Respiratory Syncytial Virus (RSV) Nursing Diagnosis & Care Plan

Respiratory syncytial virus (RSV) is a common respiratory virus that primarily affects children but can also infect adults, mimicking the common cold. Although the symptoms are mild in most cases, severe lung infections may occur, requiring hospitalization.

It can take 4 to 6 days for the symptoms to appear after exposure, and the illness can last for 1 to 2 weeks. Symptoms include:

  • Runny nose
  • Sneezing
  • Coughing
  • Sore throat
  • Low-grade fever
  • Headache

Infants are usually more severely affected and may present with symptoms of:

  • Shallow breathing
  • Chest retractions
  • Cough
  • Poor feeding
  • Lethargy/irritability

The most common way to confirm RSV is through a mouth swab or a blood test to monitor the white blood cell count. In severe cases that require the patient to be hospitalized, imaging through chest X-rays can assess for lung complications.

There are several ways that RSV can be transmitted to others:

  • When an infected person coughs or sneezes
  • Droplets with the virus reaching the eyes, nose, or mouth
  • Touching surfaces contaminated with the virus, such as toys, doorknobs, rails

Since a mild RSV infection is similar to the common cold, supportive treatment at home is usually all that is needed. Premature infants, children with heart defects, or older immunocompromised adults are at a higher risk for complications from RSV and may require inpatient treatment. In these patients, RSV can lead to serious life-threatening medical conditions such as pneumonia, worsening COPD or asthma, and congestive heart failure.

Nursing Process

RSV infection is a contagious condition that can spread by coughing, sneezing, or close contact. Nurses must educate patients and their families on preventing virus transmission. Nurses may care for sick, fragile patients in inpatient settings but can also instruct on strategies for protection of at-risk populations.

Nursing Care Plans Related to Respiratory Syncytial Virus (RSV)

Hyperthermia

A fever is one of the body’s first responses to infection.

Nursing Diagnosis: Hyperthermia

Related to:

  • RSV infection
  • Inflammation
  • Illness

As evidenced by:

  • Elevated vital signs 
  • Flushed skin
  • Warm to touch
  • Diaphoresis
  • Verbalization of headache

Expected outcomes:

  • Patient will maintain a core temperature within normal range.
  • Patient will demonstrate behaviors to promote normothermia.
  • Patient will be free of seizure activity.

Assessment:

1. Monitor the patient’s vital signs frequently.
Keeping close track of the patient’s vital signs during a fever will help to monitor the patient’s response to medications such as antivirals and antipyretics.

2. Assess neurologic response.
Though RSV is associated with a low-grade fever, a higher fever related to a worsening complication poses a risk for seizures. Note the patient’s level of consciousness/orientation, reaction to stimuli, pupil reaction, and reflexes.

Interventions:

1. Administer antipyretics as ordered.
Severe RSV infections will require antiviral medications. For the fever, use antipyretics such as acetaminophen or ibuprofen. Ensure parents are aware to never give aspirin to an infant.

2. Remove excessive clothing and blankets.
Keeping clothing and blankets to a minimum to reduce trapping heat, and keep the patient comfortable.

3. Provide a lukewarm bath.
Applying water to the skin will lower body temperature through the principles of evaporation and conduction. Lukewarm water for children is more comfortable as cold water can induce shivering, further increasing body temperature.

4. Offer fluids.
Plenty of fluids, either IV or oral, should be provided to prevent dehydration.


Impaired Gas Exchange

Inflammation may cause impaired gas exchange in patients with RSV due to their compromised respiratory systems.

Nursing Diagnosis: Impaired Gas Exchange

Related to:

  • Hypoxemia
  • Accumulation of mucus in the airway
  • Abnormal breathing pattern
  • Lung inflammation

As evidenced by:

  • Dyspnea
  • Restlessness
  • Coughing
  • Nasal flaring
  • Use of accessory muscles
  • Adventitious lung sounds
  • Cyanosis

Expected outcomes:

  • Patient will maintain a clear airway and remain free of signs of respiratory distress.
  • Patient will verbalize their understanding of oxygen and therapeutic interventions.
  • Patient will participate in their care plan within their capability or condition level.
  • Patient will maintain normal oxygen saturation levels, ABGs, respiratory rate, and pulse rate.

