You receive a patient after surgery for abscess drainage with a history of diabetes — what are your next steps? A risk for infection nursing care plan helps organize your knowledge into a structured, step-by-step approach to keep patients safe. From assessing the surgical to performing sterile dressing changes to monitoring blood glucose levels, there are dozens of nursing interventions you could implement — and knowing which ones to prioritize is essential to improving patient outcomes.
Every day, roughly one in 31 hospitalized patients develops a healthcare-associated infection (HAI). A well-structured nursing care plan for risk of infection can help ensure your patient isn’t one of them. This guide walks you through each step.
Risk for Infection Nursing Care Plan: Diagnosis
The North American Nursing Diagnosis Association (NANDA) defines risk for infection nursing diagnosis as the “susceptibility to invasion and multiplication of pathogenic organisms, which may compromise health.” This NANDA nursing diagnosis is used for patients who are vulnerable to developing an infection due to existing risk factors such as surgery, chronic illness, or taking certain medications.
Each NANDA diagnosis comes with “related to” factors, which point to what causes or conditions place the patient at risk in the first place. Common examples include the following:
- Altered skin integrity
- Malnutrition
- Obesity
- Impaired peristalsis
- Smoking
- Stasis of body fluids
- Vaccination status
Here are some examples of patients this diagnosis would apply to:
- Patient receiving corticosteroids: Immunosuppression reduces the body’s ability to fight off bacterial and viral infections.
- Oncology patient with low neutrophil count: Reduced white blood cells significantly impair immune defense, increasing infection risk during chemotherapy.
- Elderly patients with poor nutritional status: Decreased immune response and delayed tissue repair increase vulnerability to infections.
Nursing Care Plan: Risk for Infection
Creating a nursing care plan is a structured, step-by-step process, which is similar to the nursing process. Here’s a detailed breakdown of how to build one.
1. Assessment
Your first step in creating a risk for infection nursing care plan is performing a head-to-toe assessment. This is a risk diagnosis, meaning the problem is not currently present, but it could develop without appropriate nursing interventions. Because of this, you need to look carefully for anything that might increase the patient’s risk of developing an infection.
In addition to the “related to” factors we already discussed, here are key findings you should watch for:
- Recent surgery or invasive procedures
- Presence of indwelling devices such as IV lines, urinary catheters, or central lines
- Elevated blood glucose levels
- Preexisting conditions affecting immunity, such as HIV
- Medications that suppress the immune system
- Poor nutritional status
- Limited mobility or prolonged bed rest
- Breaks in skin integrity
- Poor hygiene or inability to perform self-care
- Advanced age (elderly) or very young age (infants)
- History of recurrent infections
2. Diagnosis
Creating the correct diagnosis is essential for an effective care plan — if the diagnosis isn’t accurate, the interventions won’t be either. Your nursing diagnosis should follow a clear, structured format to guide your care plan:
- Problem (NANDA-I label)
- Etiology (“related to” factors)
- Symptoms (“as evidenced by” data)
However, there’s an important distinction — for a preventive diagnosis like risk for infection, you do not include “as evidenced by.” That’s because the problem hasn’t occurred yet. In our example, it can look as simple as “risk for infection related to a surgical incision.”
A nursing care plan rarely has one diagnosis. Depending on the patient’s condition, additional or alternative ones may be needed. When working through your differential diagnosis, keep the following in mind:
- Impaired skin integrity
- Risk of shock
- Ineffective airway clearance
- Risk for pressure ulcer
- Impaired urinary elimination
- Bowel incontinence
- Risk for unstable blood glucose levels
- Imbalanced nutrition (less than body requirements)
3. Expected Outcomes
The next step in creating a risk for infection nursing care plan is to set clear expected outcomes for the patient — what you want to achieve. A helpful way to do this is by using the SMART method — setting specific, measurable, attainable, relevant, and time-bound goals. Here are some examples:
- Patient will remain free from signs and symptoms of infection (no fever, redness, swelling, or purulent drainage) throughout hospitalization.
- Patient’s surgical incision will remain clean, dry, and intact with no evidence of infection during dressing changes.
- Patient will maintain normal vital signs, including temperature within the expected range.
- Patient’s white blood cell (WBC) count will remain within normal limits.
- Patient will demonstrate proper hand hygiene and wound care technique before discharge.
- Patient will verbalize understanding of infection prevention strategies, including when to report symptoms.
4. Interventions
Your next step is to implement targeted nursing interventions that reduce the patient’s risk of developing an infection. These actions focus on preventing pathogen entry, supporting immune function, and promoting early detection of changes in condition.
For patients with a risk for infection, nursing interventions may include:
- Use aseptic technique during wound care, dressing changes, and invasive procedures.
- Monitor surgical sites, wounds, and insertion sites for redness, swelling, or increased drainage.
- Assess vital signs regularly, including temperature trends.
- Administer prescribed antibiotics on schedule and monitor for effectiveness.
