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By: Baran, Delia V. Concepcion, John Angelo L.

BSN III NCM 104

a small infectious agent that can replicate only inside the

living cells of organisms. Viruses infect all types of organisms, from animals and plants to bacteria and archaea. Virus particles (known as virions) consist of two or three parts: the genetic material made from either DNA or RNA, long molecules that carry genetic information; a proteincoat that protects these genes; and in some cases an envelope of lipids that surrounds the protein coat when they are outside a cell. The shapes of viruses range from simple helical and icosahedral forms to more complex structures. The average virus is about one-hundredth the size of the average bacterium. Most viruses are too small to be seen directly with a light microscope.

Viruses

Influenza is an acute viral infectious disease that affects

the respiratory system also known as flu. Influenza is a myxovirus belonging to the family of viruses known as Orthomyxoviridae. The virus is spread readily in aerosol droplets produced by coughing and sneezing, which are symptoms of the illness. Other symptoms include fatigue, muscle and joint pains and fever. Influenza as a disease has been recognised for centuries, even though the viruses which cause it were not correctly identified until the early 1930s, first in the UK and then in the USA. Indeed the name itself is derived from an Italian word meaning influence.

Introduction

Three types of myxoviruses. 1.) Type A - is the most prevalent, it strikes every year with new serotypes causing epidemics every 3 years. 2.)Type B - also strikes annually but only causes epidemics every 4-6 years. 3.)Type C - is endemic and causes only sporadic causes. Incubation period is 24-58 hours. Period of communicability - 5th day of illness up to 7 days. Mode of transmission: >Infection is transmitted by inhaling a respiratory droplet from an infected person or indirect contact such as drinking a contaminated glass.

Clinical Manifestations: >Client history reveals recent exposure to a person with influenza. ( no influenza vaccine receive during the past season. > After an incubation period of 24-48 hours, flu symptoms appear. >Sudden onset of chills >fever, > headache > malaise >myalgia (particularly in the back and limbs) > photophobia >nonproductive cough >occasionally laryngitis >hoarseness > rhinitis >rhinorrhea > Signs usually subsides in 3-5 days, but cough and weakness may persist. >Inspection may reveal clear nasal discharge, erythema of the nose and throat without exudates, and red watery eyes. >If client has pneumonia, breathsounds may be diminished over areas of consolidation.

Complications: Directly related to viral infection >hemorrhagic pneumonia >encephalitis >Reyes syndrome >myocarditis which may lead to cardiac failure >sudden infant death syndrome >myoglobinuria >super imposed infection due to Streptococci pneumonia, haemophilus influenza, Streptococcus pyrogens, and Staphylococcus aureus >otitis media >sinusitis >pneumonia

Pharmacologic Management: >Antipyretic drugs : Paracrtamol prevent Reyes syndrome, a severe illness characterized by acute encephalophaty and fatty liver. >Anti-inflammatory drugs or ibuprofen In influenza complicated by pneumonia, the client needs supportive care (including fluid and electrolyte replacement, oxygen and assisted ventilation).

1.) Nose and throat culture and increase serum antibody titers2.) White Blood Cells count >decreased WBC with an increased level of lymphocytes show uncomplicated cases.

Diagnostics:

Prevention and Control:

1.) Immunization to children. 2.) Immunization of influenza vaccine annually for the following categories: a. The elderly b. People who have poor immunity c. Those with conditions like diabetes, lung diseases, kidney diseases, heart and liver diseases. 3.) Avoidance with crowded places. 4.) Educate the public and health care personnel regarding the basic personal hygiene.

Drug Study

Generic Name

Brand Name

Classification

Mechanism of Action It inhibits the synthesis of prostaglandin

Adverse Effects

Nursing Implication Check that the patient is not taking any other medication containing paracetamol. - For children who may refuse medicine off a spoon try using a medicine syringe to squirt liquid slowly into the side of the child's mouth or use soluble paracetamol mixed with a drink. Paracetamol can be take in with or without food. - Alcohol increases the risk of liver damage that can occur if an overdose of paracetamol is taken.

