Nursing Care Plan for Susceptibility to Pathogens

Nursing Care Plan for Susceptibility to Pathogens

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Let’s learn about “risk of infection” together. After the COVID-19 pandemic, many people have experienced and learned preventive measures against respiratory infections. However, infections are not limited to the respiratory system.

Infections occur when pathogens are present, individuals come into contact with them, or the immune system fails to respond effectively. The likelihood of infection depends on both exposure to pathogens and the individual’s immune strength. Understanding the three key factors of infection helps us implement effective countermeasures. Let’s start by learning about these factors.

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1. Understanding the Conditions for Infection

The three key factors of infection are:

Three Factors of Infection

1. Source of Infection: The bacteria or viruses responsible for infection.
   • Blood, body fluids, secretions, excreta
2. Mode of Transmission: The means by which pathogens spread.
   • Contact transmission, droplet transmission, airborne transmission
3. Susceptible Host: Individuals with weakened resistance.
   • Age, underlying diseases, immune status, medical procedures, invasive treatments, medications (steroids, antibiotics), nutritional status

Breaking even one of these three factors can prevent infection. These factors are further classified into six components:

Six Components of Infection

1. Pathogen: Bacteria, viruses, fungi, protozoa, rickettsia, chlamydia, mycoplasma, parasites
2. Reservoir: Patients, healthcare workers, environment
3. Portal of Exit: Body openings (mouth, nose, anus), contaminated hands, medical instruments
4. Mode of Transmission: Contact transmission, airborne transmission, droplet transmission
5. Portal of Entry: Nose, mouth, wounds, catheter insertion sites
6. Decreased Immunity: Immunocompromised conditions (immune deficiency, chemotherapy, hypothermia, steroid use, immunosuppressants, etc.)

Since infection can be prevented by interrupting any of these factors, basic infection control measures such as ventilation, handwashing, and proper waste disposal play a crucial role.

2. Nursing Plan for “Risk of Infection”

1) Infection Risk Due to Underlying Diseases

• Diabetes mellitus (increased susceptibility due to impaired neutrophil function, reduced immune response, and circulatory issues)
• Diseases requiring steroid treatment (steroids suppress cellular immunity; higher doses and longer durations increase infection risk) → Immunosuppression
• Respiratory diseases: Asthma, asthmatic bronchitis, COPD (emphysema, chronic bronchitis), interstitial pneumonia (acute, idiopathic), eosinophilic pneumonia, drug-induced pneumonia, sarcoidosis, pulmonary edema, peritonsillar abscess, acute epiglottitis, Pneumocystis pneumonia, cytomegalovirus pneumonia, tuberculosis
• Cardiovascular diseases: Myocarditis (pulse therapy), pericarditis, acute rheumatic endocarditis, acute rheumatic pancarditis, Takayasu arteritis
• Gastrointestinal diseases: Ulcerative colitis, Crohn’s disease, acute hepatitis, fulminant hepatitis, drug-induced liver injury, autoimmune hepatitis, primary biliary cholangitis, typhoid fever, acute peritonitis
• Renal and urinary diseases: Rapidly progressive glomerulonephritis, nephrotic syndrome, HBV/HCV-associated nephropathy
• Hematologic diseases: Aplastic anemia, autoimmune hemolytic anemia, idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura
• Metabolic diseases: Hypoglycemia, amyloidosis
• Endocrine diseases: Hyperthyroidism (Graves’ disease), hypothyroidism, acute adrenal insufficiency, chronic primary adrenal insufficiency (Addison’s disease)
• Allergic/Immunological diseases: Rheumatoid arthritis, lupus erythematosus, polymyositis, scleroderma, systemic vasculitis (ANCA-related, etc.), Sjögren’s syndrome, Behçet’s disease
• Neurological diseases: Multiple sclerosis, polyneuropathy, Guillain-Barré syndrome, peripheral facial nerve palsy
• Malignant tumors: Leukemia, malignant lymphoma, multiple myeloma
• Musculoskeletal diseases: Herniated disc, cervicobrachial syndrome, periarthritis, carpal tunnel syndrome, acute gouty arthritis (gout)
• Dermatological diseases: Severe dermatitis, erythroderma, acute urticaria, severe drug eruption, pemphigus, bullous pemphigoid
• Others: Hemorrhagic shock, graft-versus-host disease, acute spinal cord injury, incompatible blood transfusion, anaphylactic shock, sepsis, tuberculosis, Hansen’s disease
• Diseases requiring immunosuppressants → Immunosuppression
  • Used for autoimmune diseases, organ transplant rejection prevention, and graft-versus-host disease prevention
  • Common immunosuppressants: Tacrolimus (Prograf, Graceptor), Cyclosporine (Neoral), Azathioprine (Azanin, Imuran), Rituximab (Rituxan)
• Dysphagia due to stroke

