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Nursing Diagnosis: Risk for Infection

Universal Precautions; Standard Precautions; CDC Guidelines; OSHA

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

* Immune Status
* Knowledge: Infection Control

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

* Infection Control
* Infection Protection

NANDA Definition: At increased risk for being invaded by pathogenic organisms

Persons at risk for infection are those whose natural defense mechanisms are inadequate to protect them from the inevitable injuries and
exposures that occur throughout the course of living. Infections occur when an organism (e.g., bacterium, virus, fungus, or other parasite)
invades a susceptible host. Breaks in the integument, the body’s first line of defense, and/or the mucous membranes allow invasion by
pathogens. If the host’s (patient’s) immune system cannot combat the invading organism adequately, an infection occurs. Open wounds,
traumatic or surgical, can be sites for infection; soft tissues (cells, fat, muscle) and organs (kidneys, lungs) can also be sites for infection
either after trauma, invasive procedures, or by invasion of pathogens carried through the bloodstream or lymphatic system. Infections can be
transmitted, either by contact or through airborne transmission, sexual contact, or sharing of intravenous (IV) drug paraphernalia. Being
malnourished, having inadequate resources for sanitary living conditions, and lacking knowledge about disease transmission place
individuals at risk for infection. Health care workers, to protect themselves and others from disease transmission, must understand how to
take precautions to prevent transmission. Because identification of infected individuals is not always apparent, standard precautions
recommended by the Centers for Disease Control and Prevention (CDC) are widely practiced. In addition, the Occupational Safety and
Health Administration (OSHA) has set forth the Blood Borne Pathogens Standard, developed to protect workers and the public from
infection. Ease and increase in world travel has also increased opportunities for transmission of disease from abroad. Infections prolong
healing, and can result in death if untreated. Antimicrobials are used to treat infections when susceptibility is present. Organisms may
become resistant to antimicrobials, requiring multiple antimicrobial therapy. There are organisms for which no antimicrobial is effective,
such as the human immunodeficiency virus (HIV).

* Risk Factors: Inadequate primary defenses: broken skin, injured tissue, body fluid stasis
* Inadequate secondary defenses: immunosuppression, leukopenia
* Malnutrition
* Intubation
* Indwelling catheters, drains
* Intravenous (IV) devices
* Invasive procedures
* Rupture of amniotic membranes
* Chronic disease
* Failure to avoid pathogens (exposure)
* Inadequate acquired immunity

* Expected Outcomes Patient remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds,
incisions, and tubes.
* Infection is recognized early to allow for prompt treatment.

Ongoing Assessment

* Assess for presence, existence of, and history of risk factors such as open wounds and abrasions; in-dwelling catheters (Foley, peritoneal);
wound drainage tubes (T-tubes, Penrose, Jackson-Pratt); endotracheal or tracheostomy tubes; venous or arterial access devices; and
orthopedic fixator pins. Each of these examples represent a break in the body’s normal first lines of defense.
* Monitor white blood count (WBC). Rising WBC indicates body’s efforts to combat pathogens; normal values: 4000 to 11,000 mm3. Very
low WBC (neutropenia <1000 mm3) indicates severe risk for infection because patient does not have sufficient WBCs to fight infection.
NOTE: In elderly patients, infection may be present without an increased WBC.
* Monitor the following for signs of infection:
o Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit sites of tubes, drains, or catheters Any suspicious
drainage should be cultured; antibiotic therapy is determined by pathogens identified at culture.
o Elevated temperature Fever of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, fever above
37.7° C (99.8° F) suggests infection; fever spikes that occur and subside are indicative of wound infection; very high fever accompanied by
sweating and chills may indicate septicemia.
o Color of respiratory secretions Yellow or yellow-green sputum is indicative of respiratory infection.
o Appearance of urine Cloudy, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection.
* Assess nutritional status, including weight, history of weight loss, and serum albumin. Patients with poor nutritional status may be anergic,
or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection.
* In pregnant patients, assess intactness of amniotic membranes. Prolonged rupture of amniotic membranes before delivery places the mother
and infant at increased risk for infection.
* Assess for exposure to individuals with active infections.
* Assess for history of drug use or treatment modalities that may cause immunosuppression. Antineoplastic agents and corticosteroids reduce
* Assess immunization status. Elderly patients and those not raised in the United States may not have completed immunizations, and
therefore not have sufficient acquired immunocompetence.

