Nursing Diagnosis

Risk for infection due to

inadequate primary and
secondary defenses as
manifested by:
O: traumatized tissue, with
indwelling foley catheter,
(+) immunocompromised
status, with IV line.

Objective
Nursing Intervention
Rationale
After 24 hours of Nursing
1. Place the client in a
1. To prevent nosocomial
intervention the patient will
private room.
infection.
not acquire any infection,
2. Do proper hand washing 2. To prevent transmission
no evidence of swelling and
before and after entering
of microorganisms.
redness, negative results on
the clients room.
blood culture.
3. Assess wound color,
3. Monitor status of
odor, and drainage.
patients wounds.
Report any changes.
Recognize early signs of
infection.
4. Meticulous aseptic
4. Prevent bacterial
wound care.
colonization.
5. Debride long devitalized 5. Discourage bacterial
tissue.
growth.
6. Apply a topical anti6. Acts as a prophylaxis.
infective as ordered.
7. Shave hair around burn 7. Hair can harbor
injury.
microorganisms.
8. Provide perineal
8. Prevent infection in
hygiene.
catheter site.
9. Observe for headache,
9. Indication of sepsis.
chills, change in vital
signs, hyperglycemia,
restlessness and
confusion.

Evaluation
After 24 hours of nursing
intervention, the client did
not acquire infection as
evidenced by (-) swelling
and redness, (-) blood
cultures.