Bronchiolitis Nursing Diagnosis Care Plan: Guide for Effective Patient Care

What is Bronchiolitis?

Bronchiolitis is defined as an acute viral infection affecting the lower respiratory tract, specifically the bronchioles and alveoli in young children and infants. This condition leads to inflammation and the accumulation of thick mucus, exudate, and cellular debris, causing mucosal edema that obstructs these smaller airways. The obstruction primarily affects expiration, leading to air trapping and alveolar hyperinflation. This process significantly impairs gas exchange, potentially resulting in hypoxemia and hypercapnia, which in severe cases can progress to respiratory acidosis.

Bronchiolitis is highly contagious, primarily spread through direct contact with nasal secretions, airborne droplets, and contaminated surfaces (fomites). Respiratory syncytial virus (RSV) is the most prevalent causative agent, identified in approximately 75% of bronchiolitis cases requiring hospitalization in children under two years old. Several risk factors increase susceptibility to bronchiolitis, including:

• Age less than three months: Younger infants have narrower airways and less developed immune systems.
• Low birth weight: Premature infants often have underdeveloped lungs.
• Prematurity (Gestational age): Premature infants are more vulnerable due to immature lung development.
• Lower socioeconomic status: Linked to factors like crowded living conditions and limited access to healthcare.
• Overcrowded living conditions: Increases the likelihood of exposure to respiratory viruses.
• Parental smoking: Exposure to secondhand smoke irritates airways and increases susceptibility to respiratory infections.
• Pre-existing chronic lung disease: Conditions like asthma or cystic fibrosis can exacerbate bronchiolitis severity.
• Severe congenital or acquired neurological conditions: May impair cough reflex and airway clearance.
• Airway anomalies: Structural abnormalities can predispose to airway obstruction.

Bronchiolitis predominantly affects infants, with initial symptoms often being subtle. During the typical two- to five-day incubation period, infants may exhibit increased fussiness and feeding difficulties. These early signs are usually followed by a low-grade fever, increasing coryza (nasal inflammation), and congestion. While the majority of cases are mild and resolve on their own, effective management focuses on symptomatic relief and maintaining hydration and oxygenation, as there is no specific antiviral therapy for most causes of bronchiolitis.

Nursing Care Plans & Management

Nursing care for bronchiolitis is centered on a holistic approach, aiming to support respiratory function, enhance patient comfort, ensure adequate hydration and nutrition, implement rigorous infection control measures, provide comprehensive supportive care, educate parents effectively, and foster collaboration within the healthcare team. The primary objectives are to optimize respiratory function, alleviate distressing symptoms, and facilitate a smooth and efficient recovery process.

Nursing Problem Priorities

The critical nursing priorities for managing patients with bronchiolitis and respiratory syncytial virus (RSV) are:

• Maintaining a patent airway and effective breathing pattern.
• Improving gas exchange and oxygenation.
• Promoting adequate fluid and nutritional intake.
• Reducing anxiety in both the child and parents.
• Preventing the spread of infection.
• Providing comprehensive patient and family education.

Nursing Assessment

A thorough nursing assessment is crucial for identifying the specific needs of infants and children with bronchiolitis. This involves gathering both subjective and objective data to evaluate the severity of the condition and guide appropriate interventions.

Assess for the following subjective and objective data:

• Breath Sounds: Auscultate for diminished or absent breath sounds, indicating airway obstruction or atelectasis. Note the presence of adventitious sounds such as crackles, wheezes, and rhonchi, which can suggest fluid or mucus in the airways.
• Cough Characteristics: Evaluate the nature of the cough, noting if it is paroxysmal, nonproductive, or harsh and hacking. These characteristics help differentiate bronchiolitis cough from other respiratory conditions.
• Respiratory Rate and Depth: Observe for changes in the rate and depth of respirations. Tachypnea (increased respiratory rate) and shallow respiratory excursion are common signs of respiratory distress.
• Dyspnea and Breathing Effort: Assess for signs of dyspnea (difficulty breathing), including nasal flaring, and the use of accessory muscles (suprasternal and subcostal retractions). These indicate increased work of breathing.
• Mucus and Nasal Discharge: Evaluate the amount and nature of mucus and nasal discharge. Increased mucus production and nasal discharge are typical in bronchiolitis.
• Oxygenation Status: Monitor for signs of hypoxemia such as cyanosis and changes in level of consciousness. Obtain arterial blood gases (ABGs) if indicated to assess oxygenation and ventilation status.
• Fever: Check for the presence of fever, a common systemic response to viral infection.

