This course is designed to give an overview of the care and management of the pediatric patient diagnosed with RSV. Focus will be placed on the pathophysiology, signs and symptoms as well as the transmission of RSV. Diagnosing RSV and the medical treatment options for RSV will also be discussed. Nursing interventions based on NANDA nursing diagnoses will be the final focus of this course.
Course Objectives
Upon completion of this course the student will be able to:
Describe the pathophysiology surrounding RSV.
State the presenting signs and symptoms of RSV.
Discuss how RSV is transmitted.
Explain how RSV is diagnosed.
List the medical treatment options for RSV.
State 4 appropriate nursing diagnoses for patient with RSV.
Discuss interventions for caring for patients with RSV.
About RSV:
Respiratory Syncytial Virus (RSV) was first isolated 40 years ago and has had a significant social, economic and healthcare impact ever since.
With adults; RSV presents with symptoms that are similar to the common cold (cough, runny nose, slight fever). In children however; RSV can produce more serious symptoms and disease processes such as bronchitis, bronchiolitis and or pneumonia.
RSV is a RNA virus and is unstable in the environment (lasting only 4-7 hours on environmental surfaces). This virus is easily inactivated with the use of soap, water and disinfectants. The RSV virus is seasonal and occurs in temperate climates (most often in late fall, early winter or early spring months).
RSV is the most common respiratory virus found in infants and young children and is thought to virtually infect all infants by the time they reach the age of two years old.
RSV is the most common cause of bronchiolitis and pneumonia in infants and children.
RSV may be severe enough to require hospitalization (especially in infants under the age of 6 months), as well as for children with other contributing factors or conditions such as congenital heart/lung disease.
In the United States alone, it is estimated that the cost associated with treating infants and children infected with RSV is approximately 300 million dollars a year.
Pathophysiology:
RSV is a member of the parmyxovirus family and is related to the parainfluenza, measles and mumps virus. There are two major strains of RSV which are known as strain “A” and “B”. The “A” strain is considered to be more serious and is the source of most of the severe cases of RSV.
RSV invades the bronchiolar epithelial cells and causes both inflammation and edema. The membranes of the infected cells fuse with other larger adjacent cells and form what is called syncytia (a multinucleated mass of cytoplasm that is not separated into individual cells).
As the bronchiole mucosa begins to swell and lumina fill with mucus and exudate, the cells become inflamed which results in the shedding of dead (necrotic) epithelial cells. This shedding causes an obstruction of the small airway passages which ultimately causes air trapping, poor gas exchange, hyperinflation and atelectasis.
Signs and Symptoms:
Initial signs and symptoms of RSV typically appear approximately 4 to 6 days after exposure. These symptoms include:
Congestion
Runny nose
Low grade fever
Dry cough
Sore throat
Mild headache
A general feeling of malaise
Poor eating
Irritable
For children under the age of 3 years old, symptoms may appear in a “heighten” state and include:
High fever
Severe cough
Wheezing
Rapid respiratory rate (or difficulty breathing)
Altered skin tone (bluish color secondary to decreased oxygenation)
Use of accessory muscle to breath
Transmission:
The transmission of RSV occurs through direct contact with contaminated secretions. This may involve contact with droplets or fomites that live on environmental surfaces for 4 to 7 hours or on the hands for approximately 30 minutes. Although the signs and symptoms of RSV usually appear between days 4 and 6, the actual incubation period is thought to range from days 2 to 8. The following interventions should be employed to prevent the spread of RSV in the healthcare setting:
Infants should be isolated and contact precautions put into place.
If possible, the nurse caring for the patient should remain in isolation with the child for the entire shift.
Diligent hand washing is the best practice to avoid the spread of the virus.
Physicians are asked to “round” last on infants/children diagnosed with RSV.
Clinicians should have a very low threshold for screening patient for RSV.
Staff with RSV symptoms should avoid entering nurseries and other high traffic infant areas.
Tight visitor control (especially those who are ill) should be monitored to decrease the spread of RSV.
