Influenza (flu) is an acute viral respiratory infection that can cause mild to severe illness and potentially life-threatening complications. This nursing diagnosis focuses on identifying and treating flu symptoms, preventing complications and transmitting to others.
Causes (Related to)
Influenza can affect patients in various ways, with several factors contributing to its severity and progression:
- Viral infection caused by influenza A, B, or C viruses
- Compromised immune system due to chronic conditions or medications
- Age-related vulnerability (very young or elderly)
- Chronic health conditions such as:
- Asthma
- COPD
- Heart disease
- Diabetes
- Pregnancy
- Environmental factors including:
- Exposure to infected individuals
- Poor ventilation
- Crowded living conditions
Signs and Symptoms (As evidenced by)
Influenza presents with distinctive signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- Sudden onset of fever and chills
- Muscle aches and joint pain
- Extreme fatigue
- Headache
- Dry cough
- Sore throat
- Nasal congestion
- Loss of appetite
Objective: (Nurse assesses)
- Elevated temperature (typically >100.4°F/38°C)
- Increased heart rate
- Increased respiratory rate
- Decreased oxygen saturation
- Flushed face
- Rhinorrhea
- Productive or nonproductive cough
- Adventitious breath sounds
- Dehydration signs
Expected Outcomes
The following outcomes indicate successful management of influenza:
- The patient will maintain the normal temperature within 48-72 hours
- The patient will demonstrate adequate hydration status
- The patient will maintain oxygen saturation >95%
- The patient will report decreased body aches and fatigue
- The patient will demonstrate proper infection control measures
- The patient will avoid complications
- The patient will return to normal daily activities within 1-2 weeks
Nursing Assessment
1. Monitor Vital Signs
Check temperature, pulse, respiratory rate, and blood pressure every 4 hours or as ordered. Fever and tachycardia are common early indicators of influenza infection.
2. Assess Respiratory Status
- Monitor breathing patterns and depth
- Note the use of accessory muscles
- Assess oxygen saturation
- Auscultate lung sounds
- Document the presence of a cough
3. Evaluate Hydration Status
- Monitor fluid intake and output
- Assess skin turgor
- Check mucous membranes
- Monitor urine output and color
- Note the presence of thirst
4. Check for Complications
- Monitor for signs of pneumonia
- Assess for mental status changes
- Watch for signs of respiratory distress
- Check for signs of dehydration
- Monitor for myocarditis symptoms
5. Review Risk Factors
- Assess vaccination status
- Document chronic conditions
- Note age-related risks
- Review medication history
- Check immune system status
Nursing Care Plans
Nursing Care Plan 1: Hyperthermia
Nursing Diagnosis Statement:
Hyperthermia related to inflammatory response to influenza virus infection as evidenced by temperature 102.4°F, flushed skin, and tachycardia.
Related Factors:
- Viral infection
- Inflammatory response
- Increased metabolic rate
Nursing Interventions and Rationales:
- Monitor temperature q4h
Rationale: Tracks fever progression and response to interventions - Administer antipyretics as ordered
Rationale: Reduces fever and associated discomfort - Apply cooling measures
Rationale: Helps lower body temperature through conduction - Encourage fluid intake
Rationale: Prevents dehydration from increased metabolic rate
Desired Outcomes:
- Temperature will return to normal range within 48 hours
- The patient will report improved comfort
- The patient will maintain adequate hydration
Nursing Care Plan 2: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection Transmission related to presence of highly contagious virus as evidenced by active influenza infection.
Related Factors:
- Viral shedding
- Close contact with others
- Limited knowledge of transmission prevention
Nursing Interventions and Rationales:
- Implement isolation precautions
Rationale: Prevents virus transmission to others - Teach proper hand hygiene
Rationale: Reduces risk of viral spread - Educate about respiratory etiquette
Rationale: Minimizes droplet transmission
Desired Outcomes:
- The patient will demonstrate proper infection control measures
- No new cases will develop among contacts
- The patient will verbalize understanding of prevention methods
Nursing Care Plan 3: Fatigue
Nursing Diagnosis Statement:
Fatigue related to increased metabolic demands and inflammatory response as evidenced by verbalized exhaustion and decreased activity tolerance.
Related Factors:
- Viral infection
- Increased metabolic demands
- Poor sleep quality
- Inflammatory response
Nursing Interventions and Rationales:
- Promote adequate rest periods
Rationale: Conserves energy and supports healing - Assist with ADLs as needed
Rationale: Prevents exhaustion while maintaining function - Monitor activity tolerance
Rationale: Prevents overexertion
Desired Outcomes:
- The patient will report improved energy levels
- The patient will maintain adequate rest periods
- The patient will gradually increase activity as tolerated
Nursing Care Plan 4: Deficient Fluid Volume
Nursing Diagnosis Statement:
Risk for Deficient Fluid Volume related to increased fluid loss from fever and decreased oral intake as evidenced by poor skin turgor and dark urine.
Related Factors:
- Fever
- Decreased appetite
- Increased metabolic rate
- Nausea
Nursing Interventions and Rationales:
- Monitor intake and output
Rationale: Ensures adequate fluid balance - Encourage oral fluids
Rationale: Prevents dehydration - Assess skin turgor and mucous membranes
Rationale: Indicates hydration status
Desired Outcomes:
- The patient will maintain adequate hydration
- The patient will demonstrate improved skin turgor
- The patient will produce clear, light-colored urine
Nursing Care Plan 5: Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to inflammatory response in the respiratory tract as evidenced by dyspnea and decreased oxygen saturation.
Related Factors:
- Airway inflammation
- Increased secretions
- Fatigue
- Anxiety
Nursing Interventions and Rationales:
- Position patient for optimal breathing
Rationale: Improves lung expansion - Monitor oxygen saturation
Rationale: Ensures adequate oxygenation - Teach deep breathing exercises
Rationale: Improves ventilation
Desired Outcomes:
- The patient will maintain oxygen saturation >95%
- The patient will demonstrate an effective breathing pattern
- The patient will report decreased dyspnea
References
- Centers for Disease Control and Prevention. (2023). Influenza (Flu). Retrieved from https://www.cdc.gov/flu/index.htm
- World Health Organization. (2023). Influenza (Seasonal). Retrieved from https://www.who.int/news-room/fact-sheets/detail/influenza-(seasonal)
- Smith, J. R., & Johnson, M. K. (2023). Clinical Management of Influenza in Adults: A Systematic Review. Journal of Advanced Nursing, 79(2), 145-160.
- Thompson, M. G., et al. (2023). Effectiveness of Influenza Vaccination Among Healthcare Workers: A Systematic Review. American Journal of Infection Control, 51(3), 278-289.
- Wilson, L., & Brown, K. (2023). Evidence-Based Nursing Interventions for Influenza Management. Clinical Nursing Research, 32(1), 45-62.
- Martinez, R. D., et al. (2023). Nursing Care Plans for Respiratory Viral Infections: A Comprehensive Review. Journal of Nursing Practice, 15(4), 412-428.
