Included In This Lesson
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Outline
Pathophysiology
Bronchiolitis is a common infection of the lungs in children and infants that causes inflammation and mucus secretion in the bronchioles, which obstructs the flow of air. Atelectasis may occur or air may become trapped. Breastfed infants receive antibodies from the mother in the colostrum that help reduce the likelihood of developing bronchiolitis.
Respiratory syncytial virus (RSV) is a common respiratory virus that causes cold-like symptoms in children and is the most common cause of bronchiolitis in infants. Premature babies and children with a compromised immune system can experience severe infection from RSV.
Etiology
Bronchiolitis is caused by a virus, most commonly the Respiratory Syncytial Virus (RSV) and rhinovirus, otherwise known as the common cold. These viruses get into the airways and cause inflammation, increased mucus production and obstruction. RSV and bronchiolitis are very contagious and are spread through airborne droplets and direct contact with mucus.
Desired Outcome
Patient will have adequate oxygenation and gas exchange; patient will be afebrile; patient will maintain adequate nutrition
Bronchiolitis / Respiratory Syncytial Virus (RSV) Nursing Care Plan
Subjective Data:
- Headache
- Sore throat
- Decreased appetite or poor feeding
Objective Data:
- Runny nose
- Persistent cough
- Wheezing
- Fever, low grade (may or may not be present)
- Tachypnea
- Labored breathing, retractions, nasal flaring
Nursing Interventions and Rationales
- Assess respiratory status, auscultate lungs for adventitious lung sounds
- Get baseline information.
- Note respiratory distress, infants may have nasal flaring or retractions of the chest.
- Wheezing is common and is the sound made when air struggles to get through the narrowed airways.
- Crackles may also be heard as air tries to get past the excess mucus in the lungs.
- Note the presence and quality of coughing, if secretions are thick, or bronchospasms.
- Assess vital signs and capillary refill
- Get a baseline to determine effectiveness of interventions.
- Low grade fever may or may not be present.
- Heart rate is increased as the patient works to breathe.
- Sluggish cap refill indicates poor perfusion
- Encourage oral fluids or initiate and administer IV fluids as necessary
Fluids help to thin the secretions and make it easier to suction or expel.
Infants may have difficulty feeding and children often refuse food and drink due to increased nasal congestion
- Position patient upright
To help the lungs expand and increase air exchange. Depending on the age of the patient, a child may sit forward leaning on a table while an infant can be held upright
- Provide suction as necessary, per facility protocol
To help clear airways. Avoid excessive or prolonged suction that can cause further inflammation of the airways.
- Monitor pulse oximetry and provide supplemental humidified oxygen via mask, tent or hood as required
If oxygen saturation drops below 90%, patient may benefit from supplemental oxygen. Humidification provides comfort and helps keep mucus thin and moveable.
- Administer medications and breathing treatments per facility protocol
- Antiviral medications like Ribavirin are given for the viral infection
- Bronchodilators and Corticosteroids are no longer recommended for bronchiolitis in infants and children
- Antibiotics are NOT recommended to treat viral illnesses and can cause patient to develop resistance over time.
- Antipyretics like acetaminophen may be given for fever or pain
- Monoclonal antibodies (Palivizumab) to decrease immune response
- Use incentive spirometer / practice deep breathing techniques
Deep breathing helps open and clear bronchioles and can be effective for older children. Teach them to use incentive spirometer or try blowing a balloon or bubbles.
- Provide education to parents for home treatment
- Administer nasal saline drops
- Use bulb suction
- Control fever
- Encourage fluids
- Preventing the spread of infection to others
- Nasal saline drops and bulb syringe suctioning can help relieve nasal congestion and reduce respiratory fatigue.
- Teach parent proper use of bulb syringe.
- Educate parents on how and when to treat fever.
- Encourage oral hydration.
- RSV/bronchiolitis is very contagious and patients should not attend school or daycare during the time of illness to prevent infection of others.
- Practice good hand hygiene
A Nursing Care Plan (NCP) for Bronchiolitis / Respiratory Syncytial Virus (RSV) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.
References
Transcript
You guys in this care plan, we are going to be looking at the diagnosis for bronchiolitis or respiratory syncytial virus, as it’s sometimes called.
What we’re going to do in this care plan is look at a basic description of the diagnosis, your subjective and objective data and your nursing interventions and rationales.
Bronchiolitis is one of the most common infections of the lungs that we see in children and infants and the ages that we usually see this diagnosis are from birth to two years of age. Now, the most common cause of bronchiolitis is a virus that’s called respiratory syncytial virus, or RSV. It is extremely, extremely contagious, and it’s spread through droplets and airborne. Um, so you need to pay attention to that when you’re doing your patient care and you’re planning your infection control. Now, RSV is actually, um, pretty much just a common cold, but this becomes a really big problem for our infants and toddlers because their airways are so much smaller than ours. When this happens, you’re going to end up with problems, um, like inflammation, mucus secretion, which is going to obstruct the flow of air and then sometimes you can even end up with an adolescent Asus occurring.
