7 Bronchiolitis & Respiratory Syncytial Virus (RSV) Nursing Care Plans

Utilize this comprehensive nursing care plan and management guide to provide effective care for patients diagnosed with bronchiolitis and respiratory syncytial virus (RSV). Gain valuable insights on nursing assessment, interventions, goals, and nursing diagnosis specifically tailored for bronchiolitis and RSV in this guide.

What is Bronchiolitis?

Bronchiolitis is an acute viral inflammation of the lower respiratory tract involving the bronchioles and alveoli. Accumulated thick mucus, exudate, and cellular debris and the mucosal edema from the inflammatory process obstruct the smaller airways (bronchioles). This causes a reduction in expiration, air trapping, and hyperinflation of the alveoli. The obstruction interferes with gas exchange, and in severe cases, causes hypoxemia and hypercapnia, which can lead to respiratory acidosis. 

Bronchiolitis is highly contagious. The virus that causes it is spread from person to person through direct contact with nasal secretions, airborne droplets, and fomites. Respiratory syncytial virus (RSV) is the most commonly isolated agent in 75% of children younger than 2 years who are hospitalized for bronchiolitis. Risk factors for the development of bronchiolitis include:

• Age less than three months
• Low birth weight
• Gestational age
• Lower socioeconomic group
• Crowded living conditions
• Parental smoking
• Chronic lung disease
• Severe congenital or acquired neurologic disease
• Airway anomalies

Bronchiolitis primarily affects young infants. Clinical manifestations are initially subtle. The infant may become increasingly fussy and have difficulty feeding during the two- to five-day incubation period. A low-grade fever, increasing coryza, and congestion usually follow the incubation period. In most cases, the disease is mild and self-limited.

There is no definitive antiviral therapy for most causes of bronchiolitis. Management of these infants should be directed toward symptomatic relief and maintenance of hydration and oxygenation.

Nursing Care Plans & Management

Nursing care management for bronchiolitis involves assessing and supporting respiratory function, providing comfort, promoting hydration and nutrition, implementing infection control measures, offering supportive care, educating parents, and collaborating with the healthcare team. The goal is to optimize respiratory function, alleviate symptoms, and facilitate recovery.

Nursing Problem Priorities

The following are the nursing priorities for patients with bronchiolitis & respiratory syncytial virus (RSV):

• Respiratory assessment and monitoring.
• Oxygenation and airway management.
• Optimizing nutritional status.
• Infection control.

Nursing Assessment

Assess for the following subjective and objective data:

• Diminished or absent breath sounds
• Crackles, wheezes, rhonchi
• Paroxysmal, nonproductive, and harsh, hacking cough
• Change in rate and depth of respirations
• Dyspnea and shallow respiratory excursion
• Increased mucus and nasal discharge
• Tachypnea
• Fever
• Cough
• Nasal flaring
• Dyspnea
• Shallow respiratory excursion
• Suprasternal and subcostal retractions
• Abnormal arterial blood gases (ABGs)

Assess for factors related to the cause of bronchiolitis & respiratory syncytial virus (RSV):

• Tracheobronchial obstruction
• Increased mucus secretions
• Lack of ciliary defenses
• Increased work on breathing
• Inflammatory process
• Respiratory muscle weakness
• Decreased lung expansion
• Alteration of the client’s usual oxygen/carbon dioxide ratio
• Change in the health status of the infant or small child

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with this condition based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities. 

Nursing Goals

Goals and expected outcomes may include:

• The child will demonstrate effective coughing and clear breath sounds.
• The child will be free of cyanosis and dyspnea.
• The child will maintain an effective breathing pattern, as evidenced by relaxed breathing at a normal rate and depth and the absence of dyspnea.
• The child will be free of signs or symptoms of hypoxia.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with bronchiolitis & respiratory syncytial virus (RSV) may include:

1. Improving Airways and Breathing Pattern

Bronchiolitis & respiratory syncytial virus (RSV) can lead to significant respiratory distress, making it challenging for affected individuals to maintain proper breathing patterns and adequate airflow through their airways. Efforts to improve airways and breathing patterns in patients with bronchiolitis and RSV focus on several key strategies. However, the primary goal is to ensure adequate oxygenation and ventilation while reducing the workload on the respiratory system. This involves a comprehensive approach that includes both medical interventions and supportive care.

1. Assess the airway for patency.
Maintaining a patent airway is always the first priority, especially in cases like trauma, acute neurological decompensation, or cardiac arrest. The inflammation, edema, and debris result in obstruction of bronchioles, leading to hyperinflation, increased airway resistance, atelectasis, and ventilation-perfusion mismatching (Maraqa & Steele, 2021).

2. Assess respiratory status as indicated for a decreasing respiratory rate.
Changes in breathing patterns may occur quickly as the child’s energy reserves are depleted. Assessment and monitoring baseline reveal rate and quality of air exchange. Frequent assessment and monitoring provide objective evidence of changes in the quality of respiratory effort, enabling prompt and effective intervention. Additionally, the likelihood of mechanical ventilation significantly increases in children who suffer from recurrent apnea (Maraqa & Steele, 2021).

3. Assess respirations. Note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing.
A change in the usual respiration may mean respiratory compromise. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction. During the acute stage, the client may develop small airway obstruction that leads to symptoms of respiratory distress (Justice & Le, 2022).

4. Assess the configuration of the chest by palpation; auscultate for breath sounds that indicate a movement restriction (absent or diminished, crackles or rhonchi).
This is to detect decreased or adventitious breath sounds. The small diameters of the bronchioles in the infant are susceptible to obstruction when inflammation results in edema and excess mucus. The obstruction often l; leads to atelectasis. The atelectatic area of the lungs will have no breath sounds, and the partially collapsed area will have decreased sounds.

