CHAPTER ONE

INTRODUCTION:

Influenza is a viral infection that attacks your respiratory system — your nose, throat and lungs.
Influenza is commonly called the flu, but it's not the same as stomach "flu" viruses that cause
diarrhea and vomiting. For most people, the flu resolves on its own. But sometimes, influenza
and its complications can be deadly.

WHAT IS INFLUENZA?

Influenza, one of the most common infectious diseases, is a highly contagious airborne disease
that occurs in seasonal epidemics and manifests as an acute febrile illness with variable degrees
of systemic symptoms.

 Although the seasonal strains of influenza virus that circulate in the annual influenza
cycle constitute a substantial public health concern, far more lethal influenza strains than
these have emerged periodically.
 Besides humans, influenza also infects a variety of animal species; some of these
influenza strains are species-specific, but new strains may spread from other animals to
humans.

RISK FACTORS FOR INFLUENZA

 Young children under age 5, and especially those under 6 months

 Adults older than age 65
 Residents of nursing homes and other long-term care facilities
 Pregnant women and women up to two weeks after giving birth
 People with weakened immune systems
  People who have chronic illnesses, such as asthma, heart disease, kidney
disease, liver disease and diabetes
 People who are very obese, with a body mass index (BMI) of 40 or higher

CAUSES OF INFLUENZA

 Direct contact. Transmission of influenza from poultry or pigs to humans appears to

occur predominantly as a result of direct contact with infected animals.
 Unhygienic food preparation. The risk is especially high during slaughter and
preparation for consumption; eating properly cooked meat poses no risk.
 Aerosol transmission. Influenza viruses spread from human to human via aerosols
created when an infected individual coughs or sneezes; infection occurs after an
immunologically susceptible person inhales the aerosol; if not neutralized by secretory
antibodies, the virus invades airway and respiratory tract cells.
 Contact with contaminated objects. Contact with excrement from infected birds or
contaminated surfaces or water are also considered mechanisms of infection.

 Influenza viruses travel through the air in droplets when someone with the infection
coughs, sneezes or talks. You can inhale the droplets directly, or you can pick up the
germs from an object — such as a telephone or computer keyboard — and then transfer
them to your eyes, nose or mouth.
 People with the virus are likely contagious from about a day before symptoms appear
until about five days after they start. Children and people with weakened immune
systems may be contagious for a slightly longer time.

Clinical Manifestations

The presentation of influenza virus infection varies; however, it usually includes many of
the symptoms described below.
  Cough: Cough and other respiratory symptoms may be initially minimal but frequently
progress as the infection evolves; patient may report nonproductive cough, cough-related
pleuritic chest pain, and dyspnea.
 Fever: Fever may vary widely among patients, with some having low fevers and other
developing fevers as high as 1040F; some patients report feeling feverish and feeling
chills.
 Sore throat: Sore throat may be severe and may last 3-5 days; the sore throat may be a
significant reason why patients seek medical attention.
 Myalgia: Myalgias are common and range from mild to severe.
 Weakness: Weakness and severe fatigue may prevent patients from performing their
normal activities or work; patients report needing additional sleep; in some cases, patients
with influenza may be bedridden.
Other signs and symptoms may include:

 Aching muscles
 Chills and sweats
 Headache
 Dry, persistent cough
 Shortness of breath
 Runny or stuffy nose
 Eye pain
 Vomiting and diarrhea, but this is more common in children than adults

Emergency signs and symptoms may present.

If you have emergency signs and symptoms of the flu, get medical care right away. For adults,
emergency signs and symptoms can include:

 Difficulty breathing or shortness of breath

 Chest pain
 Ongoing dizziness
 Seizures
  Worsening of existing medical conditions
 Severe weakness or muscle pain

Emergency signs and symptoms in children can include:

 Difficulty breathing
 Blue lips
 Chest pain
 Dehydration
 Severe muscle pain
 Seizures
 Worsening of existing medical condition

