Cytomegalovirus Nursing Diagnosis and Nursing Care Plan

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Cytomegalovirus Nursing Care Plans Diagnosis and Interventions

Cytomegalovirus NCLEX Review and Nursing Care Plans

Cytomegalovirus CMV infection is a common viral infection that rarely causes serious illness.

Its effects can range from nil to severe illnesses which can affect the liver, spleen, and neurologic system.

Cytomegalovirus comes from the family of herpes virus.

Like any other herpes viruses, cytomegalovirus can lay dormant in the person’s body tissues even after the infection process.

Cytomegalovirus infection is also known as CMV infection, however, other names are also associated with it, such as Cytomegalic Inclusion Disease, Giant Cell Inclusion Disease (CID), Human Cytomegalovirus Infection, and Salivary Gland Disease.

This infection typically affects children, but it may occur at any age. In the United States alone, it is estimated that one in three children are infected by the virus by the age of five.

CMV is transmitted through infected body fluids such as blood, saliva, breast milk, semen, and vaginal fluids.

Signs and Symptoms of Cytomegalovirus Infection

In most cases, cytomegalovirus infection comes with no signs and symptoms.

However, if the infection causes an illness, its manifestation can be categorized depending on the classification of the cytomegalovirus infection.

  1. Congenital. Congenital cytomegalovirus infection occurs when the CMV is transmitted by the infected mother to the baby during pregnancy. In some cases, babies born with CMV shows no signs and symptoms until later in life. The following are signs and symptoms related to babies with CMV who are sick at birth:

  • Low birth weight
  • Preterm birth
  • Jaundice
  • Hepatomegaly or enlarged liver
  • Purpura and/or petechial rash on the skin
  • Microencephaly or abnormally small head
  • Splenomegaly or enlarged spleen
  • Pneumonia
  • Seizures

2. Acute Acquired CMV infection. This refers to CMV infection in healthy people. In most cases, there may be no symptoms of the infection at all. When symptoms do appear, they may manifest as follows:

  • Fatigue
  • Low-grade fever
  • Chills and/or sweats
  • Myalgia or muscle pain
  • Low appetite
  • Lymph nodes enlargement
  • Sore throat
  • Headache

3. CMV in Immunocompromised Person. Serious illness may happen when a person with weak immune system gets CMV infection. People with AIDS, on chemotherapy, on long-term steroids, and those who received an organ transplant are at higher risk. CMV infection in these group of people can cause the following:

  • Retinitis
  • Symptoms related to the gastrointestinal system
  • Symptoms related to the nervous system such as confusion, headache, and leg weakness

Causes of Cytomegalovirus

Cytomegalovirus infection is caused by human cytomegalovirus, which is also known as the salivary gland virus and is a subgroup of the herpes simplex viruses.

The hallmark of cytomegalovirus is the active-an-inactive cycle of the infection.

Like any other herpes viruses, cytomegalovirus can stay in the body in an inactive form for a long period of time.

During its active phase, the virus is shed through body fluids – blood, urine, saliva, breast milk, tears, semen, and vaginal fluids.

It can then be transmitted to other people through sexual contact, breastfeeding, organ or blood donation, by birth, or by accidental contact of the infected body fluid to a person’s mucosa such as in the eyes, mouth, or nose.

Complications of Cytomegalovirus

Cytomegalovirus infection rarely causes complications in a healthy person. In cases of severe infection, complications are commonly related to problems with the digestive systems, the liver, and nervous system.

In people with weak immunity, the following may occur:

Congenital cytomegalovirus infection can result in the following complications:

  • Hearing loss
  • Learning disability
  • Problems with vision
  • Seizures
  • Muscle weakness
  • Lack of coordination

Diagnosis of Cytomegalovirus Infection

  • Physical examination – the diagnosis of cytomegalovirus is usually performed to confirm the illness as its signs and symptoms shares similarity with more serious infections such as Epstein-Barr virus (EBV) infection and human immunodeficiency virus (HIV) infection
  • Testing of body fluids, such as urine, stool, or blood – to detect the presence of the virus in the body and therefore establish a diagnosis.
  • Blood or tissue sample – in newborn babies suspected to have CMV infection; taken within three weeks of being born and is then tested for the presence of the virus. If the test comes back positive, additional tests may be recommended by the doctor to check the health of the baby’s organs.

