Bronchiolitis and respiratory syncytial virus (RSV): Nursing process (ADPIE)

Charlie Santos is a 2-month-old male who is brought to urgent care by his mother. She says that he has had a runny nose and an axillary temperature of 100.4 F, or 38 C, for the past two days.This morning she noticed that he seemed to need to work harder to breathe, and she tells you he has been fussy and not feeding well.

She also mentions that he attends daycare, and recently many of the children have been sick with similar symptoms. Based on Charlie’s clinical presentation and history, an infection with respiratory syncytial virus, or RSV, is suspected.

The respiratory tract is divided into two parts; the upper airway, which consists of the nasal cavity, paranasal sinuses, pharynx, and larynx; and the lower airway, which consists of the trachea, bronchi, bronchioles, alveoli, and lungs.

Inflammation of the bronchioles, which are the smallest airways of the lungs, is known as bronchiolitis. It commonly occurs during the colder months, so fall, winter, and early spring, and it’s most often caused by the respiratory syncytial virus, or RSV for short.

Other causes include viruses like adenovirus, parainfluenza virus, or rarely from bacteria like Mycoplasma pneumoniae. Now, the most important risk factor for bronchiolitis is young age, since it mostly affects children under 2 years of age, with infants less than 3 months being at the highest risk.

Other risk factors include premature birth, attending crowded places like daycare, or having older siblings who can catch it in school.

Finally, some underlying conditions may increase the risk of bronchiolitis, including chronic lung disease, congenital heart disease, or being immunocompromised.Transmission of RSV typically occurs from direct contact with respiratory droplets when an infected person talks, sneezes, or coughs.

These droplets can then land in the mouths or noses of people nearby, or be inhaled into their lungs. The virus can also survive on surfaces for a few hours, so it’s possible to get the virus by touching an infected surface, like a contaminated doorknob, and then touch their own eyes, nose, or mouth.

Now, once the virus has entered the body, it travels down the respiratory tract to the bronchioles and invades its epithelial cells, turning them into a virus factory, and ultimately killing them.

The viral invasion attracts immune cells, which cause an inflammatory reaction that leads to swelling and narrowing of the airway, as well as increased mucus production.The mucus, along with the dead epithelial cells, creates a plug that can obstruct the airway and cause the alveoli to deflate, leading to atelectasis.

The plug can also allow air to enter the lungs via inhalation, but not leave via exhalation. As a result, the lungs become more inflated with each inhalation, known as air-trapping.

Symptoms of bronchiolitis are similar to the common cold, including low-grade fever, congestion, rhinorrhea, and cough. If the disease progresses, the child may experience dyspnea and tachypnea, and can present wheezing, crackles, and diminished breath sounds.

In severe cases, the child can become lethargic, irritable, and present with poor feedings, and dehydration. In addition, the child can experience central apnea, which means that they have short periods of time where they stop breathing altogether.

This can lead to hypoxia, where there is not enough oxygen in the body, and typically presents with cyanosis. Other important complications of bronchiolitis include atelectasis, as well as pneumonia if the infection spreads to the lungs.

Ultimately, respiratory failure can develop.Diagnosis of bronchiolitis is typically based on clinical assessment. However, diagnostic testing to confirm RSV can be done by swabbing secretions from the nasopharynx and running a rapid antigen detection test, or RADT, or a polymerase chain reaction, or PCR, to determine the presence of viral antigens.

If the symptoms worsen, or if there is concern about the development of complications, a chest X-ray can be done. There’s no proven antiviral therapy for bronchiolitis, so treatment is focused on symptoms.

Most cases can be treated at home by making the child more comfortable by using a cool-mist humidifier, keeping the head elevated while awake, instilling saline nose drops and using nasal suction to ease congestion, as well as promoting adequate fluid intake to prevent dehydration.Smoke can worsen the symptoms of bronchiolitis, so it is important to maintain a smoke free environment.

