Case presentation

Influenza
Influenza, commonly known as "the flu", is an infectious disease caused by
an influenza virus. Symptoms can be mild to severe. The most common symptoms include:
high fever, runny nose, sore throat, muscle and joint pain, headache, coughing, and feeling
tired.
Influenza (also known as flu, or grippe) is an acute inflammation of the nasopharynx, trachea,
and bronchioles, with congestion, edema, and the possibility of necrosis of these respiratory
structures. Influenza is a highly contagious infection of the respiratory tract caused by three
different types of Myxovirus influenzae. It occurs sporadically or in epidemics which peaks
usually during colder months.

Risk factors:
 Age. Seasonal influenza tends to target children younger than 12 months of age and adults 65
years old or older.
 Living or working conditions. ...
 Weakened immune system. ...
 Chronic illnesses. ...
 Aspirin use under age 19. ...
 Pregnancy. ...
 Obesity.
Pathophysiology

influenza virus travels by air

Man inhales microorganism

Virus invades respiratory mucosa ( nasal, tracheal, and bronchial tree)

Client becomes vulnerable to secondary infections

Pneumococci staphylococci steptococci other agents

Edema of the respiratory tree

Passage of serosanguinous discharge

Ineffective Airway Clearance R/T hyperthermia R/T volume Risk for fluid deficit

Bronchial edema infectious process

 Signs and symptoms
 fever or feeling feverish/chills
 sore throat
 runny or stuffy nose.
 muscle or body aches.
 headaches.
 fatigue (tiredness)
 some people may have vomiting and diarrhea, though this is more common in children than
adults.

Nursing diadnosis
1. hyperthermia R/T infectious process
2. ineffective airway R/T bronchial edema
3. risk for fluid volume deficit
 Drug study
Drug Classificat Indication and Side effect and Special Nursing
ion and contraindicaton adverse precauton responsibility
mechanis reaction
m of
action
Generic Non-opioid Indication: Gastrointestinal >Check that >Do not exceed the
name: analgesic, Temporary problems, the patient is recommended
Ibuprofen Antipyretic reduction of allergic skin not taking dosage.
fever, temporary reactions any other  
Brand Mechanism relief of minor medication >Reduce dosage
name: of action: aches and pains containing with hepatic
Paracetamo Antipyretic: causes by paracetamol impairment
l Reduces fever common cold .
>Avoid using
by acting and influenza,
multiple preparat
directly on the headache, sore >For children ions containing
hypothalamic throat, who may acetaminophen.
heat- toothache, refuse Carefully check all
regulating backache, medicine off OTC products.
center to menstrual a spoon try
cause cramps. using a >Give drug with
vasodilation medicine food if GI upset
and sweating, Contraindication: syringe to occurs.
which helps >contraindicated squirt liquid  
dissipate with allergy to slowly into >Discontinue drug
heat acetaminophen. the side of if hypersensitivity
the child's reactions occur
>use cautiously mouth or
with impaired use soluble
hepatic function, paracetamol
chronic mixed with a
alcoholism, drink.
pregnancy, Paracetamol
lactation. can be take
in with or
without
food.