Risk Factors:
Although most children under the age of 2 years old will be infected with the RSV virus; the following situations are thought to further increase an infant or child’s risk factors for catching RSV:
Children who attend child care centers
Children who share toys
Children who have siblings who attend school
Children who are exposed to cigarette smoke
Children who live in high pollution communities
Infants younger then 6 months old
Children with underlying disease processes
Infants that were born prematurely
Children with weakened immune systems (chemotherapy or transplantation)
Diagnosis:
Initial assessment confirming the common symptoms associated with RSV is first completed and documented.
An antigen detection immunoassay test is preformed on respiratory secretions to detect RSV. Test results can be determined quickly (often within an hour) whereas viral cultures on the same secretions can take up to 3 to 5 days. Sensitivity of an antigen assay varies from 53% to 96% but usually falls in the 80% to 90% range.
In order to obtain a specimen for detection of the RSV antigen, loose secretions can be obtained from the nose (using a bulb syringe) or if secretions are not loose enough to obtain from the nose; nasopharyngeal swab or suctioning may be required. Aspiration from an endotracheal tube is an additional method of collecting secretions.
The use of saline as an irrigant for collection of secretions should only be used in cases where the infant/child does not have loose secretions.
Medical Treatment Options:
Treatment options for RSV require quick interventions upon diagnosis in an attempt to prevent the development of pneumonia or other life threatening respiratory complications. Infants/Children who are admitted to the hospital for treatment of RSV need to be carefully monitored for their initial response to therapy and treatment using a specific standardized protocol. The following are considered to be treatment options for RSV (the first being for mild cases and the latter being for more severe cases):
Most antibiotics thought to treat bacterial infections are not effective in treating RSV (a virus).
In most cases RSV is mild and self limiting so treatment efforts are often to just manage the symptoms and let the virus run its course (it is important to assure that a child can breath, drink, eat and sleep comfortably).
In more severe cases (those that potentially compromise breathing), hospitalization will be required.
A non-aspirin medication such as Tylenol or Panadol and Nonsteriodal Anti-inflammatory agents such as Motrin or Advil can be given for discomfort or fever.
Aspirin should be avoided in all children under the age of 15 (Reye ’s syndrome).
Infants/Children with RSV should be well hydrated (IV therapy in the hospital setting is often required).
Relief of congestion can be attained with bulb suction, nasopharyngeal or endotracheal suctioning.
Breathing treatments or Nebulizer treatments with bronchodilators can assist with opening airways (bronchus) and providing easier breathing. The most commonly used medications are beta-2-agonists such as Albuterol.
Corticosteroids are frequently used for RSV to reduce the inflammation of the lung bronchus and surrounding tissue (some studies show that steroids are only effective when the child is an asthmatic).
Ribavirin which is an antiviral may also be given as a breathing treatment. It is thought to improve oxygenation and decrease the symptoms associated with RSV.
Nasal products containing sodium chloride (ocean spray) or polyethylene glycol (Rhinaris lubricating mist) may be used to keep the nasal passages open and moist.
Infants/Children showing little or no improvement of RSV within a reasonable period may benefit from continuous Racemic Epinephrine (1:40 solution via 10/Lmin Nebulizer), which requires admission to the Pediatric Intensive Care Unit (PICU). The indications for the continuous use of Racemic Epinephrine include the following:
SPO2 less then 92%
FIO2 less then 65%
Respiratory rate greater then 60/min.
Excessive work of breathing
Intubation and mechanical ventilation support is considered and most often implemented as a treatment option in the following:
No response to continuous Racemic Epinephrine after 4 hours of treatment.
A sudden deterioration in the patient's clinical status.
The PCO2 increases to or above 65 mm/Hg
Chest physiotherapy should be ordered every 2-4 hours with the following goals:
Improvement in secretions
Improvement in breath sounds
Improvement in chest Xray findings
Improvement in symptoms
Increased ease of breathing
Increased oxygenation
Note: reassessment of chest physiotherapy should be done after 24 hours and if thought to be ineffective in meeting the above goals, should be discontinued.
Nursing Interventions (Based on NANDA nursing diagnosis):
Activity Intolerance
Definition: Insufficient physiological and psychological energy to endure or complete required or desired daily activities.
