Respiratory Syncytial Virus RSV Nursing Diagnosis and Nursing Care Plan

RSV Nursing Care Plans Diagnosis and Interventions

Respiratory Syncytial Virus NCLEX Review and Nursing Care Plans

Respiratory syncytial virus RSV infection is one of the most common viral infections affecting children.

It is caused by the virus belonging to the Paramyxoviridae family.

RSV typically causes mild cold-like symptoms, but it can also cause lower respiratory tract infections.

RSV infection is widespread, affecting about 90% of children below 2 years of age.

Reinfection is possible as humans do not develop immunity from RSV. Although it is commonly seen in children, it can also affect adults, especially those with weak immune system.

In children, it is the most common cause of bronchiolitis. Most cases of RSV infection do not require treatment; however, in more serious cases, treatment is supportive and is focused on addressing the symptoms and complications as they arise.

Signs and Symptoms of RSV

RSV infection often causes mild cold-like symptoms in both adults and children.

The clinical manifestations show about 4 to 6 days after exposure to the virus. In mild cases, the signs and symptoms may include:

  • Congested or runny nose
  • Dry cough
  • Low grade fever
  • Sore throat
  • Mild headache

In other cases, RSV infection can cause serious lower respiratory tract infections such as bronchiolitis and pneumonia.

This is particularly significant especially in children and adults with weak immune system. Manifestations may also include the following:

  • Fever
  • Severe cough
  • Wheezing
  • Rapid breathing or difficulty breathing
  • Cyanosis

Infants may present the following:

  • Short, shallow, and rapid breathing
  • Cough
  • Poor feeding
  • Lethargy
  • Irritability

Causes of RSV

RSV infection is caused by the family of viruses called Paramyxoviridae with the genus Pneumovirus.

It is contracted in several ways. The main mode of transmission of RSV is through contact with droplets from the nose and throat of an infected person.

It can also be transferred after contact with a surface that has the virus on it, such as on doorknobs or staircase railings.

It can also spread through direct contact like kissing a child who is infected with the virus.

Once the virus is contracted by an individual, signs and symptoms typically appears within 4 to 6 days.

The person will be contagious for about 3 to 8 days after exposure to the virus. However, the virus can continue to spread beyond this point in some cases.

The following are at a higher risk of developing a serious case of RSV infection:

  • Premature infants
  • Children with congenital heart and lung condition
  • Children with compromised immune system
  • Adults with compromised immune system
  • Older adults with underlying heart and lung disease

Complications of RSV

  1. Pneumonia. Inflammation of the lungs can occur because of the spread of RSV infection. It may start as bronchiolitis, or the inflammation of the airways, and then progress to pneumonia.
  2. Middle ear infection. Otitis media or middle ear infection is quite common in children. It typically occurs as a secondary infection like the presence of RSV infection.
  3. Asthma. Studies suggest that there is a link between RSV infection and asthma developing later in life.
  4. Repeated infection. Reinfection is possible in RSV infection. Once a person contracts the virus, the body does not develop immunity from it.

Diagnosis of RSV Respiratory Syncytial Virus Infection

The diagnosis of RSV infection includes the following procedures:

  • Medical history taking
  • Physical examination- breathing will be assessed through observations and auscultation.
  • Blood tests – a complete blood count is typically done; however, this test is inconclusive as It may yield a normal result.
  • Chest X-rays – imaging of the lungs is performed to check for the spread of infection.
  • Respiratory tests – there are a few tests that can be performed using respiratory secretions. A viral culture may be done to establish the presence of the virus. A Transcription-Polymerase Chain Reaction (RT-PCR) may be performed in some cases as it is more sensitive than a viral culture. Antigen testing may also be performed. Antigen testing is highly sensitive in children but not in adults.  