Over-the-counter medications like acetaminophen or ibuprofen can be given to relieve pain and reduce fever. Children with severe symptoms like difficulty breathing or cyanosis may need to be admitted to the hospital for observation and treatment, which is focused on respiratory support that usually consists of administering supplemental oxygen, along with intravenous fluid therapy to prevent dehydration.Okay, let’s get back to assess our client, Charlie.

Charlie is being held by his mother and appears uncomfortable and fussy. You begin by connecting him to a pulse oximeter, which shows an oxygen saturation of 95%.

He has a large amount of clear, thick nasal secretions, and when you auscultate his lungs, you hear wheezes on expiration.

No nasal flaring or chest retractions are present. His mucous membranes are dry, skin turgor is normal, and Mrs.

Santos says she changed a wet diaper just before bringing him to the clinic. Capillary refill is less than 3 seconds.

His vital signs are tympanic temperature 100℉ or 37.8℃; respiratory rate 65 breaths per minute; heart rate 140 beats per minute; and blood pressure 90/55 mmHg.

You document your assessment findings and communicate them to the Advanced Practice Registered Nurse, or APRN. Based on the assessment data you have collected, your nursing diagnoses include: ineffective airway clearance related to excess secretions; risk for fluid volume deficit related to decreased intake, fever, and increased respiratory rate; and deficient parental knowledge related to unfamiliarity with the disease process and treatments.Now that you’ve established some nursing diagnoses, you can collaborate with Charlie’s mother and the APRN to start planning goals of care.

After suctioning, Charlie will maintain a patent airway; Charlie will be able to consume at least 20mL of infant formula; and by the end of the visit, Charlie’s mother will demonstrate how to properly suction Charlie’s airway using a bulb syringe, and she will verbalize an understanding of home management of symptoms and when to seek additional medical attention.Okay, now you are ready to implement your interventions.

You begin by demonstrating how to use a bulb syringe to relieve nasal congestion. After clearing his airway, you ask Mrs.

Santos to feed Charlie so you can ensure he is able to tolerate feedings. Next, you explain the importance of frequent feedings and ensuring he has at least six wet diapers each day.

You recommend acetaminophen for Charlie’s fever and using a cool-mist humidifier to help decrease congestion. Next, you stress the importance of maintaining a smoke free environment and the need to keep Charlie home from daycare until he is fully recovered to prevent the spread of infection.

Finally, you urge Mrs. Santos to seek medical treatment immediately if Charlie’s rate of breathing increases, starts to have chest retractions, nasal flaring, cyanosis, a pause in breathing for more than 15-20 seconds, a decreased ability to feed, or decreased urine output.Before Charlie and his mother leave, you evaluate how he’s doing.

After consuming 25 mL of infant formula, Charlie falls asleep in his mother’s arms. His mucous membranes are moist and he is breathing comfortably with a respiratory rate of 45 breaths per minute.

His oxygen saturation is 98% on room air. Expiratory wheezes are present on auscultation.

His temporal temperature is 99℉ or 37.2℃ and his heart rate is 135 beats per minute. Charlie’s mother successfully demonstrated how to suction Charlie’s nose with a bulb syringe, she verbalizes understanding of how to manage Charlie’s symptoms at home, how to recognize the signs of respiratory distress, and when to seek additional medical treatment.Alright, as a quick recap … your client, Charlie, was brought to urgent care with nasal congestion, fever, and difficulty feeding.

Your assessment revealed thick nasal secretions, wheezes on expiration, and dry mucous membranes. Your nursing diagnoses were ineffective airway clearance, fluid volume deficit, and knowledge deficit.

The goals you identified when planning care for Charlie included maintaining a patent airway and adequate fluid volume. Your goal for Charlie’s mother included demonstrating how to use a bulb syringe, appropriate home management, and when to seek additional medical attention.

Along with the APRN, you work to implement actions to achieve the goals of Charlie’s plan of care and evaluate how the goals of care have been met.