DIAGNOSTIC INVESTIGATION OF INFLUENZA

 Rapid diagnostic tests. The US FDA waived federal Clinical Laboratories Improvement
Act (CLIA) requirements and cleared for marketing 7 rapid influenza diagnostic tests that
directly detect influenza A or B virus-associated antigens or enzyme in throat swabs,
nasal swabs, or nasal washes; these tests can produce results within 30 minutes; some
these include QuickVue Influenza A+B test (Quidel), ZstatFlu (ZymeTx), and QuickVue
Influenza test (Quidel).
 Viral culture. Culture may require 3-7 days, yielding results long after the patient has
left the clinic, office, or emergency department and well past the time when drug therapy
could be efficacious.
 Polymerase chain reaction testing. RT-PCR testing of nasopharyngeal throat secretions
is the criterion standard for confirming influenza virus infection; it is the omly in
vitro diagnostic test for influenza that is cleared by the FDA for use with lower
respiratory tract specimens.
 Direct immunofluorscent tests. Some laboratories offer direct immunofluorescent tests
on fresh specimens, but these tests are labor– and personnel-intensive and are less
sensitive than culture methods.
  Serologic testing. In order to overcome the expensive and time-consuming obstacle of
culturing, several serologic tests have become available; in reality, many of these are not
bedside tests; generally, 30-60 minutes are required to perform the test’s multiple steps.;
test sensitivities generally range from 60-70%.
 Testing for Avian infuenza. A rapid test from nasopharyngeal swab specific to H5N1
influenza (Arbor Vita Corporation) was approved by the FDA in 2009.
 Chest radiography. In elderly or high-risk patients with pulmonary symptoms, chest
radiography is indicated to exclude pneumonia; with avian influenza, pulmonary
infiltrates are seen in almost all patients; the widely varied radiographic characteristics
range from diffuse or patchy infiltrates to lobar multilobar consolidation.

PATHOPYSIOLOGY OF INFLUENZA

Human influenza virus infection replicates primarily in the respiratory epithelium. Other cell
types, including many immune cells, can be infected by the virus and will initiate viral protein
production. However, viral replication efficiency varies among cell types, and, in humans, the
respiratory epithelium is the only site where the hemagglutinin (HA) molecule is effectively
cleaved, generating infectious virus particles. Virus transmission occurs when a susceptible
individual comes into contact with aerosols or respiratory fomites from an infected individual.

The ferret has traditionally been used as a model of influenza transmission as most human
influenza viruses do not need any adaptation to infect and transmit among ferrets. Studies in
ferrets have identified the soft palate as a major source of influenza viruses that are transmitted
between individuals. Notably, the soft palate is enriched in α2,6-linked sialic acids, which are
preferred by the hemagglutinin proteins currently found in circulating human influenza viruses.
This enrichment also occurs in the soft palate of humans.

The primary mechanism of influenza pathophysiology is a result of lung inflammation and

compromise caused by direct viral infection of the respiratory epithelium, combined with the
effects of lung inflammation caused by immune responses recruited to handle the spreading
virus. This inflammation can spread systemically and manifest as a multiorgan failure, but these
consequences are generally downstream of lung compromise and severe respiratory distress.
Some associations have also been observed between influenza virus infection and cardiac
sequelae, including increased risk of myocardial disease in the weeks following influenza virus
infection.

Medical Management

Prevention is the most effective management strategy for influenza.

 Vaccines. To prevent seasonal flu, the Advisory Committee on Immunization Practices

(ACIP) of the US Centers for Disease Control and Prevention (CDC) and the American
Academy of Pediatrics (AAP) recommend routine annual influenza vaccination for all
persons aged 6 months or older, preferably before the onset of influenza activity in the
community.
 Surveillance. Enhanced surveillance with daily temperature taking and prompt reporting
with isolation through home medical leave and segregation of smaller subgroups decrease
the spread of influenza.
 Bed rest. Patients with influenza generally benefit from bed rest; most patients with
influenza recover in 3 days; however, malaise may persist for weeks.
 Hospitalization. Patients most often require hospitalization when influenza exacerbates
underlying chronic diseases; some patients, especially elderly individuals, may be too
weak to care for themselves alone at home; on occasion, the direct pathologic effects of
influenza may necessitate hospitalization.
 Prehospital care. Prehospital care is predominantly supportive; supplemental
oxygenation to manage respiratory symptoms or objective hypoxia may be needed;
ventilatory support with a bag-valve-mask device or with field intubation may be
required if the patient is in respiratory failure; intravenous access should be obtained, and
a bolus of a crystalloid can be administered to support hemodynamic stability.
 Consultations. Consultation with an infectious disease specialist is prudent in some cases
of seasonal influenza; for management of severe disease, intensive care specialists must
be involved.
Nursing Management

Nursing management of a patient with influenza include the following:

Assessment of the patient with influenza:

 History. Assess the patient’s travel history, if any.