5. Assess cough (moist, dry, hacking, paroxysmal, brassy, or croupy): onset, duration, frequency, if it occurs at night, during the day, or during activity. Assess mucus production: when produced, amount, color (clear, yellow, green), consistency (thick, tenacious, frothy). Assess ability to expectorate or if swallowing secretions, stuffy nose or nasal drainage.
Coughing is a mechanism for clearing secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled. Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious secretions are possible causes of ineffective cough.

6. Assess for the occurrence of apnea, especially when the client is asleep.
Apnea occurs early in the course of the disease and may be the presenting symptom, especially in those younger than two months of age or those born prematurely. Nonobstructive central apnea occurs during quiet sleep and is associated with increases in apnea index (the percentage of time the infant spends apneic), apnea attack rate (the number of episodes of apnea per unit time), and apnea percentage (the distribution of episodes of apnea in a given sleep state) (Maraqa & Steele, 2021).

7. Assess pulse rate and oxygen saturation using pulse oximetry.
Pulse oximetry is a helpful tool to detect alterations in oxygenation initially; but, for CO2 levels, end-tidal CO2 monitoring or arterial blood gases (ABGs) would require being obtained. Transcutaneous oxygen saturation is reduced in cases of moderate to severe bronchiolitis. Clients with persistent resting oxygen saturations below 90% in room air require a period of observation and possible admission. However, the use of pulse oximetry monitoring is not recommended routinely in infants with bronchiolitis who do not require supplemental oxygen or have oxygen saturation >90% on room air (Maraqa & Steele, 2021).

8. Note for changes in the level of consciousness and neurologic signs of complications.
Restlessness, confusion, and/or irritability can be early indicators of insufficient oxygen to the brain. As many as 1% of previously healthy children and 3% of developmentally impaired children diagnosed with bronchiolitis experience neurologic complications. These include seizures, encephalopathy with hypotonia, irritability, and abnormal tone (Maraqa & Steele, 2021).

9. Monitor the client’s intake and output.
Infants with bronchiolitis are mildly dehydrated because of decreased fluid intake and increased fluid losses from fever and tachypnea. Since adequate hydration is an essential part of care for the child diagnosed with bronchiolitis, their intake and output must be closely monitored and recorded. 

10. Provide periods of rest by organizing procedures and care and disturbing infant/child as little as possible in acute stages of illness.
This prevents unnecessary energy expenditure resulting in fatigue. Additionally, the client should be made as comfortable as possible, either held in a parent’s arm or sitting in a position of comfort.

11. Maintain a calm attitude when assisting the client during a tachypneic episode.
Assist the client in “taking control” by using deeper respirations during tachypnea. It helps the client deal with the physiological effects of hypoxia, which may be manifested as anxiety or fear.

12. Elevate the head of the bed at least 30° for the child and hold the infant and young child in the lap or in an upright position with head on the shoulder; the older child may sit up and rest head on a pillow on an overbed table.
Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange. Keeping the head elevated lowers the diaphragm, promoting aeration of lung segments and mobilization and expectoration of secretions to keep the airways patent.

13. Encourage fluid intake at frequent intervals over 24-h time periods, and specify amounts.
Fluids help minimize mucosal drying and maximize ciliary action to move secretions. The ability to maintain adequate hydration should be assessed by observing the client’s oral intake. Many dyspneic infants have difficulty taking a bottle. The goal of fluid therapy is to replace deficits and to provide maintenance requirements. Oral therapy is preferred over parenteral therapy, which is only necessary for clients who are unable to take fluids by mouth or who have a respiratory rate higher than 70 breaths/minute (Maraqa & Steele, 2021).

14. Assist in performing deep breathing and coughing exercises and repositioning every two hours.
Vibration loosens and dislodges secretions, and gravity drains the airways and lung segments. These activities promote deeper breathing by enlarging the tracheobronchial tree and initiating the cough reflex to remove secretions. Teach the parent to perform splinting of the child’s chest during coughing exercises to decrease the child’s discomfort.

15. Schedule periods of activity and rest.
Strenuous activities can increase the oxygen demand of the already hypoxic child, which results in the worsening of tachypnea. Schedule longer rest periods before and after an activity to avoid wearing the child out.

16. Assist in deep suctioning, as indicated.
Deep suctioning may provide temporary relief but has been associated with longer hospitalization. However, suctioning facilitates the removal of respiratory secretions; therefore, it may be performed if indicated by the healthcare provider.

17. Administer a monoclonal antibody as indicated and if agreed upon by the parents.
Palivizumab, a monoclonal antibody, is recommended as a prophylactic injection to prevent RSV during the RSV season. Infants eligible for palivizumab are defined by specific qualifying criteria, generally defined by gestational age less than 29 weeks or less than one year of age with preexisting health conditions, such as chronic lung disease of prematurity or congenital heart disease. Injections are given monthly during RSV season.

18. Administer supplemental humidified oxygen as prescribed.
Administer supplemental humidified oxygen, if necessary, to maintain a transcutaneous oxygen saturation higher than 90%. The use of high-flow nasal cannulas may reduce intubation rates in infants diagnosed with bronchiolitis. Clients who receive high-flow oxygen therapy early in the course of management have significantly lower rates of escalation of care due to treatment failure.

19. Administer heliox as prescribed.
Heliox is a mixture of oxygen (20 to 30%) and helium (70 to 80%) that has a lower viscosity than air. It has been used successfully in cases of airway obstruction, croup, airway surgery, and asthma to reduce respiratory effort during the period of airway compromise (Maraqa & Steele, 2021). However, while improvements have been seen in respiratory parameters, heliox has not reduced the length of hospital stay or the need for invasive ventilation (Kuitunen et al., 2022).