- Maintain proper care of indwelling devices such as IV lines, urinary catheters, and drains.
- Monitor laboratory values such as CBC, wound cultures, and urinalysis, as well as other infection markers when ordered.
- Encourage adequate nutrition and protein intake to support tissue repair and immune function.
- Promote early mobilization when appropriate to improve circulation.
- Provide patient education on infection prevention, including hand hygiene, wound care, and when to report symptoms.
Keep in mind, in patients with coexisting conditions, such as diabetes, autoimmune disease, or those affecting the digestive system, your care plan should include targeted measures that address the underlying risk factor contributing to impaired immunity or delayed healing.
5. Evaluation
The final step in the nursing care plan is evaluation, where you determine whether the expected outcomes have been met and whether the patient’s risk for infection has been effectively minimized. Based on your findings, you will determine whether goals are:
- Met – The patient remains free from infection, and risk is controlled.
- Partially met – Some risk factors are improved, but additional interventions are needed.
- Not met – Patient shows signs of infection or worsening risk factors, requiring revision of the care plan.
If outcomes are not met, you’ll need to reassess the patient, identify new or missed risk factors, and modify the nursing interventions accordingly.
Risk for Infection Nursing Care Plan: Example
A 45-year-old patient is admitted to a medical-surgical unit after a liver transplant. The patient is currently taking tacrolimus (Prograf) and prednisone as part of immunosuppressive therapy, has a clean, intact surgical incision, and has a medical history of diabetes mellitus and cirrhosis. His BP is 132/90, HR 67, RR 15, O2 Sat 99%.
Assessment: The nurse assesses the patient and notices that the surgical incision is clean, dry, and well-approximated with no redness, swelling, or drainage. Vital signs are stable. No current signs or symptoms of infection are present. However, the nurse notes that the patient has multiple risk factors, including recent surgery, ongoing immunosuppressive therapy, and a history of diabetes and cirrhosis.
Diagnosis: Risk for infection related to immunosuppressive therapy, surgical incision, and history of diabetes mellitus and cirrhosis.
Expected outcomes: The nurse documents the following expected outcomes: “The patient will remain free from signs and symptoms of infection throughout hospitalization, including absence of fever, chills, or wound-related complications. The patient's surgical incision will remain clean, dry, and intact with no redness, swelling, warmth, or drainage. The patient will maintain blood glucose levels within the target range. The patient will verbalize understanding of infection prevention strategies, including hand hygiene, incision care, and avoiding exposure to ill individuals.”
Intervention: The nurse will implement strict hand hygiene before and after all patient contact, and use aseptic technique for wound care and dressing changes. The surgical incision will be assessed regularly for early signs of infection. Vital signs will be monitored routinely. Blood glucose levels will be closely monitored and managed as prescribed. The nurse will also provide education on infection prevention strategies, including proper hand hygiene, incision care, and avoiding exposure to sick individuals.
Evaluation: The patient at discharge to a rehabilitative care facility remains afebrile with stable vital signs, and the surgical incision continues to appear clean, dry, and intact. No signs of infection are present. Blood glucose remains within the targeted range. The patient verbalizes understanding of infection prevention strategies.
Risk for Infection Nursing Care Plan: FAQ
What are the most common infections seen in hospitalized patients?
Contamination with pathogens can happen in many different ways, including unwashed hands, contaminated food, and surgical drains that create direct pathways for microorganisms to enter the body.
So, which infections show up most often in hospitals? Most HAIs are caused by bacteria, followed by fungi and viruses. The five most frequently isolated pathogens are as follows:
- Clostridioides difficile (33%)
- SARS-CoV-2 (20%)
- Acinetobacter baumannii (12%)
- Klebsiella pneumoniae (10%)
- Pseudomonas aeruginosa (8%)
Clinically, this is most often seen in the form of enterocolitis, bronchopneumonia, sepsis, surgical wound infections, and urinary tract infections.
What medications can put a patient at risk for infection?
Certain medications can weaken the immune system (immunosuppression), making patients more vulnerable to infection by reducing the body’s ability to fight bacteria, viruses, and fungi.
Common high-risk medication groups include:
- Corticosteroids (e.g., prednisone and dexamethasone)
- Chemotherapy drugs (e.g., carboplatin and doxorubicin)
- Biologic therapies (e.g., infliximab and adalimumab)
- Organ transplant medications (e.g., cyclosporine and azathioprine)
What conditions can put a patient at risk for infection?
Many medical conditions can weaken immunity, damage protective barriers, or impair healing — leading to increased infection risk.
Common high-risk conditions include:
- Autoimmune diseases (e.g., lupus, rheumatoid arthritis)
- Cancer (especially leukemia, lymphoma, and multiple myeloma)
- Chronic kidney or liver disease
- Diabetes mellitus
- HIV/AIDS
- Sickle cell disease
People who do not have a thymus — where T cells mature — or a spleen, which helps store and regulate white blood cells, also have a weakened immune system.
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