Ibuprofen

Paracetamol

Non-opioid analgesic, Antipyretic

Gastrointestinal problems, allergic skin reactions

Generic Name

Brand Name

Classification

Mechanism of Action

Adverse Effects

Nursing Implication

Aspirin

Aspirin

Non-opioid analgesic, Antipyretic

Blocks pain impulses in the central nervous system, inhibits prostaglandin synthesis, causes peripheral vasodilation resulting in antipyretic properties, decreases platelet aggregation.

heartburn; nausea; stomach upset, Severe allergic reactions: (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); black or bloody stools; confusion; diarrhea; dizziness; drowsiness; hearing loss; ringing in the ears; severe or persistent stomach pain; unusual bruising; vomiting.

For patients who have had oral or dental surgery or tonsillectomy in the last seven days avoid chewable or dispersible aspirin tablets, or aspirin in crushed tablets or gargles. - Assess pain and/or pyrexia one hour before or after medication. - In long-term therapy monitor renal and liver function and ototoxicity. - Assess other medication for possible interactions - especially warfarin which is a special hazard. - Be aware that aspirin is a common constituent of a variety of over-thecounter medications.

Pathophysiology

Influenza virus travels by air


Man inhales microorganism Virus invades respiratory mucosa (i.e.., nasal, tracheal, and bronchial tree) Client becomes vulnerable to secondary infections

Pneumococci

staphylococci

steptococci

other agents

Edema of the respiratory tree Passage of serosanguinous discharge

Ineffective Airway Clearance R/T bronchial edema

Hyperthermia R/T volume infectious process

Risk for fluid deficit

1. Hyperthermia R/T infectious process- This is our first priority because temperature is one of the basic vital signs of a man and elevation of it means that there is an infection in the body. Also, infection is the main problem of the client.

2. Ineffective Airway Clearance R/T bronchial edema- This is our second priority because it is only the result of the Influenza virus invading the respiratory system of the client.
3. Risk for Fluid Volume deficit- This is our last priority because it is a potential nursing diagnosis, meaning that it will only occur if the manifesting signs and symptoms or manifesting problems were not able to give much attention.

Prioritization of Nursing Diagnosis

Nursing Care Plan

ASSESSMENT

EXPLANATION OF THE PROBLEM Fever is considered the hallmark symptom of infection. Pyrogenic agents that act on the hypothalamus to produce fever during infection include interleukin-1 (IL1),interleukin-6 (IL-6), interferon, tumor necrosisfactor (TNF), and othercytokines.

OBJECTIVES

INTERVENTION S Dx:> Monitor and record temperature q 30min 1 hour > Note presence or absence of sweating as body attempts to increase heat loss by evaporation.

RATIONALE

EVALUATION

S> O>Febrile, >T = 38.8C >Weak in appearance >palpable lymph nodes >body malaise >Diaphoretic Nsg. Dx:> Hyperthermia R/T infectious process

STO: After 8 hours of nursing intervention, the client will be able to: Decrease body temperature from 38.8oC to 38oC Enumerate ways on preventing further elevation of temperature LTO: After 24 hours of nursing intervention, the client will be able to: Normalize body temperature from 38.8oC to 36.537.5oC Manifest signs of absence of infection

Tx:> Perform TSB with warm water.

> Minimize clients clothing

>To assess the need for intensive nursing management > Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat. > Alcohol baths are contraindicated because they increase peripheral vascular constriction and CNS depression; cold water sponges/immersion can increase shivering, producing heat. > Minimizing clients clothing helps he body in releasing heat

> Administer analgesic medications as ordered (ie., Paracetamol q 4hrs) Edx: > Encourage the patient to maximize fluid intake. > Stress the importance of drug compliance. >Recommend the avoidance of hot tubs / saunas as appropriate

inside. > Administering analgesic medications helps the body in lowering down the body temperature. > Maximizing fluid intake replaces body fluid the escape the body through expiration. > To maximize the wellness of the client. > It may cause other complications

