the need to finish all medications as prescribed to heal completely.  

Encourage the patient to maintain a healthy lifestyle by getting plenty of rest, eating well, and exercising. 

Provide encouragement and support if the patient does not want to take medication because of possible side effects. Offer to discuss these concerns with the medical team.

Observe and record the patient’s temperature every four hours, and make a note of any other signs or symptoms.  

Cultural Considerations for this Nursing Diagnosis:

The nurse must assess the cause of infection and the patient’s social and cultural beliefs.  Some people believe that if they wash their hands after fajr (early Morning Prayer) or before bedtime, it will affect a cure.  

The nurse must use culturally appropriate communication techniques when educating the patient about their condition. 

Nursing Interventions

The nurse must wear gloves at all times during the patient’s care to prevent the spread of the disease.  

Ensure that you wash your hands before and after caring for each patient. 

Do not share utensils/gadgets with other patients to reduce the spread of infection.  If TB is suspected, ask the patient whether they have been exposed to anyone known to have the disease.

Do not let a person with TB leave your care room until they are no longer infectious (check with the doctor). If it is decided that the patient does have TB, they will be isolated so that the disease does not spread further. 

The nurse must stay up to date and ask the patient about their vaccination history. 

If a patient has TB, do not let them leave your care until they are no longer infectious (check with the doctor). 

Teach patients about other preventative measures such as frequent hand washing.

The nurse should wear gloves and a mask to prevent the spread of infection.

The patient should be placed in a room by themselves to minimize transmitting pathogenic organisms from one person to another. 

A TB skin test and chest x-ray may be ordered if the patient has clinical symptoms. The nurse will then need to make sure that those tests are completed.  

Tuberculosis Treatment

Treatment depends on how contagious the individual is.

Isolation: If the patient is contagious, they will be isolated in a separate room.  Isolation precautions may include using a mask or wearing a gown and gloves when the patient is in contact with other people. Isolating the patient will help prevent the spread of infection. 

Antibiotics are given to kill off active tuberculosis. 

The patient may also be prescribed a breathing machine for some types of cases. 

If the patient has a cough, their sputum will be tested to see if it is infected. 

The nurse may need to watch for other signs of infection such as rashes on the skin, swollen glands, or an earache. 

The patient may need to take a medication that will help their breathing. These medications include nebulizers, oxygen, and intravenous (IV) steroids. 

Nursing Diagnosis Risk for Infection- Herpes Simplex Virus (HSV) Infection

Infection caused by a herpes simplex virus. This is an infection that causes painful sores or blisters on the skin and sometimes inside the mouth, nose, or other body parts.  

Symptoms for this Nursing Diagnosis:    

  • Red pimple or blister that breaks and leaves a painful sore, which may take several weeks to heal. A person with HSV infection can have sores for a few days to months. There is no way to know when the outbreak will stop, although they usually get fewer and less severe over time. In some cases, HSV can cause health problems that last a lifetime. The genital form of HSV is called genital herpes, which causes painful open sores in the genital area.  
  • Blisters on the skin may be present and are filled with fluids or pus. Some patients experience flu-like symptoms before an outbreak of blisters occurs. The sores are found on the lips and face or around the mouth, nose, or eyes. They also appear in other areas of the body, such as the chest and arms.  
  • Itching or burning sensation of skin before the appearance of blisters.  
  • Flu-like symptoms before an outbreak
  • Fever
  • Sore throat
  • Swollen glands
  • Fatigue

Nursing Interventions

The sores heal with time.    

Treatment usually involves antiviral drugs such as acyclovir, valacyclovir, or famciclovir. Skin lesions may be removed to prevent the spreading of the virus. As with all conditions, nursing diagnoses are not limited to this list. The nurse can always add more nursing diagnoses as per the need of the patient. Those mentioned above are just a few examples, and there are many more options available.

The nurse will provide care and treatment based on nursing diagnosis for patients. The Nursing diagnosis will also help a nurse plan for the patient’s care.

Nursing Diagnosis Risk for Infection -Diarrhea

Infection of the bowel, often due to bacteria, viruses, or parasites. 

Nursing Diagnosis:

Deficient Fluid Volume: Given the risk of dehydration associated with diarrhea, it is essential to assess the patient’s fluid intake and output carefully.

Imbalanced Nutrition: Less Than Body Requirements: The nurse will monitor a patient’s nutrition status by taking their hunger/ fullness scale into account.  The nurse will also measure their weight and monitor their dietary intake to ensure that they eat adequate food.