Assess for factors related to the underlying causes of bronchiolitis & respiratory syncytial virus (RSV):

• Airway Obstruction: Identify factors contributing to tracheobronchial obstruction, such as inflammation, edema, and mucus plugging.
• Mucus Secretions: Evaluate the impact of increased mucus secretions on airway patency and breathing.
• Ciliary Function: Consider the role of impaired ciliary defenses in mucus clearance.
• Work of Breathing: Assess for increased work of breathing due to airway obstruction and inflammation.
• Inflammatory Process: Understand the contribution of the inflammatory process to airway narrowing and respiratory distress.
• Respiratory Muscle Strength: Evaluate for respiratory muscle weakness and fatigue which can compromise breathing effectiveness.
• Lung Expansion: Assess for decreased lung expansion due to hyperinflation and air trapping.
• Gas Exchange Imbalance: Monitor for alterations in the client’s usual oxygen/carbon dioxide ratio, indicating impaired gas exchange.
• Changes in Health Status: Be aware of any changes in the infant or small child’s overall health status that may impact bronchiolitis severity or management.

Nursing Diagnosis

Based on a comprehensive assessment, a nursing diagnosis is formulated to specifically address the health challenges associated with bronchiolitis. This diagnosis reflects the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses provide a framework for organizing care, their practical application in clinical settings may vary. It is crucial to recognize that the use of specific diagnostic labels may not always be as prominent as other elements of the care plan. Ultimately, the nurse’s expertise and clinical judgment are paramount in tailoring the care plan to meet each patient’s individual needs, prioritizing their health concerns and care objectives.

Common Nursing Diagnoses for Bronchiolitis:

• Ineffective Airway Clearance related to increased mucus production and bronchospasm, as evidenced by adventitious breath sounds (wheezes, crackles), ineffective cough, and dyspnea.
• Ineffective Breathing Pattern related to airway obstruction and inflammation, as evidenced by tachypnea, nasal flaring, and use of accessory muscles.
• Impaired Gas Exchange related to ventilation-perfusion mismatch secondary to alveolar hyperinflation and mucus plugging, as evidenced by hypoxemia (SpO2 < 90%), cyanosis, and irritability.
• Fluid Volume Deficit related to increased respiratory rate, decreased oral intake, and fever, as evidenced by dry mucous membranes, decreased urine output, and poor skin turgor.
• Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing and decreased appetite, as evidenced by poor feeding, weight loss, and fatigue.
• Anxiety (Parental/Child) related to respiratory distress, hospitalization, and lack of knowledge about the condition, as evidenced by expressed concerns, restlessness, and crying.
• Risk for Infection Spread related to the contagious nature of RSV and other respiratory viruses, and inadequate infection control practices.

Nursing Goals

The overarching goals and expected outcomes for nursing care in bronchiolitis include:

• Maintain a patent airway: The patient will maintain a clear airway, as evidenced by clear breath sounds and effective cough.
• Achieve effective breathing pattern: The patient will demonstrate an improved breathing pattern, as evidenced by a respiratory rate within normal limits for age, and absence of nasal flaring and accessory muscle use.
• Optimize gas exchange: The patient will maintain adequate oxygenation, as evidenced by SpO2 ≥ 92% and absence of cyanosis.
• Maintain fluid balance: The patient will exhibit adequate hydration, as evidenced by moist mucous membranes, good skin turgor, and adequate urine output.
• Achieve adequate nutritional intake: The patient will receive and tolerate sufficient nutritional intake to meet metabolic needs.
• Reduce anxiety: The patient and parents will demonstrate reduced anxiety levels, as evidenced by calm demeanor, verbalization of understanding, and cooperation with care.
• Prevent infection spread: Infection transmission will be prevented through adherence to infection control measures.
• Promote family understanding and management: Parents will demonstrate understanding of bronchiolitis, its management, and home care strategies.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with bronchiolitis & respiratory syncytial virus (RSV) are designed to address the identified nursing diagnoses and achieve the desired patient outcomes. These interventions are categorized to provide a structured approach to care.

1. Improving Airways and Breathing Pattern

Bronchiolitis and RSV can significantly compromise respiratory function, making it difficult for patients to maintain effective breathing patterns and adequate airflow. Interventions aimed at improving airways and breathing patterns are crucial. The primary aim is to ensure sufficient oxygenation and ventilation while minimizing the workload on the respiratory system. This requires a comprehensive strategy involving both medical treatments and supportive care measures.

Nursing Interventions:

1. Assess Airway Patency:

   • Action: Regularly assess the patient’s airway for patency.
   • Rationale: Maintaining a patent airway is the highest priority. Inflammation, edema, and mucus in bronchiolitis can obstruct bronchioles, leading to hyperinflation, increased airway resistance, atelectasis, and ventilation-perfusion mismatch. Early detection of airway compromise allows for prompt intervention.

2. Monitor Respiratory Status:

   • Action: Continuously monitor respiratory status, noting changes in respiratory rate, depth, and effort.
   • Rationale: Changes in breathing patterns can occur rapidly, especially as the child’s energy reserves deplete. Frequent assessment provides objective data on respiratory effort and guides timely interventions. Worsening respiratory status may necessitate more aggressive interventions, including mechanical ventilation, particularly in children with recurrent apnea.