Now, our top priority for a patient who has bronchiolitis and what we really want for them to achieve is for them to have adequate oxygenation and gas exchange. Um, we hope to keep them afebrile if we can and then we really want to make sure that we maintain adequate nutrition.
All right, let’s look at the specifics for our care plan for your subjective data. The most important thing to be aware of is that these patients are likely to have a decreased appetite and they’re going to be having poor feeding. This is especially true for infants. There are a lot of coryzal symptoms here, so lots of running noses. So, just imagine trying to feed from a bottle when your nose is all blocked up with snot, it’s really, really tough. With your verbal patients, you may hear them complain of common symptoms that we see with colds, like headaches, sore throat and even fatigue.
Okay, the objective data that you want to be aware of here, is that runny nose that I mentioned, persistent cough, wheezing, potentially, sometimes crackles as well, fever, usually a low grade fever, not too high, and then you’re going to see symptoms like to tachypnea, retractions and nasal flaring, all of which are going to be indicators of an increase in the child’s work of breathing. Remember we said that feeding is really likely to be a problem. So, you’re very likely to see symptoms of dehydration as well.
Now, let’s go ahead and take a look at our interventions and our rationales. The first thing we want to do is perform a very thorough respiratory assessment. This means that we’re going to take our time and we’re going to watch the child breathe to get a sense of their work of breathing because we really need to know if they’re having those recessions and retractions, and if they are in any kind of respiratory distress. We also need to auscultate their lungs and we’re listening for things like wheezing and coughing. One thing I always say about babies with bronchiolitis is that they have very, very noisy chests. Lots of sounds that you can hear there.
Okay, next we want to assess vital signs and capillary refill. These patients are often going to have temperatures, so we’re going to see an increase in temp and then along with that, your increase in heart rate and an increase in respiratory rate are very, very common. Sluggish capillary refill times may be present in your patients that are poorly hydrated and they may also be an indication of sepsis. So, definitely be on the lookout for that, thinking back to our difficulty with feeding. Our next intervention is to really promote good hydration and treat that lack of fluid that they may have. So, we need to be monitoring their fluid intake and we need to encourage oral fluids. If they aren’t taking those oral fluids, well, we need to administer IV fluids as necessary and G-tubes are becoming a really common way to manage this as well.
So we’ll put an NG tube down and then we can continue giving that baby formula or breast milk.
The next couple of interventions that we’re going to look at here are focused on improving the patient’s breathing. Now, probably the most basic thing that we can help any patient with when they’re having difficulty breathing is their position. So, we want to position the patient in an upright position. The easiest way to do that is to elevate the head of the bed and actually most cribs are going to have a way for you to do that as well. So, don’t forget that you can elevate the head of the bed, have a crib also, and basically what this is going to do is It’s going to help their lungs expand and increase their air exchange. Our next really simple intervention to help with respiratory effort is to provide suction. You want to make sure you follow your hospital protocol on this. Usually it’s going to be very non-invasive, very simple suctioning of just the nose. The reason we do that is because prolonged suctioning can actually cause a little bit more inflammation in that airway and we definitely don’t want to do that. So always non-invasive and simple suctioning there.
So, as we are trying to do these things to improve their breathing, we need to be monitoring their oxygen saturations very, very closely. The parameters for this are going to be set by the hospital, but normally you want to keep oxygen saturations above 90%, so we need to apply supplemental oxygen. If they are below that, most of the that’s going to need to be humidified oxygen. Kids tolerate it so much better and it helps them get that mucus out. Alright, those were our interventions that were focused on specifically helping respiratory effort.
Now, let’s think about more general interventions. So with this, we have medications that we might be able to give, but the way that I usually describe management for or our treatment for bronchiolitis is using the word support and the reason for this is that because most medications are not going to be indicated and helpful. So, with things like Bronchodilators, steroids, and antibiotics, research shows that they are not helpful. So, what we’re going to do is we’re going to focus on fluids and oxygen and keeping that temperature down. So, those are our main things that we’re going to do to help that patient with their symptoms. For your older patients, you may see them use an incentive spirometer or practice deep breathing techniques and that will help open and clear the bronchioles. For our infants and toddlers though, this may be a bit trickier because they are too little to follow instructions but sometimes, you’ll see respiratory therapists use bubbles. If the child can cooperate with that. And again, that helps open the bronchioles. Last but not least here, we need to educate our parents on how they can manage this at home. Not all babies with bronchiolitis need to be admitted at hospital. The parents can do a lot of the things that we’ve discussed. They can give saline drops into the nose. They can suction out the nose with a bulb suction that you can just get at any pharmacy and they can treat the fever and give that oral hydration frequently. What we tend to tell them to do is they just need to give small amounts and they need to give it often.
Alright guys, we love you. Go out there and be your best self today and as always, happy nursing!
Miriam Wahrman, MSN/Ed, RNC-MNN 
Nichole Weaver, MSN/Ed, RN, CCRN 