2) Other Infection Risk Factors

• Infants (Maternal IgG persists until four months, then declines, causing immunodeficiency)
• Outbreaks and pandemics
• Hospitalization or institutionalization (Increased exposure to pathogens)
• Surgery (Tissue damage, homeostasis disruption, risk of wound infections, airway infections, pneumonia)
• Smoking (Chronic airway inflammation, degeneration, reduced primary defense functions)
• Anemia, circulatory failure
• Unvaccinated individuals
• Underweight (malnutrition) or overweight
• Pressure ulcers
• Medical devices:
  • Central and peripheral venous nutrition
  • Indwelling bladder catheter
  • Tracheostomy, ventilator use, difficulty clearing sputum
  • Drain placement
• Poor self-care (Neglecting handwashing, gargling, mask use) or refusal due to mental illness
• Severe burns (Equivalent to widespread open wounds)

3. Nursing Goals

The goals focus on the patient as the subject:

• The patient can prevent infection by interrupting the three factors of infection.
• The patient can maintain wound cleanliness and prevent infection.
• The patient can explain infection prevention measures.

4. Nursing Plan

1) Observation Plan (OP)

• Effects and side effects of treatment plans (use of anticancer drugs, steroids, immunosuppressants)
• Progression, symptoms, and degree of susceptibility to infection in immunocompromised diseases (AIDS, diabetes, leukemia, burns, etc.)
• Course of invasive treatments (surgery, gamma rays, etc.)
• Trends in blood test results (WBC, CRP, procalcitonin, serum amyloid A protein (SAA))
  Procalcitonin correlates with infections (normal value: ≤0.3 ng/ml)
• Signs of infection in imaging tests (XP, CT, etc.)
• Fever (increase of 1°C or more above normal temperature)
• Changes in vital signs such as tachypnea, blood pressure fluctuations, and pulse variations
• Differences in breath sounds between left and right lungs, lung noises (bronchial obstruction due to sputum, atelectasis)
• Condition around the tracheostomy site (signs of infection)
• Characteristics, volume, and odor of sputum
• Characteristics and progress of stool (gastrointestinal infections like norovirus)
• Frequency of bowel movements
• Characteristics and frequency of urination (urinary tract infections)
• Condition of the drain insertion site (signs of infection)
• Drain discharge (color, volume, odor)
• Condition of the central venous catheter insertion site (signs of infection)
• Administration of fat emulsions (propofol, Intralipid)
• Condition of the balloon catheter insertion site
• Characteristics, volume, and odor of urine
• Abnormal vaginal discharge (sexually transmitted infections), genital itching, redness, warmth
• Condition of surgical wounds (warmth, redness, swelling, pain), purulent discharge, wound dehiscence
• Awareness of infection prevention (failure to wash hands)
• Improper handling of contaminants (touching other areas with contaminated hands)
• Living environment (hospitalization, facility admission, unsanitary conditions)
• Malnutrition:
  • TP (≤6.7 g/dl), ALB (≤3.8 g/dl)
  • Cholesterol (≤120 mg/dl)
  • Hb (≤13.5 g/dl for men, ≤11.5 g/dl for women), BMI (≤18.5) Malnutrition increases the risk of pressure ulcers and wound dehiscence
• Cleanliness of the living environment (unsanitary surroundings, hoarding, etc.)
• Infectious disease outbreaks (regional outbreaks, pandemics)
• Improper handling of hygiene products (baby bottles, diapers)
• Condition of pressure ulcers (high risk of infection before epithelialization)
• Food texture (whether it is suitable for swallowing function)
• Eating behavior (coughing while eating, drop in SPO2 after meals, lung sounds, suctioned material)
• Posture during enteral nutrition feeding and immediately after
• Oral hygiene (inadequate mouth care)
• Vaccination status