3. Evaluate Respiratory Effort and Characteristics:

   • Action: Assess respirations, noting quality, rate, pattern, depth, nasal flaring, dyspnea on exertion, evidence of splinting, use of accessory muscles, and breathing position.
   • Rationale: Changes from the patient’s baseline respiratory pattern indicate potential respiratory compromise. Increased respiratory rate and altered rhythm can be compensatory responses to airway obstruction. During the acute phase, small airway obstruction can lead to significant respiratory distress.

4. Auscultate and Palpate Chest:

   • Action: Assess chest configuration by palpation; auscultate for breath sounds, noting areas of absent or diminished sounds, crackles, or rhonchi.
   • Rationale: This helps detect decreased or adventitious breath sounds. Infants’ small bronchioles are highly susceptible to obstruction from inflammation, edema, and mucus. Obstruction can lead to atelectasis. Absent breath sounds indicate atelectasis, while decreased sounds suggest partial collapse.

5. Characterize Cough and Secretions:

   • Action: Assess cough characteristics (moist, dry, hacking, paroxysmal, brassy, croupy), onset, duration, frequency, and timing (day, night, activity-related). Assess mucus production: timing, amount, color (clear, yellow, green), consistency (thick, tenacious, frothy). Note ability to expectorate or if swallowing secretions, and presence of nasal congestion or drainage.
   • Rationale: Coughing is a vital mechanism for clearing secretions. An ineffective cough compromises airway clearance and mucus expulsion. Respiratory muscle fatigue, bronchospasm, or thick secretions can cause ineffective cough.

6. Monitor for Apnea:

   • Action: Assess for apnea, particularly during sleep.
   • Rationale: Apnea can occur early in bronchiolitis and may be the presenting symptom, especially in infants younger than two months or premature infants. Central apnea, a nonobstructive type, is associated with increased apnea index and attack rate.

7. Pulse Oximetry Monitoring:

   • Action: Monitor pulse rate and oxygen saturation using pulse oximetry.
   • Rationale: Pulse oximetry is useful for detecting hypoxemia. Reduced transcutaneous oxygen saturation is common in moderate to severe bronchiolitis. Persistent resting oxygen saturations below 90% require close observation and possible hospitalization. However, routine pulse oximetry is not recommended for infants with bronchiolitis who do not need supplemental oxygen and have oxygen saturation > 90% on room air.

8. Assess Neurological Status:

   • Action: Note changes in level of consciousness and neurological signs of complications.
   • Rationale: Restlessness, confusion, and irritability can be early signs of cerebral hypoxia. Neurological complications, such as seizures and encephalopathy, can occur, especially in young or developmentally impaired children.

9. Monitor Intake and Output:

   • Action: Monitor the client’s intake and output.
   • Rationale: Infants with bronchiolitis can become mildly dehydrated due to reduced fluid intake and increased losses from fever and tachypnea. Monitoring fluid balance is essential for guiding hydration therapy.

10. Provide Rest Periods:

    • Action: Provide periods of rest by organizing procedures and care to minimize disturbances, especially in acute stages.
    • Rationale: This prevents unnecessary energy expenditure and reduces fatigue. Comfort measures, such as holding the infant or positioning the child comfortably, are also important.

11. Maintain Calm Environment:

    • Action: Maintain a calm attitude during tachypneic episodes. Assist the child in taking control by encouraging deeper respirations.
    • Rationale: Calmness helps reduce anxiety and fear associated with hypoxia. Deeper respirations can improve oxygenation and reduce respiratory distress.

12. Elevate Head of Bed:

    • Action: Elevate the head of the bed at least 30° for children; hold infants upright or position them with their head on a shoulder. Older children can sit up with head supported on a pillow on an overbed table.
    • Rationale: Upright positioning prevents abdominal contents from pressing against the diaphragm, facilitating lung expansion and improving air exchange. Head elevation promotes lung aeration and secretion mobilization.

13. Encourage Fluid Intake:

    • Action: Encourage fluid intake frequently throughout the day, specifying amounts.
    • Rationale: Fluids help maintain mucosal hydration and maximize ciliary action to clear secretions. Oral hydration is preferred unless the child cannot take fluids orally or has a respiratory rate > 70 breaths/minute.

14. Assist with Breathing and Coughing Exercises:

    • Action: Assist with deep breathing and coughing exercises and repositioning every two hours.
    • Rationale: Vibration and gravity aid in loosening and draining secretions. These activities promote deeper breathing, expand airways, and stimulate the cough reflex to expel secretions. Teach parents to splint the child’s chest during coughing to reduce discomfort.

15. Schedule Activity and Rest:

    • Action: Schedule periods of activity and rest.
    • Rationale: Strenuous activity increases oxygen demand in hypoxic children, worsening tachypnea. Scheduled rest periods prevent exhaustion.

