Nursing Diagnosis of Infection Care: Comprehensive Guide for Nurses

What is Risk for Infection and Infection Control?

Infection occurs when the body’s natural defenses are overwhelmed by invading microorganisms. These microorganisms, including bacteria, viruses, fungi, and parasites, can exploit vulnerabilities in our protective systems due to injuries or exposures. Our bodies possess a sophisticated immune system, a network of cells and tissues dedicated to defending against these threats. This system, comprised of organs like the thymus, bone marrow, lymph nodes, spleen, appendix, tonsils, and Peyer’s patches in the small intestine, is vital for survival in a microbe-rich world. When the immune system falters, infection takes hold.

Breaches in the body’s protective barriers, such as the skin, mucous membranes, soft tissues, or even internal organs like the kidneys and lungs, can become entry points for infection. These breaches can result from trauma, invasive medical procedures, or the invasion of pathogens through the bloodstream or lymphatic system. The development of an infection is a sequential process, requiring a chain of events to be complete. This chain includes six key elements: a causative organism, a reservoir where the organism resides, a mode of transmission from the reservoir to a susceptible host, a portal of entry into the host, a susceptible host, and finally, an environment conducive to infection.

It’s crucial to distinguish between infection and infectious disease. Infection refers to the invasion and multiplication of microorganisms in body tissues. Infectious disease, however, is defined as the state where the infected host exhibits a decline in health and well-being as a direct result of the infection. If the body’s immune system interacts with an organism without causing noticeable symptoms, it is considered colonization or subclinical infection, not infectious disease.

Infectious diseases commonly spread through direct person-to-person transfer of bacteria, viruses, or other pathogens. This transmission can occur via physical contact, airborne droplets, sexual contact, or the sharing of contaminated items like IV drug paraphernalia. Factors such as inadequate resources, lack of health knowledge, and malnutrition significantly increase an individual’s susceptibility to infection.

SEE ALSO: Infection Control in Nursing

Untreated infections can impede healing and even prove fatal. Antimicrobial medications are frequently employed to combat infections when the causative organism is susceptible. However, some organisms, like the human immunodeficiency virus (HIV), are resistant to many antimicrobials. Immunization is another widespread medical strategy, particularly for individuals at high risk of infection. Simple yet powerful, handwashing remains the most effective method to interrupt the chain of infection and prevent its spread.

Infection control encompasses the policies and procedures implemented to manage and minimize the dissemination of infections, especially within healthcare environments like hospitals. The primary goal of infection control is to lower infection rates and safeguard patient and healthcare worker safety. Infection control programs are fundamentally rooted in the surveillance of healthcare-associated infections (HAIs) and the application of epidemiological principles to identify and mitigate risk factors for HAIs (Habboush et al., 2023).

Specific nursing interventions are tailored to the nature and severity of infection risk. Nurses play a vital role in educating patients on recognizing infection signs and implementing preventative strategies to reduce their individual risk.

Causes and Risk Factors for Infection

Numerous health conditions and lifestyle factors can create environments that promote infection development. Understanding these causes and risk factors is essential for effective nursing diagnosis and infection care.

Cause/Risk Factor	Description	Examples
Compromised Primary Defenses	Breakdown in the body’s initial barriers against infection, such as skin integrity, mucous membranes, and normal flora.	– Skin wounds (cuts, punctures) – Tissue damage from burns or frostbite – Skin dryness – Dehydrated mucous membranes – Disruption of normal flora due to antibiotic use
Knowledge Deficit in Pathogen Avoidance	Lack of understanding regarding infection prevention strategies and exposure routes.	– Improper handwashing practices – Lack of awareness about germ transmission – Inadequate surface cleaning and disinfection – Unsafe food handling techniques
Impaired Host Defenses	Weakening of the body’s secondary defenses, encompassing the immune system, white blood cells, and inflammatory responses.	– Cancer – Immunodeficiency disorders – HIV/AIDS – Diabetes mellitus – Malnutrition – Chronic illnesses (heart, lung, kidney disease) – Immunosuppressive medications like chemotherapy and corticosteroids
Compromised Circulation	Reduced blood flow to tissues, hindering immune cell delivery and waste removal.	– Obesity – Lymphedema – Peripheral vascular disease – Smoking – Diabetes mellitus
Invasive Sites for Organisms	Openings in the body that allow pathogen entry, bypassing natural defenses.	– Surgical incisions – Burns – Skin breaks – Urinary catheters – Respiratory devices – Central venous catheters – Enteral feeding tubes
Exposure to Contagious Agents	Contact with pathogens capable of causing infection through various routes.	– Close contact with sick individuals – Touching contaminated surfaces – Inadequate respiratory etiquette (coughing/sneezing without covering)
Infant Vulnerability	Factors increasing infection susceptibility in infants due to immature immune systems and unique exposures.	– Prematurity – Low birth weight – Congenital heart defects – Cleft lip/palate – Weakened immune system
Chronic Diseases	Long-term health conditions that debilitate the immune system over time.	– Heart disease – Lung disease – Kidney disease – Diabetes mellitus – Cancer
Multiple Sexual Partners	Increased risk of sexually transmitted infections due to higher exposure probability.	– Unprotected sex with multiple partners
Lack of Immunization	Absence of vaccine-induced immunity against preventable infections.	– Missed routine vaccinations – Failure to receive recommended booster shots

