Nursing Diagnosis

Sistem Imun & Hematologi

Risk for Infection

Definition :
At increased risk for being invaded by pathogenic organisms
Risk Factors :
Chronic disease
Inadequate acquired immunity
Inadequate primary defenses (broken skin, traumalized tissue,
decrease in ciliary action)
Inadequate secondary defenses (decrease Hb, leukopenia,
suppressed inflamatory response)
Increased environmental exposure to pathogen
Malnutrition
Pharmaceutical agent (immunosuppressants)
Invasive procedure

Nursing Outcome
Classification

Immune Status
Knowledge : infection management
Risk Control
Risk Detection

Expected Outcomes
Remain free from symptoms of infection as
evidenced by : normal vital signs, absence of
purulent drainage from wounds, incisions, and
tube
Demonstrate appropriate care of infection-prone
site
Maintain WBCs within normal limits
Demonstrate appropriate hygienic measures
such as handwashing, oral care and perineal care
Infection is recognized early to allow for prompt
treatment.

Nursing Intervention
Classification
Immunization/Vaccination
Management
Infection Control
Infection Protection

Infection Protection &

Control
NIC Activity
Assess skin for color, moisture, texture
and turgor (elasticity). Keep accurate
ongoing documentation of change.
Monitor weight loss, leaving 25% or
more of food uneaten at most meals.
EBN : this study demonstrated the
above criteria as significant predictors
of protein calorie malnutrition