>Alcohol
increases the
risk of liver
damage that
can occur if
an overdose
of
paracetamol
is taken
Drug Classification Indication and Side effects Special Nursing
and contraindication and adverse precaution responsibility
mechanism reaction
of action
Generic Antivirals Indication: CNS: > This medicine >No
name: TAMIFLU is dizziness, may cause a evidence
indicated for the insomnia, serious type of supports
Oseltamivir
allergic reaction
phosphate Mechanism treatment of headache, drugs use to
called anaphylaxis.
of action: acute, vertigo, Anaphylaxis can treat
Inhibits uncomplicated fatigue be life-threatening viralinfections
Brand influenza A and illness due to and requires other than
immediate medical
name: B virus enzyme influenza A and GI :abdominal
attention. Call
influenza virus
Tamiflu Neuraminidase B infection in pain, diarrhea,
your doctor right
type A and B
which is patients 2 weeks nausea,
away if you have a
thought to play of age and older vomiting rash, itching, > Dr u g s
a role in viral who have been hoarseness, trouble must be
aggregation symptomatic for Respiratory: breathing, trouble g i v e n within
no more than 48 bronchitis. swallowing, or any 2 days of
and release swelling of your
from the host hours. cough onset of
hands, face, or
cell. symptoms
mouth while you
Neuraminidase Contraindication: or your child are
inhibition, TAMIFLU is using this >A drug
therefore, contraindicated in medicine. isn’t a
appears to patients with replacement
known serious >Make sure for the annual
interfere with your doctor
viral replication hypersensitivity knows if you or
influenza
to oseltamivir or vaccination.
your child plan
any component of to get the live
Patients for
the product. nasal mist flu whom vaccine
Severe allergic vaccine before is indicated
reactions have you start using should
included this medicine. continue to
anaphylaxis and You should not receive the
serious skin receive the vaccine each
reactions vaccine within fall
2 weeks before
including toxic
or 48 hours
epidermal after using this
>D r u g m a y
necrolysis, medicine. be given
Stevens-Johnson with meals to
Syndrome, and decrease
erythema gastrointestina
multiforme l adverse
effects.
 nursing care plan

Assessment Nursing Dx Goal/Objectives Nursing Rationale Intervention

intervention
Subjective: Fever is Short term goal: Independent: > to gain
considered the >establish patient trust
hallmark After 8 hours of rapport and
Objective: symptom of nursing >monitor vs cooperation
>Febrile, infection. intervention, the especially the > to gain
>T = 38.8 C Pyrogenic client will be temp. baseline data
>Weak in agents that act able to: >perform TSB and nte for
appearance on the •Decrease body changes
>palpable hypothalamus temperature
lymph nodes to produce from 38.8 C to Dependent:
>body malaise fever during 37 C >Administer >Administerin
>Diaphoretic infection •Enumerate analgesic g analgesic
ways on medications medications
preventing as ordered helps the
further elevation (Paracetamol body in
Nsg. Dx: of temperature q 4hrs) lowering
>Hyperthermi down the
a R/T Long term goal: body
infectious temperature.
process After 24 hours
Fever of nursing
intervention, the
client will be
able to:
•Normalize body
temperature
from 38.8oC to
36.5 C •Manifest
signs of absence
of infection
Assessment Nursing Dx Goal/Objectives nursing Rationale Intervention
intervention
Subjective: Influenza virus Short term Independent: > to gain The goals met.
invades the goal: >establish trust and The client was
Objective: client’s > after 8 hours rapport cooperation able to:
>crackles respiratory of nursing >assess > Changes in
heard over system when he interventions, respiratory respiration > Maintain a
lung field inhales the the client will rate rate indicates normal
peripherally microorganisms, be able to: >elevates respiratory respiration
>coughing at causing the >Maintain a clients head distress rate of 12-20
times virus to invade normal > To provide cpm
>productive the respiratory respiration rate maximum
cough system, then of 12-20 cpm; lung >Demonstrate
>secretion having the expansion behaviors in
characterized accumulation of >Demonstrate maintaining
as yellowish in fluid (edema) on behaviors in clear airway;
color the respiratory maintaining > monitoring
> (+) use of tree causing clear airway; Dependent: and noting > Demonstrate
accessory now the patient > Monitor and changes in absence/reduc
muscle when to have >Demonstrate note respirations, tion of
breathing difficulty in absence/reduc respirations, breath congestion
>pale in breathing, tion of breath sound, sound, rate, with breath
appearance leading to congestion with rate, and and presence sound clear,
>increased RR Ineffective breath sound presence of of respiration
of 26 cpm Airway clear, adventitious adventitious noiseless.
>restlessness Clearance. respiration sounds. sounds
>with good noiseless. reflects the
capillary refill > Evaluate effectiveness
of 2 secs. client’s of
cough, gag interventions
reflex and done.
Nsg. Dx: swallowing > To
> Ineffective ability. determine
Airway ability to
Clearance R/T > Perform protect own
bronchial chest airway.
edema physiotherapy > To help in
secreting
secretion
>Administer > To help in
prescribed effective
medication. therapeutic
regimen.