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NURSING DIAGNOSIS: Risk for Infection
Risk factors may include
- Inadequate primary defenses (decreased ciliary action, stasis of secretions)
- Inadequate acquired immunity (tissue destruction, increased environmental exposure)
- Chronic disease process
- Malnutrition
Desired Outcomes
Knowledge: Infection Control (NOC)
- Verbalize understanding of individual causative/risk factors.
- Identify interventions to prevent/reduce risk of infection.
- Demonstrate techniques, lifestyle changes to promote safe environment.
5 Chronic Obstructive Pulmonary Disease (COPD) Nursing Care Plan (NCP)
Nursing Interventions & Rationale
| Nursing Interventions | Rationale |
| Monitor temperature. | Fever may be present because of infection and/or dehydration. |
| Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake. | These activities promote mobilization and expectoration of secretions to reduce risk of developing pulmonary infection. |
| Observe color, character, odor of sputum. | Odorous, yellow, or greenish secretions suggest the presence of pulmonary infection. |
| Demonstrate and assist patient in disposal of tissues and sputum. Stress proper handwashing (nurse and patient), and use gloves when handling/disposing of tissues, sputum containers. | Prevents spread of fluid-borne pathogens. |
| Monitor visitors; provide masks as indicated. | Reduces potential for exposure to infectious illnesses, e.g., upper respiratory infection (URI). |
| Encourage balance between activity and rest. | Reduces oxygen consumption/demand imbalance, and improves patient’s resistance to infection, promoting healing. |
| Discuss need for adequate nutritional intake. | Malnutrition can affect general well-being and lower resistance to infection. |
| Recommend rinsing mouth with water and spitting, not swallowing, or use of spacer on mouthpiece of inhaled corticosteroids. | Reduces localized immunosuppressive effect of drug and risk of oral candidiasis. |
| Obtain sputum specimen by deep coughing or suctioning for Gram’s stain, culture/sensitivity. | Done to identify causative organism and susceptibility to various antimicrobials. |
| Administer antimicrobials as indicated. | May be given for specific organisms identified by culture and sensitivity, or be given prophylactically because of high risk. |
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