Nursing diagnosis Risk for surgical site infection

Risk for surgical site infection

Risk for surgical site infection

Domain 11. Safety-protection
Class 1. Infection
Diagnostic Code: 00266
Nanda label: Risk for surgical site infection
Diagnostic focus: Surgical site infection

Table of Contents

Introduction to Nursing Diagnosis - Risk for Surgical Site Infection

Nursing diagnosis is a central component of nursing care, with every patient case requiring a comprehensive assessment in order to determine an effective plan of care. A nursing diagnosis is used when a nurse identifies a problem or need related to a particular client and plans for how to address it. In this article, we will take a look at nursing diagnosis related to the risk for surgical site infection.

NANDA Nursing Diagnosis Definition

NANDA International (NANDA-I) provides standardized terminology and criteria used by nurses to identify actual or potential health problems that arise from a particular situation. NANDA's official definition of "Risk for Surgical Site Infection" is "[f]easibility of a surgical site incurring an infectious process related to qualities of the wound and effects of treatment."

Risk Factors

In order to properly diagnose and treat surgical site infections, nurses must be aware of the primary factors that place a patient at an increased risk. These risk factors include: age (age greater than 60), inflammatory response to surgery, pre-existing chronic conditions, immobility, poor nutrition, diabetes, tobacco use, obesity, and underlying illnesses.

At Risk Population

When considering the risk for surgical site infection, patients who are elderly, frail, and/or comorbid should be considered to be at a higher risk of developing an infection. Additionally, patients who have undergone a longer, more complex surgery are more likely to develop an infection.

Associated Conditions

It is important to note that some conditions, while not necessary indicative of a surgical site infection, can increase the risk. These include UV exposure, poor hygiene after the operation, any foreign matter that was introduced into the wound, poor hand hygiene by healthcare staff, inadequate sterilization or use of contaminated equipments, and untreated wounds.

Suggestions of Use and Suggested Alternative NANDA Nursing Diagnoses

In order to effectively manage the care of a patient, nurses should investigate and assess a variety of variables related to the risk for a surgical site infection. Some of these suggested alternative diagnoses include skin integrity alteration, altered nutrition: less than body requirements, altered tissue perfusion, and impaired gas exchange.

Usage Tips

When assessing a patient's risk for developing a surgical site infection, nurses should look for any key signs of infection before, during, and after the surgery. These may include redness and swelling around the incision, fever, unexpected chest pain, excessive drainage from the wound, or chills.

NOC Outcomes

The following list presents the Nursing Outcomes Classification (NOC) outcomes associated with the risk for surgical site infection.

  • Injury prevention: Patient maintains a safe environment to minimize the risk of infection.
  • Self-care deficit: Patient appropriately utilizes self-care techniques needed to prevent wound infections.
  • Skin Integrity: Patient demonstrates open wound healing without infection.
  • Hygiene: Patient engages in appropriate hygiene practices to promote optimal wound healing.
  • Tissue perfusion: Patient's serum glucose levels are monitored and maintained in normal ranges.

Evaluation Objectives and Criteria

Nurses should evaluate all NOC outcomes associated with surgical site infections against criteria for increased safety, tissue integrity, and decreased risk. To do this, nurses should utilize emotional and cognitive assessments and track changes in symptoms, such as pain, redness, drainage, among other indicators.

NIC Interventions

The following list presents the Nursing Interventions Classification (NIC) interventions associated with the risk for surgical site infection.

  • Injury Prevention: Maintain a safe environment to minimize the risk of infection.
  • Hygiene: Promote optimal wound healing with proper hygiene practices.
  • Wound Care: Perform routine wound assessments to monitor progress and prevent further infections.
  • Care Planning: Develop an individualized plan of care to address patient’s needs related to the risk for surgical site infection.
  • Health Teaching: Educate the patient about preventive measures to help reduce the risk of infection.

Nursing Activities

Nurses should practice these NIC interventions when caring for patients at risk for surgical site infection. Activities include initiating patient assessments, administering wound care, providing health teachings to reinforce preventive behaviors, utilizing evidence-based practices to develop a plan of care, and promoting a safe environment.

Conclusion

Surgical site infections are a major concern for surgical patients and nurses must take steps to identify and prevent them. Assessment and evaluation of risk factors, associated conditions, and appropriate interventions should all be included in the plan of care to ensure the highest standard of care for patients at risk for surgical site infection.

5 FAQs

  • What is the definition of risk for surgical site infection?
    NANDA International’s (NANDA-I) definition of “Risk for Surgical Site Infection” is "[f]easibility of a surgical site incurring an infectious process related to qualities of the wound and effects of treatment.
  • What are the risk factors associated with surgical site infection?
    The primary risk factors associated with surgical site infections include age (age greater than 60), inflammatory response to surgery, pre-existing chronic conditions, immobility, poor nutrition, diabetes, tobacco use, obesity, and underlying illnesses.
  • What are some associated conditions that place a patient at an increased risk for surgical site infection?
    Conditions that can increase the risk for surgical site infection include UV exposure, poor hygiene after the operation, any foreign matter that was introduced into the wound, poor hand hygiene by healthcare staff, inadequate sterilization or use of contaminated equipment, and untreated wounds.
  • What are some nursing interventions for patients at risk for surgical site infection?
    Nursing interventions include maintaining a safe environment, promoting optimal wound healing with proper hygiene practices, performing routine wound assessments, developing an individualized plan of care, and educating the patient about preventive measures.
  • What evaluation objectives and criteria should be taken into account when assessing the risk for surgical site infection?
    Nurses should evaluate all Nursing Outcomes Classification (NOC) outcomes associated with the risk for surgical site infection against criteria for increased safety, tissue integrity, and decreased risk. This should include emotional and cognitive assessments and tracking of changes in symptoms such as pain, redness, and drainage.

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