20. Assist in endotracheal intubation and mechanical ventilation, as indicated.
Infants diagnosed with bronchiolitis and recurrent apnea or increased work of breathing with respiratory failure occasionally require mechanical ventilation. Continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV) with positive end-expiratory pressure (PEEP) have been successfully used to treat these infants. Negative-pressure ventilation has been used successfully in infants with bronchiolitis, with a reduced need for endotracheal intubation and shortened lengths of stay (Maraqa & Steele, 2021).

21. Teach parents and the older child about medication administration and its adverse effects.
This ensures compliance with correct drug dosage and other considerations for administrations for desired results, and what to do if side effects occur. However, medications have a limited role in the management of bronchiolitis. Healthy children diagnosed with bronchiolitis usually have a limited disease. These clients usually do well with supportive care only (Maraqa & Steele, 2021).

22. Administer medications for bronchiolitis as prescribed.
See Pharmacologic Management

2. Administering Medications & Pharmacological Support

Administering medications and providing pharmacological support are critical components in the management of patients with bronchiolitis and respiratory syncytial virus (RSV) infection. These respiratory conditions primarily affect infants and young children, often leading to respiratory distress and compromised breathing. Medications play a crucial role in relieving symptoms, reducing airway inflammation, and improving the overall respiratory function in affected individuals.

1. Bronchodilators.
These medications help relax the smooth muscles surrounding the airways, improving airflow and reducing bronchospasms. Commonly used bronchodilators include:

• Beta-agonists (e.g., albuterol): Administered via inhalation, these medications provide quick relief by opening up the airways and alleviating wheezing and respiratory distress.

2. Corticosteroids.
These anti-inflammatory medications can help reduce airway inflammation and improve breathing patterns. They are typically used in more severe cases of bronchiolitis. Commonly used corticosteroids include:

• Dexamethasone: Administered orally or via intravenous (IV) route, dexamethasone helps reduce airway inflammation and improve respiratory function.

3. Antipyretics.
These medications help reduce fever, which is a common symptom associated with bronchiolitis and RSV. Commonly used antipyretics include:

• Acetaminophen: Administered orally or rectally, acetaminophen can help lower fever and relieve discomfort.
• Ibuprofen: Administered orally, ibuprofen is another option to reduce fever and provide relief from associated symptoms.

4. Antiviral medications.
In certain cases, particularly when there are specific risk factors or severe symptoms, antiviral medications may be considered. These medications can help inhibit the replication of the RSV virus. Commonly used antiviral medications for RSV include:

• Ribavirin: Administered via inhalation or, in severe cases, through a specific device called a small particle aerosol generator (SPAG-2), ribavirin can help reduce the severity and duration of RSV infection.

5. Intranasal decongestants.
Aerosolized racemic epinephrine may be primarily beneficial as a nasal decongestant. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation (Maraqa & Steele, 2021).

• Oxymetazoline. Oxymetazoline is applied directly to mucous membranes, where it causes vasoconstriction.

6. Administer hypertonic saline solution through nebulization.
Hypertonic saline was shown to be more effective than normal saline in improving bronchiolitis clinical symptoms. Hypertonic saline shifts the flow of water into the mucus layer by osmosis, reducing submucosal edema, reducing the viscosity of mucus, improving mucus clearance, and rehydrating the air surface liquid. The updated American Academy of Pediatrics (AAP) guidelines support the use of hypertonic saline nebulization for infants and children hospitalized for bronchiolitis, except in the emergency department setting (Baron & El-Chaar, 2016).

3. Monitoring Diagnostic Procedures and Laboratory Studies

Diagnostic procedures and laboratory studies are essential in the evaluation and diagnosis of patients with bronchiolitis and RSV infection. By utilizing clinical assessments, laboratory tests, imaging studies, and viral detection techniques, healthcare professionals can accurately identify bronchiolitis, determine the presence of RSV, and guide appropriate treatment strategies. These diagnostic tools aid in providing targeted and effective care to patients, facilitating better outcomes and promoting timely management of bronchiolitis and RSV infection.

1. Nasopharyngeal Swab.
A nasopharyngeal swab is commonly performed to collect respiratory secretions from the back of the nasal cavity. This sample is then tested for the presence of respiratory viruses, including RSV, through various laboratory techniques, such as polymerase chain reaction (PCR) or viral antigen detection.

2. Chest X-ray.
A chest X-ray may be ordered to evaluate the lungs and assess the extent of lung involvement. It helps in identifying signs of inflammation, consolidation, or other abnormalities associated with bronchiolitis and RSV infection.

3. Blood Tests.
Laboratory studies, including a complete blood count (CBC), may be conducted to assess the patient’s overall health status. CBC provides information on white blood cell count, which may be elevated in the presence of infection.

4. Arterial Blood Gas (ABG) Analysis.
ABG analysis may be performed in more severe cases or when there is concern about respiratory compromise. It provides information about oxygen and carbon dioxide levels in the blood, helping to assess the severity of respiratory distress.

5. Pulse Oximetry.
Pulse oximetry is a non-invasive procedure that measures the oxygen saturation level in the blood. It involves placing a sensor on a finger or toe to assess the patient’s oxygenation status and monitor response to treatment.

6. Viral Panel Testing.
In some cases, particularly if there is a need for further identification of respiratory viruses, a viral panel test may be conducted. This test can simultaneously detect multiple respiratory viruses, including RSV, to aid in the diagnosis.