Treatment for RSV Respiratory Syncytial Virus Infection

Treatment for RSV infection is not typically required in mild cases. However, in more serious cases, treatment options fall into three categories which are as follows:

  1. Supportive Care. Supportive care is the common treatment approach for patients with respiratory syncytial virus infection. Supportive care includes interventions aimed in addressing the needs of the patient as they arise.
    • Nasal suctioning and lubrication to relieve nasal congestion
    • Administration of antipyretics for fever
    • Oxygen support for hypoxia
    • Supplemental hydration and nutrition support
    • Ventilator support for highly compromised patients
  2. Immune prophylaxis. A passive form of immune prophylaxis may be given in some cases of RSV infection. The administration of a humanized murine monoclonal antibody may be performed as it works against RSV protein. It will need to be administered monthly for the duration of the RSV season commonly between September to April. However, the use of this form of treatment is controversial due to the cost-effectivity of it.
  3. Antiviral medication. Currently, an antiviral drug has been approved for use in the U.S. It is a nucleoside analog with proven activity against RSV. It may be administered in aerosolized form. However, it remains controversial due to its cost and efficacy.

RSV Nursing Diagnosis

RSV Nursing Care Plan 1

Nursing Diagnosis: Infection related to RSV infection as evidenced by positive RSV viral culture result, temperature of 38.2 degrees Celsius, headache, dry cough, and sore throat.

Desired Outcome: The patient will be cured of RSV infection and prevent its spread.

RSV 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 antiviral. To treat severe RSV infection.
Teach the patient to avoid direct social contact as much as possible. Ideally, the patient should self-isolate for at least 8 days or as long as symptoms persist.To prevent the risk of spreading the virus. RSV patients are contagious about 3 to 8 days after catching it but can still be contagious for a longer period in some cases.  
Provide symptomatic relief for the patient.Treatment of RSV is not required in most cases. In a healthy individual, recovery is expected after a week. Treatment options for RSV infection is focused on the severity of the signs and symptoms.
Teach the patient and carer how to perform proper hand hygiene.To prevent the risk of spreading the virus.
Obtain a new respiratory culture for RSV.To confirm that the infection has been completely treated.

RSV Nursing Care Plan 2

 Nursing Diagnosis: Hyperthermia related to RSV 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.

RSV 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 antiviral and anti-pyretic medications.Use the antiviral for patients with serious RSV 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.

RSV Nursing Care Plan 3

Nursing Diagnosis: Fatigue related to body weakness secondary to RSV infection as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, lack of appetite, 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.

RSV 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.

RSV Nursing Care Plan 4

Impaired Gas Exchange

Nursing Diagnosis: Impaired Gas Exchange related to suspected viral pneumonia secondary to respiratory syncytial virus (RSV) infection as evidenced by hypoxemia, irregular breathing pattern, uneasiness, and cyanosis.

Desired Outcomes:

  • The patient will have an appropriate gas exchange, as shown by their normal mental condition, independent breathing at 12–20 breaths per minute, oximetry values within the accepted value, blood gases within the normal range, and their standard heart rate.
  • The patient will show signs of diminished or negative respiratory distress symptoms.
  • The Patient will take part in procedures to improve oxygenation and in a care regimen that is appropriate for their state of capability/condition.
RSV Nursing InterventionsRationale
Examine the lungs for areas of reduced ventilation and signs of atelectasis. Listen for unusual lung sounds.The collapse of the alveoli can result in hypoxemia. Breathing irregularities may reveal the basis for poor gas exchange. The nurse may be made aware of an airway obstruction that is causing or aggravating existing hypoxia by the appearance of crackles and wheezes. Poor ventilation is associated with diminished breath sounds.
Assess vital signs every 15 minutes for alterations in blood pressure and heart rate.As hypoxemia/hypercapnia worsens, heart rate and blood pressure increase initially, then decline as the gas exchange deficit worsens.
Monitor oxygen saturation using a continuous pulse oximeter.An accurate assessment of the patient’s oxygen level and the effectiveness of therapies is made possible by a continuous pulse oximeter.
Provide oxygen at a rate of 2 liters per minute via nasal cannula as directedAdditional oxygen can assist in keeping oxygen saturation at a healthy level.
Observe the patient’s behavior and mental condition for the development of restlessness, agitation, disorientation, and (in the late stages) excessive tiredness.Early indications of decreased gas exchange may include changes in behavior or mental state. Severe hypoxia may result in mental impairments.
Take note of the color of the tongue and the mucous membranes in the mouth, and observe for cyanosis in the skin and nail beds.Bluish discoloration of the tongue and oral mucosa suggests chronic hypoxia and is considered a medical emergency. Peripheral cyanosis in the extremities might be serious or not.
Determine the patient’s nutritional health.Several medical conditions affect lung expansion. Obesity may limit the diaphragm’s ability to move downward, which raises the danger of atelectasis, hypoventilation, and respiratory infections. As a result of the increased weight on the chest wall, severe obesity causes labored breathing. Malnutrition can impair muscle function by reducing respiratory strength and capacity.
Place the patient in a semi-position Fowler’s with the bed’s head elevated and at a 45-degree angle while supine,  As tolerated.  A semi-or Fowler’s upright position allows for enhanced lung expansion, entire diaphragmatic descent, and increased thoracic capacity, limiting the abdominal contents from compressing.
Promote or help with ambulation as directed by a physician.Ambulation encourages deep breathing while facilitating lung expansion and secretion discharge.
Assist the patient with deep breathing and controlled coughing. As tolerated, encourage the patient to inhale deeply, hold their breathing for a few seconds, cough two to three times with their mouths open, and contract their upper abdominal muscles.This method can improve sputum clearance and the reduction of cough spasms. Controlled coughing involves the diaphragmatic muscles, increasing the force and effectiveness of the cough.