16. Suction as Needed:

    • Action: Assist with deep suctioning as indicated.
    • Rationale: Suctioning removes respiratory secretions and may provide temporary relief, although it might be associated with longer hospitalization. Perform suctioning as clinically indicated.

17. Administer Prophylactic Antibody:

    • Action: Administer monoclonal antibody (palivizumab) as indicated and if agreed upon by parents.
    • Rationale: Palivizumab is a prophylactic injection to prevent RSV in high-risk infants (e.g., premature infants, those with chronic lung disease or congenital heart disease) during RSV season.

18. Administer Supplemental Humidified Oxygen:

    • Action: Administer supplemental humidified oxygen as prescribed.
    • Rationale: Maintain transcutaneous oxygen saturation > 90%. High-flow nasal cannulas may reduce intubation rates. Early high-flow oxygen therapy can lower the risk of treatment escalation.

19. Administer Heliox:

    • Action: Administer heliox as prescribed.
    • Rationale: Heliox (oxygen and helium mixture) has lower viscosity than air, reducing respiratory effort in airway obstruction. It may improve respiratory parameters but does not consistently reduce hospital stay or need for invasive ventilation.

20. Prepare for Ventilation:

    • Action: Assist in endotracheal intubation and mechanical ventilation if indicated.
    • Rationale: Mechanical ventilation may be necessary for infants with bronchiolitis and recurrent apnea or respiratory failure. CPAP, IMV with PEEP, and negative-pressure ventilation can be used.

21. Educate on Medication Administration:

    • Action: Teach parents and older children about medication administration and adverse effects.
    • Rationale: Ensures compliance with correct dosage and administration, and awareness of potential side effects. Medications have a limited role in bronchiolitis management, with supportive care being primary.

22. Administer Medications:

    • Action: Administer medications for bronchiolitis as prescribed.
    • Rationale: See Pharmacologic Management section.

2. Administering Medications & Pharmacological Support

Medications play a supportive role in managing bronchiolitis and RSV, aimed at symptom relief and improving respiratory function.

Nursing Interventions:

1. Administer Bronchodilators:

   • Medications: Albuterol, levalbuterol.
   • Rationale: Bronchodilators relax airway smooth muscles, improving airflow and reducing bronchospasms.

2. Administer Corticosteroids (Limited Use):

   • Medications: Prednisolone, dexamethasone (typically in severe cases and under specific guidelines).
   • Rationale: Corticosteroids reduce airway inflammation. Their use in bronchiolitis is controversial and generally reserved for specific situations due to limited evidence of broad benefit.

3. Administer Antipyretics:

   • Medications: Acetaminophen, ibuprofen.
   • Rationale: Antipyretics reduce fever, a common symptom of bronchiolitis and RSV, improving comfort.

4. Administer Antiviral Medications (Limited Use):

   • Medications: Ribavirin (in severe cases for high-risk patients, not routinely recommended).
   • Rationale: Antiviral medications like ribavirin may be considered in specific, severe cases, but are not standard treatment for bronchiolitis.

5. Administer Intranasal Decongestants:

   • Medications: Aerosolized racemic epinephrine.
   • Rationale: Intranasal decongestants may provide temporary relief from nasal congestion without significant systemic effects.

6. Administer Hypertonic Saline Nebulization:

   • Medications: 3% hypertonic saline solution.
   • Rationale: Hypertonic saline via nebulization is more effective than normal saline in improving bronchiolitis symptoms. It reduces submucosal edema, mucus viscosity, and improves mucus clearance through osmosis. AAP guidelines support hypertonic saline nebulization for hospitalized infants with bronchiolitis, except in the emergency department setting.

3. Monitoring Diagnostic Procedures and Laboratory Studies

Diagnostic procedures and laboratory tests are crucial for accurate diagnosis and assessment of bronchiolitis and RSV.

Nursing Interventions:

1. Nasopharyngeal Swab Collection:

   • Action: Assist with collecting a nasopharyngeal swab.
   • Rationale: Nasopharyngeal swabs are used to collect respiratory secretions for viral testing, including RSV, using PCR or viral antigen detection.

2. Assist with Chest X-ray:

   • Action: Prepare the patient for a Chest X-ray.
   • Rationale: Chest X-rays evaluate lung involvement, identifying inflammation, consolidation, or other abnormalities associated with bronchiolitis.

3. Obtain Blood Tests:

   • Action: Obtain blood samples for laboratory studies, including a complete blood count (CBC).
   • Rationale: CBC assesses overall health and may show elevated white blood cell count in infection.

4. Arterial Blood Gas (ABG) Analysis:

   • Action: Assist with arterial blood gas (ABG) analysis if ordered.
   • Rationale: ABG analysis assesses oxygen and carbon dioxide levels in the blood, crucial in severe cases or when respiratory compromise is suspected.

5. Perform Pulse Oximetry:

   • Action: Continuously monitor oxygen saturation using pulse oximetry.
   • Rationale: Pulse oximetry non-invasively monitors oxygen saturation and response to treatment.

