Risk Of Influenza Spread & Imbalanced Fluid Volume Nursing Assessment

Question:

Discuss about the Immune Responses to Influenza Virus Infection.

Jim was last one day ago and on admission, an initial assessment is done. Preliminary diagnosis prior to admission indicates Influenza. On a problem-based focus, the key assessments to be undertaken are on the unproductive airway clearance, an ineffective breathing pattern and hyperthermia.

The airway clearance is ineffective, on inspection it is evident that there is copious nasal discharge and inflammation of the tonsils. Assessment of rhinorrhoea and tonsillar   inflammation serves to ensure a proper respiratory mechanism. The patency of the airway in the case is important. A backflow of the nasal discharge could cause fluid aspiration into the lungs causing aspiration pneumonia. The unchecked tonsillar inflammation can result in asphyxia.

Assessment of the pattern of breathing is crucial on admission. His airways should be inspected, the chest palpated, inspected then auscultation done to rule on the previous indication of bilateral wheezing. Adequate objective data to this account provide the on the necessities admission especially on the oxygen administration. In spite having good air entry, there is a possibility of pulmonary oedema and reduced oxygen perfusion. The initial oxygen saturation is at 94% of recommended (90-100%). Ineffective scrutiny of this vital could end up in shortness of breath and eventually culminate in respiratory distress and eventually an airway shutdown.

Temperature is a crucial assessment focus.  It is previously shown that the patient had hyperthermia with a body temperature of 38.3°C .This is an evidence of fever and validated by the pulse rate of 105 bpm. There is also increased sweating. Assessment of temperature is necessary to ensure that appropriate measures are taken on admission including fluid and electrolyte replacement and ensure there is adequate hydration.  Unmonitored hypothermia can cause accelerated reduction in the metabolism and reduction in the level of consciousness (Yagil, R., Etzion, Z., & Oren, A. (1983)). There is also a possibility of an increased cardiac output, heart rate and eventually risk of a myocardial infarction.

Note:  Dot points recommended in care plan.   Click and type in each cell, click enter in a cell to make it longer. Do not remove text from the template.