2) Action Plan (TP)

• Follow cleanroom usage guidelines to prevent pathogen entry
• Maintain a clean living environment (regular ventilation, tidying, cleaning, environmental maintenance)
• Encourage mask-wearing and handwashing during outbreaks or pandemics; avoid the “three Cs” (closed spaces, crowded places, close-contact settings)
• Promote habitual mask-wearing and handwashing among immunocompromised patients
• Enforce hand hygiene between procedures (handwashing or hand sanitizer)
• Implement standard precautions as needed
  Standard Precautions: Treat all blood, body fluids, and mucous membranes as infectious, ensuring thorough hand hygiene and appropriate PPE use.PPE Usage:
  • Wearing: Handwashing → Gown → Mask → Face shield → Gloves (gloves may be worn before gowning)
  • Removing: Gloves → Hand sanitizer → Face shield → Mask → Gown (gloves are removed first as they are the most contaminated)
• For dysphagia, perform neck and shoulder exercises, swallowing exercises (mouth and tongue exercises, “Pa-Ta-Ka-Ra” exercise), and salivary gland massage before meals
• Modify food texture for dysphagia (thickened liquids, bite-sized pieces, minced with sauce, mousse, or pureed food)
• Use assistive devices for dysphagia (appropriately sized spoons for portion control)
• Ensure proper posture during meals and enteral nutrition
• Perform oral care to maintain oral hygiene
• Suction excess sputum to ensure airway clearance
• Change diapers regularly to prevent skin issues due to excretions
• Reposition patients regularly to prevent pressure ulcers
• Use air mattresses for patients unable to reposition themselves to avoid excessive pressure on ulcer-prone areas
• Secure Ba catheters properly to prevent urethral damage
• Maintain hygiene when disposing of urine from Ba catheters
• Change CV catheter dressings aseptically
• Inspect CV catheter insertion site and tubing for damage or abnormalities
• Report signs of CV catheter infections to a physician (assist in culturing catheter tips if needed)
• Replace propofol infusion lines every 12 hours
• Do not use blood transfusion lines for more than 24 hours
  Refer to CDC Guidelines: CDC Guideline 2011
• Replace indwelling needles and IV lines every 72–96 hours
• Check for AV shunt infections and assess for a thrill in dialysis patients
• Secure drains properly to prevent dislodgement
• Maintain sterility when replacing drainage bags (e.g., brain drains, epidural anesthesia)
• Provide airway clearance support for sedated or neuromuscular patients to prevent pneumonia
• Monitor sedation levels using RASS to prevent over-sedation
• Prevent ventilator-associated pneumonia (VAP) by inspecting circuits and using aseptic suctioning
• For peripheral circulatory failure or necrosis in lower limbs, perform foot baths for cleanliness and circulation maintenance
• Encourage vaccinations based on immunization schedules
• Promote influenza and pneumococcal vaccinations in the elderly
• Perform sterile dressing changes on postoperative wounds
• Admit airborne infection patients with N95 masks and place them in negative pressure rooms
• Isolate multiple infectious disease patients to prevent spread (zoning)
• Disinfect norovirus-contaminated areas with chlorine-based disinfectants (floors, surfaces, bedding)
• Handle norovirus-infected excretions by sealing them in plastic bags for safe disposal

3) Education Plan (EP)　

• Explain the increased infection risk in immunocompromised patients
• Educate on infection prevention behaviors (handwashing, masks, avoiding crowded places) during immunosuppression
• Instruct immunocompromised patients (e.g., those on chemotherapy) to follow hospital guidelines
  (e.g., avoiding raw foods, soil in potted plants due to bacteria, etc.)
• Explain the benefits and side effects of vaccinations
• Educate on keeping Ba catheters, drains, and IV lines from touching the ground to avoid contamination
• Advise against pulling on inserted medical devices
• Provide training for caregivers on proper techniques (sputum suctioning, diaper changing, handling excretions, food texture considerations, meal assistance)
• Instruct patients to report wound pain or exudate
• Encourage balanced nutrition for better wound healing and skin barrier function
• Promote behavior changes to prevent recurring STIs, emphasizing the importance of condoms and avoiding multiple partners; educate on STI-related risks such as infertility and life-threatening complications