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.
Here are six (6) nursing care plans (NCP) and nursing diagnosis (NDx) for Influenza (Flu):
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Acute Pain
- Deficient Knowledge
- Risk for Deficient Fluid Volume
Ineffective Breathing Pattern
Influenza viruses spread from human to human via aerosols created when an infected individual coughs or sneezes. If not neutralized by secretory antibodies, the virus invades airway and respiratory tract cells. Once the virus is within host cells, cellular dysfunction and degeneration occur. As in other viral infections, systemic symptoms such as dyspnea or tachypnea result from the release of inflammatory mediators (Nguyen & Stuart, 2022).
May be related to
- Inflammation from viral infection
- Hemorrhagic bronchitis
Possibly evidenced by
- Pulmonary edema
- Warm flushed skin
- Erythema to tonsils, soft and hard palate, and pharyngeal wall
- Abnormal chest X-rays
- The client will achieve and maintain normal respiratory pattern and rate, with no adventitious breath sounds to auscultation.
- The client will be able to expectorate secretions effectively.
- The client will maintain and adhere to isolation precautions.
- The client will be able to utilize relaxation techniques to improve pain and facilitate breathing.
Nursing Assessment and Rationales
1. Assess vital signs and carefully monitor respiratory status for baseline rate, rhythm, and character.
Respiratory distress and changes in vital signs occur because of physiological stress or may indicate developing shock due to hypoxia. A review of avian influenza cases in four countries found that the clinical course progressed to ARDS and respiratory failure in 70 to 100% of clients (Nguyen & Stuart, 2022).
2. Monitor pulse oximetry readings.
Oximetry approximates arterial blood gas oxygen saturation and helps to identify oxygenation dysfunction and respiratory status changes. In severe cases of influenza, the client is likely to have hypoxemia, and the alveolar-arterial gradient may be increased (>35 mm Hg) (Nguyen & Stuart, 2022).
3. Auscultate breath sounds every four hours and as needed.
This assists with the identification of changes in respiratory status, the presence of adventitious breath sound or decreased breath sounds. The older adult client may have infiltrates in the interstitium, bilateral lobes, and anterior and lower lung fields. Generally, pulmonary findings may include dry cough with clear lungs or rhonchi, as well as focal wheezing (Nguyen & Stuart, 2022).
4. Assess the client for complaints of pain and medicate as needed.
Pain decreases respiratory effort and chest excursion, which decreases ventilation and perfusion. Analgesia relieves pain and promotes improved respiratory effort. Cough-related pleuritic chest pain is a common manifestation of respiratory infections. Additionally, any type of infection has the potential to spread to the pleura, but viral infections are usually responsible.
Nursing Interventions and Rationales
1. Maintain a calm attitude, assisting the client to “take control” by using slower, deeper respirations.
This assists the client in dealing with the physiological effects of hypoxia, which may be manifested as anxiety or fear. Breathing may no longer be an involuntary activity but require conscious effort, depending on the involvement of respiratory muscles.
2. Encourage the client to maintain a semi-Fowler or high-Fowler position as tolerated.
This promotes chest expansion and enhances respiratory effort. Standing and sitting have been shown to lead to the highest lung volumes. At higher lung volumes, the elastic recoil of the lungs and the chest wall is greater. In addition, the expiratory muscles are capable of generating higher intrathoracic pressure, pushing air through narrow airways at high speed, which results in higher peak expiratory flow (PEF) and FVC (Katz et al., 2018).
3. Encourage the client and assist with the use of incentive spirometry, nebulizers, etc., as ordered.
These interventions assist in preventing atelectasis or lung collapse and ensure proper use of equipment. Incentive spirometry has been widely used to prevent pulmonary complications and to improve lung function in clients with respiratory disorders. Flutter and Acapella devices combine positive expiratory pressure therapy and high-frequency oscillations in the airway. They can reduce airway collapse and improve mucus discharge, enhancing lung function and oxygenation (Shin, 2019).
4. Perform chest physiotherapy, chest percussion, and postural drainage as ordered.
In percussion, cupped hands or the palm cup are used to manually clap the affected lung and perform postural drainage. This allows the shifting of secretions from the peripheral airway to the central airway, enhancing airway clearance. Vibrations can be performed manually or using mechanical devices (Shin, 2019).
5. Encourage the client to change position every two hours and as needed, and assist as needed.
This facilitates comfort and mobilizes pulmonary secretions. Although there is a lack of evidence for the interval of position change, it is generally performed at two to four-hour intervals, which can help reduce the incidence of pulmonary complications such as nosocomial pneumonia and atelectasis (Shin, 2019).
6. Maintain ordered isolation techniques.
Place the client 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 in a healthcare facility (Centers for Disease Control and Prevention, 2021).
7. Instruct the client and/or family members regarding isolation requirements and ensure that they adhere to the proper techniques.
Clients under droplet precautions should wear a facemask and follow respiratory hygiene and cough etiquette and hand hygiene during transport outside of the isolation room. Before discharge, communicate the client’s diagnosis and current precautions with post-hospital care providers as well as transporting personnel (Centers for Disease Control and Prevention, 2021).
8. Teach the client how to use a pillow to split the chest with cough efforts.
Splinting assists in reducing pain associated with cough. Supporting the chest and abdominal muscles makes coughing more effective and less traumatic. Additionally, instruct the client to place hands below the diaphragm and push upward as the client exhales. This is called a “quad cough”. This technique is generally reserved for clients with stable injuries once they are in the rehabilitation stage.
9. Instruct the client in relaxation techniques, guided imagery, muscle relaxation, and breathing exercises.
These interventions assist in pain reduction and alleviate anxiety which may improve respiratory effort and oxygenation. Deep breathing exercises introduce air into the lungs using negative air pressure generated by the client’s diaphragm instead of the accessory respiratory muscles. This can restore atelectasis, improve oxygenation and lung recruitment, increase functional residual capacity and tidal volume, and potentially help clear secretions (Shin, 2019).
10. Administer oxygen as ordered.
This provides supplemental oxygen and helps alleviate respiratory distress caused by hypoxemia. Supplemental oxygenation is given to manage respiratory symptoms or objective hypoxia. Ventilatory support with a bag-valve-mask device or field intubation may be required if the client is in respiratory failure (Nguyen & Stuart, 2022).
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its 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 showing 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.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is 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.
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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