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
Acute infections often stimulate a febrile response. A mild fever appears to improve outcomes and diminish viral replication by several mechanisms and improve host defense mechanisms against the pathogen. However, a fever may also damage host cellular and tissue function and increase metabolic demands. At temperatures at the lower end of the febrile range, the benefit of the fever appears to outweigh the detrimental effects. However, at higher temperatures, the outcome worsens, suggesting that the disadvantages of fever on the host predominate (Walter, 2021).
May be related to
- Influenza viral infection
- Exposure to infection
- Alterations in fluid and electrolyte balance
Possibly evidenced by
- Increased temperature
- Warm, flushed skin
- Dry mucous membranes
- Changes in mentation
- Increased BUN and creatinine
- Electrolyte imbalances
- The client will achieve and maintain a normal temperature and be free of chills.
- The client will achieve and maintain a balanced intake and output with adequate hydration.
- The client will be afebrile with stable vital signs.
- The client will experience no associated complications.
Nursing Assessment and Rationales
1. Monitor vital signs especially temperature, every two to four hours and as needed. Utilize the same methods of temperature reading with each measurement.
This helps to evaluate the efficacy of treatment and monitors for complications that may occur as a result of increased temperature. Consistency in methods allows for accurate data collection and correlation. Increased temperature is a response to the inflammatory process associated with the disease. Fever may vary widely among clients, with some having low fevers (in the 100℉ [37.7℃] range) and others developing fevers as high as 104℉ (40℃) (Nguyen & Stuart, 2022).
2. Note shaking chills or profuse diaphoresis.
Some clients may report feeling feverish and feeling chills. Chills often precede temperature spikes and are a normal physiological response to an increased temperature. During an infection, the body tries to generate more heat and sets up a new higher temperature point. The body then recognizes that it is below that higher temperature goal, therefore the client feels cold and may start shivering. Shivering generates more heat by making the muscles contract.
3. Monitor intake and output every two to four hours.
This helps to identify fluid status changes and imbalances and allows for prompt treatment. Clients who have been febrile with poor fluid intake may show signs of mild volume depletion with dry skin (Nguyen & Stuart, 2022).
4. Monitor the client for seizures.
A seizure may occur with high temperatures because of hyperactivity within the brain, which can cause further impairment in tissue perfusion. Acute encephalopathy has been associated with the influenza A virus. Clinical features included altered mental status, coma, seizures, and ataxia. Of the clients who underwent further testing, most had abnormal cerebrospinal fluid, magnetic resonance imaging, and electroencephalographic findings (Nguyen & Stuart, 2022).
5. Assess environmental temperature.
Room temperature and linens should be altered to maintain a near-normal body temperature. Incidences of a raised temperature may be due to heat gain in excess of heat loss because of an unusually warm room temperature (Walter, 2021).
Nursing Interventions and Rationale
1. Provide tepid sponge baths.
Tepid sponge baths increase heat loss by evaporation. Additionally, tepid baths help prevent chilling that may aggravate and increase temperature and help reduce fever. However, the use of ice water or alcohol may cause chills, actually elevating the temperature. Alcohol can also cause skin dehydration.
2. Use a cooling blanket if the temperature will not decrease with the use of other methods and if the temperature is above 102.5ºF (39.1º C)
Hypothermia blankets remove heat by conduction via the cool solution that is circulated in the mattress placed above and/or below the client. The cooling blanket must be covered to prevent skin tissue injury and burns. They may also lower the temperature quickly and should be monitored to ensure that a hypothermic condition does not occur. Shivering actually increases the client’s metabolic rate and temperature.
3. Decrease the environmental temperature and remove extra blankets as warranted.
Manipulating the room temperature around the client will aid in releasing extra heat from the body. Removing or adding extra linens or blankets should be done to maintain a near-normal body temperature and according to the client’s current body temperature.
4. Encourage an increase in fluid intake to three to four liters/day unless contraindicated.
An increase in body temperature multiplies insensible fluid losses by 10% for every one degree Celsius of increase in body temperature, which may result in dehydration. Water and broth are acceptable, as well as solutions that contain water and salts proportioned to replenish fluids and electrolytes such as Pedialyte (Sparks, 2017).
5. Perform evaporative cooling as indicated.
Evaporative cooling is a noninvasive technique for cooling moderate hyperthermia. It was reported by volunteers that it reduces core body temperature by approximately 0.3℃ per minute. The client’s clothing is all removed and the temperature is continuously monitored during the procedure. The client is misted constantly using spray bottles filled with tepid (15℃) water. Large fans are placed to circulate warm room air directed at the client (Schraga & Wiener, 2022).
6. Perform strategic ice packing as indicated.
This is a commonly used technique, often used in conjunction with evaporative cooling, that reduces core temperature from approximately 0.02 to 0.03℃ per minute. Ice packs are placed in the client’s groin and in the axillae. The client’s clothing is all removed, and ice packs are removed once the core temperature reaches the desired goal (Schraga & Wiener, 2022).
7. Notify the healthcare provider of temperature increases that do not respond to any measure used.
This may indicate other sources of temperature aberration and may cause permanent organ damage. Hyperpyrexia is associated with the disruption of the cellular structural mechanisms and exacerbation of oxidative stress as a consequence of increased free radical production in the tissues. Acute kidney injury has been described across heat stress conditions of various etiologies (Walter, 2021).
8. Instruct the client on the use of a hypothermia blanket, reasons for use, signs, and symptoms of complications, etc.
This provides knowledge and helps to involve the client and the family in care. The blankets are used with specific criteria regarding the temperature goal to be reached and how long the client is to be kept at the target temperature. The client may lay on top or underneath the hyperthermia blanket. The client’s temperature should be closely monitored during blanket use because an extremely decreased temperature is also a dangerous medical condition (Tibbits, 2022).