6. Assist with Viral Panel Testing:

   • Action: Assist with viral panel testing if ordered.
   • Rationale: Viral panel testing can identify multiple respiratory viruses, including RSV, for comprehensive diagnosis.

4. Reducing Anxiety & Providing Emotional Support

Managing anxiety in both children and parents is critical during bronchiolitis, given the respiratory distress and discomfort involved. Emotional support and clear communication are essential.

Nursing Interventions:

1. Assess Anxiety Source and Level:

   • Action: Assess the source and level of anxiety, how it manifests, and information needs.
   • Rationale: Helps identify anxiety sources (e.g., fear, uncertainty, guilt) and tailor interventions. Parents often experience anxiety due to lack of knowledge about bronchiolitis.

2. Evaluate Understanding of Diagnosis:

   • Action: Evaluate the client’s and parents’ understanding of the diagnosis.
   • Rationale: Determines their comprehension of the condition and sets the basis for individualized education and support.

3. Communicate Openly and Honestly:

   • Action: Communicate openly, answer questions calmly and honestly.
   • Rationale: Promotes a supportive environment. Open communication builds trust and provides personalized reassurance, addressing parental discomfort in asking questions.

4. Acknowledge Fears and Concerns:

   • Action: Acknowledge fears and concerns, encourage expression of feelings.
   • Rationale: Support allows exploration and coping with the situation. Parents may need time to identify and express their feelings about the unfamiliar illness.

5. Accept but Do Not Reinforce Denial:

   • Action: Accept, but do not reinforce, denial.
   • Rationale: Address denial that interferes with treatment by explaining issues and exploring resolutions.

6. Allow Expression of Concerns and Questions:

   • Action: Allow expression of concerns and questions about the condition and recovery.
   • Rationale: Provides an outlet for feelings and secures needed information to reduce anxiety. Ensure mutual understanding of terms.

7. Encourage Parental Involvement:

   • Action: Encourage parents to remain calm and involved in care and decision-making.
   • Rationale: Promotes continuous monitoring and strengthens the parent-healthcare provider partnership. Engaged parents can ease the transition from hospital to home care.

8. Facilitate Parental Presence and Participation:

   • Action: Encourage parental presence, open visitation, phone contact; involve parents in care (holding, feeding, diapering), and suggest routines.
   • Rationale: Parental involvement reduces anxiety for both child and parents. Absence and uncertainty increase anxiety. Participation restores some parental control and independence.

9. Educate About Disease Process:

   • Action: Teach parents about the disease process, physical effects, and symptoms.
   • Rationale: Provides information to alleviate anxiety by managing expectations. Many parents are unfamiliar with bronchiolitis and benefit from understanding the illness course, including worsening signs like respiratory distress and dehydration.

10. Provide Written Information:

    • Action: Provide written information about the disease and process (pamphlets, apps, videos, websites).
    • Rationale: Addresses parents’ need for information and reassurance. Written resources are valuable for retention and post-discharge reference.

11. Explain Procedures and Therapies:

    • Action: Explain the reason for each procedure or therapy and diagnostic tests.
    • Rationale: Reduces fear of the unknown. Preparation time helps parents and children feel more in control. Explain hospitalization reasons and discharge criteria.

12. Clarify Misinformation:

    • Action: Clarify misinformation, answer questions in lay terms, ensure consistent explanations from staff.
    • Rationale: Prevents anxiety from inaccurate knowledge or conflicting information. Emphasize that bronchiolitis symptoms can persist, and worsening symptoms need medical attention.

13. Explain Supportive Care Importance:

    • Action: Explain the importance of supportive care and indications for pharmacologic treatment.
    • Rationale: Helps parents understand and accept the necessity of supportive measures, as evidence-based medication options are limited. Detail supportive modalities like oxygen therapy and hydration. Avoid stating “no treatment,” which can increase anxiety.

14. Provide Detailed Discharge Recommendations:

    • Action: Give detailed discharge recommendations.
    • Rationale: Addresses parental preference for clear discharge criteria. Discuss potential discharge criteria at admission, adapting to each family. Improves trust and treatment adherence.

5. Promoting Rest & Energy Conservation

Rest and energy conservation are crucial in managing bronchiolitis, as respiratory distress increases energy expenditure.

Nursing Interventions:

1. Assess Weakness and Fatigue:

   • Action: Assess for extreme weakness and fatigue, ability to rest, sleep, and amount of movement in bed.
   • Rationale: Determines the impact of dyspnea and work of breathing on energy levels. Guides measures to improve mobility and rest.

2. Monitor Vital Signs:

   • Action: Monitor vital signs, noting pulse rate at rest and during activity.
   • Rationale: Tachycardia is common, even at rest, as the body compensates for hypoxemia. Pulse rate elevation with activity indicates increased oxygen demand.