Assessment:

1. Assess respiratory rate, noting depth and effort.
Elevated respiratory rate, abdominal breathing, and the use of accessory muscles or nasal flaring may be observed in patients experiencing hypoxia and signals respiratory distress.

2. Monitor the patient’s mental status.
Changes in a person’s behavior and mental status signal gas exchange impairment. Monitor for changes in alertness, consciousness, or behavior.

3. Observe the nail beds and oral mucous membranes for cyanosis.
Peripheral cyanosis may or may not be serious, but central cyanosis in the tongue and oral mucosa indicates severe hypoxia and is considered a medical emergency. Especially in children, observation of objective signs and symptoms is crucial in recognizing respiratory distress, as they cannot verbalize as effectively as adults.

4. Monitor oxygen saturation.
Pulse oximetry is a necessary tool for monitoring and detecting changes in oxygenation. The normal range for SpO2 is 95% to 100%. A level of < 90% indicates significant oxygenation problems.

Interventions:

1. Administer oxygen as prescribed.
Supplemental oxygen can assist in optimal gas exchange. Continue to monitor SpO2 and ABGs to ensure oxygenation is effective.

2. Assist with ambulation.
Ambulation will help improve lung expansion and movement of secretions. Assist older adults in ambulation as tolerated.

3. Use humidifiers to keep the air moist.
Moist air will help ease congestion and coughing, ultimately leading to the loosening of secretions for expectoration.

4. Educate the patient on deep breathing and controlled coughing.
Controlled coughing involves the diaphragmatic muscles and increases the force and effectiveness of the cough.

5. Suction secretions.
RSV causes an increase in mucus which makes breathing difficult. Infants may need nasal passages suctioned with a bulb syringe.


Fatigue

During infections, the body’s immune system responds by attacking the invading pathogen. This response will leave patients feeling unusually tired and lethargic.

Nursing Diagnosis: Fatigue

Related to:

  • Body weakness
  • Acute infection

As evidenced by:

  • Verbalization of feeling tired
  • Inability to maintain usual routine or play
  • Irritability
  • Increased need for sleep or rest
  • Lethargy
  • Poor feeding
  • Decreased appetite

Expected outcomes:

  • Patient will demonstrate an increase in activity levels.
  • Child will be able to eat, play, and drink without fatigue.
  • Patient will actively participate in activities, both necessary and desired.
  • Patient will verbalize feeling less tired with more energy.

Assessment:

1. Assess baseline activity.
Ask the patient or parent of the child about their usual routine and any limitations they are currently experiencing. The labor involved in breathing with dyspnea can become exhaustive, which depletes energy reserves.

2. Assess the patient’s sleep pattern.
Changes in the sleep pattern and lack of sleep can contribute to the development of fatigue. When a patient has difficulty breathing and generally feels unwell, this impedes restful sleep.

Interventions:

1. Restrict environmental stimuli during sleep and rest periods.
Noise, distractions, and any disturbance in the patient’s environment can limit relaxation, shorten sleep, and contribute to fatigue.

2. Teach energy conservation methods.
Organization and time management can help the patient conserve energy and reduce fatigue. Encourage the parents to utilize measures to prevent fatigue in the child. Consider play that doesn’t require too much physical activity, such as reading or board games.

3. Provide comfort.
Massages, baths, music, and rocking can soothe an infant. Adults may benefit from quiet and dark environments.

4. Encourage proper nutrition.
Poor feeding is expected with RSV in infants. Difficulty breathing and symptoms of the virus may decrease appetite. IV or nasogastric nutrition may be necessary for infants and children in the hospital setting. Small, high-calorie meals or snacks are best for adults.


References

  1. Respiratory syncytial virus (RSV). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/respiratory-syncytial-virus/symptoms-causes/syc-20353098. Accessed on Dec. 14, 2022
  2. Respiratory Syncytial Virus Infection (RSV). Centers for Disease Control and Prevention. https://www.cdc.gov/rsv/index.html. Accessed on Dec. 14, 2022
  3. RSV in Children and Adults. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8282-respiratory-syncytial-virus-in-children-and-adults. Accessed on Dec. 14, 2022
  4. Doenges, M. E., Moorhouse, M. F. (1993). Nurses’s Pocket Guide: Nursing Diagnoses with Interventions (4th Ed.). F.A. Davis Company.
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Maegan Wagner, BSN, RN, CCM

Maegan Wagner is a registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.