4. Reducing Anxiety & Providing Emotional Support

Bronchiolitis and RSV infections primarily affect infants and young children, often leading to respiratory distress and discomfort. Managing anxiety in both parents and child patients is essential to alleviate their fears, provide emotional support, and facilitate a more positive care experience during this challenging time. For parents, it is crucial to offer emotional support and open lines of communication. Healthcare professionals play a vital role in educating parents about bronchiolitis and RSV, including the expected course of the illness, available treatments, and strategies for symptom management. Clear and accurate information helps alleviate anxiety by empowering parents with knowledge and enabling them to actively participate in their child’s care

1. Assess the source and level of anxiety, how anxiety is manifested, and the need for information that will relieve anxiety.
This provides information about anxiety levels and the need for interventions to relieve it; sources of anxiety may include fear and uncertainty about treatment and recovery, guilt for the presence of illness, possible loss of parental role, and loss of responsibility if hospitalized. Mostly, parents are worried about their child’s health during an acute episode of bronchiolitis because they had little knowledge about the disease before their child contracted the infection, and this contributed to their anxiety (Piche-Renaud et al., 2020).

2. Evaluate the level of understanding of the diagnosis by the client and parents.
The client and parents are hearing and assimilating new information that includes changes in self-image and lifestyle. Understanding the perceptions of those involved sets the tone for individualizing care and provides information necessary for choosing appropriate interventions.

3. Communicate openly with parents and answer questions calmly and honestly.
This promotes a calm and supportive environment. In a study, parents felt uncomfortable about asking healthcare professionals questions, as they did not want to bother them or ask questions that would be seen as unimportant. Parents expressed greater satisfaction if they received comprehensive and complete explanations. Communicating openly establishes a trustworthy relationship with the parents and gives them personalized support and reassurance (Piche-Renaud et al., 2020).

4. Acknowledge the reality of the client’s and parent’s fears and concerns and encourage the expression of feelings.
Support may enable the child and the parents to begin exploring and dealing with the situation. The parents may need time to identify their feelings regarding an unfamiliar disease condition and possibly even more time to begin to express them.

5. Accept, but do not reinforce, the parent’s or child’s denial of the situation.
When extreme denial or anxiety is interfering with the progress of treatment or recovery, the issues facing the parents and the child need to be explained, and resolutions must be explored.

6. Allow expression of concerns and opportunity to ask questions about the condition and recovery of ill infant/small child.
This provides an opportunity to vent feelings, and secure information needed to reduce anxiety. Ensure that both parties have the same understanding of the terms used. This establishes trust and reduces misperceptions or misinterpretations of information.

7. Encourage parents to remain calm and involved in care and decision-making regarding the infant or the younger child.
This promotes constant monitoring of the infant or the younger child for improvement or worsening of symptoms. Many parents want to be engaged in their child’s care when they witness the supportive measures provided by the nursing staff; therefore, they should be assisted in developing their abilities so that it is could ease the transition from hospital care to treatment at home (Piche-Renaud et al., 2020).

8. Encourage parents to stay with infant/ small child or allow open visitation and telephoning, have parents assist in care (holding, feeding, diapering), and suggest routines and methods of treatment.
This allows parents to care for and support the child; absence and wondering about the condition of the child may increase anxiety. Involve the parents in care planning to help restore some feeling of control and independence to parents or the child who feels powerless in dealing with the diagnosis and treatment.

9. Teach parents about the disease process and the physical effects and symptoms of the disease.
This provides information to relieve anxiety by informing parents of what to expect. In a study, most parents had never heard of bronchiolitis, and they wished they had known more about the disease beforehand, in order to be able to correctly recognize the problem, anticipate its course, and help their child. Education as to the course of illness is important. Understanding signs that could indicate worsening illness, such as respiratory distress and dehydration, are critical during care.

10. Provide written information about the disease and its process.
Parents have expressed a strong need for information and reassurance from the healthcare team throughout their child’s illness. However, they feel that high levels of anxiety could impede their ability to retain information. Preferences for the information included pamphlets, applications, videos, and websites. These are sources of information that they could consult even after discharge from the ED or the hospital, which are particularly important to them. Along with verbal explanations, reliable sources of standardized information on bronchiolitis must be provided routinely (Piche-Renaud et al., 2020).

11. Explain the reason for each procedure or type of therapy and the effects of any diagnostic tests on parents.
This prevents anxiety by reducing the fear of the unknown. Allow both the child and the parents enough time to prepare for events and treatments so that they can still feel in control of the situation. After admission, explain the possible reasons for hospitalization and identify discharge criteria jointly with the parents (Piche-Renaud et al., 2020). 

12. Clarify any misinformation and answer questions in lay terms when parents are able to listen, and give the same explanation other staff and/or physicians gave regarding disease process and transmission.
This prevents unnecessary anxiety resulting from inaccurate knowledge or beliefs, or inconsistencies in information. Additionally, parents need to understand that the symptoms of bronchiolitis can continue for an extended period of time, although worsening symptoms (such as recurrence of fever after the first few days of illness) should be brought to medical attention to evaluate for secondary infection.

13. Explain the importance of supportive care and indications for pharmacologic treatment.
It can be difficult for most parents to understand and accept that most supportive measures are necessary and there is a limited option for evidence-based treatment to help the child. Explain that supportive treatment is recommended for bronchiolitis and detail its different modalities, such as oxygen therapy, adequate hydration, etc. Never say that “there is no treatment because it may increase the parents’ fear and anxiety about their child’s situation. Additionally, caregivers should understand that medications, such as antibiotics, have no role in the treatment of viral illnesses  (Piche-Renaud et al., 2020).

14. Give detailed discharge recommendations.
Most parents of hospitalized children report that they would have preferred to have been given clear discharge criteria by their healthcare providers. This could be challenging as there are no universal discharge criteria for bronchiolitis and subsequent practice variations. The healthcare team should endeavor to identify potential discharge criteria with the parents at the time of admission and adapt them to each client and their family. This improves the trusting relationship between parents and healthcare professionals, making the treatment process smooth and unhindered (Piche-Renaud et al., 2020).