3. Assess for Respiratory Distress Signs:

   • Action: Assess for tachypnea, dyspnea, pallor, and cyanosis.
   • Rationale: Increased oxygen demand in a hypermetabolic state increases hypoxia risk with activity. Infants may become fussy and cry during feeding, expending energy and worsening fatigue.

4. Acknowledge Fatigue:

   • Action: Accept the presence of fatigue and activity intolerance.
   • Rationale: Non-judgmental acceptance promotes self-esteem, especially in older children frustrated by limitations.

5. Provide Restful Environment:

   • Action: Schedule rest periods in a quiet, comfortable environment (temperature and humidity controlled).
   • Rationale: Promotes rest, reduces stimuli, and decreases fatigue risk. Avoid alarm fatigue from continuous pulse oximetry monitoring by using it judiciously.

6. Minimize Disturbances:

   • Action: Disturb the child only when necessary, consolidate care activities.
   • Rationale: Conserves energy and prevents rest interruptions. Plan care with consistent rest periods and naps.

7. Encourage Fatigue Prevention Measures:

   • Action: Encourage parents to use measures to prevent fatigue (holding, rocking, small feedings, quiet play, diversions like TV and toys).
   • Rationale: Provides support and conserves energy. Calming activities use nervous energy constructively and distract from discomfort.

8. Facilitate Quiet Play:

   • Action: Allow quiet play with familiar toys during bed rest.
   • Rationale: Rest reduces fatigue and respiratory distress; quiet play prevents excessive activity. Reduce overstimulation by dimming lights and lowering TV volume.

9. Teach Parents to Respond to Crying:

   • Action: Teach parents to pick up an infant if crying longer than one to two minutes.
   • Rationale: Prevents fatigue from prolonged crying. Calming techniques like rocking, gentle back rubs, and lullabies can help.

10. Plan Care Around Rest Periods:

    • Action: Assist parents in planning feeding, bathing, and diaper changes around rest periods.
    • Rationale: Prevents rest interruption. Involve parents in decision-making to improve satisfaction and adherence to care plans.

11. Administer Heated Humidified Oxygen:

    • Action: Administer heated, humidified oxygen as indicated.
    • Rationale: Heated, humidified high-flow nasal cannula (HFNC) delivers high gas flows, potentially providing CPAP, reducing respiratory rate, intubation rate, and work of breathing.

6. Promoting Optimal Nutrition & Fluid Balance

Adequate nutrition and fluid balance are vital for immune function, recovery, and preventing complications in bronchiolitis.

Nursing Interventions:

1. Monitor Vital Signs:

   • Action: Assess vital signs (increased temperature, tachycardia, tachypnea).
   • Rationale: Elevated temperature increases metabolic rate and fluid loss. Tachypnea interferes with feeding, leading to dehydration. Tachycardia may indicate fluid deficit.

2. Monitor Intake and Output:

   • Action: Monitor intake and output closely.
   • Rationale: Provides data on fluid volume status and replacement needs. Note urine color, characteristics, and specific gravity for fluid balance assessment.

3. Assess Hydration Status:

   • Action: Assess skin turgor and mucous membrane moisture.
   • Rationale: Indirect indicators of fluid volume status. Oral mucous membranes may be dry due to mouth breathing and oxygen therapy.

4. Identify Barriers to Eating:

   • Action: Identify factors hindering the ability to eat.
   • Rationale: Interventions depend on the cause. Copious secretions and breathing difficulty can impair oral intake. Severe bronchiolitis may necessitate intubation, and respiratory distress increases aspiration risk.

5. Evaluate Nutritional State:

   • Action: Evaluate the client’s general nutritional state.
   • Rationale: Children with bronchiolitis may be malnourished at admission. Respiratory distress and oxygen needs can delay feeding, causing insufficient nutrient intake.

6. Auscultate Bowel Sounds:

   • Action: Auscultate bowel sounds and observe for abdominal distention.
   • Rationale: Bowel sounds may be diminished in severe or prolonged infection. Abdominal distention can result from air swallowing due to irritability and crying.

7. Obtain Baseline Weight:

   • Action: Obtain baseline weight at admission.
   • Rationale: Establishes baseline nutritional status. Compare admission weight and length to WHO growth standards.

8. Monitor Weight Periodically:

   • Action: Weigh the client periodically.
   • Rationale: Tracks fluid balance changes. Infants have higher total body water content and dehydrate differently than older children. Weigh diapers to measure urine output.

9. Suction Before Feedings:

   • Action: Perform non-invasive nasal suctioning before oral feedings.
   • Rationale: Nasal suctioning with saline improves upper airway obstruction from nasal congestion, enhancing feeding ability.

10. Provide Small, Frequent Feedings:

    • Action: Provide small, frequent feedings if tolerated.
    • Rationale: Enhances intake despite reduced appetite. Offer dry foods and appealing foods that minimize aspiration risk.