Signs and Symptoms of Infection

Recognizing the signs and symptoms of infection is crucial for timely nursing diagnosis and intervention. These indicators can be categorized as subjective (reported by the patient) and objective (observable and measurable).

Subjective Data:

• Reports of persistent fatigue and malaise (general unwell feeling)
• Complaints of pain or discomfort in a specific area or generalized
• Reports of decreased appetite or anorexia

Objective Data:

• Elevated body temperature or fever (above normal baseline)
• Localized redness (erythema), swelling (edema), warmth, and pain at a potential infection site
• Presence of purulent or unusual wound drainage or discharge
• Elevated heart rate (tachycardia)
• Increased respiratory rate (tachypnea)
• Laboratory findings indicating leukocytosis (elevated white blood cell count)
• Positive culture results from blood, urine, wound, or other bodily fluids
• Clinical signs of inflammation, such as localized heat, redness, swelling, pain, and loss of function
• Delayed wound healing or wound dehiscence/evisceration
• Skin breakdown, rashes, or lesions

Image of Chain of Infection. Six elements are necessary, including a causative organism, a reservoir, a mode of transmission from the reservoir to the host, and a mode of entry into a susceptible host.
Alt text: Diagram illustrating the chain of infection, showing six key elements: causative agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

Nursing Care Plans and Management for Infection Risk

Nursing care plans for patients at risk of infection are structured to provide a systematic approach to care. They emphasize comprehensive assessment, early infection detection, swift treatment initiation, and thorough patient and healthcare provider education. These plans are designed to mitigate the risks of healthcare-associated infections (HAIs) and enhance patient well-being across diverse healthcare settings, including hospitals, long-term care facilities, outpatient clinics, and home healthcare environments.

Nursing Problem Priorities for Infection Risk

Prioritizing nursing actions is essential in managing patients at risk for infection. Key nursing priorities include:

1. Infection control and prevention. Implementing rigorous infection prevention strategies to minimize the risk of infection transmission is paramount.
2. Assessment and early detection. Prompt identification of infection is crucial for timely intervention and preventing complications.
3. Isolation precautions. Employing appropriate isolation measures based on the suspected or confirmed mode of transmission to protect both patients and healthcare personnel.
4. Surgical asepsis. Maintaining strict adherence to surgical aseptic principles during invasive procedures to prevent surgical site infections.
5. Patient and caregiver education. Empowering patients and their caregivers with knowledge and skills for infection prevention at home and in healthcare settings.

Nursing Assessment for Infection Risk

A thorough nursing assessment is the foundation for identifying patients at risk for infection and detecting infections early. Assessment involves gathering both subjective and objective data related to the patient’s condition and risk factors.

Key Assessment Areas (Subjective and Objective Data):

• Fever. Assess body temperature for elevation above the patient’s baseline. Note the presence of chills, sweats, or fluctuations in temperature.
• Pain or tenderness. Evaluate for localized or generalized pain, tenderness to touch, or new onset of discomfort. Determine the location, character, and intensity of pain.
• Redness and swelling (Inflammation). Observe for signs of inflammation, including redness, warmth to touch, swelling, and localized pain.
• Tachycardia and tachypnea. Monitor vital signs for elevated heart rate and respiratory rate, which can indicate the body’s response to infection or systemic illness.
• Malaise. Inquire about and observe for general feelings of discomfort, weakness, fatigue, or “not feeling well.”
• White blood cell count (WBC). Review laboratory results for WBC count. Elevated WBC count (leukocytosis) often indicates an active infection. Note any abnormalities in WBC differential.