Defining Characteristics (Subjective and Objective):
Fatigue
Weakness
Abnormal heart rate/blood pressure in response to activity
Exertional discomfort or dyspnea
Expected Patient Outcomes:
Ability to participate in physical activity with normal cardiac/respiratory response.
Ability to state the adverse symptoms and report symptoms immediately (not an expected outcome for infants and young children).
Maintain normal skin color with activity (warm, dry and pink).
Verbalize an understanding for regular activity (again not an expected outcome for infants and young children).
Demonstration of normal activities of daily living.
Nursing Interventions:
Determine cause of activity intolerance and determine whether cause is physical, psychological or motivational.
Assess the infant/child’s normal daily activity.
When appropriate; gradually increase activity.
Provide and appropriate rest/activity balance for the infant/child.
Attempt to group nursing activities to avoid interrupting sleep/naps.
Ensure that all activity is completed with safety in mind.
Perform range of motion exercises for infant/children who are bed ridden due to illness.
Promote small measures of independence with activity (teeth/hair brushing, bathing, changing pajamas).
Patient/Family Teaching (most teaching will be to the parents):
Instruct the patient/family on measures to avoid activity intolerance.
Teach the patient/family effective methods for the child to cough and expel secretions.
Teach the patient/family methods to minimize exertion with the infant/child’s ADL’s.
Teach the patient/family the importance of good nutrition.
Describe the symptoms of activity intolerance to the patient/family so they can be minimized during ADL’s.
Anxiety
Definition: A vague uneasy feeling of discomfort or dread accompanied by an autonomic response. The source of this feeling is either known or unknown to the individual, but causes a feeling of apprehension, or possible danger. Anxiety is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat (NOTE: this diagnosis is often geared towards the parents of an ill infant/child).
Defining Characteristics:
Diminished productivity
Scanning and vigilance
Poor eye contact
Restless behavior
Glancing about
Extraneous movement (repetitive movement, foot shuffling)
Expressed concern resulting from life changes
Insomnia
Fidgeting
Irritability
Regretful/helpless/worried
Quivering voice/trembling/hand tremors
Elevated pulse and blood pressure
Expected Patient Outcomes:
Identifies and verbalizes symptoms of anxiety (older children).
Identifies and demonstrates methods to decrease anxiety (older children).
Verbalizes absence or decrease in subjective distress.
Normal vital signs.
Reports sleeping better and denies insomnia (use language that a child will understand for this assessment).
Demonstrates improved concentration.
Demonstrates return ability to problem solve.
Demonstrates some ability to reassure self.
Nursing Interventions:
Assess patient/family level of anxiety as well of knowledge of existence and cause.
Use presence, touch (with permission), verbalization and environmental factors to assist in decreasing anxiety.
Provide the infant/child with distractions such as toys, puzzles and other activities as tolerated.
Accept the patient/family defenses or explanations of anxiety.
Do not try to argue or demean the patient/family for their feelings.
Allow and reinforce the patient/family member’s expressions of pain, discomfort and/or threats to their well being (or their child’s well being).
Help the patient/family develop coping strategies that will decrease anxiety.
Avoid “excessive reassurance” as this may cause the patient/family to worry unnecessarily.
Intervene when possible to remove sources of stress.
Explain, Explain, Explain (all activities, procedures, tests, and goals).
Patient/Family Teaching:
Teach patient/family the symptoms of anxiety.
Explain equipment (especially if in the ICU) and the monitors in the room. Reinforce that most equipment is to make the assessment of the patient easier and not actually NECESSARY as part of the patient treatment or therapy.
Help the patient/family to be able to define anxiety levels (from easily tolerated to intolerable). Use a color or number code for easy identification.
Teach the patient/family self help techniques to avoid or minimize stress and anxiety.
Teach the patient/family the use of distracters to avoid or minimize stress and anxiety.
Teach the patient/family relaxation and deep breathing exercises.
Teach the patient/family the correlation between balancing sleep, nutrition, exercise and lifestyle to avoid anxiety.
Help the patient/family distinguish between anxiety and panic.
Teach the patient/family appropriate community support for hospitalized children.
Provide social services consult if patient/family showing signs of severe anxiety.
Encourage the family to keep a note pad handy to jot down questions or concerns that they may have.