11. Provide Oral Fluids:

    • Action: Provide oral fluids as appropriate.
    • Rationale: Oral therapy is preferred if possible without increasing aspiration risk. Oral rehydration is preferred for mild dehydration. Continue breastfeeding.

12. Elevate Head During Oral Fluids:

    • Action: Elevate the head of the bed when providing oral fluids.
    • Rationale: Reduces aspiration risk during respiratory distress. Head elevation facilitates swallowing and prevents aspiration.

13. Provide Oral Care Regularly:

    • Action: Provide oral care regularly.
    • Rationale: Prevents dry mucous membranes from dehydration and mouth breathing. Clean mouth with damp cloth to remove residue and add moisture.

14. Repeat Suctioning Before Feedings:

    • Action: Repeat non-invasive nasal suctioning before oral feedings as needed.
    • Rationale: Ensures clear nasal passages to improve feeding.

15. Small, Frequent Feedings Repeated:

    • Action: Continue small, frequent feedings.
    • Rationale: Optimizes nutrient intake.

16. Encourage Breastfeeding:

    • Action: Encourage continued breastfeeding.
    • Rationale: Breastfeeding offers immunologic benefits and may improve intake and immune response. Support breastfeeding to prevent disruption and weaning risks during illness.

17. Nasogastric Tube Feeding:

    • Action: Insert a nasogastric tube for feedings if indicated.
    • Rationale: If oral hydration is insufficient due to tachypnea, NG feeding is an alternative. Enteral hydration offers physiological benefits and calorie provision, even during high-flow oxygen. NG tube insertion may be easier than IV insertion in infants.

18. Intravenous Line Insertion:

    • Action: Insert an intravenous line if necessary.
    • Rationale: IV therapy is needed if oral intake is impossible or respiratory rate is > 70 breaths/minute. Clients with apnea also need IV hydration.

19. Monitor Sodium Levels:

    • Action: Monitor sodium levels.
    • Rationale: Hyponatremia can occur due to volume-dependent activation of the renin-angiotensin-aldosterone system and inappropriate antidiuretic hormone secretion, worsened by hypotonic solutions.

20. Promote Protein Intake:

    • Action: Promote protein intake for clients able to eat orally.
    • Rationale: High protein turnover in severe bronchiolitis necessitates increased protein intake to improve nitrogen balance.

21. Early Enteral Nutrition:

    • Action: Start enteral nutrition early for severely ill children.
    • Rationale: Early enteral nutrition improves outcomes in critically ill patients by protecting intestinal mucosa and preventing sepsis.

22. Administer Isotonic IV Solutions:

    • Action: Administer isotonic IV solutions as prescribed.
    • Rationale: Isotonic solutions are preferred to prevent hyponatremia, which can be exacerbated by hypotonic IV solutions.

23. Administer Medications:

    • Action: Administer medication as prescribed.
    • Rationale: See Pharmacologic Management section.

7. Providing Patient Education & Health Teachings

Patient education is crucial for parents and older children to understand bronchiolitis, its management, and prevention.

Nursing Interventions:

1. Assess Knowledge of Prevention and Treatment:

   • Action: Assess existing knowledge of disease prevention, transmission, and treatment.
   • Rationale: Establishes a baseline for education and helps tailor information to prevent transmission and reduce anxiety.

2. Review Lung Function and Pathology:

   • Action: Review normal lung function and bronchiolitis pathology.
   • Rationale: Promotes understanding of the condition and the importance of treatment adherence.

3. Emphasize Smoking Cessation:

   • Action: Review the importance of smoking cessation.
   • Rationale: Smoking impairs ciliary action, irritates mucosa, and compromises defenses against infection.

4. Provide Written Information:

   • Action: Provide written or electronic educational materials.
   • Rationale: Fatigue and depression can impair information assimilation. Written materials (pamphlets, apps, videos, websites) aid retention.

5. Teach Transmission Routes:

   • Action: Teach that the virus spreads via direct and indirect contact through nose and eyes; emphasize hand hygiene.
   • Rationale: Explains transmission routes (contact, droplets) and the importance of hand hygiene to prevent spread.

6. Educate on Respiratory Distress Signs:

   • Action: Teach signs and symptoms of respiratory distress and infection (fever, dyspnea, tachypnea, sputum).
   • Rationale: Encourages prompt medical attention. Early intervention minimizes complications. Parents need to recognize worsening symptoms.

7. Educate on Virus Spread to Family:

   • Action: Teach about the potential for virus spread within the family and need for segregation.
   • Rationale: Bronchiolitis is highly contagious, and family members are at high risk of infection.

8. Explain Transmission to Family Members:

   • Action: Educate that the virus is easily transmitted, affecting family members. Viral shedding continues for days after symptom onset.
   • Rationale: Secondary infections are common in families and childcare settings. Crowded living and parental smoking increase spread risk.

9. Suggest Protective Eyewear:

   • Action: Suggest wearing plastic goggles when caring for the child.
   • Rationale: Prevents viral contact via the eyes, reducing self-inoculation risk.