Insufficient Knowledge: The nurse may instruct dietary changes and the importance of having sufficient fluid intake.

Self-care Deficit: The nurse will instruct the patient on proper hand hygiene to minimize their risk of contracting a disease, such as a gastrointestinal infection. 

Pain:  The nurse will assess the severity of pain based on how it interferes with the patient’s daily activities.  

Signs and Symptoms:

  • The patient may experience vomiting or diarrhea. – They might also have chills, fever, and abdominal pains.
  • And in some cases (severe form), there can be dehydration.

Diarrhea Risk of Infection Care Plan

The nurse should follow the same dietary restrictions advised by their physician.

The patient’s diet will be limited to clear liquids only and then slowly advance to a regular diet after 24 hours of starting antibiotics. If the diarrhea is severe, this parameter may need to be adjusted as per the doctor’s advice. The doctor will also prescribe anti-diarrhea medications.  

The nurse should check the patient’s toilet bowel before taking them to the bathroom.  They should assist as needed, such as using a bedpan, urinal, or commode chair. If the patient has a Foley catheter, they must ensure that they change their bag on time. 

The nurse should also teach a patient about proper hygiene and cleanliness, including washing hands after using the bathroom or an assisted device.    

They must ensure that a patient with diarrhea does not have any open sores while going to the toilet as per the doctor’s instructions. It can increase the risk of contaminating the stool with bacteria that causes infections. 

The patient is advised to eat smaller, more frequent meals while taking antibiotics to prevent further loose stools. The patient should get sufficient fluid intake to avoid dehydration.

As prescribed by a physician, a nurse can also give an enema if needed. They must ensure no sores on the patient’s skin and protect their health by wearing gloves. The enema can be helpful for patients who have additional stress from the disease or because of an inadequate intake of food.

Nursing Interventions for Patient with risk of Infection- Diarrhea

  • Provide Education to the patient.

The nurse should teach patients and their family members how to prevent a possible infection.  This will include wiping off the toilet seat with wet paper after using it, not using other people’s bathroom items like towels, toothbrushes, etc. Washing hands after using the bathroom or an assisted device, covering nose and mouth when sneezing, and not sharing personal items, including food, utensils.

The nurse should also teach a patient about proper hygiene and cleanliness in the bathroom, including washing hands after using the toilet or an assisted device.

  • Provide emotional support.  

The nurse will offer emotional support by listening to the patient’s concerns, feelings, and emotions, talking with a family member, or helping them find someone to talk to.

  • Instruct the patient in activities of daily living.  

The nurse will teach a patient about ways to help them stay healthier, such as eating a balanced diet with sufficient fluid intake. They should be taught the importance of following their doctor’s orders for taking medications and getting enough rest. The nurses should also advise the patient to avoid excessive physical exercise.

  • Enforce preventive measures

The nurse will reinforce instructions on how to prevent diarrhea.  They must ensure that a patient with diarrhea does not have any open sores while going to the toilet as per the doctor’s instructions. It can increase the risk of contaminating the stool with bacteria that causes infections.

  • Provide Pain relief

The nurse will inquire about pain and provide analgesics if needed.

Treatment can include an oral rehydration solution (ORS) to replace the fluids and salts lost through diarrhea.  

The nurse may also have to prepare a clean, dry area for the patient to lay down. The nurse must be able to observe symptoms of dehydration in case it occurs. This will require frequent monitoring of vital signs, intake and output, and skin turgor.  

Severe dehydration will require intravenous fluid therapy. In severe dehydration, the doctor may want to start an IV with fluids like saline or Ringer’s lactate solution.

Nursing Diagnosis Risk for Infection- Infections During Surgery

Infections that can be transmitted during an operation include infections caused by bacteria, viruses, and fungi.

Infections can be transmitted from the patient to the surgeon or technician during surgery. Equipment is used on multiple patients without proper sterilization or just from touching a contaminated surface in the operating room.

The most commonly used instrument in an operating room includes surgical tools like scalpels, retractors, forceps, and scissors. They are used for cutting tissue or holding it to a specific position for surgery during procedures that include removal of abdominal organs (laparoscopic surgery) and orthopedic surgeries.

Nursing Diagnosis Risk for Infection- Bacteria and Viral Hepatitis During Surgery

Bacterial hepatitis can be transmitted from one patient to the other during surgery. It is a liver disease caused by bacterial infection. It is commonly transmitted when an instrument that has been used on more than one person without proper sterilization comes in contact with a patient’s blood. The devices can transmit the disease through broken skin or cuts and sores during surgery.

