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Nursing Care Plan | NCP Bronchiolitis (Respiratory Syncytial Viral Infection)

Bronchiolitis is a common disease of the lower respiratory tract that is most commonly caused by the respiratory syncytial virus (RSV). The infection, which causes inflammation leading to obstruction of the small respiratory airways, can range from a mild infection that lasts only a few days to a severe episode that causes severe respiratory distress. Older children and adults often experience a “mild” upper respiratory infection with RSV because they have larger airways and can tolerate the airway swelling with fewer symptoms than do infants. The virus leads to necrosis of the bronchiolar epithelium, hypersecretion of mucus, and infiltration and edema of the surrounding cells. These changes are further complicated by mucous plugs that obstruct the bronchioles and lead to collapse of the distal lung tissue.

The incubation period is approximately 4 days from the time of exposure to the time of the first manifestation of the illness. Infants shed the virus for up to 12 days, and the spread of infection occurs when large infected droplets (airborne or through direct contact with secretions) are inoculated in the nose or eyes of a susceptible person. In temperate climates, infants most often contract RSV during the winter months. Mortality of infants with a lower respiratory infection due to RSV is approximately 2%. Young premature infants have a poorer outcome. A significant number of infants who developbronchiolitishave reactive airway disease later in life. The peak incidence occurs during winter and spring, and bronchiolitis is a major reason for hospital admission for infants less than 12 months of age, particularly children who live in poverty and in urban areas. Bronchiolitis accounts for approximately 4500 deaths and 90,000 hospital admissions each year.

Causes of Bronchiolitis (Respiratory Syncytial Viral Infection)
Bronchiolitis has a viral derivation; RSV is responsible for up to 75% of the cases, but other viruses such as parainfluenza virus (type 3), mycoplasma, or adenoviruses cause the remainder of illnesses. RSV is a medium-sized RNA virus that develops within the infected cell and reproduces by budding from the cell membrane. Generally, the source of the RSV is an older family member with a mild upper respiratory infection.

Nursing care plan assessment and examination
Ask if any members of the household have had a cold or upper respiratory infection. The infant usually has a history of an upper respiratory infection and runny nose (rhinorrhea) that lasts for several days. Infants may have increasing restlessness or depressed sensorium. Infants often have a moderate fever of approximately 102°F, a decrease in appetite, poor feeding, and gradual development of respiratory distress. A cough usually appears after the first few days of symptoms. Some children wheeze audibly.
Nursing care plan
The infant or child appears to be in acute respiratory distress with a rapid respiratory rate, air hunger, nasal flaring, hyperexpansion of the lungs, and even intercostal and subcostal retractions with cyanosis. When you auscultate the infant’s chest, you will likely hear diffuse rhonchi, fine crackles, and wheezes. The liver and spleen are easily palpable because they are pushed down by the hyperinflated lungs. Signs of life-threatening respiratory distress include listlessness, central cyanosis, tachypnea at a respiratory rate of over 70 breaths a minute, and apnea. Usually, the most critically ill infants have greatly hyperexpanded chests that are silent to air movement upon auscultation. Inspect the infant for a rash and conjunctivitis.

The parents and child will be apprehensive. Assess the parents’ ability to cope with the acute or emergency situation and intervene as appropriate. Note that many children are treated at home rather than in the hospital; your teaching plan may need to consider home rather than hospital management.

Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to bronchial infection and obstruction.

Nursing care plan intervention and treatment
The aim of treatment is to maintain a patent airway and provide adequate respiratory exchange. Medical management includes cool, oxygenated mist for severely ill infants who require hospitalization and careful intravenous hydration. Tube feeding for hydration is preferable to intravenous therapy if suckling is difficult. Generally, antibiotics are not considered useful and lead to bacterial resistance. Antiviral drugs are used in the most severely ill infants. Measures to ensure prevention are very important. During RSV season, high-risk infants should be separated from those with respiratory symptoms. Careful hand washing and isolation techniques are important for all healthcare personnel.

Ongoing, continuous observation of the patency of the child’s airway is essential to identify impending obstruction. Prop infants up on pillows or place them in an infant seat; older children should have the head of the bed elevated so that they are in Fowler’s position. Usually, seriously and critically ill infants are hospitalized because their care at home is difficult. Hospitalized infants are usually elevated to a sitting position at 30 to 40 degrees with the neck extended at the same 30- to 40-degree angle.

Children should be allowed to rest as much as possible to conserve their energy; organize your interventions to limit disturbances. Provide age-appropriate activities. Crying increases the child’s difficulty in breathing and should be limited if possible by comfort measures and the presence of the parents; parents should be allowed to hold and comfort the child as much as possible. If the child is in a cool mist tent, parents may need to be enclosed with the child, or the child may need to be held by the parents with the mist directed toward them. Children sense anxiety from their parents; if you support the parents in dealing with their anxiety and fear, the children are less fearful. Careful explanation of all procedures and allowing the parents to participate in the care of the child as much as possible help relieve the anxiety of both child and parents. Provide adequate hydration to liquefy secretions and to replace fluid loss from increased sensible loss (increased respirations and fever). The child might also have a decreased fluid intake during the illness. Apply lubricant or ointment around the child’s mouth and lips to decrease the irritation from secretions and mouth breathing.
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