Risk for Infection Nursing Care Plan (Example + Template)
Risk for Infection Nursing Care Plan
Oct 8, 2026 · Lindsey BSN, RN
Risk for infection is one of the most common nursing diagnoses you will write in nursing school. In fact, it applies to almost every hospitalized patient with an incision, an IV, a urinary catheter, or a weakened immune system. For that reason, below is a complete, ready-to-study example: a realistic patient scenario, the diagnosis written correctly, SMART goals, interventions with rationales, and an evaluation.
Quick summary
- Diagnosis type: Risk diagnosis. The problem has not happened yet, so there are no signs and symptoms, only risk factors.
- Top priorities: Hand hygiene, aseptic technique, removing invasive devices as soon as they are no longer needed, and catching early signs of infection.
- Key things to monitor: Temperature, heart rate, WBC count, blood glucose, and every incision and line site.
- Most common in: Post-op patients, diabetes, older adults, patients with central lines or urinary catheters, burns, and chemotherapy.
What Is Risk for Infection?
Risk for infection means your patient has factors that make it easier for germs to get in and cause illness, but no infection has started yet. Because it is a risk diagnosis, you are writing a plan to prevent a problem, not treat one. If your patient already has a fever, purulent drainage, or a positive culture, they have an infection, and a different diagnosis fits better.
Common risk factors
| Category | Examples |
|---|---|
| Broken skin or tissue | Surgical incisions, pressure injuries, burns, trauma wounds |
| Invasive devices | Peripheral IVs, central lines, urinary catheters, endotracheal tubes, chest tubes, drains |
| Chronic illness | Diabetes (especially poor glucose control), kidney disease, COPD, liver disease |
| Weakened immune response | Chemotherapy, long-term steroids, HIV, low WBC count, malnutrition |
| Stasis of body fluids | Immobility, urinary retention, shallow breathing after surgery |
| Age | Older adults and newborns |
| Exposure | Hospitalization, incomplete vaccinations, contact with infectious patients |
How to write it
A risk diagnosis has two parts: the label and the risk factors. It has no “as evidenced by” signs and symptoms, because nothing has happened yet. In fact, this is one of the most common mistakes students make.
- Correct: Risk for infection related to surgical incision, indwelling urinary catheter, and hyperglycemia.
- Incorrect: Risk for infection related to surgery as evidenced by redness at the incision site. (Redness is a sign of an actual problem, and “surgery” is too vague.)
Also, some programs use the NANDA-I format “Risk for infection as evidenced by risk factors of…” instead of “related to.” Follow whichever format your instructor uses. For more help, see Mastering the Art of Writing a Nursing Diagnosis.
Patient Scenario
Mr. Carter is a 68-year-old man on post-op day 1 after an open sigmoid colectomy for complicated diverticulitis. His history includes type 2 diabetes, hypertension, and obesity (BMI 32). He quit smoking 5 years ago after 30 years of smoking.
He has a midline abdominal incision covered by a dry sterile dressing, a peripheral IV in his left forearm placed 2 days ago, and an indwelling urinary catheter placed in the OR. He has been reluctant to cough, deep breathe, or get out of bed because of incision pain.
Assessment Data
Subjective
- “It hurts too much to cough or use that breathing thing.” Rates incision pain 6/10 with movement.
- “My sugars are usually in the 200s at home. I don’t check them much.”
- “I don’t really want to get up yet.”
Objective
| Finding | Value | Why it matters |
|---|---|---|
| Temperature | 37.4°C (99.3°F) | Normal; establishes a baseline |
| Heart rate / BP | 88 bpm / 136/78 mmHg | Normal; baseline for trends |
| SpO2 / respiratory rate | 94% on room air / 18, shallow | Shallow breathing raises pneumonia risk |
| Blood glucose | 212 mg/dL | Hyperglycemia impairs wound healing and immune function |
| WBC | 10.2 × 10³/µL | Normal (about 4.5–11); no infection yet |
| Albumin | 3.2 g/dL | Low (normal about 3.5–5.0); poor nutrition slows healing |
| Incision | Edges approximated, dressing dry and intact, no redness or drainage | No signs of infection yet |
| IV site | No redness, swelling, or tenderness | Device is a portal of entry |
| Urinary catheter | Draining clear yellow urine | Each catheter day raises CAUTI risk |
| Incentive spirometer | 750 mL (goal 1,500 mL); used 3 times since surgery | Underuse leads to atelectasis and pneumonia |
| Activity | Has not been out of bed since surgery | Immobility increases fluid stasis |
Nursing Diagnosis
Risk for infection related to surgical incision, invasive devices (peripheral IV and indwelling urinary catheter), hyperglycemia, decreased mobility, and inadequate nutrition.