5. Promoting Rest & Energy Conservation

Promoting rest and energy conservation is a vital aspect of the care provided to patients with bronchiolitis and respiratory syncytial virus (RSV) infection. Promoting rest involves providing a conducive environment that supports uninterrupted sleep and minimizes disturbances. Meanwhile, energy conservation strategies aim to minimize unnecessary exertion and preserve the patient’s limited energy resources. By emphasizing rest and energy conservation, healthcare professionals aim to optimize the healing process, reduce respiratory strain, and enhance the overall recovery of patients with bronchiolitis and RSV.

1. Assess for extreme weakness and fatigue; ability to rest, sleep, and amount of movement in bed.
This provides information to determine the effects of dyspnea and the work of breathing over a period of time, which becomes exhaustive and depletes the child’s energy reserves and the ability to rest, eat, and drink. Knowledge of these factors also provides an opportunity to develop effective measures to maintain or improve the child’s mobility.

2. Monitor the client’s vital signs, noting the pulse rate when the client is at rest or when active.
Pulse can be typically elevated during activity, and even at rest, tachycardia up to 160 beats/minute may be present. Tachycardia can also manifest as the body compensates for the decreased oxygen levels caused by bronchial obstruction and ventilation-perfusion mismatch.

3. Assess for the development of tachypnea, dyspnea, pallor, and cyanosis.
Oxygen demand and consumption are increased in a hypermetabolic state, increasing the risk of hypoxia with activity. The infant may become fussy and cry during feeding time, thus expending more energy, making the infant more irritable and weak after.

4. Accept the presence of fatigue or when the older child is unable to perform activities.
Activity intolerance can vary from time to time. Nonjudgemental acceptance of the client’s evaluation of their day-to-day functioning provides an opportunity to promote their self-esteem, especially in the school-aged child. School-aged children may resent being admitted to the hospital, and the lack of energy to do activities that they like may frustrate them even more.

5. Schedule and provide rest periods in a quiet, comfortable environment (temperature and humidity).
This promotes adequate rest and reduces stimuli in order to decrease the risk of fatigue. Recently, frequent alarms from pulse oximetry due to erroneous assessment in an active infant or child might result in alarm fatigue. Therefore, continuous pulse oximetry monitoring is not recommended by the AAP (Hendaus et al., 2018). Fatigue commonly worsens when exposed to high temperatures due to weather, environmental heat, or fever. 

6. Disturb the child only when necessary, and perform all care at one time instead of spreading over a long period of time.
This conserves energy and prevents interruptions in rest. Plan the client’s care together with consistent rest periods and encourage afternoon naps to reduce fatigue during procedures and aggravation of muscle weakness due to increased, labored breathing.

7. Encourage parents to use measures to prevent fatigue in the child (holding and/or rocking, feeding in small amounts, playing with the child, offering diversions such as TV, and toys).
This provides support to the child and conserves energy. Calming activities such as reading and watching tv allow for the use of nervous energy in a constructive manner. It may also serve as a distraction and reduce anxiety.

8. Allow quiet play with a familiar toy while maintaining bed rest.
Rest decreases fatigue and respiratory distress; quiet play prevents excessive activity, which depletes energy and increases respiration. If watching TV, the volume levels may be turned down and the lights dimmed to avoid overstimulation. The parent may read to the child or just stroke the child’s back while lying down.

9. Teach parents to pick up an infant if crying longer than one to two minutes.
This prevents fatigue, as prolonged crying is exhaustive. An infant diagnosed with bronchiolitis can be extremely fussy and irritable and may cry frequently. Calming the infant by picking them up and rocking them to sleep may help them wind down. Rubbing their back gently or playing soft lullabies may also help calm the infant down.

10. Assist parents in developing a plan to provide feeding, bathing, and changing diapers around rest periods.
This prevents interruption in rest and sleep. Literature has shown that parents are willing to share in medical decisions as long as they are provided with support and information to guide them. Involving parents in decision-making in regard to their children’s health augments satisfaction and leads to improved adherence to the plans discussed. With both medical proof and personal values defined, the healthcare team and the family can jointly decide on the treatment plan (Hendaus et al., 2018).

11. Administer heated, humidified oxygen as indicated.
A heated, humidified high-flow nasal cannula (HFNC) is a relatively new therapy that allows the delivery of high-inspired gas flows with or without increased oxygen concentration. Ideally, these devices should deliver flow greater than the client’s peak inspiratory demand to fully support their minute ventilation. Additionally, HFNC provides some level of CPAP. It decreases respiratory rate to a greater extent than other devices, decreasing the rate of intubation and the work of breathing by the child’s tired respiratory muscles (Tasker, 2013).

6. Promoting Optimal Nutrition & Fluid Balance

Ensuring adequate nutrition and maintaining proper fluid balance are vital for supporting the immune system, optimizing recovery, and minimizing complications in patients with bronchiolitis and respiratory syncytial virus (RSV) infection. Promoting optimal nutrition involves assessing the patient’s nutritional status and providing appropriate interventions to meet their dietary needs. Additionally, healthcare providers monitor the patient’s fluid balance to ensure hydration and prevent dehydration. It is essential for nurses to collaborate with parents to encourage and support adequate nutrition and hydration. By promoting optimal nutrition and fluid balance, healthcare professionals aim to support the immune system, maintain energy levels, and facilitate the healing process in patients with bronchiolitis and RSV.

1. Assess vital signs, such as increased temperature, tachycardia, and tachypnea.
Elevated temperature increases the metabolic rate and fluid losses through evaporation. The increased respiratory rate or tachypnea interferes with successful feeding, and the infant becomes dehydrated. Steadily increasing tachycardia may indicate systemic fluid deficit.

2. Monitor the child’s intake and output.
Monitoring the intake and output closely may provide information about the adequacy of fluid volume and replacement needs. Note the color and characteristics of urine and its specific gravity. Urine-specific gravity may provide useful information regarding fluid balance and possible dehydration (Maraqa & Steele, 2021).

