Influenza (also known as flu, or grippe) is an acute inflammation of the nasopharynx, trachea, and bronchioles, with congestion, edema, and the possibility of necrosis of these respiratory structures. Influenza is a highly contagious airborne disease of the respiratory tract caused by three different types of Myxovirus influenzae. It occurs sporadically or in epidemics which peaks usually during colder months. In tropical areas, influenza occurs throughout the year. The WHO estimates that 1 billion influenza cases, 3 to 5 million severe cases, and 290,000 to 650,000 influenza-related respiratory deaths occur each year worldwide (Nguyen & Stuart, 2022).
The presentation of influenza virus infection varies, but it usually overlaps with those of many other viral upper respiratory tract infections (URTI). Typical signs and symptoms include cough, fever, sore throat, myalgias, headache, nasal discharge, weakness and severe fatigue, tachycardia, and red, watery eyes. Influenza has been diagnosed traditionally on the basis of clinical criteria, but rapid diagnostic tests are becoming more widely used. The gold standard for diagnosing influenza a and B is a viral culture of nasopharyngeal samples or throat samples (Nguyen & Stuart, 2022).
Nursing Care Plans
Unless complications occur, influenza doesn’t require hospitalization and nursing care usually focuses on the prevention of the disease and relief of symptoms.
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Acute Pain
- Deficient Knowledge
- Risk for Deficient Fluid Volume
Ineffective Airway Clearance
Viral respiratory tract infections are among the most common illnesses worldwide, and their severity widely varies from the common cold to severe respiratory tract infections. Influenza A virus causes seasonal respiratory infections, leading to half a million deaths annually. Only a few clinically effective vaccines or specific antiviral drugs are available for the prevention and treatment of viral respiratory infections. Thus, the mechanisms by which viruses are removed from the respiratory tract are indispensable for effective viral clearance and airway host defense. Mucociliary clearance is an important defense mechanism that requires coordinated ciliary activity and proper mucus production to propel airway surface liquids that trap pathogens and pollutants (Kamiya et al., 2020).
May be related to
- Tracheobronchial and nasal secretions
- Increased peripheral airway resistance caused by drug therapy
Possibly evidenced by
- Rhinorrhea or “runny nose”
- Changes in respiratory rate and depth
- Irritating nonproductive cough
- Decreased breath sounds
- Adventitious breath sounds
- Production of sputum
- The client will achieve the return of and ability to maintain patent airways and respiratory status baselines.
- The client will have clear breath sounds to auscultation and will have respiratory status parameters with optimal air exchange.
- The client will be compliant and be able to accurately administer medications on a daily basis, preventing exacerbations of the disease process.
- The client will be able to cough up secretions and perform coughing and deep-breathing exercises.
Nursing Assessment and Rationales
1. Assess respiratory status for rate, depth, ease, use of accessory muscles, and work of breathing
Changes may vary from minimal to extreme caused by bronchial swelling, increased mucus secretions caused by oversecretion of goblet cells and tracheobronchial infection, narrowing of air passageways, and the presence of other disease states complicate the current condition. Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of the discomfort of moving chest walls or secretions in the lung.
2. Auscultate the lung fields for the presence of wheezes, crackles (rales), rhonchi, or decreased breath sounds.
Wheezing is caused by the squeezing of air past the narrowed airways during expiration which is caused by bronchospasms, edema, and secretions obstructing the airways. Crackles or rales, result from the consolidation of leukocytes and fibrin in the lung causing an infection or fluid accumulation in the lungs. Decreased breath sounds may indicate alveolar collapse with little to no air exchange in the lung area being auscultated and usually results in poor ventilation.
3. Monitor oxygen saturation by pulse oximetry, and notify the healthcare provider of readings <90% or as prescribed.
High-level oxygen can cause severe damage to tissues, oxygen toxicity, increases in A-a gradients, microatelectasis, and ARDS. Oximetry readings of 90% are associated with increased morbidity and mortality and correlate with PaO2 of 60 mmHg and levels below 60 mmHg, which indicate hypoxemia (Majumdar et al., 2011).