9. Instruct the client on medications, side effects, and symptoms to report to the nurse.
Involves the client and family in care and provide knowledge that facilitates compliance. Acetaminophen can cause adverse effects such as skin rashes and hypersensitivity reactions, nephrotoxicity, nausea and vomiting, constipation, and abdominal pain (Gerriets & Nappe, 2022). NSAIDs have well-known adverse effects affecting the gastric mucosa, renal system, cardiovascular system, hepatic system, and hematologic system (Ghlichloo & Gerriets, 2022).
10. Administer antipyretics as ordered.
This type of drug affects the hypothalamic control center to reduce the elevated temperature. Fever should be controlled in clients who are neutropenic or asplenic. However, fever may be beneficial for limiting the growth of organisms and enhancing the autodestruction of infected cells. The presence of fever increases neutrophil production and activity, and fever appears to improve the attraction and migration of neutrophils to the site of infection (Walter, 2021).
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
- Adeyinka, A., & Kondamudi, N. P. (2022, August 14). Cyanosis – StatPearls – NCBI Bookshelf. NCBI. Retrieved December 6, 2022.
- Bertoldo, G., Pesce, A., Pepe, A., Pelullo, C. P., & Di Giuseppe, G. (2019). Seasonal influenza: Knowledge, attitude and vaccine uptake among adults with chronic conditions in Italy. PLOS ONE, 14(5).
- Centers for Disease Control and Prevention. (2021). Prevention Strategies for Seasonal Influenza in Healthcare Settings. CDC. Retrieved December 6, 2022.
- Centers for Disease Control and Prevention. (2022, October). Clinical Signs and Symptoms of Influenza. CDC. Retrieved December 8, 2022.
- Duda, K. (2022, September 9). Body Aches Caused By the Flu: Causes and Treatment. Verywell Health. Retrieved December 7, 2022.
- Gerriets, V., & Nappe, T. M. (2022, September 18). Acetaminophen – StatPearls – NCBI Bookshelf. NCBI. Retrieved December 7, 2022.
- Ghlichloo, I., & Gerriets, V. (2022, May 19). Nonsteroidal Anti-inflammatory Drugs (NSAIDs) – StatPearls – NCBI Bookshelf. NCBI. Retrieved December 7, 2022.
- Gregory, E. (2021). Cooling Techniques For Hyperthermia – StatPearls – NCBI Bookshelf. NCBI. Retrieved December 7, 2022.
- Huang, L. H., & Corden, T. E. (2018, December 7). Dehydration: Background, Pathophysiology, Etiology. Medscape Reference. Retrieved December 11, 2022.
- Kalarikkal, S. M., & Jaishankar, G. B. (2022, January 20). Influenza Vaccine – StatPearls – NCBI Bookshelf. NCBI. Retrieved December 10, 2022.
- Kamiya, Y., Fujisawa, T., Katsumata, M., Yasui, H., Suzuki, Y., Karayama, M., Hozumi, H., Furuhashi, K., Enomoto, N., Nakamura, Y., Inui, N., Setou, M., Ito, M., Suzuki, T., Ikegami, K., & Suda, T. (2020). Influenza A virus enhances ciliary activity and mucociliary clearance via TLR3 in airway epithelium. Respiratory Research, 21(282).
- Katz, S., Arish, N., Rokach, A., Zaltzman, Y., & Marcus, E.-L. (2018). The effect of body position on pulmonary function: a systematic review. BMC Pulmonary Medicine, 18(159).
- Majumdar, S. R., Eurich, D. T., Gamble, J.-M., Senthselvan, A., & Marrie, T. J. (2011, February 01). Oxygen Saturations Less than 92% are Associated with Major Adverse Events in Outpatients with Pneumonia: A Population-Based Cohort Study. Clinical Infectious Diseases, 52(3), 325-331.
- Mauk, K. L. (2006, February). Reaching and teaching older adults. Nursing, 36(2), 17.
- Moorhouse, M. F., Doenges, M. E., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- News in Health. (2013). Soothing a Sore Throat. NIH News in Health. Retrieved December 7, 2022.
- Nguyen, H. H., & Stuart, M. (2022, October 31). Influenza: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved December 6, 2022.
- Romine, W. L., Barrow, L. H., & Folk, W. R. (2013, March 21). Exploring Secondary Students’ Knowledge and Misconceptions about Influenza: Development, validation, and implementation of a multiple choice influenza knowledge scale. International Journal of Science Education, 35(11), 1874-1901.
- Sagor, K. H., & AlAteeq, M. A. (2018). Beliefs, attitudes, and barriers associated with the uptake of the seasonal influenza vaccine among patients visiting primary healthcare clinics. Saudi Medical Journal, 39(7).
- Schraga, E. D., & Wiener, S. W. (2022, July 20). Cooling Techniques for Hyperthermia: Overview, Indications, Contraindications. Medscape Reference. Retrieved December 7, 2022.
- Sereearuno, T., Rittayamai, N., Lawansil, S., & thirapatarapong, W. (2020). Effectiveness of a chest physiotherapy care map in hospitalized patients. Heart & Lung, 49(5).
- Shin, M. (2019). Pulmonary and Physical Rehabilitation in Critically Ill Patients. NCBI. Retrieved December 6, 2022.
- Sparks, D. (2017, July 21). Home Remedies: Fighting a fever. Mayo Clinic News Network. Retrieved December 7, 2022.
- Tibbits, D. (2022, November 13). What Is a Hypothermia Blanket? (with pictures). Wise Geek. Retrieved December 7, 2022.
- Walter, E. (2021). Effect of a fever in viral infections — the ‘Goldilocks’ phenomenon? NCBI. Retrieved December 7, 2022.
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