RSV Nursing Care Plan 5

Fluid Volume Deficit

Nursing Diagnosis: Fluid Volume Deficit related to decreasing fluid intake secondary to the respiratory syncytial virus (RSV) infection as evidenced by weakness, extreme thirst, hypotension, tachycardia, decreased urine output, and dizziness.

Desired Outcomes:

  • The patient will have normal vital signs, including normal skin turgor, systolic blood pressure greater than 90 mm Hg, heart rate between 60 and 100 beats per minute, and urine output greater than 30 mL/hr.
  • The patient will discuss what actions should be taken at home to keep hydrated and avoid dehydration.
RSV Nursing InterventionsRationale
Keep track of and record the patient’s vital signs, particularly the heart rate and blood pressure. Check blood pressure and heart rate for orthostatic changes as well (Changes observed when transitioning from a supine to a standing position).Tachycardia and hypotension may result from a decrease in the volume of blood in circulation. Changes in heart rate can be a compensatory method for maintaining cardiac output. Postural hypotension is a common symptom of fluid loss. It is characterized by a 20-mm Hg reduction in systolic blood pressure and a 10-mm Hg decline in diastolic blood pressure.  
Evaluate skin turgor and oral mucosa for indications of dehydration.The skin can also reveal signs of dehydration. The skin of older people loses elasticity, thus skin turgor should be evaluated above the sternum or on the inner thighs. Around the tongue, longitudinal furrows could be seen.
Examine any changes in mentation/sensorium (Disorientation, anxiousness, sluggish responses).  Alterations in mentation/sensorium can be induced by excessively high or low glucose levels, electrolyte imbalances, acidosis, decreased cerebral perfusion, or progressive hypoxia.
Weigh the patient every day, ideally during the same time of day, using the same scale.The best indicator of a potential fluid volume imbalance is weight. A weekly weight gain of 2 lbs is considered acceptable.
Encourage the patient to drink the recommended amount of fluid.Oral fluid replacement is advised for mild fluid losses and is a cost-effective technique of replacement treatment. Older individuals may require constant reminders to drink since they have a diminished sensation of thirst. Fluid replacement can be made easier by using novel fluid sources, such as flavored gelatin, frozen juice bars, and sports drinks. It may be necessary to use oral hydrating products.  
Assist the patient if they are unable to eat on their own and encourage the SO or family to help out with feedings as needed.Patients who are dehydrated may be fatigued and incapable of independently fulfilling their recommended intake.
Discuss the importance of good oral hygiene.A dry, sticky mouth may be brought on by a hydration deficiency. Drinking interest is increased and the discomfort of dry oral mucosa is decreased by paying attention to oral hygiene.
As directed, infuse parenteral fluids. Consider the necessity for an IV hydration challenge with immediate fluid infusion for patients who have abnormal vital signs.To keep hydrated, fluid intake is required. Depending on the patient’s clinical condition, the type, quantity, and infusion rate of the fluid replacement will be different.
Monitor the patient’s input and output. Instruct family members on how to measure both intake and output in the home.A key indicator of a patient’s fluid status is an accurate measurement of fluid intake and output.