Nursing Diagnosis for Infection Risk

Following a comprehensive assessment, nursing diagnoses are formulated to specifically address the identified infection risks and actual infections. These diagnoses guide the development of individualized care plans. Nursing diagnoses are clinical judgments made by nurses based on their assessment data and professional expertise. While standardized nursing diagnoses provide a framework for care, the nurse’s clinical judgment is essential in tailoring the care plan to each patient’s unique needs and clinical context.

Here are examples of nursing diagnoses commonly used for patients at risk for or experiencing infection:

• Risk for Infection: This diagnosis is used when a patient has identifiable risk factors that increase their susceptibility to infection.
• Infection: This diagnosis is used when there is clinical evidence of an active infection, supported by signs, symptoms, and diagnostic findings.
• Deficient Knowledge: This diagnosis may be applicable if the patient lacks understanding regarding infection prevention measures and self-care strategies to reduce infection risk.
• Impaired Skin Integrity: This diagnosis is relevant when there are breaks in the skin or mucous membranes, creating potential portals of entry for pathogens.
• Imbalanced Nutrition: Less Than Body Requirements: This diagnosis can be used if nutritional deficits are contributing to weakened immunity and increased infection risk.

Nursing Goals for Infection Care

Establishing clear and measurable goals is essential for effective infection care planning. Patient goals and expected outcomes for patients at risk for infection include:

• The patient will remain free from infection, as evidenced by stable vital signs within normal limits and the absence of signs and symptoms of infection throughout their care.
• The patient will demonstrate effective maintenance or restoration of their natural defenses against infection.
• The patient, or their caregiver, will verbalize early recognition of infection signs and symptoms, enabling prompt treatment seeking.
• The patient will demonstrate correct and consistent application of meticulous hand-hygiene techniques.
• Patient-reported problems and discomforts related to any existing infection will be alleviated or minimized.

Nursing Interventions and Actions for Infection Care

Nursing interventions are the specific actions nurses implement to achieve patient goals and address nursing diagnoses related to infection risk. These interventions are categorized to provide a structured approach to infection care.

1. Assessment and Early Detection Interventions

Early identification of infection is crucial for initiating timely treatment and preventing complications.

1. Assess for predisposing factors and common causes of infection (as listed previously).
Rationale: Identifying risk factors helps determine a patient’s susceptibility to infection and guides preventative measures. These factors often represent disruptions in the body’s natural defenses. Understanding the causative microorganisms (bacteria, viruses, fungi, parasites) informs appropriate diagnostic and treatment strategies.

2. Assess for localized infectious processes in skin, mucous membranes, or wounds.
Rationale: Localized signs of infection, such as swelling, redness, pain, heat, and impaired function, indicate the body’s inflammatory response to pathogens at a specific site. For example, Staphylococcus aureus colonization on skin may not cause immediate infection unless there’s a break in skin integrity, such as an incision.

3. Monitor and document vital signs, noting any signs and symptoms of infection.
Rationale: Changes in vital signs (fever, tachycardia, tachypnea) and the appearance of infection symptoms (drainage, redness, pain) are critical indicators of developing or worsening infection. Systematic monitoring allows for early recognition and prompt intervention.

4. Monitor white blood cell (WBC) count and differential.
Rationale: Elevated WBC count (leukocytosis), particularly neutrophils, is a common indicator of the body’s immune response to infection. Normal WBC range is 4,500 – 11,000 cells/µL. Significantly low WBC counts suggest severe immunocompromise. In older adults, infections may present without marked WBC elevation. WBC differential can provide more specific information about the type of infection.

5. Assess and monitor nutritional status, weight, history of weight loss, and serum albumin levels.
Rationale: Malnutrition weakens the immune system, impairing the body’s ability to fight infection. Deficiencies in micronutrients (vitamins, minerals) negatively impact immune function. Vitamin D deficiency, for example, increases respiratory infection risk. Albumin is a marker of protein status and overall nutritional health.

6. Investigate medication history and treatments that may cause immunosuppression.
Rationale: Certain medications, like antineoplastic agents and corticosteroids, suppress the immune system, increasing infection susceptibility. Immunosuppressants, including TNF inhibitors, can increase the risk of opportunistic infections, including fungal infections.

7. Assess immunization status and history.
Rationale: Complete immunization provides acquired active immunity against vaccine-preventable diseases. Reviewing immunization history identifies individuals at risk due to incomplete or absent vaccinations. Vaccination programs have dramatically reduced the incidence of many infectious diseases.