Treatment of Cytomegalovirus Infection

  1. Symptomatic control. Treatment of cytomegalovirus is not required in most cases. In a healthy individual, recovery is expected after a few weeks. Treatment options for cytomegalovirus infection is focused on the severity of the signs and symptoms. Babies born with cytomegalovirus infection and are ill from it will be monitored for possible complications The same goes for adults with compromised immune system. Monitoring of the effects of the infection to body organs will be done. The signs and symptoms will also be addressed as the primary mode of treatment.
  2. Antivirals. In some cases, antivirals are used to slow the reproduction of the virus. However, possible side effects from antivirals will need to be closely monitored as well.

Nursing Diagnosis for Cytomegalovirus

Cytomegalovirus Nursing Care Plan 1

Nursing Diagnosis: Infection related to CMV infection as evidenced by positive CMV blood smear result, temperature of 38.2 degrees Celsius, myalgia, and fatigue

Desired Outcome: The patient will be able to avoid the development of an infection.

Cytomegalovirus Nursing InterventionsRationales
Assess vital signs and monitor the signs of infection.To establish baseline observations and check the progress of the infection as the patient receives medical treatment.
Administer the prescribed antivirals. To treat the severe CMV infection.
Inform the patient or caregiver that there is no need to avoid direct social contact.  The risk of spreading the CMV infection is low, as it can only be transmitted when it is in its active state. Isolation is unnecessary as CMV rarely causes any serious illness.  
Obtain a new blood sample for CMV smear.To confirm that the infection has been completely treated.
Provide symptomatic relief for the patient.Treatment of cytomegalovirus is not required in most cases. In a healthy individual, recovery is expected after a few weeks. Treatment options for cytomegalovirus infection is focused on the severity of the signs and symptoms.

Cytomegalovirus Nursing Care Plan 2

 Nursing Diagnosis: Hyperthermia related to CMV infection as evidenced by temperature of 38.2 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

Cytomegalovirus Nursing InterventionsRationales
Assess the patient’s vital signs at least every hour. Increase the intervals between vital signs taking as the patient’s vital signs become stable.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs administered.
Remove excessive clothing, blankets and linens. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.
Administer the prescribed antivirals and anti-pyretic medications.Use the antiviral for immunocompromised patients with serious CMV infection. Use the anti-pyretic medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Cytomegalovirus Nursing Care Plan 3

Nursing Diagnosis: Fatigue related to body weakness secondary to CMV infection as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, lack of appetite, and shortness of breath upon exertion

Nursing Stat Facts x
Nursing Stat Facts

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

Cytomegalovirus Nursing InterventionsRationales
Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.To gradually increase the patient’s tolerance to physical activity.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.To allow the patient to relax while at rest. To allow enough oxygenation in the room.
Refer the patient to dietitian and physiotherapy / occupational therapy team as required.To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity and improving nutritional intake / appetite.

Cytomegalovirus Nursing Care Plan 4

Nursing Diagnosis: Acute Pain related to infection process secondary to CMV infection as evidenced by pain score of 6 out of 10, headache, body malaise, and restlessness

Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.

Cytomegalovirus Nursing InterventionsRationale
Administer prescribed pain medications.To alleviate the symptoms of acute pain.
Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.  To monitor effectiveness of medical treatment for the relief of pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.  
Elevate the head of the bed and position the patient in semi Fowler’s.To increase the oxygen level by allowing optimal lung expansion.
Place the patient in complete bed rest during severe episodes of pain. Perform non-pharmacological pain relief methods such as relaxation techniques such as deep breathing exercises, guided imagery, and provision of distractions such as TV or radio.To reduce environmental stimulations that may worsen pain. To provide optimal comfort to the patient.

More Cytomegalovirus Nursing Diagnosis

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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