Hyperthermia
Definition: A body temperature that elevated above the normal range.
Defining Characteristics:
Fever: is a core body temperature that is greater than 0.8 to 1.1 degrees above the individual’s normal body temperature.
Hyperthermia: is a core body temperature that is greater than 40 degrees C. or 104 degrees F.
Expected Patient Outcomes:
Maintain oral temperature with in the adaptive or normal levels.
Remain comfortable.
Remain free from dehydration.
Nursing Interventions:
Monitor temperature Q 2-4 hours.
Monitor for signs of fever such as chills, sweating or signs of infection.
Assure that temperature is being measured appropriate for the age of the child.
Use the same site or method for measuring the infant/child’s temperature.
Administer antipyretic medication as ordered.
Apply ice or cool towels as tolerated.
The use of a cooling blanket may be necessary.
For severe hyperthermia, cool water NG tube lavage may be necessary.
Assess for insensible fluid loss due to fever and replace fluids as necessary.
Prevent shivering caused by cooling measures.
Encourage liberal fluid intake
Patient/Family Teaching:
Teach parents to report any signs of shivering.
Teach parents to avoid unnecessary bundling of the infant/child in sweaters and blankets.
Emphasize the important role a fever plays in enhancing the immune system and that a slight elevation in temperature (0.6 to 1.1 degrees above normal) may actually be beneficial to the infant/child.
Educate family to cooling measures that are beneficial in reducing temperature.
Altered Nutrition (less then bodily requirements)
Definition: Intake of nutrients is insufficient to meet the metabolic needs of the infant/child.
Defining Characteristics:
Body weight that is less than 20% of the ideal weight for the infant/child.
Pale conjunctiva and mucous membranes.
Weakness of muscle required for mastication or swallowing.
Reported altered taste sensation.
Aversion to eating.
Abdominal cramping/pain with or without pathology.
Poor muscle tone/weakness/malaise.
Nausea/vomiting/diarrhea.
Expected Patient Outcomes:
Progressive and appropriate weight gain.
Weight within normal limits.
Recognition of factors that have contributed to being underweight.
Identification of nutritional requirements.
Consumes adequate food intake during hospitalization.
Is free of signs of malnutrition.
Nursing Interventions:
Determine healthy body weight for infant/child (dietician consult may be required).
Daily weights for children suspected of having a nutritional deficit.
Compare usual food intake to current intake.
Determine infant/child’s food preferences, encourage the infant/child to make food choices from the hospital menu.
Keep a running 24 hour calorie count in consultation with the dietician.
Assess the child’s access and ability to participate and consume nutritious foods.
Assess parent’s knowledge of nutrition. Determine if the parents understand the need for increased nutrition when their child is ill.
Observe the infant/child’s ability to eat (nasal congestion often interferes with bottle or breast feeding).
Monitor electrolytes for signs of altered nutrition (high hemoglobin and Hematocrit levels can be a sign of dehydration).
Assess for signs of nausea, vomiting or excessive diarrhea.
Assess the infant/child’s ability to chew and or swallow food.
Maintain a high level of suspicion of the role that malnutrition has in infection and visa versa.
Be alert to possible food/drug interactions and any medications that have the side affect of “decreased appetite”.
Assess for recent changes in nutritional intake (besides current RSV diagnosis).
If the mother is breastfeeding, use reliable tools to determine if breastfeeding performance adequacy, and the need for possible supplemental assistance while the child is ill.
Patient/Family Teaching:
If malnutrition is determined to be caused by other then the current diagnosis of RSV, assure that patient/family are provided outside resources to learn about proper nutrition.
Build on the strengths of the patient/family food habits.
Assure that there are adequate resources to purchase nutritious foods for the patient.
Select appropriate teaching aids for patient/family members to assure there is good understanding of the importance of good and healthy eating.
Assure that infants are tolerating bottle feedings, allergy testing/tolerance testing may be required if the infant is not and has not been feeding well.
Ineffective Airway Clearance
Definition: Inability to clear secretions or obstructions from the respiratory tract in order to maintain a clear airway.