8. Observe for subtle signs of infection in older adults, such as low-grade fever or new onset of confusion.
Rationale: Older adults often present with atypical infection symptoms. Low-grade fever or new confusion may be the primary indicators, as classic signs like high fever or pain may be blunted or absent. Cognitive impairment can further mask typical infection presentations.

9. Obtain travel history from patients, especially those presenting with infectious symptoms.
Rationale: Travel history is crucial for identifying potential exposures to geographically specific pathogens. Travel-associated illnesses are common, especially in travelers to low- and middle-income countries. Post-travel infections may manifest weeks or months after return.

10. Determine specific travel exposures (food, water, insect bites, activities).
Rationale: Detailed exposure history during travel helps narrow down potential infectious agents. Contaminated food/water, insect bites, and freshwater exposure are common routes of infection acquisition during travel. Accommodation type and activities also influence disease risk.

11. For pregnant patients, assess the integrity of amniotic membranes.
Rationale: Prolonged rupture of amniotic membranes before delivery increases infection risk for both mother and neonate. Intact membranes provide a protective barrier. Asymptomatic infections in pregnant women are common, necessitating vigilant screening.

12. Perform group B streptococcus (GBS) screening in pregnant women at 35-37 weeks gestation.
Rationale: GBS is a leading cause of severe neonatal infections. Universal screening via vaginal/rectal swab at 35-37 weeks allows for intrapartum antibiotic prophylaxis to prevent neonatal GBS disease.

13. Identify factors that may reduce hand hygiene effectiveness (skin condition, jewelry).
Rationale: Compromised skin integrity (cracks, dermatitis, cuts) and jewelry (rings, bracelets) can harbor bacteria and hinder effective hand hygiene. Bracelets, if non-removable, should be positioned above the wrist during hand hygiene.

14. Assess for latex allergy history.
Rationale: Latex allergy is a reaction to natural rubber latex proteins. Powdered latex gloves are particularly associated with allergies. Healthcare workers, individuals with multiple surgeries, and those with other allergies are at higher risk.

15. In case of blood or body fluid exposure, perform urgent risk assessment.
Rationale: Prompt risk assessment (within 2 hours) after potential blood/body fluid exposure is crucial to determine the need for post-exposure prophylaxis (PEP) for bloodborne pathogens like HIV, hepatitis B, and hepatitis C.

16. Monitor C-reactive protein (CRP) levels.
Rationale: CRP is an inflammatory marker that rises rapidly in response to infection. It can be used to monitor infection progression and response to treatment, especially in older adults where other inflammatory markers may be less reliable.

17. Utilize validated biomarkers for infection prediction in older adults (e.g., CURB-65, Pneumonia Severity Index (PSI)).
Rationale: Validated scoring systems like CURB-65 and PSI aid in risk stratification and predicting outcomes in older adults with infections like pneumonia. CURB-65 assesses confusion, uremia, respiratory rate, blood pressure, and age ≥65. PSI helps determine inpatient vs. outpatient management of community-acquired pneumonia (CAP).

2. Infection Control and Prevention Interventions

Implementing robust infection control measures is fundamental to preventing infection transmission.

1. Maintain strict asepsis during dressing changes, wound care, IV therapy, and catheter handling.
Rationale: Aseptic technique minimizes pathogen introduction and spread. It is critical to interrupt the chain of infection. For urinary catheters, use sterile, closed drainage systems and the smallest effective catheter size. Asepsis is equally vital in wound care and dressing changes.

2. Practice meticulous hand hygiene (“5 Moments for Hand Hygiene”):

• Before touching a patient.
• Before clean/aseptic procedures (dressing change, IV insertion).
• After body fluid exposure risk.
• After touching a patient.
• After touching patient surroundings.
  Rationale: Hand hygiene is the cornerstone of infection prevention. Friction and running water effectively remove microorganisms. Antiseptic soap and water for at least 15 seconds, or alcohol-based hand rubs (ABHR) when hands are not visibly soiled, are recommended. ABHRs are highly effective.

3. Encourage protein-rich, calorie-rich, and balanced diet.
Rationale: Optimal nutrition supports immune system function and tissue health. Adequate protein and calorie intake enables tissue repair and immune response. Micronutrients like zinc, vitamin E, and vitamin D are vital for immune function, particularly in older adults.

