6 Influenza (Flu) Nursing Care Plans

Hyperthermia

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).

Nursing Diagnosis

• Hyperthermia

May be related to

• Influenza viral infection
• Exposure to infection
• Alterations in fluid and electrolyte balance

Possibly evidenced by

• Increased temperature
• Warm, flushed skin
• Tachycardia
• Tachypnea
• Dry mucous membranes
• Dehydration
• Oliguria
• Seizure
• Changes in mentation
• Increased BUN and creatinine
• Electrolyte imbalances

Desired Outcomes

• 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).