A reminder that all rationales must be referenced 

Nursing problem: Risk of spread of infection
Underlying cause or reason: Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immunocompromised patients in the hospital setting are at higher risk of contracting disease resulting in adverse events.
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
To prevent and control the spread of influenza within the healthcare facility and the community.	·       Isolate the client in a room with monitored negative air pressure, with the room door closed, and the client remaining in the room. Always wear appropriate respiratory protection when you enter the client room.  Limit the movement and transport of the client from the room to essential purposes only. If need be the patient to be on mask during transport. ·       Limit the number of relatives and visitors coming to see Jim and also protect those allowed from getting the infection by giving them protective masks and gowns before entering Jims room. ·       Practice proper hand washing before and after giving care to the client, also after being in contact with the patient environment. I will also educate Jim and his visitors on the importance of hand washing in disease prevention and when appropriate to wash hands to ensure the patient hygienic care. ·       Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature	·       Such set of precautions are meant to prevents airborne transmission and contact transmission of the disease. (La Rosa, G., Fratini, M., Libera, S. D., Iaconelli, M., & Muscillo, M. (2013). ·       Hygienic care is important to prevent infection in at-risk clients (Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2010) ·       The onset of infection activates the immune system and the signs of infections appear. (Iwasaki, A., & Medzhitov, R. (2010).)	There are no signs of infection noticed The hospital staff, patient and his visitors practice proper hand washing The patient remains isolated in a room with monitored negative air pressure.
Nursing problem: Self-care deficit
Underlying cause or reason: muscle pain, fatigue and general weakness of the patient limits performance of self-care activities independently.
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
To ensure patient executes self-care activities to utmost capability.	·       Guide the patient in accepting the need of assistance ·       Boost maximum dependence ·       Enhance positive reinforcements of all activities attempted and note any partial achievements ·       Develop and apply a regular routines and ensure that the patient gets adequate time to complete task.	·       Patient may require help in determining the safe limits of trying to be independent versus asking for assistance when necessary (Tamura-Lis, W. (2013). ·       The goal of rehabilitation is one of achieving the highest level of independence possible ·       The goal of rehabilitation is one of achieving the highest level of independence possible (leach, 2010) ·       An established routine will help the client organize and carry out self-care tasks with less effort (SPENCE LASCHINGER, H. K., Gilbert, S., Smith, L. M., & Leslie, K. (2010).	The patent response positively and can effectively attempt to perform tasks to his capability
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: There is excessive fluid loss due to fever
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
To demonstrate appropriate fluid balance with appropriate parameters such as moist mucous membranes, good skin turgor, stable vital signs.	·       Assess and monitor vital signs to note for any changes; increasing temperature ·       Assess the skin turgor, moisture of mucous membranes. ·       Monitor fluid intake and output and chart appropriately. ·       Administer medication as prescribed: antipyretics i.e Paracetamol 4/24 orally prn	·       Elevated temperature and prolonged fever increases metabolic rate and fluid loss through evaporation. (Stolwijk, J. A., & Hardy, J. D. (2011).) ·       Monitoring provide information about fluid adequacy and replacement needs (lobo, 2013) ·       To reduce fluid loss.( Thompson, H. J., & Kagan, S. H. (2011)	Fever reduce and the parameters of adequate body fluids is seen, that is, good skin turgor, moist mucous membranes, rapid capillary refill.
Nursing problem: Ineffective airway clearance
Underlying cause or reason: Tracheobronchial and nasal secretions
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
Patient will achieve and maintain a patent airway.	·       Assess respiratory status for rate, depth, ease, use of accessory muscles, and work of breathing ·       Assess patient for pallor or cyanosis	·       Changes may vary from minimal to extremes caused by bronchial swellings and other disease states that complicate the current illness (Ackley, B. J., & Ladwig, G. B. (2010). ) ·       Indicators of loss of airway patency may indicate hypoxemia(Hemmelgarn, C., & Gannon, K. (2013).)	The patient should achieve a patient airway and maintain it
Nursing problem: Ineffective breathing pattern
Underlying cause or reason: inflammation from the viral infection
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
Patient will achieve and maintain normal respiratory pattern and rate, with no adventitious breath sounds on auscultation.	·       Carefully Monitor the respiratory rate, rhythm and character. Notify the physician any abnormal findings or changes ·       Monitor pulse oximetry readings and notify physician if <90% ·       Advise and encourage the patient to stay in a semi fowlers position as tolerated. ·       Auscultate breathe sounds after every 2-4 hours and notify the physician of any changes.	·       Changes may show early signs of respiratory compromise and insufficiency (Chien, Y. S., Su, C. P., Tsai, H. T., Huang, A. S., Lien, C. E., Hung, M. N., ... & Chang, S. C. (2010).) ·       Oximetry approximates arterial blood gas oxygen saturation, and hence helping in identifying oxygenation dysfunction and respiratory status changes. (Holley, A. D. (2014).) ·       Semi fowlers position promote chest expansion and enhances respiratory effort. (Frownfelter, D. (2014).) ·       Auscultation assists with identification of changes in respiratory status and presence of adventitious breath sounds or decreased breath sounds (Meredith, T., & Massey, D. (2011).)	The client achieves and maintain a normal breathing range (12-20 breaths per min) No adventitious breath sounds on auscultation.

Jim is given a preliminary diagnosis of Influenza. The viral replication does peak before the manifestation of clinical symptoms and the efficacy of medication depends on the initiation of the medication. In this case, Jim is given oseltamivir, a neuraminidase inhibitor. It is an analogue of sialic acid and acts by interfering with the budding of the influenza virus and curbing the spread in the respiratory tract. The 75mg Bd dose is favourable due to the half-life of 6-10 hours. The dose administered should be as prescribed, given at the right intervals and dosage. The patient response well documented and assessed frequently. Oseltamivir is associated with nausea, vomiting and abdominal pain. The side effects should be clearly dissociated from the presenting complaints.