Signs and Symptoms of Bacterial Hepatitis

Symptoms may appear within a few days to two weeks after an infected patient is exposed, and it can also occur in healthy persons who have never been exposed.

  • The most common signs and symptoms include yellowing of skin and eyes (jaundice), general weakness, nausea with intermittent vomiting, fever, abdominal pain, and dark-colored urine.

The hepatitis B vaccine will be administered to patients before surgery if they have not already been vaccinated against it. The vaccination can help prevent infection if the wound does become infected during surgery. While there is no definitive treatment for hepatitis, an early diagnosis and antiviral medications effectively stop or limit its severity.

Risk for infection is high if bacterial hepatitis is diagnosed during surgery or if a patient has hepatitis C virus (HCV).  

Nursing Diagnosis Risk for Infection- Fungal Infections During Surgery

Infections caused by fungi are rare, and every effort needs to be made to prevent them from occurring in patients. The fungi that have been associated with infections in the past include Candida albicans, Aspergillus, and Fusarium species.

A patient may get an infection from fungus if they previously had a wound or skin ulcer on their body that was not appropriately treated before surgery. Sometimes immunocompromised patients are at a greater risk for fungal infections.

Signs and Symptoms

  • Skin infections that are caused by fungi usually start as red bumps, open sores, or blisters. In more advanced stages, the infection may appear as pus-filled bumps with scaling on the affected area of the skin.
  • If the fungal infection spreads to other infective areas, it can cause severe fever, chills, nausea, vomiting, and diarrhea.

Fungal Infections Nursing Care Plan

Patients that are at high risk for fungal infections should be treated prophylactically with antifungal medications. Prophylactic treatment will prevent the infection if surgery is required on other parts of the patient’s body. An additional dose of treatment with antifungal medications is necessary if the patient gets an infection during surgery. This can be given intravenously along with other antibiotics for a 24 to 48-hour duration.

The risk for infection is high in cases of patients who have a weakened immune system due to chronic conditions like diabetes and cancer or any malignancy treated for candida infections, including oral medications that are administered once a day and require several weeks to take effect. The infection may also be treated with topical antifungal solutions or creams, depending on the location of the infection.

The medical team should use proper medical gear (PPEs and gloves) to prevent the risk of transmitting pathogens from one body area to another.

The doctor will prescribe a medication to the patient if they have a fungal infection. The fungus can be treated with antifungal medications or systemic antifungals. Surgery may have to be postponed in patients diagnosed with a fungal infection if they are taking drugs to treat it.

Nursing Diagnosis Risk for Infection- Bacterial Skin Infestation During Surgery

Skin infestations that occur during surgery can turn into sepsis which is a life-threatening condition. The bacteria involved in these infections are primarily from the soil, including Streptococcus, Clostridium perfringens, E. coli, and Klebsiella pneumonia.

Patients who have had recent surgeries or whose immune system is compromised have a greater risk for bacterial skin infestation. The bacteria can spread to other infective areas of the body if the infection isn’t treated correctly.

Signs and Symptoms:

  • Bacterial skin infections can cause redness around an area, swelling, pain, or tenderness in that area of the body. The skin can also appear warm and shiny, and when a person touches it, it may feel firm to the touch.

Bacterial Skin Infestation Nursing Care

The patient should be treated with antibiotics that are effective in taking care of bacterial infections. These drugs are given intravenously for several days, and usually, the symptoms will go away in that period. For more severe infections, surgery may be required to remove infected foreign material from the patient’s body.

The risk for infection is high when patients have a lowered immune system due to chronic conditions like diabetes and cancer or any malignancy treated with treatment for candida infections, including oral medications that are administered once a day and require several weeks to take effect. The infection may also be treated with topical antifungal solutions or creams, depending on the location of the infection.

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Summary

Healthcare providers (and patients) need to be aware of what kind of infections they are dealing with and how this may affect them in the longer term. For example, certain types of infections can lead to more severe complications like sepsis or even death. Identifying if a patient is at risk of infection and suffering from an infection can be the difference between a patient’s life being saved and further complications occurring.

Patients who may be at risk of infection need to take extra precautions. They should watch what they eat or drink, becoming more aware of how/where they treat their wounds, wearing gloves or a mask to prevent the spread of infection before/after being in contact with someone that may be sick, etc. 

Infections can happen to anyone. It is essential to understand certain things about them (as outlined in the article). If you find yourself at risk, you know how to properly manage yourself not to cross the line and fall into a life-threatening infection such as sepsis.

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