Therapeutic Interventions

* Maintain or teach asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access
* Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient. Friction and
running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from
one area of the body to another (e.g., perineal care or central line care). Use of disposable gloves does not reduce the need for hand washing.
* Limit visitors. This reduces the number of organisms in patient’s environment and restricts visitation by individuals with any type of
infection to reduce the transmission of pathogens to the patient at risk for infection. The most common modes of transmission are by direct
contact (touching) and by droplet (airborne).
* Encourage intake of protein- and calorie-rich foods. This maintains optimal nutritional status.
* Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). Fluids promote diluted urine and frequent
emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).
* Encourage coughing and deep breathing; consider use of incentive spirometer. These measures reduce stasis of secretions in the lungs and
bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.
* Administer or teach use of antimicrobial (antibiotic) drugs as ordered. Antimicrobial drugs include antibacterial, antifungal, antiparasitic,
and antiviral agents. All of these agents are either toxic to the pathogen or retard the pathogen’s growth. Ideally, the selection of the drug is
based on cultures from the infected area; this is often impossible or impractical, and in these cases, empirical management usually is
undertaken with a broad-spectrum drug.
* Place patient in protective isolation if patient is at very high risk. Protective isolation is established if white blood cell counts indicate
neutropenia (<500 to 1000 mm3). Institutional protocols may vary.
* Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes.

Education/Continuity of Care

* Teach patient or caregiver to wash hands often, especially after toileting, before meals, and before and after administering self-care.
Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; hand washing
reduces these risks.
* Teach patient the importance of avoiding contact with those who have infections or colds.
* Teach family members and caregivers about protecting susceptible patient from themselves and others with infections or colds.
* Teach patient, family, and caregivers the purpose and proper technique for maintaining isolation.
* Teach patient to take antibiotics as prescribed. Most antibiotics work best when a constant blood level is maintained; a constant blood level
is maintained when medications are taken as prescribed. The absorption of some antibiotics is hindered by certain foods; patient should be
instructed accordingly.
* Teach patient and caregiver the signs and symptoms of infection, and when to report these to the physician or nurse.
* Demonstrate and allow return demonstration of all high-risk procedures that patient or caregiver will do after discharge, such as dressing
changes, peripheral or central IV site care, peritoneal dialysis, self-catheterization (may use clean technique). Bladder infection is more
related to overdistended bladder resulting from infrequent catheterization than to use of clean versus sterile technique.
Nursing Diagnosis: Acute Pain
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

* Comfort Level
* Medication Response
* Pain Control

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

* Analgesic Administration
* Conscious Sedation
* Pain Management
* Patient-Controlled Analgesia Assistance

NANDA Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of
such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated
or predictable end and a duration of less than 6 months

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the
sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain
can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment
can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

* Defining Characteristics: Patient reports pain

* Guarding behavior, protecting body part
* Self-focused
* Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
* Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)
* Facial mask of pain
* Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
* Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor;

* Related Factors: Postoperative pain

* Cardiovascular pain
* Musculoskeletal pain
* Obstetrical pain
* Pain resulting from medical problems
* Pain resulting from diagnostic procedures or medical treatments
* Pain resulting from trauma
* Pain resulting from emotional, psychological, spiritual, or cultural distress

* Expected Outcomes Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.

