Domain 11. Safety-protection
Class 1. Infection
Diagnostic Code: 00004
Nanda label: Risk for infection
Diagnostic focus: Infection
Nursing diagnosis is the assessment of the patient's status, which includes the patient's mental, physical and emotional wellbeing. It is the identification of a healthcare problem that requires professional knowledge and skills to be managed and intervened. Risk for infection is one of the diagnoses included in the NANDA International classification system and its purpose is to identify patients who are vulnerable to developing an infection.
NANDA Nursing Diagnosis Definition
The official definition of NANDA nursing diagnosis for risk for infection is “at risk for being invaded by pathogenic organisms” or “susceptibility to infection caused by an alteration in the host’s defenses or the presence of a pathogen”. This means that people with a weakened immune system, altered defenses or contact with a pathogen are at risk of getting an infection.
Risk Factors
There are many factors that can put someone at risk of developing an infection. These include:
- Weakened Immune System: People with a weakened immune system have difficulty fighting infections. This can be due to diseases, medication use or other causes.
- Altered Defenses: Damaged skin, mucous membranes and other body parts can make it harder for the body to defend itself against infection.
- Contact with Pathogen: Some people can be exposed to a pathogen through contact with an infected person or direct contact with a contaminated object.
At Risk Population
People who are more likely to be affected by this diagnosis include:
- Elderly: Older people are more susceptible to infection because their immune systems are weaker.
- Infants and Children: Young children have weaker immune systems than adults.
- People with Chronic Conditions: People with chronic medical conditions such as diabetes, HIV/AIDS, cancer or kidney failure are more likely to be affected by this diagnosis.
- People with Poor Hygiene: Poor hygiene can also contribute to a weakened immune system, making it easier to get an infection.
Associated Conditions
There are a number of associated conditions that can be related to this diagnosis. These include:
- Respiratory Infection: This can be caused by bacteria or viruses, and can affect the lungs.
- Urinary Tract Infection (UTI): This is an infection of the bladder or kidneys.
- Gastrointestinal Infection: This is an infection of the stomach and intestines, which can cause nausea, vomiting and diarrhea.
- Skin Infection: This can be caused by bacteria, viruses or fungi and can affect any part of the body.
- Bloodinfection: A blood infection, also known as sepsis, is caused by bacteria or other pathogens entering the bloodstream.
Suggestions of Use
This nursing diagnosis can be used to assess a patient’s risk of developing an infection. The nurse should consider the patient’s risk factors, history, current condition and other associated conditions when diagnosing a patient with this nursing diagnosis. Assessment of a patient’s risk of infection should also include an evaluation of the patient’s physical environment, such as sanitation and cleanliness, and social support system.
Suggested Alternative NANDA Nursing Diagnosis
In some cases, a nurse may determine that a different nursing diagnosis is more appropriate for the patient. Some potential alternative nursing diagnoses for risk for infection include:
- Risk for Deficient Fluid Volume: This diagnosis is used to identify patients who are at risk for fluid volume loss due to dehydration or inadequate fluid intake.
- Impaired Oral Mucous Membrane: This diagnosis is used to identify patients with dry mouth, ulcerations or sores in the mouth.
- Impaired Skin Integrity: This diagnosis is used to identify patients with skin damage due to injury, sun exposure, pressure ulcers or other causes.
- Ineffective Therapeutic Regimen Management: This diagnosis is used to identify patients who are not following medical instructions.
Usage Tips
When using this nursing diagnosis, it is important for the nurse to remember to evaluate the patient’s risk factors, environmental factors and associated conditions to ensure that an accurate diagnosis is made. Additionally, the nurse should assess the patient’s social support system to determine if additional resources such as family support or home health care may be needed.
NOC Outcomes
When assessing a patient with this nursing diagnosis, the nurse should use the following Nurse Outcome Classification (NOC) outcomes:
- Immune Status: This outcome is used to measure the patient’s ability to protect themselves from infection.
- Skin Integrity: This outcome is used to measure the patient’s skin condition to assess their risk for infection.
- Body Temperature Regulation: This outcome is used to measure the patient’s ability to maintain normal body temperature.
- Health Maintenance: This outcome is used to measure the patient’s ability to follow medical instructions, such as hand washing, taking medications and using preventative measures.
- Infection Status: This outcome is used to measure the patient’s risk of developing an infection.
Evaluation Objectives and Criteria
The nurse should use the following evaluation objectives and criteria when evaluating the patient with this nursing diagnosis:
- Immune Status: The nurse should assess the patient’s immune system to identify any weaknesses that may put the patient at risk of infection.
- Skin Integrity: The nurse should assess the patient’s skin condition to identify any areas of damage or inflammation that may put the patient at risk of infection.
- Body Temperature Regulation: The nurse should assess the patient’s temperature to ensure that it is stable and that the patient does not have a fever or other symptoms of infection.
- Health Maintenance: The nurse should assess the patient’s knowledge and understanding of medical instructions to ensure the patient is able to follow instructions and take preventative measures.
- Infection Status: The nurse should assess the patient’s risk of infection and take appropriate steps to reduce the risk.
NIC Interventions
When intervening on this nursing diagnosis, the nurse should use the following Nursing Interventions Classification (NIC) interventions:
- Immunization: This intervention is used to protect the patient from infection by providing immunizations.
- Hydration Therapy: This intervention is used to keep the patient hydrated and prevent dehydration.
- Skin Care: This intervention is used to protect the patient’s skin from damage and prevent infection.
- Medication Administration: This intervention is used to administer medication to treat existing infections or prevent future infections.
- Infection Control: This intervention is used to control infectious organisms by using proper hygiene, sterilization and disinfection techniques.
Nursing Activities
When intervening on this nursing diagnosis, the nurse should perform the following activities:
- Assess the patient’s risk factors, history and current condition.
- Evaluate the patient’s physical environment, such as sanitation and cleanliness.
- Assess the patient’s social support system.
- Provide immunization and other preventive measures to reduce the risk of infection.
- Provide education on proper hygiene and infection control.
- Administer medication to treat or prevent infection.
- Monitor the patient for signs and symptoms of infection.
Conclusion
Risk for infection is a common nursing diagnosis that can affect any patient, but certain populations are more at risk. Nursing interventions are available to reduce the risk of infection and to treat existing infections, and nurses should assess the patient’s risk factors, environment and social support system to ensure the best possible outcome for the patient.
FAQs
- What is Risk for Infection? Risk for infection is a nursing diagnosis that is used to identify patients who are susceptible to developing an infection. This diagnosis can be used to assess a patient’s risk of developing an infection, and should include an evaluation of the patient’s risk factors, history, current condition and other associated conditions.
- What are the Risk Factors for Infection? There are many risk factors for infection, including weakened immune system, altered defenses, contact with a pathogen and poor hygiene.
- What are the NOC Outcomes for Risk for Infection? The nurse should use the following NOC outcomes when assessing a patient with this nursing diagnosis: Immune Status, Skin Integrity, Body Temperature Regulation, Health Maintenance and Infection Status.
- What are the NIC Interventions for Risk for Infection? The nurse should use the following NIC interventions when intervening on this nursing diagnosis: Immunization, Hydration Therapy, Skin Care, Medication Administration and Infection Control.
- What Nursing Activities Should Be Performed? When intervening on this nursing diagnosis, the nurse should assess the patient’s risk factors, history, current condition and environmental factors, provide immunization and other preventive measures, provide education on proper hygiene and infection control, administer medication to treat or prevent infection, and monitor the patient for signs and symptoms of infection.
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