Paracetamol is a central acting antipyretic and analgesic that acts by weakly inhibiting COX enzymes thus eliciting anti-inflammatory actions (Sin, B; Wai, M; Tatunchak, T; Motov, 2016). The paracetamol dose is administered 6 hourly to maintain the concentration of the acetaminophen. The administration of paracetamol should be at the regular intervals and at the right dosage to minimise the lethargy caused the fever and alleviate the pain secondary to the muscular pain. Paracetamol also requires monitoring of the fever and avoid any propensity of an overdose. It is indicated in Sin et al (2016) that acetaminophen causes depletion of glutathione and hepatic damage. Dose adjustments should be made after consultion.

Fluvax IM is administered in a trivalent dosage to adults. This is to avoid the risk of the complications of the flu. Inoculation of the antigen in the attenuated influenza virus stimulates the production of antibodies. The immunity to antigens expressed on the surface especially haemagluttin reduces the possibility of infection and severity of recurrent infection. The subsequent vaccinations should then be scheduled and documentation made. The vaccination may be associated with hyperthermia, malaise, and headache and may increase the sweating. In this case all the temperature has to be recorded frequently.

Jim is a known smoker with an average smoking standard rate of 5-10 cigarettes per day. He has to understand how smoking causes hypertension and the health implications of the smoking lifestyle. The possible courses of rehabilitation and a behavioural change model made clear and he is left to make a decision. The effect of the hypertension on his response to infection should also made lucid.

Smoking doubles the risk to hypertension and vascular malfunction. The vascular endothelium becomes fibrous and the arterial pressure is increased. This increased pressure results is a cumulative increase in the blood pressure and the manifestation of hypertension. Cigarette smoke has toxic compounds that increase cardiovascular inflammation, cause oxidation of low-density lipoprotein cholesterol (Ambrose, J. A., & Barua, R. S. (2010).

Furthermore it should be clear to Jim that smoking causes the loss of life expectancy of the patient. The toxins in cigarette smoking accelerate the aging process. The effect of the toxins on the lungs should also be explained. Exposure of the lungs to the toxins increase the risk of developing throat and lung cancer respectively. The tar also causes toot discolouration and occurrences of bad breath.

Moreover, smoking is a possible cause of blunted weight gain and this has to be made clear to Jim. More to this, the overall decrease in libido and increase in the predisposition to erectile dysfunction should be elaborate to depth. The benefits of living free of smoking should also be set viz-a-viz the effects of the smoking routine

Initiatives towards cessation of the code should be initiated with cigarette reduction therapy. Jim has to live a healthy lifestyle. He has to stick on a good diet, with all the necessary nutrients. Undergo psychological therapy and health education. On his lifestyle he has to embrace physical exercise and change attitudes towards smoking as a recreational activity. He also has to be referred to social welfare agencies to provide care and food since he is homeless.

The possible cause of the fever is occurrence of a bacterial infection after completion of the antiviral therapy. In many occasions, the influenza virus is transmitted together with bacteria. The initial line of treatment was focused on the virus alone but no prophylaxis was given for a bacterial infection.

Multiplication of bacterial colonies result in the activation of the immune system. The adaptive and the innate immune systems are both activated. Inflammatory cytokines are released into circulation and initiate the attack to the bacteria. This immune system reaction result in the elevation of the body temperature hence the resurgence of the fever. The multiplier effect of the fever culminated in hyperventilation and increased heart rate. Jim should be given sponge baths and antipyretics as ordered. The physician should be notified of the change.

Nursing Problem: Risk of Spread of Infection

Jim is a 58-year-old homeless Indigenous male of no fixed address. He presented to the Emergency Department with dyspnea, myalgia, fatigue, malaise, rhinorrhea and headache.  His symptoms began approximately 3 day ago and he has tested positive for Influenza A and his influenza symptoms have decreased over the past 24 - 48 hours with continued medications. He has a past medical History of asymptomatic hypertension though he is not currently on any antihypertensive because he did not take his previous medication when prescribed. On assessment he was found to be febrile and has shortness of breath. He is allergic to chickens but has no known drug allergies. He states he used to smoke but not so much anymore as he cannot afford them however he does smoke up to 5 – 10 per day if he can get them. 

Vital signs
Temperature	39.6oC
Heart rate	125 beats per min
Respiratory rate	24 resps per min
Blood pressure	124/79 mmHg
O2 saturations	86% on room air

 

References

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