Nursing Care Plan for Influenza

Pathophysiology

Influenza, commonly known as “the flu”, is an infectious disease caused by an influenza virus. Influenza is spread by droplets in the air or by transferring droplets from surfaces to mucus membranes (like the eyes, nose, mouth, and throat). Therefore, its primary symptoms are respiratory or systemic in nature. Occasionally it can cause gastroenteritis with vomiting – commonly known as the “stomach flu”.

Etiology

There are multiple strains of the influenza virus affecting both humans (A, B, and C) and animals (swine, avian).

Desired Outcome

To prevent respiratory distress and support symptoms so the patient can return to baseline level of health.

Influenza Nursing Care Plan

Subjective Data:

  • Shortness of breath
  • Fatigue
  • Muscle aches
  • Headache
  • Reports cough, runny nose, sore throat
  • Reports sudden onset
  • Reports vomiting

Objective Data:

  • High fever (102-104°F)
  • Productive cough
  • Vomiting
  • Positive flu swab

Nursing Interventions and Rationales

  1. Screen patients for vaccine necessity and administer as appropriate

    • No contraindications
    • Provide VIS sheet
    • Document if received or declined
    • The best method for managing influenza is to prevent it in the first place. The flu vaccine is the best method to prevent the flu.
    • Ensure they meet indications and have no contraindications (allergy to eggs or latex, history of Guillain-Barre, recent bone marrow or organ transplant) to avoid complications.  
    • Always educate the patient on the possible side effects (injection site pain, runny nose) and provide the VIS sheet so they can read it.
    • Always document the details of the vaccine (lot number, expiration, etc.). OR document if they declined.

  2. Maintain droplet precautions if hospitalized

  3. Influenza is spread via droplets. Should wear gloves and a simple mask and use good hand hygiene

  4. Assess lung sounds

  5. Influenza primarily affects the respiratory system. Monitor for any changes in lung sounds that might indicate decompensation.

  6. Monitor oxygenation and give supplemental O2 as needed

  7. Influenza primarily affects the respiratory system. Patients may struggle to oxygenate appropriately because of mucus buildup. Support oxygenation as appropriate (caution in COPD patients).

  8. Monitor for signs of sepsis or septic shock (increasing fever, decreasing blood pressure)

  9. Influenza can escalate quickly, especially in immunocompromised patients. Monitor vital signs frequently to detect and signs of sepsis. Catching it early can improve outcomes

  10. Encourage nutrition – small, frequent meals if needed – or nutrient dense options

  11. Patients may lose their appetite or be too fatigued to eat. Proper nutrition can promote faster healing. It’s important to encourage them to eat, even if small meals.

    Nutrient dense options like Boost shakes or Magic Cups can provide more protein in a smaller amount

  12. Administer IV fluids and/or encourage PO intake

  13. Because of the high fever and poor PO intake, patients can often get dehydrated. Providers may order maintenance IV fluids. If not, encourage PO intake of fluids to maintain proper hydration.

  14. Educate patient and family on prevention of spread

    • Hand-hygiene
    • Cover cough
    • Don’t touch eyes, nose, mouth
    • Avoid public gatherings if symptomatic
  15. Influenza is highly contagious. Preventing the spread to other patients is the purpose of our droplet precautions. However, it is important to educate the patient and family so that friends and family members don’t contract the flu or spread it to others.

    Hand hygiene is the #1 way to prevent spread of influenza.

  16. Administer antivirals as ordered

  17. Oseltamivir (Tamiflu) is most effective when given within 48 hours of onset of symptoms. Educate patients on possible side effects.


References

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