Introduction to NANDA Nursing Diagnosis: Risk of Surgical Wound Infection
The risk of surgical wound infection is one of the most common and serious complications associated with surgeries and procedures. Infections are the most frequent cause of post-operation morbidity, mortality and prolonged hospital stay. The NANDA nursing diagnosis provides a framework for nurses to assess, plan, intervene and evaluate the care of patients at increased risk of surgical wound infection.
NANDA Nursing Diagnosis Definition
Risk of surgical wound infection is defined by NANDA as “The state in which an individual is at risk of developing a surgical wound infection”.
- Expresses fear of acquiring surgical wound infection
- Verbalizes the need for wound cleaning and care
- Reports a recent or past surgery
- Reports history of an infection
- Lack of knowledge: Inadequate understanding of the mechanisms and prevention of infections is common in health professionals and patients.
- Diagnostic techniques: Diagnosis of infection can be challenging and require specialized techniques that may not always be available.
- Immunosuppression: Immune compromised patients are at higher risk of developing an infection.
- Environmental conditions: Poor air circulation, overcrowding, contaminated premises and equipment, inadequate sanitation and insufficient disinfection.
- Elderly: They are more prone to infections due to their reduced immune system functioning and decreased ability to fight off infections.
- Obese and morbidly obese: They have an increased surface area and decreased skin strength, leading to greater risk of wound trauma and increasing the likelihood of infection.
- Chemically dependent: They are at increased risk for infections due to immunosuppression and inadequate nutrition.
- Patients receiving immunosuppressive drugs following organ transplant: They have a compromised immune system and are at higher risk of developing infections.
- Bacteremia: Bacterial infection of the bloodstream caused by bacteria entering the body through the surgical wound.
- Septic shock: Systemic inflammatory response syndrome caused by an infection in the body.
- Cellulitis: Inflammation of the soft tissue caused by bacterial infection.
- Organ failure: Malfunction of organ due to infection spread from the surgical wound.
- Mortality: Death can occur due to severe infection and sepsis.
Suggestions for Use
Nurses should ensure that patients are well informed regarding preventive measures such as effective hand washing, reducing environmental contamination, preventing skin breakdown, and adhering to antibiotic protocols to reduce the risk of surgical wound infections.
Suggested Alternative NANDA Nursing Diagnoses
- Risk for imbalanced nutrition: less than body requirements
- Risk for impaired wound healing
- Ineffective tissue perfusion: Peripheral
- Impaired physical mobility
- Ineffective protection
Nurses should use evidence-based approaches in assessing and intervening with patients who are at risk of surgical wound infections. Collaboration and communication amongst medical teams is key in preventing post-surgery infections and optimizing patient outcome.
- Infection Status: The patient’s ability to resist infection.
- Tissue Integrity: Ability to maintain intact skin and mucosal membranes.
- Skin Integrity: An individual’s ability to maintain healthy skin.
- Immune Status: Ability to defend against infection.
- Health Education: Knowledge about how to prevent illness and maintain health.
- Mobility: Physical: Ability to move about in an effective manner.
- Infection Control: Establishing practices to reduce the risk of infection.
- Skin Surveillance: Monitoring the patient’s skin condition regularly.
- Nutritional/Metabolic Monitoring: Assessing of the biochemical components affecting tissue integrity and the healing process.
- Pre- operative Nursing Care: Assisting the patient before, during and after surgery.
- Postoperative Recovery Phase Management: Facilitating recovery time by monitoring vital signs and administering medications.
- Health Teaching: Providing instruction about precautions needed to reduce the risk of surgical wound infection.
The risk of surgical wound infection is a real and life-threatening complication that must be considered when assessing and caring for patients who are undergoing surgery or other invasive procedures. NANDA nursing diagnosis helps nurses to identify and manage patients at higher risk of surgical wound infections and to develop evidence-based plans for prevention and assessment of the patient’s surgical safety.
- What is NANDA nursing diagnosis?
- What is the definition of “Risk of Surgical Wound Infection” according to NANDA?
- What are the associated problems of surgical wound infection?
NANDA nursing diagnosis is an international standard to classify nursing diagnoses, promoted by the North American Nursing Diagnosis Association. It is a structured system of defining and classifying problems encountered in clinical practice.
“Risk of surgical wound infection” is defined by NANDA as the state in which an individual is at risk of developing a surgical wound infection.
The associated problems of surgical wound infection include bacteremia, septic shock, cellulitis, organ failure, and mortality.