Risk for infection vs infection? Need help with nursing diagnoses.

My NANDA nursing diagnosis handbook only lists risk for infection as a nursing diagnosis. While writing my care plan I feel that the main concern with most of my patients is infection, but not risk for. They are exhibiting signs of infection (high WBC, fever, cloudy urine, purulent drainage, etc.), so I can not list that as risk for infection because it is apparent that the infection already exists. I don't understand why plain old infection is not a nursing diagnosis when I have so much assessment data that I could put toward that diagnosis.

Does anyone have an explanation for this, or know a way to still include certain information/data under a different diagnosis?

8 Answers

Nursing is responsible for identifying risk factors for infection so they can mitigate or eliminate them using nursing interventions. Once an infection has occurred, though, that becomes a medical diagnosis, and the nursing care shifts to implementing the interventions in the medical plan of care we're responsible for implementing.

Of course, we will probably still be able to look at risk for infection in other places-- if there's a wound infection developed in the belly, for example, we can still do what we can to decrease the chances of ventilator-associated pneumonia, urinary tract infection, oral thrush, and the like. We can also be sure to decrease the chances of making the existing infection worse, by being sure to implement nursing measures to decrease the chances of introducing new pathogens into that belly wound, for example, or spreading the ones in it to other places.

See how that works?

Because infection is a medical diagnosis. Maybe if you think of what infection can lead to, you can come up with some nursing diagnoses that are appropriate.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Your patient has an infection now what has that done to the body? Do they have a temp? Then your nursing diagnosis would be fever. Are their vital signs stable? Is their heart rate elevated? Are they adequately hydrated? Do they have any other symptoms?

Care plans are all about your assessment. Vitals signs what do you see? What do they need?

Care plans are all about the patient and the patients problems. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

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  1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. Planning (write measurable goals/outcomes and nursing interventions)
  4. Implementation (initiate the care plan)
  5. Evaluation (determine if goals/outcomes have been met)

Tell me your assessment...What does this patient need? Tell me about your patient....you have told me what is wrong with him but nothing about your assessment

Your post was very informative.. I still don't understand which diagnosis to choose.. I am a first semester student and my patient has an ulcer on the leg and swelling on the other leg with cellulitus on both legs.. she also has edema on her thighs and is obese.. she uses a walker and is in a lot of pain.. she can walk to the bathroom but complains of leg restlessness when she stands... I don't know which to choose from the following : Risk for infection, Risk for immobility and immobility, nutrition, chronic or acute pain... after reading what you wrote i was leaning more towards acute pain because that's something that i would try to focus on and that is to manage her pain because she's obviously in a lot of pain.. however, i'm not quite sure what else to do as an intervention besides giving pain meds..? I would greatly appreciate it if you could help me with that..

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Your care plan is about what your patient has....what they need

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my patient has an ulcer on the leg and swelling on the other leg with cellulitis on both legs.. she also has edema on her thighs and is obese.. she uses a walker and is in a lot of pain.. she can walk to the bathroom but complains of leg restlessness when she stands... she's obviously in a lot of pain

Looking at this...what applies to your patient? What is your patient assessment? What comorbidities exist? What meds is she on?

She has pain, skin open wounds, obese ... she has trouble with mobility ... what care plan resource do you use?

Class09 said:
Your post was very informative.. I still don't understand which diagnosis to choose.. I am a first semester student and my patient has an ulcer on the leg and swelling on the other leg with cellulitus on both legs.. she also has edema on her thighs and is obese.. she uses a walker and is in a lot of pain.. she can walk to the bathroom but complains of leg restlessness when she stands... I don't know which to choose from the following : Risk for infection, Risk for immobility and immobility, nutrition, chronic or acute pain... after reading what you wrote I was leaning more towards acute pain because that's something that I would try to focus on and that is to manage her pain because she's obviously in a lot of pain.. however, I'm not quite sure what else to do as an intervention besides giving pain meds..? I would greatly appreciate it if you could help me with that..

You don't "choose" a nursing diagnosis, you MAKE a nursing diagnosis, based on your assessment data.

If you have diagnosed this lady with pain, your responsibility is to look at nursing actions that will decrease it. "Give pain meds as prescribed" (we don't take "orders," we're not in the military and the physician is not our superior officer) is something that nurses do, certainly, but is not an independent, autonomous nursing action, which is what a nursing plan of care is.

What might be? Perhaps you might figure out times that her pain is worse, and mitigate the activities that cause it. Perhaps you might time her PRN med to plan ahead for an activity you know will be painful for her. Perhaps you might teach her some meditation or other visualization to help her manage her pain. Perhaps you might assess that she has fear about something (ya think?) and we know fear potentiates pain, and figure out a way to help with that. ... Get the idea?

so that others will see: what I didnt see others posting is that because "infection" is a medical diagnosis, so you can say "abnormal labs" if your WBC is high. Or you can say pain AEB pain rating R/T dx of infection. that is if the HCP has dx the patient as such.

Nursing diagnosis: Risk for infection (Domain 11, safety and protection; Class 1, infection)

Definition: Vulnerable to invasion and multiplication of pathogenic organisms, which may compromise health

Risk factors (many listed-- chronic illness, inadequate vaccination, invasive procedure, others)

Then:

Inadequate primary defenses: (things like alterations in peristalsis, pH of secretions, skin integrity, decrease in ciliary action, and others)

Inadequate secondary defenses: decrease in hemoglobin, immunosuppression, leukopenia, suppressed inflammatory response (e.g., IL-6, CRP), inadequate vaccination

Increased environmental exposure: exposure to disease outbreak

In terms of not being able to use the term "infection" as a nursing diagnosis... well, what are you going to do with that? You can't prescribe antibiotics, or amputate a gangrenous foot, or lance a boil. See, nursing diagnosis is your entree into providing nursing care, things that nursing can do autonomously to treat the nursing diagnosis.

So... think about what the effect of that infection (medical diagnosis) is upon the patient, then see if you can make a nursing diagnosis (validate your hunch against the NANDA-I diagnoses by finding "infection" as a related (causative) factor for your defining characteristic(s), and you're starting to think like a nurse and not a physician appendage.

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