4. Change soiled or wet dressings and bandages promptly.
Rationale: Soiled dressings are a potential reservoir for pathogens. Maintaining a clean, dry wound environment is essential for preventing infection and promoting healing. Change dressings as per physician orders or more frequently if visibly soiled.

5. Assist patients with appropriate skin hygiene.
Rationale: Regular skin cleansing, especially handwashing, reduces viral and bacterial load and prevents self-inoculation of mucous membranes.

6. Dispose of soiled linens properly (containment, avoid shaking).
Rationale: Soiled linens, especially those contaminated with body fluids, can harbor pathogens. Proper disposal procedures prevent environmental contamination and pathogen spread. Avoid shaking linens to minimize airborne dispersal of microorganisms.

7. Avoid talking, coughing, or sneezing over open wounds or sterile fields.
Rationale: Respiratory droplets can contaminate sterile fields and open wounds. Respiratory hygiene is crucial for preventing wound infections and protecting sterile environments.

8. Wear gloves when handling patient body fluids.
Rationale: Gloves provide a barrier against microorganisms in body fluids. Wear gloves when contact with secretions or excretions is anticipated and discard after each patient contact. Hand hygiene is still necessary after glove removal, as gloves can develop micro-perforations and hands can become contaminated during removal.

9. Instruct patients on hand hygiene before handling food or eating.
Rationale: Hand hygiene before meals prevents ingestion of pathogens and reduces the risk of foodborne illness and cross-contamination.

10. Encourage increased fluid intake (unless contraindicated).
Rationale: Adequate fluid intake promotes urine dilution and frequent bladder emptying, reducing urinary stasis and the risk of urinary tract infections (UTIs). Hydration also supports overall physiological function, replaces fluids lost during fever, and maintains skin and mucous membrane moisture.

11. Encourage coughing and deep breathing exercises and frequent position changes.
Rationale: These measures prevent respiratory secretion stasis in the lungs. Stasis increases the risk of respiratory infections, including pneumonia. Chest physiotherapy techniques can also aid in secretion removal and improve ventilation.

12. Recommend soft-bristled toothbrushes and stool softeners.
Rationale: Soft toothbrushes minimize trauma to oral mucous membranes, reducing potential entry points for pathogens. Stool softeners prevent straining and potential rectal tissue damage, especially in immunocompromised patients.

13. Promote nail care; keep patient and nurse fingernails short and clean.
Rationale: Long or unclean fingernails can harbor microorganisms and increase the risk of pathogen transmission. Short, clean nails are easier to clean and less likely to puncture gloves.

14. Encourage adequate sleep and rest.
Rationale: Sleep is a critical modulator of immune function. Sleep deprivation weakens immunity and increases infection susceptibility. Regular sleep patterns support optimal immune responses.

15. Assist patients in learning stress-reduction techniques.
Rationale: Chronic stress can suppress the immune system. Stress-reduction techniques (meditation, deep breathing) can help modulate stress hormones and promote balanced immune function.

16. Follow proper cleaning and disinfecting procedures for patient environment and equipment.
Rationale: Environmental cleaning and disinfection reduce pathogen load in the patient’s surroundings. Use agency-approved disinfectants and protocols. Clean frequently touched surfaces and equipment.

17. Avoid eating or drinking in patient care areas.
Rationale: Eating and drinking in patient areas increases the risk of pathogen transmission to healthcare workers. The mouth is a common portal of exit for pathogens. Designated break areas away from patient care zones are essential.

18. Avoid artificial nails and nail extenders; keep natural nails short.
Rationale: Artificial nails and extenders harbor significantly higher bacterial loads than natural nails. They are not recommended for healthcare workers. Nails should be kept short (≤¼ inch) and clean.

19. Use warm water and appropriate products for hand hygiene.
Rationale: Warm water is effective for hand hygiene and less damaging to skin than hot water. Use adequate soap to emulsify oils and fatty materials. Dispense products from disposable pump containers to prevent contamination.

20. Carry alcohol-based hand rub (ABHR) for frequent hand hygiene, especially during patient care.
Rationale: ABHR is a convenient and highly effective hand hygiene method, particularly at the point of care. ABHRs with 60-90% alcohol concentration are recommended.

21. For blood/body fluid exposures, wash thoroughly and follow agency policy.
Rationale: Immediate washing with soap and water or saline (for mucous membranes) is essential after exposure. Follow agency protocols for reporting, risk assessment, and potential post-exposure prophylaxis. Avoid actions that may increase bleeding from percutaneous injuries.