 Physical examination. Assess respiratory status for rate, depth, ease, use of accessory
muscles, and work of breathing; auscultate the lung fields for the presence of wheezes,
crackles (rales), rhonchi, or decreased breath sounds.
Based on the assessment data, the major nursing diagnosis for influenza are as follows:

 Ineffective airway clearance related to tracheobronchial and nasal secretions.

 Ineffective breathing pattern related to inflammation from viral infection.
 Hyperthermia related to exposure to infection.
 Acute pain related to influenza virus.
 Deficient knowledge related to lack of knowledge about the disease process (Influenza).
The following are the nursing interventions for a patient with influenza:

 Maintain patent airway. Administer oxygen as ordered; monitor oxygen saturation by

pulse oximetry, and notify the physician of readings <90% or as prescribed by the
physician; position patient in high Fowler’s or semi-Fowler’s position, if possible;
administer bronchodilators as ordered; perform postural drainage and percussion, as
ordered; encourage fluids, up to 3-4 L/day unless contraindicated; and encourage deep
breathing exercises and coughing exercises every 2 hours.
 Maintain normal breathing pattern. Perform chest physiotherapy, chest percussion,
and postural drainage as ordered; encourage patient to change position every 2 hours and
as needed, and assist as needed; and provide and encourage fluid intake of at least 2
L/day unless contraindicated.
 Achieve normal temperature. Monitor VS especially temperature, every 2-4 hours and
as needed; utilize the same methods of temperature reading with each measurement;
administer antipyretics as ordered; provide tepid sponge baths; and instruct patient/family
 in use of hypothermia blanket, reasons for use, signs, and symptoms of complications,
etc.
 Achieve relief from pain. Administer analgesics as ordered; provide warm baths or
heating pad to aching muscles; encourage gargling with warm water; provide throat
lozenges as necessary; and instruct patient or SO in deep breathing, relaxation techniques,
guided imagery, massage, and other nonpharmacologic aids.
 Educate patient and folks. Use limited amounts of time for teaching, with the provision
of a quiet environment; inform people receiving the vaccine of the possible adverse
effects and report them immediately; instruct patient and/or SO about influenza types,
when typical outbreaks occur, and methods to avoid infection; and instruct patient and/or
SO about newer antiviral drugs, their effects, when to seek immediate medical attention,
and side effects of medications.

COMPLICATIONS OF INFLUENZA

If you're young and healthy, the flu usually isn't serious. Although you may feel miserable while
you have it, the flu usually goes away in a week or two with no lasting effects. But children and
adults at high risk may develop complications that may include:

 Pneumonia
 Bronchitis
 Asthma flare-ups
 Heart problems
 Ear infections
 Acute respiratory distress syndrome

Pneumonia is one of the most serious complications. For older adults and people with a chronic
illness, pneumonia can be deadly.

PREVENTION OF INFLUENZA

The influenza vaccine isn't 100% effective, so it's also important to take several measures to
reduce the spread of infection, including:
 Wash your hands. Washing your hands often with soap and water for at least 20 seconds
is an effective way to prevent many common infections. Or use alcohol-based hand
sanitizers if soap and water aren't available.
 Avoid touching your face. Avoid touching your eyes, nose and mouth.
 Cover your coughs and sneezes. Cough or sneeze into a tissue or your elbow. Then
wash your hands.
 Clean surfaces. Regularly clean often-touched surfaces to prevent spread of infection
from touching a surface with the virus on it and then your face.
 Avoid crowds. The flu spreads easily wherever people gather — in child care centers,
schools, office buildings, auditoriums and public transportation. By avoiding crowds
during peak flu season, you reduce your chances of infection.

Also avoid anyone who is sick. And if you're sick, stay home for at least 24 hours after
your fever is gone so that you lessen your chance of infecting others.
 CONCLUSION

Influenza virus affects the respiratory tract by direct viral infection or by damage from the
immune system response. In humans, the respiratory epithelium is the only site where the
hemagglutinin (HA) molecule is effectively cleaved, generating infectious virus particles. Virus
transmission occurs through a susceptible individual’s contact with aerosols or respiratory
fomites from an infected individual. The inability of the lung to perform its primary function of
gas exchange can result from multiple mechanisms, including obstruction of the airways, loss of
alveolar structure, loss of lung epithelial integrity from direct epithelial cell killing, and
degradation of the critical extracellular matrix. Approximately 30–40% of hospitalized patients
with laboratory-confirmed influenza are diagnosed with acute pneumonia. These patients who
develop pneumonia are more likely to be < 5 years old, > 65 years old, Caucasian, and nursing
home residents; have chronic lung or heart disease and history of smoking, and are
immunocompromised.
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