- Fatigue Related to Body weakness and Acute infection as evidenced by Inability to maintain usual routine or play
- Hyperthermia related to RSV infection and Inflammation as evidenced by elevated vital signs and Warm to touch
- Impaired Gas Exchange Related to Hypoxemia and Lung inflammation as evidenced by Dyspnea and adventitious lung sounds
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbalization of feeling tired Objective data: -Inability to maintain usual routine or play -Irritability -Increased need for sleep or rest -Lethargy -Poor feeding -Decreased appetite | Fatigue Related to Body weakness and Acute infection as evidenced by Inability to maintain usual routine or play | 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. | 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. | Patient demonstrated an increase in activity levels. Child will be able to eat, play, and drink without fatigue. Patient actively participated in activities, both necessary and desired. Patient verbalized feeling less tired with more energy. |
| Subjective data: Verbalizes increased body temperature Objective data: -Elevated vital signs -Flushed skin -Warm to touch -Diaphoresis -Verbalization of headache | Hyperthermia related to RSV infection and Inflammation as evidenced by elevated vital signs and Warm to touch | Patient will maintain a core temperature within normal range. Patient will demonstrate behaviors to promote normothermia. Patient will be free of seizure activity. | 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. | Patient maintained a core temperature within normal range. Patient demonstrated behaviours to promote normothermia. Patient free of seizure activity. |
| Subjective data: -Dyspnea -Diaphoresis (excessive sweating) -Headaches Objective data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -Irritability | Impaired Gas Exchange Related to Hypoxemia and Lung inflammation as evidenced by Dyspnea and adventitious lung sounds | 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 | 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. | Patient maintained a clear airway and remained free of signs of respiratory distress. Patient verbalized their understanding of oxygen and therapeutic interventions. Patient participated in their care plan within their capability or condition level. Patient maintained normal oxygen saturation levels, ABGs, respiratory rate, and pulse rate |