3. Assess skin turgor and the moisture of mucous membranes.
Skin turgor and the moisture in the mucous membranes, particularly the lips and tongue, are indirect indicators of the adequacy of fluid volume, although oral mucous membranes may be dry because of mouth breathing and supplemental oxygen administered.

4. Identify factors that contribute to an inability to eat.
The choice of interventions may depend on the underlying cause of the problem. Copious secretions which lead to difficulty in breathing may affect the client’s ability for oral intake. Some barriers to providing optimal nutrition in children diagnosed with severe bronchiolitis include the potential need for intubation and the risk of aspiration in children with respiratory distress (Ng et al., 2020).

5. Evaluate the client’s general nutritional state.
Children admitted with bronchiolitis are often malnourished, to begin with, as respiratory distress and supplemental oxygen requirement in bronchiolitis often delay the decision to commence feeding, leading to insufficient fluid and nutrient intake (Ng et al., 2020).

6. Auscultate bowel sounds and observe for abdominal distention.
The client’s bowel sounds may be diminished or absent if the infectious process is severe or prolonged. Abdominal distention may occur because of air swallowing as the child becomes more irritable and fussy, therefore crying frequently.

7. Obtain the client’s general baseline weight.
To determine baseline nutritional status, admission weight and length should be obtained from medical records, and weight-for-length scores can be calculated according to the World Health Organization (WHO) growth standards (Ng et al., 2020). The WHO charts reflect growth patterns among children who were predominantly breastfed for at least four months and still breastfeeding at 12 months (World Health Organization, 2010).

8. Weigh the client periodically.
The degree of dehydration between an older child and an infant is slightly different as the infant could have a total body water (TBW) content of 70 to 80% of the body weight, and older children have TBW of 60% of body weight. An infant has to lose more body weight than an older child to get the same level of dehydration (Vega, 2022). Weigh the infant’s diaper before and after use to determine the urine output.

9. Perform non-invasive nasal suctioning prior to oral feedings.
Suctioning of the nasopharynx with saline in infants diagnosed with bronchiolitis is a common practice to improve upper airway obstruction caused by nasal congestion and thus improve the infant’s ability to feed (Cahill & Cohen, 2018).

10. Provide small, frequent feedings if the client is able to tolerate them.
These measures may enhance intake even though appetite may be slow to return. Provide dry foods, such as toast or crackers, and foods that are appealing to the client but do not put them at risk for aspiration.

11. Provide oral fluids as individually appropriate.
Oral therapy is still preferred for a client diagnosed with bronchiolitis, as long as the client is still capable of oral intake without increasing the risk of aspiration. Oral rehydration therapy is the most preferred way of hydration for clients with mild dehydration. Breastfeeding should be continued (Vega, 2022).

12. Elevate the client’s head of the bed when providing oral fluids.
The client may be at increased risk for aspiration when respiratory distress is manifested. If the client is still able to take in oral fluids, raising the head of the bed when the client drinks make it easier for them to swallow the liquid and prevents aspiration.

13. Provide oral care regularly.
The client may experience dry mucous membranes due to dehydration and mouth breathing, and it may cause cracking of the lips, which can be painful to the infant or the younger child. Clean the infant’s mouth with a damp, soft cotton cloth to remove milk residue and provide additional moisture to the oral mucous membranes inside.

14. Perform non-invasive nasal suctioning prior to oral feedings.
Suctioning of the nasopharynx with saline in infants diagnosed with bronchiolitis is a common practice to improve upper airway obstruction caused by nasal congestion and thus improve the infant’s ability to feed (Cahill & Cohen, 2018).

15. Provide small, frequent feedings if the client is able to tolerate them.
These measures may enhance intake even though appetite may be slow to return. Provide dry foods, such as toast or crackers, and foods that are appealing to the client but do not put them at risk for aspiration.

16. Encourage the parent to continue breastfeeding.
The immunologic benefits of breastfeeding to prevent bronchiolitis have been highlighted in several studies; maintaining breastfeeding may also have a beneficial impact on total intakes and immune response to viral regression (Valla et al., 2019). Breastfeeding disruption during hospitalization can often be prevented by a set of measures to support breastfeeding and to inform caregivers and clients about the specific risk of weaning during the child’s respiratory disease, especially in infants whose breastfeeding is not yet stable (Gueriba et al., 2021).

17. Insert a nasogastric tube for feedings, as indicated.
If oral hydration cannot be maintained due to tachypnea and increased work of breathing, then IV or NG fluids should be administered. Enteral hydration has several theoretical advantages, such as physiological benefits and allowing additional administration of calories. Additionally, enteral feeding could be safely conducted during high-flow oxygen delivery. A further advantage of hydration via NGT is that fewer attempts are needed in infants to achieve successful placement compared to IV insertion (Babl et al., 2020).

18. Insert an intravenous line if necessary.
IV therapy may be necessary for those clients who are unable to take fluids by mouth or who have a respiratory rate higher than 70 breaths/minute. Clients with apneic episodes should also have access to IV hydration (Maraqa & Steele, 2021).

19. Monitor the client’s sodium levels.
Hyponatremia is more likely to be the consequence of a volume-dependent activation of the renin-angiotensin-aldosterone system, combined with an appropriate antidiuretic hormone secretion which may also be inappropriately triggered by a volume-independent stimulus. Additionally, bronchiolitis-related hyponatremia may be worsened by the use of IV hypotonic solutions (Valla et al., 2019).

20. Promote protein intake for clients capable of oral intake.
Children with severe bronchiolitis experience a high protein turnover, and higher protein intake have been shown to significantly improve nitrogen balance. More recent pediatric intensive care unit (PICU) guidelines have suggested that 1.5/kg/day may be the minimum protein requirement and that higher protein intake may be required in infants and young children with lower muscle reserves (Valla et al., 2019).

