RSV, or respiratory syncytial virus, 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.
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, respiratory failure, and congestive heart failure.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Hyperthermia
- Impaired Gas Exchange
- Ineffective Protection
- Risk for Infection
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 Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to respiratory syncytial virus.
Review of Health History
1. Note the time of exposure and the patient’s general symptoms.
The symptoms can take 4 to 6 days to appear after exposure, and the illness typically lasts 1 to 2 weeks. Symptoms include:
- Runny nose
- Sneezing
- Cough
- 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
2. Determine the patient’s risk factors.
The following risk factors increase the risk of developing severe or even life-threatening RSV infections:
- Premature newborns or infants less than six months old
- Chronic lung disease, congenital heart disease, or neuromuscular diseases in children
- Compromised immune systems
- Lung or heart disease in adults
- Adults age 65 or older
3. Identify the possible patient exposure.
Infection can spread through the following:
- Coughing
- Sneezing
- Direct touch (such as handshake)
- Contaminated surfaces (like toys, crib rails, and countertops)
4. Estimate the date of exposure.
Estimating the date of exposure will help the nurse know when the patient is most contagious. The first week or so after infection is the most contagious period. However, patients with compromised immune systems may continue to spread the virus even after symptoms have subsided.
Physical Assessment
1. Assess the respiratory status.
RSV symptoms include:
- General:
- Fever
- Myalgia (muscle pain)
- Upper respiratory tract:
- Rhinorrhea (runny nose)
- Rhinitis (nasal congestion)
- Coughing
- Sneezing
- Lower respiratory tract:
- Bronchiolitis
- Tachypnea
- Wheezing
- Use of accessory muscles
- Adventitious breath sounds
- Prolonged expiration
2. Observe the patient’s breathing.
Rapid breathing, intercostal retractions, and wheezing signal respiratory distress. In severe bronchiolitis, there can be nasal flaring and tracheal tugging.
3. Auscultate breath sounds.
Rales (coarse or fine crackles) are frequently heard during auscultation and are sometimes connected to a prolonged expiratory phase.
4. Observe the patient’s oxygen saturation.
Decreased oxygen saturation results from reduced oxygen levels in the body (hypoxia).
Diagnostic Procedures
1. Send samples for non-specific laboratory tests.
Testing is not typically required for mild cases of RSV. The following lab tests may be performed as necessary:
- Complete blood count (CBC) may reveal normal or mildly increased WBC count
- Serum electrolyte levels
- Urinalysis
- Blood cultures are routinely taken, but it is uncommon to have positive bacterial growth
- Arterial blood gas analysis may show carbon dioxide retention
2. Obtain samples for specific tests.
Rapid antigen testing and polymerase-chain-reaction-based (PCR) testing are the two most often used types of RSV testing. Nasal secretions can be tested for antigens quickly, cheaply, and accurately. PCR testing is more sensitive than antigen testing but is more expensive.
3. Assist the patient with imaging tests.
The radiographic findings for RSV are the same as those of bronchiolitis. Hyperinflation, patchy atelectasis, and peribronchial thickening are possible chest x-ray indications of RSV bronchiolitis; however, separating them from bacterial pneumonia may be challenging.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with respiratory syncytial virus.
Provide Supportive Care
Supportive care remains the primary treatment for RSV, regardless of inpatient or outpatient treatment.
1. Administer oxygen as ordered.
Gas exchange can be optimized with supplemental oxygen. Oxygen is administered through a mask, nasal cannula, or an oxygen tent. To ensure oxygenation is effective, regularly monitor SpO2 and ABGs.
2. Keep the air moist.
Use humidifiers or vaporizers to maintain moisture in the air. Moisture can ease coughing and congestion, which will help expectorate secretions.
3. Suction secretions as needed.
RSV increases mucus production, which makes breathing challenging. Suction the airway as needed. Babies may require bulb syringe suction of their nasal passages.
4. Prepare for mechanical ventilation.
Extremely sick children and adults may require a mechanical ventilator to assist with breathing. RSV can cause pneumonia and acute respiratory distress syndrome in high-risk patients.
