00004 Risk for infection

Domain 11: security/protection
Class 1: infection
Diagnostic Code: 00004
Nanda label: infection risk
Diagnostic focus: infection
Approved 1986 • Revised 2010, 2013, 2017, 2020 • Level of evidence 3.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « infection risk » is defined as: likely to suffer an invasion and multiplication of pathogenic organisms, which can compromise health.

Risk factors

  • Difficulty in managing long -term invasive devices
  • Difficulty in managing wound care
  • Gastrointestinal motility dysfunctional
  • Exclusive artificial nutrition
  • Deterioration of cutaneous integrity
  • Inappropriate access to individual protection equipment
  • Adhesion inadequate to public health recommendations
  • Inadequate environment hygiene
  • Inadequate health literacy
  • Inadequate hygiene
  • Inappropriate knowledge to avoid exposure to pathogens
  • Inadequate oral hygiene habits
  • Inadequate vaccination
  • Malnutrition
  • Mixed breastfeeding
  • Obesity
  • smoking
  • Body fluid retention

Risk population

  • People at economic disadvantage
  • People exposed to disease outbreak
  • People exposed to an increase in pathogens in the environment
  • People with low educational level
  • Breastfeeding infants

Associated problems

  • PH alteration of secretions
  • Anemia
  • Chronic condition
  • Decrease in ciliary action
  • Immunosuppression
  • Invasive procedure
  • Leukopenia
  • Premature rupture of the amniotic membrane
  • Prolonged rupture of the amniotic membrane
  • Suppression of the inflammatory response

Suggestions of use

  • Do not use this label routinely in patients who have surgical incisions. For most surgical patients, the maintenance of routine standards will avoid incision infection.
  • Similarly, a risk of infection in patients who have a permanent probe should not be used. An aseptic technique is required. In a sense, anyone is exposed to a risk of infection. Therefore, this nursing diagnosis will only be used for those patients who are at a higher risk of the “usual”, for example, for those who have nutritional deficit or a committed immune system. In the case of patients with a real infection, use a collaboration problem (for example, possible complication: septicemia).

Suggested alternative diagnostics

  • Nutritional imbalance: intake less than needs
  • Cutaneous integrity, deterioration of the
  • Tissue integrity, deterioration of the
  • injury, risk of
  • Ineffective protection

NOC Results

  • Community Risk Control: Contagious disease: Community actions to eliminate or reduce the spread of infectious agents that threaten public health
  • Risk Control: Infectious process: Personal actions to prevent, eliminate or reduce the threat of infection
  • Risk control: Sexually transmitted diseases (STDs): Personal actions to prevent, eliminate or reduce behaviors associated with sexually transmitted diseases
  • Wound healing: First intention: scope of cell regeneration and tissue after an intentional closure
  • Wound healing: Second intention: Cell regeneration and tissue regeneration in an open wound
  • Immune state: natural and acquired resistance, adequately directed to internal and external antigens
  • Gravity of the infection: gravity of the infection and associated symptoms
  • Gravity of the infection: newborn: gravity of infection and associated symptoms during the first 28 days of life

Evaluation objectives and criteria

  • The risk factors of infection are eliminated, as evidenced by community risk control: contagious disease, immune state, risk control: infectious process, risk control: sexually transmitted diseases; In addition, wound healing: first and second intention
  • The patient demonstrates risk control: sexually transmitted diseases (STDs), as the following indicators manifest (specify from 1 to 5: never, sometimes, sometimes, often or usually):
    • Watch personal behavior with respect to the risk of exposure to STD
    • Use certain exposure control strategies
    • Use methods to control ETS transmission

Other examples

The patient and his family will be able to:

  • Do not show any sign or symptom of infection
  • Check adequate personal hygiene
  • Inform that gastrointestinal, respiratory, genitourinary and immune devices are within normal limits
  • Describe factors that contribute to the transmission of infections
  • Inform about signs and symptoms of infection and follow the control and surveillance procedures

NIC Interventions

  • Infection control: decrease in the acquisition and transmission of infectious agents
  • Wound care: prevention of wound complications and help for cure
  • Probe care: Urinary: Management of a patient with urinary drainage equipment
  • Incision site care: cleaning, surveillance and promotion of healing a closed wound by suture, clips or staples
  • Teaching: Safe sex: instruct on sexual protection during sexual activity
  • Handling of contagious diseases: I work with a community to reduce and manage the incidence and prevalence of contagious diseases in a certain population
  • IMMUNIZATION MANAGEMENT/VACCINE ADMINISTRATION: IMMUNIZATION STATE CONTROL, FACILITATION OF ACCESS TO IMMUNIZATIONS AND PROVISION OF IMMUNIZATIONS TO PREVENE CONTAGIOUS DISEASES
  • Infection protection: Prevention and early detection of infections in a patient at risk
  • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions

Nursing Activities

Valuations

  • Monitor the signs and symptoms of infection (such as temperature, pulse, drainage, wound appearance, secretions, urine appearance, skin temperature, skin lesions, fatigue, discomfort)
  • Assess the factors that increase vulnerability to infections (advanced age, age less than one year, immunodeficiency, malnutrition)
  • Monitor the laboratory results (hemogram, total granulocyte count, leukocytic formula results, crops, serum proteins and albumin)
  • Control personal hygiene practices to protect against infections

Patient and family education

  • Explain to the patient and family why disease or therapy increase the risk of infection
  • Instruct about personal hygiene practices (such as hand washing) to protect yourself from infections
  • Explain the foundations and advantages of immunizations, as well as their side effects
  • Offer the patient and family a method to register immunizations (for example, form, daily)
  • (NIC) Control of infections:
    • Instruct the patient about the appropriate techniques for hand washing
    • Indicate visitors to wash their hands before entering and when leaving the patient’s room

Collaboration activities

  • Follow the institutional protocol to inform about possible positive infections or crops
  • (NIC) Control of infections: Manage an antibiotic therapy, as required

Others

  • Protect the patient from cross pollution by not assigning the same nurse to another patient who has an infection, and refrain from including in the patient’s room an infected patient
  • (NIC) Control of infections:
    • Clean the environment properly after treating each patient
    • Apply isolation techniques, as needed
    • Apply universal precautions
    • Limit the number of visits, as required

At home

  • Teach basic hygiene measures, such as hand washing and not share towels or glasses.
  • Teach the safe management, preparation or storage methods of food
  • Help the patient and the family identify the factors of their environment, lifestyle or health practices that increase the risk of infection
  • Teach the family to eliminate dirty bandages and other biological waste
  • Do not make home visits if you are sick
  • Channel to the patient and family to social services or community resources to help them manage domestic hygiene and nutrition
  • (NIC) Control of infections: instruct the patient and the family about the signs and symptoms of an infection and when they should inform them to the doctor

Babies and Children

  • Inform parents about the Dipter, Tetanos, Tospherine, Polyomyelitis, Measles, Paper and Rubeola Program
  • Channel to social services to obtain help for immunizations (for example, insurance coverage and health clinics)
  • Control the frequent use of antibiotics in babies and children; Inform parents that a common cold should not be treated with antibiotics

Older people

  • Recognize that, as the immune system depresses, older people may not show the usual symptoms, even in the case of serious infections. Monitor the presence of a low temperature or states of confusion
  • Channel to the patient to a podiatrist for the care of the feet (for example, growth in the nails of the foot, elimination of calluses), in addition to the nail cut
  • RECOMMEND VACCINES AGAINST INFLUENZA AND PNEUMONY; Recommend a limited exposure to other people during the critical periods of the influenza season
  • Assess the factors that increase the risk of patient infection (for example, chronic disease, depression)