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

Ineffective Airway Clearance

Infants are affected most often because of their small airways, high closing volumes, and insufficient collateral ventilation. Recovery begins with the regeneration of bronchiolar epithelium after three to four days; however, cilia do not appear for as long as two weeks. Mucus plugs are instead predominantly removed by macrophages (Maraqa & Steele, 2021).

Nursing Diagnosis

• Ineffective Airway Clearance

May be related to

• Tracheobronchial obstruction 
• Increased mucus secretions
• Lack of ciliary defenses

Possibly evidenced by

• 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
• Hyperresonance
• Increased mucus and nasal discharge
• Tachypnea
• Fever

Desired Outcomes

• The child will demonstrate effective coughing and clear breath sounds.
• The child will be free of cyanosis and dyspnea.

Nursing Assessment and Rationales

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 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).

3. Assess breath sounds by auscultation.
Abnormal breath sounds can be heard as fluid and mucus accumulate. This may indicate airway is obstructed. A physical examination may reveal wheezing, rhonchi, and crackles. The degree of wheezing correlates poorly with hypoxia.

4. 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.

5. 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).

6. 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. 

Nursing Interventions and Rationales

1. 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.

2. 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.

3. 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).

4. 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.

5. 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).

6. Administer medications for bronchiolitis as prescribed:

• 6.1. Bronchodilators
  Bronchodilators are among the most common therapies for bronchiolitis; studies have reported that their use ranges from approximately 50% of cases to more than 90%. They act by decreasing muscle tone in both small and large airways in the lungs, thus increasing ventilation (Maraqa & Steele, 2021). However, bronchodilators do not affect disease resolution, the need for hospitalization, or the length of stay (Baron & El-Chaar, 2016).
• 6.2. Intranasal decongestants
  Aerosolized racemic epinephrine may be primarily beneficial as a nasal decongestant. Oxymetazoline is applied directly to mucous membranes, where it causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation (Maraqa & Steele, 2021).
• 6.3. 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).