10. Teach Handwashing and PPE Use:

    • Action: Teach good handwashing to family and proper PPE use to staff.
    • Rationale: Prevents transmission via hands, the main carriers of organisms. RSV survives on hands and surfaces, making hand hygiene and PPE crucial.

11. Encourage Good Nutrition and Hydration:

    • Action: Encourage good nutrition and hydration, emphasizing calorie-rich diet and increased fluids.
    • Rationale: Promotes secretion liquefaction, replaces calories, and boosts natural defenses. Breastfeeding reduces respiratory infection risk.

12. Teach Medication Administration:

    • Action: Teach medication administration as prescribed.
    • Rationale: Improves consistent medication administration and recognition of side effects. Medications have limited role but are often used.

13. Adhere to Infection Control Policies:

    • Action: If hospitalized, adhere to infection control policies for RSV bronchiolitis.
    • Rationale: Protects against secretion exposure and virus transmission to other patients. RSV is highly contagious and survives on surfaces, necessitating strict infection control and hand hygiene.

14. Encourage Parental Involvement in Hospital Care:

    • Action: Encourage parental care involvement within treatment constraints.
    • Rationale: Assign care to the parent not caring for high-risk children. Familiarize parents with equipment and encourage participation in care.

15. Teach About Prophylactic Drugs:

    • Action: Teach about prophylactic drugs (palivizumab) if ordered.
    • Rationale: Explain palivizumab as RSV prevention for high-risk infants via monthly intramuscular injections during RSV season.

16. Instruct on Visitor Limitations:

    • Action: Instruct parents to limit visitors and screen them for recent illnesses.
    • Rationale: Prevents hospital-acquired infections. RSV-diagnosed children require contact isolation precautions to prevent spread.

Recommended Resources

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See Also

Other recommended site resources for this nursing care plan:

Other nursing care plans related to respiratory system disorders:

References and Sources

To further your reading and research about bronchiolitis, please check out these references below:

[1] Baron, J., & El-Chaar, G. M. (2016). Hypertonic saline for acute viral bronchiolitis in infants. Annals of Pharmacotherapy, 50(8), 691-697.
[2] Babl, F. E., Borland, M. L., Phillips, N., Kochar, A., Dalton, S., Roberts, G., … & Furyk, J. (2020). Enteral versus intravenous rehydration for pediatric bronchiolitis: a randomized trial. Pediatrics, 145(2).
[3] Cahill, N., & Cohen, A. (2018). Nasal saline for bronchiolitis: a systematic review and meta-analysis. Pediatrics, 142(6).
[4] Erickson, J. S., Arneson, A., Moulton, E. A., & Grantz, K. L. (2022). Association of breastfeeding with bronchiolitis and pneumonia among infants in the first year of life. JAMA network open, 5(1), e2139808-e2139808.
[5] Gueriba, R., Monteil, V., Boudet-Berquier, J., Pauchard, Y., & Traversier, R. (2021). Breastfeeding disruption during hospitalization of infants with bronchiolitis: a prospective observational study. Breastfeeding Medicine, 16(7), 573-579.
[6] Hendaus, M. A., Jaleel, M. A., Alhammadi, A. H., & Kamal, H. (2018). Continuous pulse oximetry monitoring in bronchiolitis: is it essential?. Clinical Pediatrics, 57(14), 1666-1671.
[7] Justice, J. P., & Le, J. K. (2022). Bronchiolitis. In StatPearls [Internet]. StatPearls Publishing.
[8] Kuitunen, M. J., Vuori, V., Rautiainen, P., & Ruuskanen, O. (2022). Heliox in bronchiolitis: a systematic review and meta-analysis. European Journal of Pediatrics, 181(4), 1363-1371.
[9] Maraqa, N. F., & Steele, R. W. (2021). Bronchiolitis. In Nelson Textbook of Pediatrics (pp. 1503-1509). Elsevier.
[10] Ng, S. S., Ko, C. W., Cheung, C. L., Chan, P. K., & Wong, G. W. (2020). Nutritional status and feeding practices in children hospitalized with bronchiolitis. Nutrients, 12(2), 529.
[11] Piche-Renaud, P., Pelletier, A., Gravel, J., & Chalifoux, M. (2020). Parents’ lived experience of their infant’s bronchiolitis: a qualitative study. BMC pediatrics, 20(1), 1-11.
[12] Tasker, R. C. (2013). High-flow nasal cannula oxygen therapy in infants with bronchiolitis. Archives of Disease in Childhood-Education and Practice Edition, 98(4), 146-150.
[13] Valla, F. V., Berner, M. E., Gouyon, J. B., & Chouraqui, J. P. (2019). Nutritional management of bronchiolitis in infants. Nutrients, 11(1), 169.
[14] Vega, R. M. (2022). Dehydration in children. Medscape.

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