5. Promote hydration.
IV hydration may be required for very sick patients, especially infants who are unable to tolerate breast or formula feedings. If PO intake is tolerable for children and adults, encourage warm liquids that may help thin secretions.
6. Manage the fever.
Antipyretics like acetaminophen can lower the temperature. Children should never be given aspirin unless on the advice of a doctor.
Prevent Infection
1. Administer prophylaxis against RSV.
Palivizumab, a monoclonal antibody, is an effective passive immunological prophylaxis for RSV. Administered monthly through RSV season, this medication can offer protection for premature infants or infants with heart, lung, or neuromuscular disorders.
2. Teach proper handwashing.
Teach children the purpose of washing their hands. Encourage patients to wash their hands with soap and water for at least 20 seconds.
3. Encourage the patient to stay away from crowded areas.
To avoid contracting various infections, advise the patient to avoid crowds (such as at events and social gatherings), especially if they are immunocompromised. Wearing a mask can also offer protection.
4. Ask the patient to demonstrate proper cough and sneeze etiquette.
While coughing or sneezing, ask the patient to cover their mouth and nose. Always wash or sanitize your hands after coughing or sneezing.
5. Maintain proper sanitation.
To reduce the risk of infection and transmission:
- Discard used tissues immediately.
- Avoid sharing utensils and personal items.
- Do not smoke around children. Babies exposed to cigarette smoke are more likely to develop RSV and may experience more severe symptoms.
- Regularly wash the items that the child touches, such as toys, high chairs, and blankets.
6. Implement droplet precautions.
RSV is mainly transmitted by direct contact with infectious respiratory secretions and droplets. The nurse should implement droplet precautions to protect staff, other patients, and visitors. Droplet precautions consist of placing the patient in a private room and donning PPE, including gowns, gloves, masks, and goggles, before entering. Medical equipment should not be shared between patients on droplet precautions and other patients.
7. Educate about immunizations.
Infants should receive recommended pneumococcal, influenza, varicella, DTaP (diphtheria, tetanus, pertussis), hepatitis A, and hepatitis B vaccinations to boost their ability to fight infection.
Treat the Infection
1. Administer antiviral medications as ordered.
High-risk patients with severe RSV disease may benefit from antiviral medication. At the first sign of infection, treatment must be started immediately to inhibit the replicating virus effectively.
2. Provide bronchodilators as prescribed.
Bronchodilators lower muscle tone in the lungs’ small and large airways to increase ventilation. The bronchospasm seen in bronchiolitis is frequently treated with beta2-adrenergic and alpha-adrenergic medications (through inhalation). Bronchodilator efficacy is not convincing in the treatment of RSV but is commonly used.
3. Give epinephrine racemic as ordered.
Aerosolized racemic epinephrine can be effective in treating patients with severe RSV symptoms.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for respiratory syncytial virus, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for RSV.
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.
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.
Ineffective Protection
Certain internal and environmental factors increase the patient’s risk of acquiring RSV infection.
Nursing Diagnosis: Ineffective Protection
Related to:
- Compromised immune function
- Poor nutrition
- Young infant or age over 65
- Close living conditions or settings with others (daycare)
As evidenced by:
- Presence of underlying respiratory conditions (i.e., asthma and COPD)
- Frequent respiratory infections
- Malnutrition
- Anorexia
Expected outcomes:
- Patient will not manifest signs of RSV infection.
- Patient and/or caregiver will demonstrate appropriate hygienic measures.
Assessment:
1. Assess for alterations in nutrition.
Monitor the infant’s current weight and any abnormalities in feeding. Monitor the adult patient’s muscle mass, protein, and albumin levels and any changes in appetite. Proper nutrition is crucial for immune support.
2. Assess immune status.
RSV is one of the leading causes of morbidity among patients with weak immune systems, such as those taking steroids, diagnosed with diabetes mellitus, chronic lung or heart diseases, etc. The risk of morbidity and mortality increases when the infection progresses from the upper respiratory structure to the lower respiratory area.