Every risk factor in this statement comes straight from the assessment data. As a result, your instructor should be able to trace each one back to a finding above.
Goals and Expected Outcomes
Long-term goal: The patient will remain free of infection throughout hospitalization and through discharge.
Short-term goals:
- The patient will maintain a temperature below 38.0°C (100.4°F) and a WBC count within normal limits throughout hospitalization.
- The incision will remain free of redness, swelling, warmth, and purulent drainage, with edges approximated, through discharge.
- The patient’s blood glucose will stay within the target range ordered by the provider (often 140–180 mg/dL in the hospital) within 48 hours.
- The urinary catheter will be removed as early as possible (ideally within 24 hours after surgery), and the patient will void without difficulty within 8 hours of removal.
- The patient will use the incentive spirometer 10 times per hour while awake and walk in the hallway at least 3 times daily starting today.
- Before discharge, the patient will demonstrate proper hand hygiene and name at least 4 signs of infection to report.
Nursing Interventions and Rationales
Assessment
| Intervention | Rationale |
|---|---|
| Monitor temperature, heart rate, BP, and respiratory rate at least every 4 hours, and trend them against baseline. | Fever and tachycardia are early signs of infection. Older adults may not run a high fever, so a small rise from baseline or new confusion can be the first clue. |
| Assess the incision every shift for redness, edema, ecchymosis, drainage, and approximation (REEDA). | Surgical site infections usually show up 3–7 days after surgery. A consistent tool makes changes easy to spot and document. |
| Assess the IV site every shift and ask daily whether the line is still needed. | Peripheral IVs can cause phlebitis and bloodstream infections. Removing unneeded lines removes a portal of entry. |
| Check daily whether the urinary catheter is still indicated, and monitor urine color, clarity, and odor. | Catheter-associated UTI risk rises with every day the catheter stays in. Cloudy, foul-smelling urine can signal infection. |
| Monitor WBC with differential, blood glucose as ordered, and albumin. | A rising WBC can signal infection. High glucose and low albumin both slow healing and weaken immune defenses. |
| Auscultate lung sounds and check SpO2 every 4 hours. | Shallow breathing after abdominal surgery leads to atelectasis, which can progress to pneumonia. |
Therapeutic
| Intervention | Rationale |
|---|---|
| Perform hand hygiene before and after every patient contact, and before touching any line, catheter, or dressing. | Hand hygiene is the single most effective way to prevent healthcare-associated infections. |
| Use aseptic technique for dressing changes, and leave the original surgical dressing in place for the time ordered by the surgeon (commonly 24–48 hours). | Aseptic technique keeps organisms out of the wound while the skin barrier is still healing. |
| Maintain the closed catheter system, keep the bag below bladder level and off the floor, and advocate for removal as soon as it is no longer needed. | Opening the system or letting urine flow back into the bladder introduces bacteria. Early removal is the most effective CAUTI prevention. |
| Scrub the hub before accessing the IV and change or remove the line per facility policy. | Hubs and connectors are common entry points for bacteria into the bloodstream. |
| Give insulin and check glucose as ordered; report readings outside the target range. | Good glucose control around surgery lowers the risk of surgical site infection. |
| Coach incentive spirometer use 10 times per hour while awake, plus coughing and deep breathing with a pillow splinted over the incision. | Full lung expansion prevents atelectasis and pneumonia. Splinting reduces pain, so the patient is more likely to do it. |
| Pre-medicate for pain as ordered before ambulation and breathing exercises. | Uncontrolled pain is why this patient is avoiding movement and deep breathing. |
| Help the patient walk at least 3 times daily, increasing as tolerated. | Mobility improves lung expansion and circulation and reduces fluid stasis. |
