influenza

Influenza Nursing Diagnosis Interventions and Care Plans

Influenza NCLEX Review Care Plans

Nursing Study Guide on Influenza

Influenza, also known as flu, is a common viral infection caused by influenza viruses and affects the respiratory system.

The patient groups that are high risk for influenza involve young children under the age of 5 and old people over the age of 65.

Immuno-compromised patients and nursing home residents are also at high risk of contracting this viral infection.

Prevention of influenza involves annual vaccination, although it is not fully guaranteed to prevent flu.

In most cases, treatment can be done at home with fluids and plenty of rest. Worsening of flu symptoms require urgent medical attention.

Signs and Symptoms of Influenza

  • Usually dry cough
  • Nasal congestion – stuffy nose
  • Sneezing
  • Sore throat
  • Onset of high fever
  • Dyspnea – difficulty of breathing
  • Headache
  • Tiredness and fatigue
  • Chills
  • Myalgia – muscle aches
  • In children, gastrointestinal symptoms such as nausea, vomiting, and diarrhea my be evident

Causes and Risk Factors of Influenza

Influenza viruses are transmitted via air droplet method through coughing, sneezing, or even talking.

The droplets can be inhaled directly or can be transferred indirectly through touching objects contaminated with the virus.

These influenza viruses are changing constantly and research reveals that new strains come out annually, thus the need for annual vaccination.

The following risk factors can make an individual to experience a serious case of influenza:

  • Age – common on those children ages 6 months- to 5 years old
  • Certain residential or work conditions – those who reside and have a job in hospitals or care facilities, or those who live in military barracks
  • Weakened immune system such as people on treatments that block or weaken the immune system, such as chemotherapy and steroids; people who that are immunocompromised, such as HIV or AIDS
  • Chronic illnesses that need a regular follow up such as diabetes and other metabolic disorders
  • Race/Ethnicity –Native Americans are at high risk for influenza.  Influenza interventions might be difficult to implement in those minority areas, because of some factors like broad disparities in health and social status, as well las barriers in culture, education and language
  • Long-term aspirin therapy -e specially on children and adolescents
  • Pregnancy – particularly in the 2nd and 3rd trimesters
  • Obesity – having a body mass index (BMI) of above 40

Diagnosis of Influenza

  • Physical exam – people with flu usually manifest respiratory symptoms such as fever, colds, sore throat, nasal congestion, headaches, myalgia or body aches, chills, and fatigue
  • Rapid Influenza Diagnostic Test (RIDTs) -one of the most common flu tests; detects the antigen part of a virus by stimulating immune response
  • Chest X-ray – on severe cases

Complications of Influenza

Normally, a patient with influenza is expected to have recovery after a few days or less than two weeks. However, some people may develop complications such as:

  1. Dehydration
  2. Pneumonia or bronchitis
  3. Sinus and ear infection
  4. Myocarditis/ heart inflammation
  5. Encephalitis
  6. Myositis

Treatment for Influenza

  1. At-home care. Mild cases of influenza can be resolved by having plenty of rest and proper hydration. It is important for the patient to eat right and stay at home to lessen exposure and possible transmission of the virus to other people.
  2. Antipyretics and pain relievers. The patient can be prescribed with antipyretics to lower fever as well as to relieve muscle aches.
  3. Antivirals. Severe influenza infections can be treated by antiviral medications that can be oral or intravenous in form. They aim to reduce the number of sick days of the patient and to prevent the development of serious complications.

Prevention of Influenza

Influenza can be prevented from spreading and infecting others by:

  • Proper handwashing
  • Cleaning of objects and surfaces
  • Covering the mouth when coughing
  • Avoiding crowded places

Nursing Care Plans for Influenza

Nursing Care Plan 1

Ineffective Airway Clearance related to nasal congestion secondary to influenza as evidenced by shortness of breath, wheeze, SpO2 level of 92%, cough,

Desired Outcome: The patient will be able to maintain airway patency and to improve airway clearance as evidenced by being able to expectorate phlegm effectively, respiratory rates between 12 to 20 breaths per minutes, oxygen saturation within the target range (usually above 96%) and verbalize ease of breathing.

InterventionsRationales
Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. Assess breath sounds via auscultation.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Breath sounds are important signs of complications of severe influenza such as pneumonia and bronchitis.
Suction secretions if needed.To help clear any phlegm that the patient is unable to expectorate.
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is within the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value within the target.
Administer the prescribed  medications (e.g. antivirals and antipyretics).To help treat influenza and resolve temperature.
Elevate the head of the bed and assist the patient to assume semi-Fowler’s position.Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively.

Nursing Care Plan 2

Nursing Diagnosis: Ineffective Breathing Pattern related to nasal congestion secondary to influenza as evidenced by shortness of breath, SpO2 level of 92%, and dry cough

Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation within the target range, and verbalize ease of breathing.

InterventionsRationales
Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is within the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value within the target range.
Administer the prescribed  medications (e.g. antivirals and antipyretics).To help treat influenza and resolve temperature.
Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position. Encourage plenty of rest and adequate hydration.Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.
Perform chest physiotherapy such as percussion and vibration, if not contraindicated. Nebulization using sodium chloride (NaCl) may also be done, as ordered by the physician. Steam inhalation may also be performed.To facilitate clearance of any thick airway secretions.

Nursing Care Plan 3

Nursing Diagnosis: Activity intolerance related to difficulty of breathing secondary to influenza, as evidenced by fatigue, overwhelming lack of energy, verbalization of tiredness, generalized weakness, headache, and shortness of breath upon exertion

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

InterventionsRationales
Assess the patient’s 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 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 60-90 minutes of undisturbed rest.To gradually increase the patient’s tolerance to physical activity. To allow the patient to pace activity versus rest.
Teach deep breathing exercises and relaxation techniques.  Provide adequate ventilation in the room.To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.

Nursing Care Plan 4

 Nursing Diagnosis: Risk for Infection (Cross-contamination)

Desired Outcome: The patient will be able to avoid the cross-contamination of the viral infection.

InterventionsRationales
Assess vital signs and observe for any signs of infection as well as for any signs of respiratory distress.To establish patient’s baseline and monitor for any changes in vital signs and flu symptoms.
Place the patient in isolation and provide adequate ventilation in the room.To reduce the risk of infecting other patients, staff, and visitors in the hospital ward or care facility. To allow enough oxygenation in the room.
Obtain a sputum sample for culture if the patient develops any phlegm.To confirm the presence of any complication of influenza (such as pneumonia or bronchitis) and its causative agent.
Teach the patient how to perform proper hand hygiene, covering the mouth when coughing, and oral care.To maintain patient’s safety. To prevent spreading airborne pathogens and reduce the risk of cross-contamination.

Nursing Care Plan 5

Nursing Diagnosis: Hyperthermia related to infective process of influenza as evidenced by temperature of 38.5 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.

InterventionsRationales
Assess the patient’s vital signs at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antivirals and antipyretics 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 antiviral and anti-pyretic medications.Use the antiviral to treat the viral infection, which is the underlying cause of the patient’s hyperthermia. Use the antipyretic 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.

Other nursing diagnoses:

  • Fatigue
  • Deficient Knowledge

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. (2017). 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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