22. Provide micronutrient supplementation as appropriate (vitamins, zinc, omega-3s).
Rationale: Supplementation can address nutritional gaps and support optimal immune function. Vitamin C, vitamin D, zinc, and omega-3 fatty acids play key roles in immune health. Consider multivitamin/mineral supplements as well.

23. Ensure staff vaccinations and health screenings are up-to-date.
Rationale: Healthcare worker vaccinations (influenza, measles, rubella, pertussis, tetanus, hepatitis B, varicella) protect both staff and patients. Regular TB screening is also essential. Employee health programs should promote staff well-being and infection prevention.

24. Implement antimicrobial stewardship programs rigorously.
Rationale: Antimicrobial stewardship programs control antibiotic resistance, improve patient outcomes, and reduce healthcare costs. Monitoring antimicrobial susceptibility patterns is crucial for guiding antibiotic selection and preventing resistance development.

25. Collaborate on infection control policy development and interventions.
Rationale: Infection control programs require multidisciplinary collaboration to develop, implement, and evaluate effective policies and interventions. Vertical interventions target specific pathogens (e.g., MRSA surveillance), while horizontal interventions address broader transmission mechanisms (e.g., hand hygiene).

26. Promote appropriate oral hygiene.
Rationale: Poor oral hygiene is linked to increased infection risk, poor health outcomes, and malnutrition. Regular oral care (morning, after meals, bedtime) is essential.

27. Encourage daily bathing.
Rationale: Daily bathing, especially with chlorhexidine gluconate (CHG) products, can significantly reduce HAIs. CHG is more effective than traditional soap and water. Wash basins can be reservoirs for pathogens.

28. Disinfect mobile phones and gadgets frequently.
Rationale: Mobile devices are often heavily contaminated with pathogens. Regular disinfection of phones and other gadgets used by patients, staff, and visitors is important to prevent pathogen spread.

3. Implementing Isolation Precautions

Isolation precautions are essential to prevent the transmission of infectious agents based on their mode of transmission.

1. Instruct patients not to share personal care items.
Rationale: Sharing personal items (toothbrushes, towels, razors) can transmit pathogens. Educate patients on infection transmission routes and the importance of individual hygiene items.

2. Limit visitors and reinforce reporting of infection signs.
Rationale: Limiting visitors reduces potential pathogen exposure. Educate visitors and staff on reporting respiratory or other infection symptoms and avoiding contact when ill.

3. Provide surgical masks to coughing visitors and enforce respiratory etiquette.
Rationale: Masks and respiratory etiquette (covering coughs/sneezes with elbow, tissue disposal, hand hygiene) prevent droplet transmission. Provide masks to symptomatic visitors and ensure availability of tissues and no-touch disposal receptacles.

4. Place high-risk patients (e.g., neutropenic) in protective isolation.
Rationale: Protective isolation (reverse isolation) protects immunocompromised patients from external pathogens. Single-patient rooms with enhanced ventilation are ideal.

Initiate specific precautions based on suspected agents (CDC guidelines).

Standard Precautions

Standard Precautions: Applied to all patients regardless of suspected or confirmed infection status. Assume all patients are potentially infectious.

• Hand hygiene: Frequent handwashing or ABHR use.
• Glove use: Wear gloves for contact with body fluids, secretions, excretions, contaminated items. Discard gloves after each patient contact.
• Needlestick prevention: Avoid recapping needles. Dispose of sharps in puncture-resistant containers. Use one-handed recapping technique if absolutely necessary.
• Splash and spray avoidance: Use barriers (goggles, masks, gowns) when splash or spray of body fluids is possible.

Airborne Precautions

Airborne Precautions: For pathogens transmitted via small airborne particles (e.g., tuberculosis, varicella, measles).

• Airborne infection isolation room (AIIR): Negative pressure, rapid air exchange, HEPA filtration or direct exhaust to outside.
• N95 respirator: Fit-tested N95 respirators required for healthcare workers.
• Patient placement: AIIR or single-patient room. Keep door closed.
• Restrict susceptible personnel: Limit room entry to immune individuals.
• Signage: Post airborne precaution signage on door.

Droplet Precautions

Droplet Precautions: For pathogens transmitted via large respiratory droplets (e.g., influenza, meningococcus).

• Facemask: Wear facemask when within 3-6 feet of patient.
• PPE: Masks and eye protection (goggles or face shield).

