RSV - Nursing Case Study

Pathophysiology

• Primary mechanism: RSV (Respiratory Syncytial Virus) enters the respiratory tract and attaches to cells lining the bronchi and bronchioles. It replicates, causing cell death and sloughing off, leading to airway obstruction.

• Secondary mechanism: The immune response to RSV can cause inflammation and swelling in the small airways (bronchioles), leading to symptoms like coughing, wheezing, and difficulty breathing.

• Key complication: In severe cases, RSV can spread to the lower respiratory tract causing bronchiolitis or pneumonia. This can further obstruct airflow, potentially leading to respiratory failure especially in high-risk populations like infants, elderly, or those with weakened immune systems.

Patient Profile

Demographics:

3-year-old male, full-time daycare attendee

History:

• No significant past medical history

• No current medications

• No known allergies

Current Presentation:

• Chief complaint: Runny nose and mild cough for 2 days

• Key symptoms: Low-grade fever, occasional cough, clear nasal discharge, slight decrease in appetite, otherwise active and alert

• Vital signs: Temperature: 99.5°F, Pulse: 90 bpm, Respiratory rate: 24 breaths per minute, Blood pressure: 90/60 mmHg, Oxygen saturation: 98% on room air.

Section 1

Initial Assessment Findings:

Upon physical examination, the young patient presented with a slightly reddened throat and clear nasal discharge indicative of a common upper respiratory infection. Auscultation of the lungs revealed normal breath sounds with no evidence of wheezing or crackles, supporting the likelihood that the RSV infection is currently confined to the upper respiratory tract. The child's vital signs remained stable with a temperature of 99.8°F, pulse of 92 bpm, respiratory rate of 24 breaths per minute, blood pressure of 90/60 mmHg, and an oxygen saturation of 98% on room air.

Despite the slight decrease in appetite, the child was able to maintain adequate hydration and nutritional intake. The child was also responsive, active, and alert, showing no signs of lethargy or irritability that could indicate a progression of the infection or the onset of new complications. The initial assessment findings suggest that the child's current condition is stable, but continuous monitoring is required to track any changes in symptoms or vital signs that could point towards a worsening of the RSV infection.

Section 2

Change in Patient Status:

After 24 hours, the child's temperature increased slightly to 100.5°F, but still within the low-grade fever range. The respiratory rate also increased to 28 breaths per minute. The child appeared more restless than the previous day and experienced bouts of coughing, especially during the night. The cough was dry and harsh, sometimes leading to gagging but without any emesis. The child's appetite also decreased further, leading to a lower intake of fluids and solids.

Auscultation of the lungs now revealed faint wheezing in the lower lobes, suggesting that the RSV infection might be spreading to the lower respiratory tract. Despite these changes, the child's oxygen saturation remained stable at 98%, and there were no signs of respiratory distress such as nasal flaring or use of accessory muscles. Overall, these findings indicate a mild progression of the RSV infection, necessitating a revision in the care plan to manage the new symptoms and prevent further complications.

Section 3

Change in Patient Status:

A day later, the child's temperature rose to 101.2°F and the respiratory rate increased to 32 breaths per minute. The bouts of coughing became more frequent and were accompanied by a runny nose. The child's restlessness intensified, making it difficult to sleep and causing further reduction in fluid and food intake. The child's parents also noticed an increased difficulty in breathing, particularly at night.

Upon physical examination, wheezing was now audible without the need for auscultation, indicating that the RSV infection was progressing further into the lower respiratory tract. Additionally, the child began to exhibit signs of slight dehydration, including dry lips and decreased urine output, likely due to the reduced fluid intake. However, the child's oxygen saturation remained stable at 98%, and there were still no signs of acute respiratory distress. These findings necessitate continued vigilant monitoring of the child's condition and possible modifications to the care plan to manage the evolving symptoms.

Section 4

Response to Interventions:

The nursing team responded to the child's escalating symptoms by administering intravenous fluids to mitigate dehydration. This intervention was successful in stabilizing the child's hydration level, as evidenced by the return of normal urine output and disappearance of dry lips. Antipyretics were also administered to control the fever, which successfully reduced the temperature to a near-normal range of 99.5°F within a few hours.

However, the child's respiratory symptoms did not improve significantly. Despite the child being positioned in a high Fowler's position to promote easier respiration and comfort, the coughing bouts, increased respiratory rate, and wheezing persisted. The nursing team also attempted suctioning the child's nasal passages to alleviate the symptoms of congestion, but this intervention only provided temporary relief. These persistent respiratory symptoms, despite initial interventions, indicate a need to reevaluate the care plan and consider additional interventions or changes in medication. The child's oxygen saturation remained stable, which is a positive sign, but the progression of the RSV infection must be closely monitored and managed.

Section 5

New Diagnostic Results:

On the third day of hospitalization, the child's condition remained stable but the respiratory symptoms persisted. Lab results showed an elevated white blood cell count of 15,000 cells/mcL, indicating that the body was still fighting an infection. Chest X-ray results came back clear, eliminating the possibility of pneumonia. However, the Rapid RSV Diagnostic Test, a nasal swab test, was positive, confirming the diagnosis of RSV.

Despite the confirmation of RSV, the child's pediatrician ordered a respiratory panel PCR test to rule out any co-infections. The test results revealed the presence of rhinovirus, a common cause of the common cold, alongside the RSV. This co-infection could be contributing to the persistence of the child's respiratory symptoms and complicates the course of treatment. The nursing team, in collaboration with the child's pediatrician, will need to adjust the care plan to address this new finding.