4. Assess the client for pallor or cyanosis, especially to nail beds and around the mouth.
Although not a reliable indicator of the loss of airway patency, this may indicate hypoxemia. Oxygen might not reach hemoglobin in adequate or in sufficient amounts as a result of conditions affecting the respiratory system such as influenza (Adeyinka & Kondamudi, 2022). Cyanosis does not occur until a level of 5 grams of reduced hemoglobin/100 ml of blood in the superficial capillaries is reached.
5. Monitor the client for cough and production of sputum, noting amount, color, character, and the client’s ability to expectorate secretions, and the ability to cough.
Mucus color from yellow to green may indicate the presence of infection. Tenacious, thick secretions require more effort and energy to expectorate through coughing, and may actually create an obstruction stasis that leads to infection and respiratory changes. Cough and other respiratory symptoms initially may be minimal but frequently progress as the infection evolves. The client may report a nonproductive cough, or cough-related pleuritic chest pain, and dyspnea (Nguyen & Stuart, 2022).
6. Monitor the client’s vital signs.
Fever may vary widely among clients, with some having low fevers (in the 100℉ [37.7℃]) and others developing fevers as high as 104℉. Some clients report feeling feverish and feeling chills. Tachycardia may occur, which most likely results from hypoxia, fever, or both (Nguyen & Stuart, 2022).
7. Assess skin and mucous membrane changes.
The skin may be warm to hot, depending on the core temperature status. A client who has been febrile with poor fluid intake may show signs of mild volume depletion with dry skin (Nguyen & Stuart, 2022).
8. Observe the client’s general appearance and strength.
Some clients appear acutely ill, with some weakness and respiratory findings, whereas others appear only mildly ill. The client’s eyes may be red and watery. Weakness and severe fatigue may prevent the client from performing their normal activities or work. The client may also report needing additional sleep. In some cases, clients diagnosed with influenza may be bedridden (Nguyen & Stuart, 2022).
Nursing Interventions and Rationales
1. Position the client in a high Fowler or semi-Fowler position, if possible.
One of the main goals of positioning, and specifically the use of upright positions, is to improve lung function in clients with respiratory disorders. A study found that forced expiratory volume in 1 second (FEV1) is higher in erect positions. Recumbent positions limit expiratory volumes and flow, which may reflect an increase in airway resistance, a decrease in elastic recoil of the lung, or decreased mechanical advantage of forced expiration, presumably affecting large airways (Katz et al., 2018).
2. Turn the client in every two hours and as needed.
Repositioning promotes drainage of pulmonary secretions and enhances ventilation to decrease the potential for atelectasis. In side-lying positions, when the bed is flat, the abdominal contents fall forward. The dependent hemidiaphragm is stretched to a good length for tension generation, while the non-dependent hemidiaphragm is more flattened. Changes in lung volumes may thus balance themselves out due to a better diaphragmatic contraction but decreased space in the thorax (Katz et al., 2018).
3. Encourage early ambulation and aerobic exercises as indicated.
Early and protocol-based mobilization is important for functional recovery and shortening the length of hospital stay. Mobilization generally includes sitting on the edge of the bed, moving from the bed to the chair, standing next to the bed, walking on the spot, and walking with or without ambulatory assisting devices (Katz et al., 2018).
4. Perform postural drainage and percussion, as ordered.
Postural drainage utilizes gravity to help raise secretions and clear sputum. Percussion and/or vibration may assist with the movement of secretions away from bronchial walls and enable the client to cough them up and increase the force of expiration. Some positions utilized during chest physiotherapy may be contraindicated in older adults as they may not tolerate intense percussion because of the fragility of bones and skin (Sereearuno et al., 2020).
5. Encourage fluids, up to three to four liters/day unless contraindicated.
This provides hydration and helps to thin secretions for easier mobilization and removal. Fluids, especially warm fluids, aid in the mobilization and expectoration of secretions. The client must avoid extremely hot, or cold, beverages, however, because they may predispose the client to cough spells, leading to dyspnea or bronchospasms.
6. Encourage deep breathing exercises and coughing exercises every two hours. Instruct the client to splint the chest when performing coughing exercises.