Ongoing Assessment

* Assess pain characteristics:

o Quality (e.g., sharp, burning, shooting)
o Severity (scale of 1 to 10, with 10 being the most severe) Other methods such as a visual analog scale or descriptive scales can be used to
identify extent of pain.
o Location (anatomical description)
o Onset (gradual or sudden)
o Duration (how long; intermittent or continuous)
o Precipitating or relieving factors
* Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness,
and ability to focus. Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in
evaluating pain.
* Assess for probable cause of pain. Different etiological factors respond better to different therapies.
* Assess patient’s knowledge of or preference for the array of pain-relief strategies available. Some patients may be unaware of the
effectiveness of nonpharmacological methods and may be willing to try them, either with or instead of traditional analgesic medications.
Often a combination of therapies (e.g., mild analgesics with distraction or heat) may prove most effective.
* Evaluate patient’s response to pain and medications or therapeutics aimed at abolishing or relieving pain. It is important to help patients
express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures. Discrepancies
between behavior or appearance and what patient says about pain relief (or lack of it) may be more a reflection of other methods patient is
using to cope with than pain relief itself.
* Assess to what degree cultural, environmental, intrapersonal, and intrapsychic factors may contribute to pain or pain relief. These variables
may modify the patient’s expression of his or her experience. For example, some cultures openly express feelings, while others restrain such
expression. However, health care providers should not stereotype any patient response but rather evaluate the unique response of each
* Evaluate what the pain means to the individual. The meaning of the pain will directly influence the patient’s response. Some patients,
especially the dying, may feel that the "act of suffering" meets a spiritual need.
* Assess patient’s expectations for pain relief. Some patients may be content to have pain decreased; others will expect complete elimination
of pain. This affects their perceptions of the effectiveness of the treatment modality and their willingness to participate in additional
* Assess patient’s willingness or ability to explore a range of techniques aimed at controlling pain. Some patients will feel uncomfortable
exploring alternative methods of pain relief. However, patients need to be informed that there are multiple ways to manage pain.
* Assess appropriateness of patient as a patient-controlled analgesia (PCA) candidate: no history of substance abuse; no allergy to narcotic
analgesics; clear sensorium; cooperative and motivated about use; no history of renal, hepatic, or respiratory disease; manual dexterity; and
no history of major psychiatric disorder. PCA is the intravenous (IV) infusion of a narcotic (usually morphine or Demerol) through an
infusion pump that is controlled by the patient. This allows the patient to manage pain relief within prescribed limits. In the hospice or home
setting, a nurse or caregiver may be needed to assist the patient in managing the infusion.
* Monitor for changes in general condition that may herald need for change in pain relief method. For example, a PCA patient becomes
confused and cannot manage PCA, or a successful modality ceases to provide adequate pain relief, as in relaxation breathing.
* If patient is on PCA, assess the following:
o Pain relief The basal or lock-out dose may need to be increased to cover the patient’s pain.
o Intactness of IV line If the IV is not patent, patient will not receive pain medication.
o Amount of pain medication patient is requesting If demands for medication are quite frequent, patient’s dosage may need to be increased.
If demands are very low, patient may require further instruction to properly use PCA.
o Possible PCA complications such as excessive sedation, respiratory distress, urinary retention, nausea/vomiting, constipation, and IV site
pain, redness, or swelling Patients may also experience mild allergic response to the analgesic agent, marked by generalized itching or nausea
and vomiting.
* If patient is receiving epidural analgesia, assess the following:
o Pain relief Intermittent epidurals require redosing at intervals. Variations in anatomy may result in a "patch effect."
o Numbness, tingling in extremities, a metallic taste in the mouth These symptoms may be indicators of an allergic response to the anesthesia
agent, or of improper catheter placement.
o Possible epidural analgesia complications such as excessive sedation, respiratory distress, urinary retention, or catheter migration
Respiratory depression and intravascular infusion of anesthesia (resulting from catheter migration) can be potentially life-threatening.

