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
Risk for Deficient Fluid Volume
Influenza virus infection of the respiratory tract can cause a wide range of complications that can result in severe disease. In people of all ages, influenza can result in dehydration due to insensible fluid losses and decreased fluid intake. Both primary influenza viral pneumonia and secondary invasive bacterial pneumonia can lead to exacerbation of underlying disease conditions and even lead to respiratory distress, acute lung injury, septic shock, and multi-organ failure (Centers for Disease Control and Prevention, 2022).
- Risk for Deficient Fluid Volume
- Profuse diaphoresis
- Mouth breathing and hyperventilation
- Decreased oral intake
Possibly evidenced by
- Not applicable; the presence of signs and symptoms establishes an actual diagnosis
- The client will demonstrate adequate fluid balance as evidenced by moist mucous membranes, good skin turgor, and prompt capillary refill.
- The client will display stable vital signs and adequate peripheral tissue perfusion.
Nursing Assessment and Rationales
1. Assess vital sign changes, such as increased temperature, prolonged fever, tachycardia, and orthostatic hypertension.
Elevated temperature or prolonged fever increases metabolic rate and fluid loss through evaporation. Orthostatic BP changes and increasing tachycardia may indicate systemic fluid deficit.
2. Assess skin turgor and moisture of mucous membranes such as lips and tongue.
Indirect indicators of adequacy of fluid volume, although oral mucous membranes may be dry because of mouth breathing and supplemental oxygen. The client’s skin may be warm to hot, depending on core temperature status; clients who have been febrile with poor fluid intake may show signs of mild volume depletion with dry skin (Nguyen & Stuart, 2022).
3. Assess for reports of nausea and vomiting.
Children diagnosed with swine flu or H1N1 influenza may experience signs of severe disease including diarrhea and vomiting, which may lead to dehydration (Nguyen & Stuart, 2022).
4. Monitor intake and output. Note the color and character of the urine.
This provides information about the adequacy of fluid volume and replacement needs. The decreasing output of concentrated urine with increasing specific gravity suggests dehydration and the need for increased fluids.
Nursing Interventions and Rationales
1. Promote increased fluid intake to at least 3,000 ml daily.
Daily maintenance fluid requirements may be roughly estimated as follows: less than 10 kg=100 mL/kg; 10 to 20 kg=1000+50 mL/kg for each kg over 10 kg; and if greater than 20 kg=1500+20 mL/kg for each kg over 20 kg. The daily maintenance fluid is added to the fluid deficit (Huang & Corden, 2018).
2. Provide oral rehydration solutions (ORS).
Rapid oral rehydration with the appropriate solution has been shown to be as effective as intravenous fluid therapy in restoring intravascular volume. All of the commercially available rehydration fluids are acceptable for oral rehydration therapy (ORT). They contain 2 to 3 g/dL of glucose, 45 to 90 mEq/L of sodium, 30 mEq/L of base, and 20 to 25 mEq/L of potassium (Huang & Corden, 2018).
3. Administer ORS in small volumes orally. If not tolerated, administer ORS via nasogastric tube.
The oral rehydration solution should be administered in small volumes very frequently to minimize gastric distention and reflex vomiting. Generally, 5 mL of ORS every minute is well tolerated. If vomiting persists, an infusion of oral rehydration solution via a nasogastric tube may be temporarily used to achieve rehydration (Huang & Corden, 2018).
4. Encourage intake of carbohydrate-rich foods, fruits, and vegetables.
Foods that contain complex carbohydrates such as rice, wheat, potatoes, bread, or cereals; lean meats; fruits; and vegetables are encouraged. Fatty foods and simple carbohydrates should be avoided (Huang & Corden, 2018).
5. Monitor laboratory studies such as serum electrolytes, BUN, and creatinine levels.
Serum sodium should be determined because hyponatremia and hypernatremia require specific treatment regimens. Potassium may be elevated. Bicarbonate levels can be reduced because of the loss of bicarbonate in diarrheal stools. BUN and creatinine levels may be elevated because of renal hypoperfusion (Huang & Corden, 2018).
6. Avoid administering antimotility or antidiarrheal agents if the client has diarrhea.
Medications such as loperamide are not recommended for dehydration because of questionable efficacy and potential adverse effects. Antidiarrheal agents are not recommended because of the high incidence of side effects including lethargy, respiratory depression, and coma (Huang & Corden, 2018).
7. Administer supplemental IV fluids as necessary.
Intravenous access should be obtained, and a bolus of a crystalloid solution can be administered to support hemodynamic stability (Nguyen & Stuart, 2022). In the presence of reduced intake or excessive loss, the use of the parenteral route may correct or prevent deficiency.
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 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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- Centers for Disease Control and Prevention. (2021). Prevention Strategies for Seasonal Influenza in Healthcare Settings. CDC. Retrieved December 6, 2022.
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- Huang, L. H., & Corden, T. E. (2018, December 7). Dehydration: Background, Pathophysiology, Etiology. Medscape Reference. Retrieved December 11, 2022.
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- 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).
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- 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.
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