21. Start enteral nutrition as early as possible for severely ill children.
Early enteral nutrition has been associated with improved outcomes in severely critically ill populations. In children diagnosed with bronchiolitis requiring high-flow nasal cannula oxygen, the initiation of nutrition within the first 16 hours of PICU stay was associated with a shorter PICU stay. Early provision of enteral nutrition is thought to be beneficial in critically ill children, as it protects the intestinal mucosa and its barrier function, in turn, preventing the progression of sepsis which can cause the failure of multiple organs (Valla et al., 2019).

22. Administer isotonic IV solutions, as prescribed.
A study found that three out of four infants admitted to the PICU with hyponatremic seizures had received hypotonic IV solutions prior to admission. Isotonic solution use should be standard practice (Valla et al., 2019).

23. Administer medication as prescribed.
See Pharmacologic Management

7. Providing Patient Education & Health Teachings

Providing patient education and health teachings to parents and child patients with bronchiolitis and respiratory syncytial virus (RSV) is crucial for their understanding of the condition, its management, and the promotion of overall well-being. For parents, health teachings focus on strategies to manage symptoms, promote comfort, and facilitate a healthy recovery. In addition to parent education, providing age-appropriate health teachings directly to the child patient can contribute to their understanding and cooperation during the care process. Empowering parents and child patients through education also includes addressing common concerns and misconceptions. Clearing any misconceptions about the illness, addressing anxieties, and providing realistic expectations about the duration of symptoms and recovery process can alleviate stress and promote a sense of control.

1. Assess existing knowledge of disease prevention, transmission, and treatment.
This provides a baseline for the type of information needed to prevent infection transmission to the child. Information can enhance coping and help reduce anxiety and excessive concern. Respiratory symptoms may be slow to resolve, and fatigue can persist for an extended period.

2. Review normal lung function and pathology of the condition.
Reviewing the normal lung processes promotes an understanding of the current situation and the importance of cooperating with the treatment regimen.

3. Review the importance of smoking cessation.
Smoking destroys tracheobronchial ciliary action, irritates the bronchial mucosa, and inhibits alveolar macrophages, compromising the body’s natural defenses against infection.

4. Provide information in written or electronically available materials.
Fatigue and depression can affect the ability to assimilate information and follow a medical regimen. Preferences for education materials include pamphlets, applications, videos, and websites. Most parents in a study suggested broad information campaigns about bronchiolitis, including information on symptoms and how to mitigate the transmission of respiratory viruses in young children (Piche-Renaud et al., 2020).

5. Teach that the virus is transmitted by direct and indirect contact via the nose and eyes and that hands should be kept away from these areas.
Explain that kissing and cuddling the child, and fomites that are on hard, smooth surfaces are sources of contact with the virus. Most cases of bronchiolitis result from a viral pathogen, such as RSV, rhinovirus, human metapneumovirus, parainfluenza virus, adenovirus, coronavirus, influenza virus, or human bocavirus. Bronchiolitis is highly contagious and can also be spread through airborne droplets (Maraqa & Steele, 2021).

6. Teach parents about the signs and symptoms of respiratory distress and infection, including fever, dyspnea, tachypnea, and expectoration of yellow/green sputum.
This encourages parents to seek prompt medical attention, as needed. Prompt evaluation and timely intervention may prevent or minimize complications. A study found that most parents report receiving insufficient information on how to recognize the symptoms of bronchiolitis. Parents prefer to receive explanations personally from healthcare professionals; therefore, detailed recommendations on when to seek further medical care should be given during discharge (Piche-Renaud et al., 2020).

7. Teach of the potential for the spread of the virus to other family members and the need for segregation of the child from others.

8. Educate the family members that the virus is easily transmitted, with an incidence as high as half of the family members acquiring viral infections. Viral shedding of RSV in nasal secretions continues 6 to 21 days after symptoms develop. Crowded living conditions and parental smoking are some of the risk factors that contribute to the development and spread of bronchiolitis in the family home. Secondary RSV infections occur in 46% of family members, and 98% of other children attending a childcare center (Maraqa & Steele, 2021).

9. Suggest that plastic goggles may be worn when caring for the child.
This prevents the risk of contact with the virus via the eyes. Infection can be spread through self-inoculation of ocular mucous membranes after direct contact with respiratory secretions (Maraqa & Steele, 2021).

10. Teach good handwashing techniques to the child and family members and proper use of PPEs to staff members.
This prevents transmission by the hands, which are the main sources of contamination and carriers of organisms to the face area. RSV can survive for several hours on hands and surfaces; therefore, handwashing and using disposable gloves and gowns may reduce the nosocomial spread of the virus (Maraqa & Steele, 2021).

11. Encourage parents to provide good nutrition and hydration, emphasizing a high-calorie balanced diet and increased fluids.
This promotes the liquefication of secretions and replaces calories used to fight infection, thereby boosting the child’s own natural body defense. Ensuring that the infant is well-hydrated is key, especially for those who cannot eat. Healthcare providers should encourage breastfeeding as it has been shown to reduce the risk of respiratory infections in children (Erickson et al., 2022).

12. Teach parents about the administration of medications prescribed.
This improves the consistency of medication administration and the recognition of adverse side effects. Medications may have a limited role in the management of bronchiolitis, but several drugs are still commonly used. However, there is little evidence to support the routine use of any drug in the management of bronchiolitis (Maraqa & Steele, 2021).

13. If hospitalized, adhere to infection control policies for clients with RSV bronchiolitis.
This protects from exposure to secretions and transmission of the virus to other patients. Because RSV infection spreads readily from person to person and can survive on surfaces for an extended period of time (> 6 hours), infection control and hand hygiene are important to reduce the risk of transmission.

14. Encourage and teach parents to provide care for the hospitalized child at a level they are comfortable with and within the constraints of necessary treatments.
The care of infants with RSV should be assigned to the parent who is not caring for other children that may be at high risk for adverse responses to RSV. The parent can be familiarized with the mist tent and encouraged to participate in the care and feeding of the child.