Therapeutic Interventions

* Anticipate need for pain relief. One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount
of analgesic required.
* Respond immediately to complaint of pain. In the midst of painful experiences a patient’s perception of time may become distorted.
Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patient’s welfare and comfort
fosters the development of a trusting relationship.
* Eliminate additional stressors or sources of discomfort whenever possible. Patients may experience an exaggeration in pain or a decreased
ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them.
* Provide rest periods to facilitate comfort, sleep, and relaxation. The patient’s experiences of pain may become exaggerated as the result of
fatigue. In a cyclic fashion, pain may result in fatigue, which may result in exaggerated pain and exhaustion. A quiet environment, a
darkened room, and a disconnected phone are all measures geared toward facilitating rest.
* Determine the appropriate pain relief method.
1. Pharmacological methods include the following: Nonsteroidal antiinflammatory drugs (NSAIDs) that may be administered orally or
parenterally (to date, ketorolac is the only available parenteral NSAID).
2. Use of opiates that may be administered orally, intramuscularly, subcutaneously, intravenously, systemically by patient-controlled
analgesia (PCA) systems, or epidurally (either by bolus or continuous infusion). Narcotics are indicated for severe pain, especially in the
hospice or home setting.
3. Local anesthetic agents.
1. Nonpharmacological methods include the following: Cognitive-behavioral strategies as follows:
o Imagery The use of a mental picture or an imagined event involves use of the five senses to distract oneself from painful stimuli.
o Distraction techniques Heighten one’s concentration upon nonpainful stimuli to decrease one’s awareness and experience of pain. Some
methods are breathing modifications and nerve stimulation.
o Relaxation exercises Techniques are used to bring about a state of physical and mental awareness and tranquility. The goal of these
techniques is to reduce tension, subsequently reducing pain.
o Biofeedback, breathing exercises, music therapy
2. Cutaneous stimulation as follows:
o Massage of affected area when appropriate Massage decreases muscle tension and can promote comfort.
o Transcutaneous electrical nerve stimulation (TENS) units
o Hot or cold compress Hot, moist compresses have a penetrating effect. The warmth rushes blood to the affected area to promote healing.
Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort.
* Give analgesics as ordered, evaluating effectiveness and observing for any signs and symptoms of untoward effects. Pain medications are
absorbed and metabolized differently by patients, so their effectiveness must be evaluated from patient to patient. Analgesics may cause side
effects that range from mild to life-threatening.
* Notify physician if interventions are unsuccessful or if current complaint is a significant change from patient’s past experience of pain.
Patients who request pain medications at more frequent intervals than prescribed may actually require higher doses or more potent
* Whenever possible, reassure patient that pain is time-limited and that there is more than one approach to easing pain. When pain is
perceived as everlasting and unresolvable, patient may give up trying to cope with or experience a sense of hopelessness and loss of control.

* If patient is on PCA: Dedicate use of IV line for PCA only; consult pharmacist before mixing drug with narcotic being infused. IV
incompatibilities are possible.

* If patient is receiving epidural analgesia: Label all tubing (e.g., epidural catheter, IV tubing to epidural catheter) clearly to prevent
inadvertent administration of inappropriate fluids or drugs into epidural space.

* For patients with PCA or epidural analgesia: Keep Narcan or other narcotic-reversing agent readily available. In the event of respiratory
depression, these drugs reverse the narcotic effect.
* Post "No additional analgesia" sign over bed. This prevents inadvertent analgesic overdosing.

Education/Continuity of Care

* Provide anticipatory instruction on pain causes, appropriate prevention, and relief measures.
* Explain cause of pain or discomfort, if known.
* Instruct patient to report pain. Relief measures may be instituted.
* Instruct patient to evaluate and report effectiveness of measures used.
* Teach patient effective timing of medication dose in relation to potentially uncomfortable activities and prevention of peak pain periods.

* For patients on PCA or those receiving epidural analgesia: Teach patient preoperatively. Anesthesia effects should not obscure teaching.
* Teach patient the purpose, benefits, techniques of use/action, need for IV line (PCA only), other alternatives for pain control, and of the
need to notify nurse of machine alarm and occurrence of untoward effects.