Defining Characteristics:
Dyspnea
Diminished breath sounds
Orthopnea
Adventitious breath sounds (crackles, wheezing)
Cough
Ineffective or absent sputum production
Cyanosis
Difficulty speaking
Wide eyed
Changes in respiratory/cardiac rate
Restlessness
Expected Patient Outcomes:
Demonstration of effective cough
Clear breath sounds
Absence of dyspnea
Maintenance of a patent airway at all times
The ability to relate methods of expelling secretions
State measure to avoid exertion (older children)
Nursing Interventions:
Auscultate lung sounds Q 1-4 hours and document/report changes (crackles = moisture, wheezing = obstruction or constriction of the bronchus).
Monitor respiratory patterns (rate, depth, and effort).
Monitor blood gases/pulse oximetry.
Position patient for optimal respiration (HOB at 30-45 degrees).
Reposition patient Q 2 hours and prn.
Educate and assist patient with deep breathing exercises Q 1-2 hours as tolerated.
Encourage the use of an incentive spirometry (children often find this fun).
Assist with clearing secretions (nasal or nasopharyngeal suctioning).
Observe sputum for color, consistency, odor and volume.
Maintain adequate fluid intake.
Document all assessment and interventions on the nursing flow sheet.
Encourage activity and ambulation as tolerated.
Administer supplemental oxygen as ordered.
Administer or work with respiratory therapy to assure all meds (Nebulizer treatments) are timely and effective.
Monitor effects of chest physiotherapy.
Patient/Family Teaching:
Teach the patient/family deep breathing exercises (and the use of the incentive spirometer).
Teach the patient/family methods to avoid specific factors that exacerbate respiratory difficulties (second hand smoke, excessive pollen or pollution).
Educate the patient/family of the importance of good hand washing and need to avoid spreading RSV to other children or members of the family.
Teach the patient/family the importance of respiratory medications (or antibiotics) and the proper administration of these medications (some children go home and still require Nebulizer treatments).
Teach the patient/family about the signs and symptoms of RSV as well as other methods to prevent the virus from returning.
Ineffective Breathing Pattern
Definition: Inspiration and/or expiration that does not provide adequate ventilation and/or oxygenation.
Defining Characteristics:
Decreased inspiratory/expiratory pressure
Decreased minute ventilation
Use of accessory muscles to breathe
Nasal flaring/dyspnea/chest excursion/SOB
Prolonged expiratory phase
Decrease vital capacity
Hyper/Hypoventilation
Expected Patient Outcomes:
Demonstration of adequate breathing pattern.
Report of ability to breathe comfortably.
Demonstration of controlled, easy and comfortable breathing.
No use of accessory muscles to breathe.
Identification of activities that exacerbate breathing patterns.
Nursing Interventions:
The same interventions that would be employed for a NANDA diagnosis of ineffective airway, would also apply to the diagnosis of ineffective breathing pattern. Of importance is the need to clearly identify if there are specific triggers such as increased secretions, increased stimulation/activity or increased physiological findings that are contributing to the infant/child’s ineffective breathing pattern. If noted, remove as many of these factors as possible.
Patient/Family Teaching:
Teach patient/family methods to control breathing patterns and eliminate outside factors that are negatively contributing to the problem.
Educate parents to medications that may be required upon discharge. Also educate patterns to signs and symptoms of respiratory difficulties or reoccurrence of RSV symptoms.
Additional NANDA Nursing Diagnoses for Consideration:
Infection
Fluid Volume Deficit
Ineffective Family Coping (this applies to all pediatric diseases/disorders).
Knowledge Deficit
References
Ackley, B., J., & Ladwig, G., B. (2004). Nursing diagnosis handbook: A guide to planning. (6th ed.). Mosby. Printed in the United States.
American Academy of Pediatrics. The Red Book 2000, 25th ed. Report of the Committee on Infectious Disease. pgs. 483-487. Retrieved on April 21, 2007 at:
Chan, P., D., M.D. (2007). Pediatrics: A current clinical strategies medical book. Current Clinical Strategies Publishing. Laguna Hills, Ca.
Cooper, A., C. (2004). Management and prevention strategies for respiratory syncytial virus bronchiolitis in infants and young children: A review of evidence base practice interventions. Retrieved on April 21, 2007 at:
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