15. Teach parents about the prophylactic drugs (if ordered), such as palivizumab (Synagis).
Prevention of RSV is available via a monoclonal antibody, palivizumab (Synagis), given in monthly intramuscular injections. This medication is started at the onset of the RSV season and is terminated at the end of the season (usually from November to March). The AAP practice guidelines state that candidates for preventive therapy include infants with bronchopulmonary dysplasia, severe immunodeficiencies, or significant congenital heart disease. However, the high cost of administering these products has led to debate regarding which children should receive such prophylaxis (Maraqa & Steele, 2021).

16. Instruct parents on the importance of limiting the number of visitors and screening them for recent illnesses.
Hospital-acquired infection can be a major problem because caregivers may be carrying the organism. For this reason, an infant or child diagnosed with RSV bronchiolitis is placed on transmission-based contact isolation precautions to prevent the spread of RSV to other sick children, caregivers, or even visitors.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See Also

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database ^{MUST READ!}
  Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
  Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Other nursing care plans related to respiratory system disorders:

• Asthma
• Aspiration Risk & Aspiration Pneumonia
• Airway Clearance Therapy & Coughing
• Bronchiolitis
• Bronchopulmonary Dysplasia (BPD)
• Chronic Obstructive Pulmonary Disease (COPD)
• Cystic Fibrosis
• Hemothorax and Pneumothorax
• Influenza (Flu)
• Ineffective Breathing Pattern (Dyspnea)
• Impairment of Gas Exchange
• Lung Cancer
• Mechanical Ventilation
• Near-Drowning
• Pleural Effusion
• Pneumonia
• Pulmonary Embolism
• Pulmonary Tuberculosis
• Tracheostomy

References and Sources

To further your reading and research about bronchiolitis, please check out these references below:

• Babl, F. E., Franklin, D., Schlapbach, L. J., Oakley, E., Dalziel, S., Whitty, J. A., Neutze, J., Furyk, J., Craig, S., Fraser, J. F., Jones, M., & Schibler, A. (2020, February 11). Enteral hydration in high-flow therapy for infants with bronchiolitis: Secondary analysis of a randomized trial. Journal of Paediatrics and Child Health, 56(6), 950-955.
• Baron, J., & El-Chaar, G. (2016). Hypertonic Saline for the Treatment of Bronchiolitis in Infants and Young Children: A Critical Review of the Literature. NCBI. Retrieved November 9, 2022.
• Ben Gueriba, K., Heilbronner, C., Grimaud, M., Roy, E., Hadchouel, A., Hachern, T., de Barbeyrac, C., Murmu, M., Renolleau, S., & Rigourd, V. (2021, January). Simple actions to support breastfeeding can avoid unwanted weaning in infants younger than 6 months hospitalized for bronchiolitis: a before/after study (Bronchilact II). Archives de Pédiatrie, 28(1), 53-58.
• Cahill, A. A., & Cohen, J. (2018, March). Improving Evidence-Based Bronchiolitis Care. Clinical Pediatric Emergency Medicine, 19(1), 33-39.
• Erickson, E. N., Bhakta, R. T., & Mendez, M. D. (2022, June 27). Pediatric Bronchiolitis – StatPearls. NCBI. Retrieved November 10, 2022.
• Hendaus, M. A., Nassar, S., Leghrouz, B. A., Alhammadi, A. H., & Alamri, M. (2018, April 3). Parental preference and perspectives on continuous pulse oximetry in infants and children with bronchiolitis. NCBI. Retrieved November 10, 2022.
• Justice, N. A., & Le, J. K. (2022, June 27). Bronchiolitis – StatPearls. NCBI. Retrieved November 8, 2022.
• Kuitunen, I., Kiviranta, P., Sankilampi, U., Salmi, H., & Renko, M. (2022, June). Helium–oxygen in bronchiolitis—A systematic review and meta‐analysis. NCBI. Retrieved November 9, 2022.
• Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
• Maraqa, N. F., & Steele, R. W. (2021, May 17). Bronchiolitis: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved November 8, 2022.
• Ng, G., Ong, C., Wong, J., Teoh, O. H., Sultana, R., Mok, Y. H., & Lee, J. H. (2020, February 28). Nutritional status, intake, and outcomes in critically ill children with bronchiolitis. Pediatric Pulmonology, 55(5), 1199-1206.
• Piche-Renaud, P.-P., Thibault, L.-P., Essouri, S., Chainey, A., Theriault, C., Bernier, G., & Gaucher, N. (2020, October 02). Parents’ perspectives, information needs, and healthcare preferences when consulting for their children with bronchiolitis: A qualitative study. Acta Paediatrica, 110(3), 944-951.
• Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
• Tasker, R. C. (2013). Bronchiolitis – PMC. NCBI. Retrieved November 10, 2022.
• Valla, F. V., Baudin, F., Demaret, P., Rooze, S., Moullet, C., Cotting, J., Ford-Chessel, C., Pouyau, R., Peretti, N., Tume, L. N., Milesi, C., & Le Roux, B. G. (2019). Nutritional management of young infants presenting with acute bronchiolitis in Belgium, France, and Switzerland: survey of current practices and documentary search of national guidelines worldwide. European Journal of Pediatrics, 178, 331-340.
• Vega, R. M. (2022, August 1). Pediatric Dehydration – StatPearls. NCBI. Retrieved November 11, 2022.
• World Health Organization. (2010, September 9). Growth Charts – WHO Child Growth Standards. CDC. Retrieved November 11, 2022.
• Wrotek, A., Kobialka, M., & Jackowska, T. (2021, August 23). Capillary Blood Gas Predicts Risk of Intensive Care in Children with Bronchiolitis. NCBI. Retrieved November 9, 2022.