ASSESSMENT

EXPLANATION OF THE PROBLEM

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

S> O> Coarse crackles heard over left lung field peripherally >coughing at times >productive cough >secretion characterized as yellowish in color >(+) use of accessory muscle when breathing >pale in appearance >increased RR of 26 cpm >restlessness >with good capillary refill of 2 secs. >with good appetite

Influenza virus invades the clients respiratory system when he inhales the microorganisms, causing the virus to invade the respiratory system, then having the accumulation of fluid (edema) on the respiratory tree causing now the patient to have difficulty in breathing, leading to Ineffective Airway Clearance.

STO: > after 8 hours of nursing interventions, the client will be able to: Maintain a normal respiration rate of 12-20 cpm; Demonstrate behaviors in maintaining clear airway; Demonstrate absence/reduc tion of congestion with breath sound clear, respiration noiseless.

Dx: > assess respiration rate

> Monitor and note respirations, breath sound, rate, and presence of adventitious sounds.

> Evaluate clients cough, gag reflex and swallowing ability. Tx:> Elevate clients head > Perform chest physiotherapy > Provide cool, humidified air, change water daily >Administer prescribed medication.

> Changes in respiration rate indicates respiratory distress > monitoring and noting changes in respirations, breath sound, rate, and presence of adventitious sounds reflects the effectiveness of interventions done. > To determine ability to protect own airway. >To provide maximum lung expansion >To help in secreting secretion >To prevent pseudomones infection. >To help in effective therapeutic regimen.

STO: Goal met. The client was able to: Maintain a normal respiration rate of 12-20 cpm; Demonstrate behaviors in maintaining clear airway; Demonstrate absence/reduc tion of congestion with breath sound clear, respiration noiseless.

Nsg. Dx> Ineffective Airway Clearance R/T bronchial edema

>Assist with procedures such as suctioning if necessary Edx:> Encourage to verbalize feelings.

>To clear/maintain open airway

>Verbalization of feelings may help the nurse and other health care members for an effective intervention.

>Encourage client to increase fluid intake to atleast 2000mL/day as tolerated. > Teach and advise to perform deep breathing exercise and deep coughing exercise.

> Hydration can help to liquefy secretions and to improve secretion clearance. > To help in clearing/ maintaining open airway

ASSESSMENT

S> O> Coarse crackles heard over left lung field peripherally >coughing at times >productive cough >secretion characterized as yellowish in color >(+) use of accessory muscle when breathing >pale in appearance >increased RR of 26 cpm >restlessness >with good capillary refill of 2 secs. >with good appetite >Febrile, >T = 38.8C >Weak in appearance >palpable lymph nodes

EXPLANATION OF THE PROBLEM When a client is having fever, fluid from the body escapes outside causing now the patient to be diaphoretic. When the client reports body malaise, he dont have the energy to give himself a drink therefore, he will not drink to replace fluid loss causing now imbalance between fluid intake and output leading now the patient to be risk on fluid volume deficit.

OBJECTIVES

INTERVENTION S Dx: >Monitor I and O > Assess clients weight >Assess clients level of consciousness Tx: >Assist in IV placing >Provide maximum fluid intake Edx: > Stress the importance of drug compliance >Advise to verbalize feelings

RATIONALE

EVALUATION

STO: After 8 hours of nursing intervention, the patient will be able to: Identify individual risk factors and appropriate interventions; Demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit LTO: After 24 hours of nursing intervention, the patient will be able to: Not exhibit signs of dehydration Maintain an adequate intake, either orally or IV Maintain a normal fluid volume, as evidenced by normal vital signs and I and O.

>To ensure accurate picture of fluid status >To determine trends >To evaluate ability to express needs > IV fluids replaces loss fluids from the body. > For replacement of fluid loss >For healing process >Verbalization of feeling can help the health care team in effective management of the disease

>Diaphoretic Nsg. Dx:> Risk for Fluid Volume Deficit