Contact Precautions

Contact Precautions: For pathogens spread by direct or indirect contact (e.g., antibiotic-resistant organisms, C. difficile).

• Gloves and gowns: Wear gloves and gowns upon room entry.
• Dedicated equipment: Use disposable or dedicated patient equipment.
• Hand hygiene: Soap and water handwashing preferred over ABHR for C. difficile (spores resistant to alcohol).
• Bleach-based disinfectants: Use bleach-containing products for environmental cleaning, especially for C. difficile.

Proper Wearing of PPE (Donning and Doffing)

Wear PPE correctly (Gloves, Masks, Gowns, Eye Protection):

• Gloves: Double gloving may be considered for surgical procedures. Select appropriate glove type based on risk.
• Masks: Masks, goggles, face shields protect mucous membranes. Cloth masks offer less protection than NIOSH-approved respirators.
• Gowns: Wear gowns for direct contact with uncontained secretions/excretions. Single-use gowns only. USP 800 guidelines specify gown standards for handling hazardous drugs.

Limit patient transport: Transport only for essential procedures. Use appropriate barriers during transport. Notify receiving personnel of precautions.

Institute enteric precautions: For gastrointestinal pathogens (e.g., C. difficile, norovirus). Contact precautions plus:

• Gown use: Gowns always required in patient room due to fecal contamination risk.
• Soap and water handwashing: Soap and water preferred over ABHR for C. difficile.
• Special disinfection: Terminal disinfection including mattress disinfection after patient discharge.

Door signage: Post signs indicating required isolation precautions. Private rooms or cohorting patients with the same infection is acceptable. Private bathrooms are preferred.

Donning PPE (Sequence):

1. Hand hygiene.
2. Gown.
3. Mask or respirator.
4. Goggles or face shield.
5. Gloves (over gown cuffs).

Doffing PPE (Sequence):

1. Gloves (hand hygiene after removal).
2. Gown (avoid contamination of clothing; roll inward and discard; hand hygiene after removal).
3. Eye protection (handle by sides, front is contaminated).
4. Mask or respirator (handle by straps/ties, front is contaminated; hand hygiene after removal).

4. Promoting Surgical Asepsis

Surgical asepsis aims to create and maintain a sterile environment during invasive procedures to prevent surgical site infections.

1. Perform thorough surgical scrub before procedures.
Rationale: Surgical scrubbing with antiseptic soap and water or alcohol-based scrubs reduces microbial load on hands and arms.

2. Wear appropriate sterile PPE (gowns, gloves, caps, masks) for surgical procedures.
Rationale: Sterile PPE creates a barrier against microorganisms from surgical team members. Cover hair and respiratory tract to minimize contamination of surgical site.

3. Meticulously prepare patient’s surgical site (skin cleansing, antiseptic application, hair removal if needed).
Rationale: Preoperative skin preparation reduces microbial load at the surgical site. Use antiseptic solutions and shave hair (if needed) with electric clippers immediately before surgery.

4. Ensure all surgical articles are properly sterilized or disinfected.
Rationale: Sterilization or high-level disinfection eliminates microorganisms from surgical instruments, supplies, and equipment.

5. Maintain sterility; avoid touching sterile objects with non-sterile items.
Rationale: Sterile objects must only contact other sterile items. When sterility is uncertain, consider the object contaminated. Keep forceps tips pointed down during sterile procedures to prevent fluid contamination.

6. Keep sterile items above waist level.
Rationale: Items below waist level are considered non-sterile due to potential contamination.

7. Keep sterile field in constant view.
Rationale: Maintain visual oversight of sterile field to ensure sterility is maintained. Never turn your back on a sterile field. Maintain a safe distance from sterile field (at least 1 foot).

8. Avoid contamination when opening sterile equipment.
Rationale: Open sterile packages carefully to prevent contamination of sterile contents. Package edges are considered non-sterile after opening.

9. Do not use equipment with breached sterile barriers (punctures, tears, moisture).
Rationale: Compromised sterile barriers indicate contamination. Replace damaged sterile supplies.

10. Avoid touching the border of a sterile field (1-inch edge).
Rationale: The 1-inch border of a sterile drape is considered non-sterile. Place sterile items within the central sterile field, away from the border.

11. Continuously monitor sterile fields and address any breaks in technique.
Rationale: Constant vigilance is needed to maintain sterility. Items of questionable sterility are considered non-sterile. Prepare sterile fields close to the time of use.