RSV Nursing Care Plan 6

Ineffective Breathing Pattern

Nursing Diagnosis: Ineffective Breathing Pattern related to inflammatory process secondary to the respiratory syncytial virus as evidenced by cough, difficulty of breathing, tachypnea, and shallow respiratory excursion.

Desired Outcomes:

  • The patient’s breathing pattern will remain effective, as demonstrated by comfortable breathing at normal range and depth and without dyspnea.
  • The patient’s ABG values will be within normal ranges.
  • The patient will use breathing strategies to enhance breathing patterns and will be able to perform ADLs without experiencing dyspnea.
RSV Nursing InterventionsRationale
Evaluate respiratory status at least every 2-4 hours, or more frequently if there is a decline in breathing rate or occurrences of apnea.Changes in the respiratory pattern may happen immediately if the patient’s energy supplies are reduced. Air exchange rate and quality are revealed via baseline assessment and monitoring.
Palpate the chest to determine its structure and listen for breath sounds that might suggest a mobility limitation (absent or diminished, crackles or rhonchi).This is done to listen for diminished or abnormal breath sounds.
Monitor for changes in the patient’s consciousness level.Early warning signs of inadequate brain oxygenation include restlessness, disorientation, and/or irritation.
Assess skin color, body temperature, capillary refill, and the difference between central and peripheral cyanosis.Blue/cyanosis color of the lips, tongue, and fingers is caused by a lack of oxygen. Cyanosis of the mouth is considered a medical emergency.
Evaluate oxygen saturation and heart rate using pulse oximetry.Pulse oximetry is a useful tool to initially identify changes in oxygenation; however, to determine CO2 levels, arterial blood gases (ABGs) or end-tidal CO2 monitoring would need to be obtained.
Obtain and monitor arterial blood gases as prescribed.Monitors the status of oxygenation and ventilation.
Promote regular rest periods and instruct the patient on how to pace their activities.Increased activity can make breathing difficulties worse. Make sure that the patient takes a break from exhausting activities.
Demonstrate good deep breathing techniques and assist the patient if needed.Deep inspiration is encouraged, to improve oxygenation and reduce atelectasis.
Demonstrate good deep breathing techniques and assist the patient if needed.Deep inspiration is encouraged, to improve oxygenation and reduce atelectasis.
Encourage the patient to successfully cough up their secretions to maintain the airway open.Allows for sufficient elimination of secretions.
Aid the patient in sitting up in a semi-Fowler’s or high Fowler’s position.An upright position promotes lung expansion, resulting in an increased amount of air into the lungs for oxygenation.
Offer small, frequent meals  Smaller meals are easier to consume and take less effort. The patient can rest and recover energy for the following meal or activity by eating tiny portions.
As prescribed by a doctor, give respiratory medicines and oxygen.  The bronchodilation brought on by beta-adrenergic agonist drugs opens the airways by relaxing the smooth muscles of the airways.
In cases of severe respiratory distress, remain with the patient.This reduces the patient’s anxiety level and lowers oxygen demand.

More RSV 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. (2020). 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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Anna C. RN, BSN, PHN

Anna C. RN, BSN, PHN
Clinical Nurse Instructor

Emergency Room Registered Nurse
Critical Care Transport Nurse
Clinical Nurse Instructor for LVN and BSN students

Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process.

Her experience spans almost 30 years in nursing, starting as an LVN in 1993. She received her RN license in 1997. She has worked in Medical-Surgical, Telemetry, ICU and the ER. She found a passion in the ER and has stayed in this department for 30 years.

She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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