Risk for Infection

Risk factors may include

Inadequate secondary defenses and immunosuppression, e.g., bone

marrow suppression (dose-limiting side effect of both chemotherapy and
radiation).

Desired Outcomes

Remain afebrile and achieve timely healing as appropriate.

Identify and participate in interventions to prevent/reduce risk of infection.

Nursing Interventions

Rationale

Promote good handwashing

Protects patient from sources of

procedures by staff and visitors.

infection, such as visitors and staff

Screen and limit visitors who may

who may have an upper respiratory

have infections. Place in reverse

infection (URI).

isolation as indicated.
Emphasize personal hygiene.

Limits potential sources of infection

and secondary overgrowth.

Monitor temperature.

Temperature elevation may occur (if

not masked by corticosteroids or antiinflammatory drugs) because of
various factors (chemotherapy side
effects, disease process, or infection).
Early identification of infectious
process enables appropriate therapy
to be started promptly.

Assess all systems (skin, respiratory,

Early recognition and intervention

genitourinary) for signs and symptoms

may prevent progression to more

of infection on a continual basis.

serious situation or sepsis.

Nursing Interventions

Rationale

Reposition frequently; keep linens dry

Reduces pressure and irritation to

and wrinkle-free.

tissues and may prevent skin

breakdown (potential site for bacterial
growth).

Promote adequate rest and exercise

Limits fatigue, yet encourages

periods.

sufficient movement to prevent stasis

complications (pneumonia, decubitus,
and thrombus formation).

Stress importance of good oral

Development of stomatitis increases

hygiene.

risk of infection and secondary

overgrowth.

Avoid or limit invasive procedures.

Reduces risk of contamination, limits

Adhere to aseptic techniques.

portal of entry for infectious agents.

Monitor CBC with differential WBC

Bone marrow activity may be inhibited

and granulocyte count, and platelets

by effects of chemotherapy, the

as indicated.

disease state, or radiation therapy.

Monitoring status of
myelosuppression is important for
preventing further complications
(infection, anemia, or hemorrhage)
and scheduling drug delivery.