12. Ensure movements around sterile field do not compromise sterility.
Rationale: Avoid coughing, sneezing, laughing, or talking directly over sterile fields. Do not reach across sterile fields. When pouring sterile solutions, maintain sterility of pouring lip and inner cap and avoid splashing.

13. Select sterile or clean gloves based on procedure and risk.
Rationale: Sterile gloves are required for invasive procedures or when contact with sterile tissues/body cavities is anticipated. Clean gloves are appropriate for routine patient care with risk of body fluid exposure or contact with contaminated surfaces.

5. Providing Patient and Caregiver Education

Patient and caregiver education is critical for promoting infection prevention and management outside of healthcare settings.

1. Educate patients and caregivers about the infectious process.
Rationale: Knowledge empowers patients and families to understand infection risks, transmission, and prevention strategies. Address misconceptions and stigma associated with infectious diseases. Nurses may also need to report certain cases to public health for contact tracing and follow-up.

2. Instruct caregivers on accurate temperature measurement.
Rationale: Accurate temperature readings are essential for monitoring infection severity and treatment response, especially in outpatients. Educate caregivers on proper thermometer use and interpretation of readings.

3. Educate on proper cleaning, disinfecting, and sterilizing items at home.
Rationale: Knowledge of home hygiene practices reduces pathogen load and transmission risk. Explain the differences between cleaning, sanitizing, and disinfecting. Emphasize cleaning before sanitizing or disinfecting for optimal effectiveness.

4. Teach the importance of avoiding contact with individuals with infections and practicing physical distancing.
Rationale: Limiting exposure to sick individuals reduces infection risk, especially for vulnerable populations. Explain transmission routes (direct contact, airborne, fomites) and the benefits of physical distancing, especially during outbreaks.

5. Demonstrate and provide return demonstration opportunities for high-risk procedures (dressing changes, IV care).
Rationale: Hands-on training ensures patients and caregivers can safely and effectively perform necessary procedures at home, reducing infection risk. Return demonstration verifies competency.

6. Teach the purpose and proper techniques for isolation at home if indicated.
Rationale: If home isolation is necessary, educate patients and families on specific isolation guidelines to prevent transmission within the household and community.

7. If infection occurs, instruct on proper use of prescribed anti-infectives (e.g., antibiotics).
Rationale: Ensure patients understand medication regimen, dosage, frequency, duration, and potential side effects. Emphasize completing the full course of antibiotics to prevent resistance and recurrence, even if symptoms improve.

8. Encourage patients and caregivers to remind healthcare workers about infection control procedures.
Rationale: Empower patients and families to be active participants in infection prevention. Encourage them to politely remind healthcare workers to perform hand hygiene.

9. Provide information on the importance of vaccines and vaccination programs.
Rationale: Promote vaccine uptake to prevent vaccine-preventable diseases. Explain vaccine benefits and address common misconceptions. Provide information on recommended vaccines for different age groups and risk factors.

10. Educate patients to report any problems after vaccination.
Rationale: Vaccine adverse events, though rare, should be reported. Instruct patients on how to report adverse events through the Vaccine Adverse Event Reporting System (VAERS).

11. Instruct caregivers to regularly disinfect medical equipment used at home and use aseptic technique.
Rationale: Proper equipment disinfection and aseptic technique are essential for preventing infections in home healthcare settings. Emphasize catheter care, wound care, and other procedures requiring aseptic principles.

12. Educate family members on strategies to reduce infection risk within the household.
Rationale: Household infection control measures protect all family members, especially when caring for an infected or immunocompromised individual. Address specific risks based on the patient’s condition (e.g., TB, varicella).

13. Provide sharps safety education for patients with bloodborne infections managing care at home.
Rationale: If patients manage sharps (needles, lancets) at home, provide comprehensive sharps safety education to prevent accidental needlesticks and bloodborne pathogen transmission. Emphasize proper sharps disposal in designated containers.

14. Encourage spending time outdoors and improving indoor ventilation.
Rationale: Improved ventilation and outdoor time reduce airborne pathogen concentration, lowering the risk of respiratory infections like COVID-19 and influenza.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources for further learning:

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health

Other recommended site resources for this nursing care plan: (Links to relevant articles within nurseslabs.com – already integrated throughout the article)

References and Sources

(References from the original article are implicitly retained throughout and are cited inline where applicable. For a comprehensive list, please refer to the original Nurseslabs article.)