Interventions:
1. Restrict children’s time in daycare centers during seasons with peak RSV activity.
RSV infects 90% of children aged 0 to 2 years old and frequently reinfects older children and adults. RSV spread generally starts during fall and peaks in the winter. Limit the infant’s exposure to others who could transmit the virus.
2. Review and schedule vaccinations.
Palivizumab is a prophylactic injection that may be given to premature infants with chronic conditions to protect against RSV. Other vaccinations, such as influenza, pneumococcal, varicella, and DTaP (diphtheria, tetanus, pertussis), should be given as recommended to protect against diseases that can complicate RSV.
3. Provide adequate respiratory support.
If the patient has an underlying respiratory condition, such as asthma or COPD, ensure they receive appropriate respiratory support, such as bronchodilators or inhalers, to prevent respiratory distress and potential RSV infection.
4. Educate the patient and family about RSV infection control measures.
RSV is highly contagious. Some infection control measures include:
- Avoid contact with sick individuals
- Observe good hand hygiene practices
- Avoid touching the face with contaminated hands
- Do not share eating utensils and cups
5. Do not smoke, and avoid smoking around children.
Smoking can worsen the severity of RSV. Secondhand smoking increases the risk of RSV in infants.
Risk for Infection
Some patients are at a higher risk for acquiring respiratory syncytial virus that could progress to more serious respiratory diseases such as pneumonia and sepsis.
Nursing Diagnosis: Risk for Infection
Related to:
- Compromised immune system
- Exposure to RSV-infected contacts
- Insufficient knowledge to prevent exposure to pathogens
- Premature newborns
- Chronic heart or lung disease
- Less than two years of age or older than 65
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will remain free from RSV infection as evidenced by the absence of the following:
- Rhinorrhea
- Nasal congestion
- Cough
- Sneezing
- Fever
- Myalgia
- Patient and/or caregiver will demonstrate measures to prevent RSV infection.
Assessment:
1. Assess risk factors contributing to the risk of contracting RSV infection.
Most children will acquire RSV at some point without severe symptoms. Newborns born prematurely, infants or young children with heart, lung, or neuromuscular conditions, and those with compromised immune systems are at risk of serious complications from RSV.
2. Assess for signs of infection.
The presence of a cough, runny nose, sneezing, and fever must be investigated further. Infants may display changes in breathing, poor feeding, and lethargy.
Interventions:
1. Ensure droplet precautions.
Droplet precautions should be implemented to prevent the spread of RSV to others. This involves placing the patient in a private room and ensuring that all healthcare providers wear appropriate protective equipment, including gowns, gloves, masks, and eyewear, when entering the room.
2. Monitor vitamin D levels.
Low vitamin D levels in neonates correlate with a greater risk of RSV within the first year of life. Vitamin D affects the immune system by influencing the production of endogenous antimicrobial peptides and regulating the inflammatory process.
3. Administer PO and IV fluids.
Adequate hydration is vital in managing the symptoms of RSV. Infants may not be able to tolerate breast or formula feedings and are more susceptible to dehydration, requiring IV fluids. Encourage PO intake for children and adults.
4. Educate on hand hygiene and environmental cleanliness.
RSV is spread through infected respiratory secretions in the air, through hand-to-hand contact, and contaminated surfaces. Educate caregivers on handwashing and the use of hand sanitizers. Recommend disinfecting objects that infants and children commonly touch, such as toys, doorknobs, table surfaces, and more.
References
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- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Center for Disease Control and Prevention. (2022). Respiratory syncytial virus infection (RSV). https://www.cdc.gov/rsv/index.html
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- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
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- Respiratory Syncytial Virus Infection (RSV). Centers for Disease Control and Prevention. https://www.cdc.gov/rsv/index.html. Accessed on Dec. 14, 2022
- Respiratory syncytial virus (RSV). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/respiratory-syncytial-virus/symptoms-causes/syc-20353098. Accessed on Dec. 14, 2022
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