| Encourage protein intake and fluids as the diet advances, and consult a dietitian. | Protein and adequate nutrition are needed for wound healing and immune function. |
| Give prescribed antibiotics on time. | On-time dosing keeps blood levels steady enough to work. |
Education
| Intervention | Rationale |
|---|---|
| Teach and have the patient demonstrate hand hygiene; ask visitors to clean their hands too. | Patients and visitors are also sources of transmission. A return demonstration confirms learning. |
| Teach the signs of infection to report: fever over 38.0°C (100.4°F), increasing redness, warmth, or swelling, pus or foul drainage, the wound opening, worsening pain, and burning with urination. | Early reporting after discharge leads to earlier treatment. |
| Teach incision care at home and to avoid soaking the incision in a bath, hot tub, or pool until the surgeon clears it. | Soaking softens the healing skin and can let bacteria in. |
| Review home glucose monitoring and when to call the provider about high readings. | High glucose at home continues to slow healing after discharge. |
| Teach the patient to finish any prescribed antibiotics, even after feeling better. | Stopping antibiotics early can let the infection return and contributes to antibiotic resistance. |
Evaluation
On post-op day 3, the plan is evaluated against each goal.
| Goal | Outcome | Status |
|---|---|---|
| Temperature below 38.0°C, WBC normal | Highest temperature 37.6°C (99.7°F); WBC 9.4 × 10³/µL | Met (ongoing) |
| Incision free of signs of infection | Edges approximated, no redness or drainage | Met (ongoing) |
| Glucose within target range | Readings 150–196 mg/dL; two readings above 180 | Partially met |
| Catheter removed early; voiding | Removed POD 1; voided 350 mL within 6 hours | Met |
| Incentive spirometer and ambulation | Reaches 1,250 mL; walking 3 times daily | Partially met |
| Hand hygiene and signs of infection | Demonstrated hand hygiene; named 3 of 4 signs | Partially met |
Plan revision: Notify the provider about the high glucose readings for a possible insulin adjustment. Next, continue spirometer coaching toward the 1,500 mL goal. Finally, reinforce the signs of infection with written teaching materials before discharge.
If signs of infection develop (fever, a rising WBC, wound redness or drainage), notify the provider promptly. Expect orders such as cultures and antibiotics, and update the care plan to address the actual infection.
Frequently Asked Questions
What is the difference between risk for infection and an actual infection? Risk for infection is used when the patient has risk factors but no signs of infection. Once signs appear (fever, purulent drainage, positive cultures), the patient has an actual infection, and the care plan changes to focus on treatment.
Can I use risk for infection for every patient? Many hospitalized patients qualify, but it should not be your automatic first choice. Instead, use it when the risk factors are significant and specific, and prioritize it above other diagnoses only when infection is the biggest threat to the patient.
What are the signs of infection in older adults? Unlike younger patients, older adults may not develop a high fever. Instead, watch for new confusion, falls, loss of appetite, a small rise in temperature from baseline, or a fast heart rate.
Test Yourself
Practice what you just learned with the Free Infection Prevention Practice Questions for Nursing Students.
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References
- Centers for Disease Control and Prevention. Guideline for Prevention of Catheter-Associated Urinary Tract Infections.
- Berríos-Torres, S. I., et al. (2017). Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surgery, 152(8), 784–791.
- Centers for Disease Control and Prevention. Hand hygiene in healthcare settings.
- American Diabetes Association. Standards of Care in Diabetes: Diabetes care in the hospital. Diabetes Care (current edition).
- Herdman, T. H., Kamitsuru, S., & Takao Lopes, C. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification (current edition).
Written by Lindsey BSN, RN. Reviewed by Anthony MSN AGACNP-BC CCRN 10/08/2026 For educational purposes only; follow your facility’s policies and your provider’s orders.