Risk for Infection - Nursing Assessment and Nursing Diagnosis


Infection is an invasion of the body by pathogens or microorganisms capable of causing illness (Potter and Perry, 2005).

Some of the factors that trigger the risk of infection in patients by Potter and Perry (2005) are:

1) Agent
The agent causing the infection, the microorganism can enter because the agent itself or because the toxins are released.

2) Host
The hosts were infected, so even if there is an agent, if no one can be charged, there is no infection. Hosts are usually people or animals in accordance with the needs of the agent to survive or breed.

3) Environment
Environment, the environment around the agent and the host, such as temperature, humidity, sunlight, oxygen and so on. There are certain agents that can only survive or infect certain environmental conditions as well.


Signs and Symptoms

Signs and symptoms are common in infections (Smeltzer, 2002) as follows:



1. Rubor
Rubor or redness is first seen in areas that become inflamed. When inflammatory reactions arise, dilation of the arterioles that supply blood to areas of inflammation. So that more blood flows to local microcirculation and capillary stretch quickly filled with blood. This condition is called hyperemia or congestion, causing local red color because of acute inflammation.

2. Calor
Calor occur simultaneously with redness of acute inflammatory reactions. Calor is also caused by increased blood circulation. Because blood has a temperature of 37 degrees Celsius is channeled to the body surface inflamed to the area more than normal.

3. Dolor
Changes in local pH or local concentration of certain ions can stimulate nerve endings. Spending substances such as histamine or other bioactive can stimulate nerves. The pain is caused also by the pressure was rising due to swelling of inflamed tissue.

4. Tumor
Swelling partly due to hyperemia and mostly caused by the delivery of fluid and cells from the blood circulation into the interstitial tissues.

5. Functio Laesa
Functio laesa is a loss of function or a disturbance of function.


Diagnostic

Laboratory tests are directly related to the infection include a complete blood count that includes: hemoglobin, leukocytes, hematocrit, erythrocytes, platelets, MCH, MCHV, basophils, eosinophils, stem segments, lymphocytes, and monocytes, erythrocyte sedimentation rate (ESR), random blood glucose, and albumin.


Medical Management

1. Aseptic
Actions taken in health care. This term is used to describe all the work done to prevent the entry of microorganisms into the body that are likely to lead to infection. The end goal is to reduce or eliminate the number of microorganisms, both on the surface of animate objects and inanimate objects so that medical equipment can be safely used.

2. Antiseptic
Efforts to prevent infection by killing or inhibiting the growth of microorganisms on the skin and other body tissues.

3. Decontamination
Actions taken so that an inanimate object can be handled safely by health workers, particularly medical clearance officer before washing done. An example is the examination table, medical equipment and gloves contaminated with blood or body fluids when actions are performed.

4. Washing
The removal of all blood, body fluids, or any foreign objects such as dust and dirt.

5. Sterilization
The removal of all microorganisms (bacteria, fungi, parasites and viruses), including bacterial endospore of inanimate objects.

6. Disinfection
The removal of most (not all) of disease-causing microorganisms from inanimate objects. High-level disinfection is done by boiling or using chemical solutions. This action can eliminate all microorganisms except some bacterial endospore.


Nursing Assessment

1. Identity
Getting the patient identity data, including name, age, education, occupation, address, registration number, and medical diagnostics.

2. Health history
  • The main complaints: Complaints are most felt by the patient to seek help.
  • Health history now: What is being felt now.
  • Past medical history : Is the possibility of patients had never had this disease or have ever been.
  • Family health history: Covering hereditary diseases or non-communicable diseases.

3. The need for Bio-Psycho-Social-Spiritual.
Needs Bio-Psycho-Social-Spiritual include breathing, eating, drinking, elimination, motion and activity, rest - sleep, personal hygiene, temperature control, security and comfort, socialization and communication, achievement and productivity, knowledge, recreation and worship.

4. Physical Examination
a. General State
The general state include: general impression, awareness, posture, skin color, skin turgor, and personal hygiene.
b. Cardinal Symptoms
Cardinal symptoms include: temperature, pulse, blood pressure, and respiration.
c. Physical State
Includes examining the physical state of the head to the lower extremities.
  • Inspection: examine the skin, mucous membrane color, general appearance, adequacy systemic circulation, breathing pattern, chest wall movement.
  • Palpation: local tenderness, feeling a lump or axilla and breeast tissue, peripheral circulation, the peripheral pulse, skin temperature, color and capillary refill.
  • Percussion: knowing abnormal fluid, the air in the lungs, or the working diaphragm.
  • Auscultation: abnormal sounds, murmurs, as well as friction sound, or the sound of an extra breath.


Nursing Diagnoses

Risk for Infection

Definition: Having an increased risk of pathogenic organisms

Risk Factor:

Chronic Diseases
  • Diabetes mellitus
  • Obesity
Knowledge is not enough to avoid pathogen exposure.
Defence inadequate primary body.
  • Impaired peristaltic
  • Damage to skin integrity (intravenous catheterization, an invasive procedure)
  • Changes in pH secretion
  • Decrease in work ciliary
  • Premature rupture of membranes
  • Smoking
  • Static body fluids
  • Tissue trauma network (ie., trauma, tissue destruction)
Inadequate secondary defenses
  • Decrease in hemoglobin
  • Immunosuppression (ie., Immunity acquired is inadequate, pharmaceutical agents including immunosuppressants, steroids, monoclonal antibodies, immunomodulators)
  • Leukopenia
  • Suspension inflammatory response
Vaccination inadequate
Exposure to environmental pathogens which increased
  • outbreak
Invasive procedures
Malnutrition
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