Deep breathing facilitates the maximum expansion of the lungs and smaller airways. This can restore atelectasis, improve oxygenation and lung recruitment, increase functional residual capacity and tidal volume, and potentially help clear secretions (Shin, 2019). Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.
7. Suction the client if needed, or if oxygen desaturation is present.
The client may be too weak or fatigued to remove their own secretions. Suctioning may also stimulate coughing or mechanically clear the airway in a client who is unable to do so because of an ineffective cough or decreased level of consciousness.
8. Instruct the client on alternative types of coughing exercises, such as quad thrusts or mechanical insufflation-exsufflation (MIE), if the client has difficulty during coughing.
This minimizes fatigue by assisting the client in increasing expiratory pressure and facilitating cough. MIE is a commonly used method to remove excessive sputum from clients who cannot effectively expectorate sputum due to an impaired cough. Manual techniques such as assistant cough or thoracoabdominal thrusts may be applied to facilitate sputum release (Shin, 2019).
9. Instruct the client on the use of incentive spirometry.
Incentive spirometry has been widely used to prevent pulmonary complications and to improve lung function in nonambulatory clients. Deep breathing exercises can more effectively induce maximal inspiration when clients receive visual feedback through incentive spirometry. Generally, the client performs five to ten repetitions of a sequence of performing deep breathing slowly, holding the breath for two to three seconds, and then exhaling slowly. If sputum needs to be released, it is expectorated by coughing at the end of the session (Shin, 2019).
10. Encourage the client to join smoking cessation programs.
Smoking causes increased mucus production, vasoconstriction, increased blood pressure, inflammation of the lung lining, and decreased numbers of macrophages in the airways and mucociliary blanket.
11. Instruct the client to avoid crowds and persons with upper respiratory infections when possible.
This prevents possible transmission of infection to the client who already is immunocompromised. Influenza A is generally more pathogenic than influenza B. Epidemics of influenza C have been reported, especially in young children (Nguyen & Stuart, 2022).
12. Place the client in droplet precaution interventions.
Droplet precautions should be implemented for clients with suspected or confirmed influenza for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while the client is admitted. The healthcare personnel entering the client’s room must strictly wear a facemask and remove it when leaving the room (Centers for Disease Control and Prevention, 2021).
13. Administer antivirals as ordered.
Antiviral treatment is recommended as soon as possible for clients with confirmed or suspected influenza who have severe, complicated, or progressive illnesses or who require hospitalization. For outpatient clients, antivirals are recommended if there is a confirmed or suspected risk for influenza complications on the basis of age or underlying medical conditions. Currently recommended antiviral medications include oseltamivir, zanamivir, peramivir, and baloxavir marboxil (Nguyen & Stuart, 2022).
14. Administer influenza vaccine as prescribed.
The influenza vaccine provides reasonable protection against immunized strains. The vaccination becomes effective 10 to 14 days after administration. It has a 50 to 60% efficacy against influenza B viruses and 70% efficacy against influenza B viruses. Vaccines against seasonal influenza are reformulated annually to contain the most recently circulating strains (Nguyen & Stuart, 2022).
Recommended nursing diagnosis and nursing care plan books and resources.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses as reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of it’s evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions show how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
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 | 9 Care Plans UPDATED!
- Bronchiolitis | 7 Care Plans UPDATED!
- Bronchopulmonary Dysplasia (BPD) | 7 Care Plans UPDATED!
- Chronic Obstructive Pulmonary Disease (COPD) | 7 Care Plans UPDATED!
- Cystic Fibrosis | 6 Care Plans UPDATED!
- Hemothorax, Pneumothorax, and Pleural Effusion | 5 Care Plans UPDATED!
- Influenza (Flu) | 6 Care Plans UPDATED!
- Lung Cancer | 7 Care Plans UPDATED!
- Mechanical Ventilation & Endotracheal Intubation | 10 Care Plans UPDATED!
- Drowning (Submersion Injury) | 7 Care Plans UPDATED!
- Pneumonia | 11 Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans
References and Sources
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