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Jan.30.2020View related content

Flu Management (Ambulatory) - CE

ALERT

Do not attempt to collect a throat specimen for culture if acute epiglottitis is suspected because trauma from the swab may cause increased edema, resulting in airway occlusion.12

Collect oropharyngeal and nasopharyngeal specimens within 3 days of symptom onset if possible but no later than 7 days of symptom onset and before the start of antimicrobial therapy.7

Pregnant patients, young children, or older adults may require transfer and admission to an acute care facility if the illness is severe of if respiratory distress is suspected.

OVERVIEW

Influenza is a febrile illness affecting the respiratory system caused by an infection of the influenza virus.8 Seasonal epidemics occur yearly due to the spread of influenza A and influenza B. There are multiple classifications of influenza, with the two most common strains being influenza A and influenza B. Influenza affects all ages and all levels of health. The patients most at risk for serious complications from influenza are very young children and older adults as well as those who are immunocompromised, have comorbid chronic illnesses, are morbidly obese, or are pregnant.8

Influenza is transmitted through droplets when an infected person coughs or sneezes and the virus comes in contact with a susceptible person’s mucus membranes. Transmission can also be spread through autoinoculation. This occurs when a susceptible person comes in contact with a contaminated surface and then contaminates himself or herself by touching mucus membranes.9,11 Adults may be considered contagious starting 1 day before symptoms onset and up to 5 to 7 days after, whereas children may be considered contagious for more than 7 days.9

Classic signs and symptoms of influenza virus include an abrupt onset of high fever, myalgia, headache, anorexia, fatigue, cough, prominent rhinorrhea, and congestion.8 In children, the symptoms may be more gastrointestinal related, such as nausea, vomiting, and diarrhea. These signs and symptoms are not common in adults with influenza. Some signs and symptoms tend to last as long as 2 weeks.8

The influenza virus is present year-round, but the peak season is fall through winter. According to the Centers for Disease Control and Prevention (CDC), over the last 36 years, the month of February has the highest percentage of influenza infections.4

During a seasonal epidemic, a history and physical are normally sufficient for a diagnosis, but a rapid influenza diagnostic test (RIDT) or nasopharyngeal swab may be performed to aid in diagnosis confirmation.1 RIDT results can be obtained within 10 to 15 minutes.6 An RIDT that results positive is considered a diagnosis for influenza A or influenza B because of the high specificity.1 Negative test results obtained from RIDTs that detect influenza viral antigens do not exclude influenza virus infection in patients with signs and symptoms of influenza. A negative test result could be a false-negative result and should not preclude further diagnostic testing, such as a polymerase chain reaction (PCR), and starting empiric antiviral treatment.2

Antiviral medications, known as neuraminidase inhibitors, may be started as soon as a diagnosis is made. These medicines may also be given prophylactically if the patient is not vaccinated and is at risk for complications to influenza. Antiviral treatment should begin as soon as possible after illness onset, ideally within 48 hours of the onset of signs and symptoms, and continue for 5 days.8

The goals of influenza treatment are to treat signs and symptoms, provide supportive therapy, and prevent further complications. Fever, pain, and congestion may be treated with over-the-counter medications.

Infants, children, and adults 6 months old or older, including those who are pregnant, should get a yearly influenza vaccination.3 A influenza vaccination can be performed through an intramuscular injection or as a nasal spray. Infants younger than 6 months old and patients who have life-threatening allergies to the ingredients in the vaccination or who have a history of Guillain-Barré syndrome should not get the influenza vaccination.8 Those with a history of egg allergy, regardless of severity, may receive any of the recommended age-appropriate influenza vaccines.8 Patients should receive their annual influenza vaccination by the end of October. Upward of 79,000 patients died in the United States from influenza-related complications, per the CDC mortality math model.5

SUPPLIES

Click here for a list of supplies.

EDUCATION

  • Teach the patient the signs and symptoms of influenza (e.g., fever, headache, myalgia, cough, rhinorrhea, dehydration, severe nausea and vomiting) and instruct him or her to seek additional care.
  • Educate the patient on the importance of yearly influenza vaccinations.
  • Instruct the patient to cough and sneeze into tissues and to discard them in a trash receptacle and to always practice good hand hygiene, especially during influenza season.
  • Educate the patient about adequate rest and fluid intake while experiencing signs and symptoms of influenza.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene and don gloves. Don a mask and eye protection or face shield if the patient is suspected of having influenza and place him or her on droplet precautions.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Ensure that evaluation findings and laboratory results are communicated to the clinical team leader per the organization’s practice.
  6. Obtain the patient’s vital signs, including oxygen saturation.
  7. Evaluate the patient’s respiratory and cardiovascular status. Evaluate for tachypnea, tachycardia, hypotension, cervical lymph node swelling, and abnormal lung sounds.
    Rationale: During auscultation of lung sounds, a patient with influenza may have clear lungs; rales or rhonchi are suggestive of viral or secondary bacterial pneumonia. 8
  8. Evaluate the patient’s nasal mucosa and sinuses and observe for any drainage.
  9. Determine if the patient is experiencing postnasal drip, sinus headache or tenderness, nasal congestion, or sore throat, or if he or she has been exposed to others with similar signs and symptoms.
  10. Evaluate the condition of the patient’s posterior pharynx.
  11. Evaluate the patient for systemic signs of infection (e.g., fever, chills, fatigue, dehydration, severe nausea and vomiting).
  12. Review the practitioner’s orders to determine if a nasal specimen, throat specimen, or both are needed.
  13. Obtain assistance for collecting nasal specimens, as needed.
  14. Position the patient sitting upright, if possible. Have a patient who is acutely ill or a young child lie back against the examination table with the head raised.
  15. Have the swab and the culture tube ready for use. If using a prepackaged culture swab in a tube, loosen the top so that the swab can be removed easily.
    Rationale: By having the swab and the culture tube ready, the swab can be grasped easily without danger of contamination.
  16. Ask the patient to occlude each nostril one at a time and to exhale. As the patient breathes through each open nostril, determine the nostril with the greater patency.
  17. Ask the patient to tilt his or her head back and use a penlight to check the nasal passage for patency. If the patient is lying down on an examination table, place a pillow behind his or her shoulders.
  18. Carefully insert the swab into the nostril until it reaches the portion of mucosa that is inflamed or contains exudate. Rotate the swab quickly and gently.
    Rationale: The swab should remain sterile until it reaches the area to be cultured. Rotating the swab ensures that it touches all surfaces where exudate is present.
  19. Remove the swab without touching the sides of the nose.
    Rationale: Avoiding contact with the sides of the nose prevents contaminating the swab with resident bacteria.
  20. Perform the same steps on the opposite nostril if ordered.
  21. Offer the patient a facial tissue to blow his or her nose if needed.
  22. Insert the swab into the culture tube and push the tip into the liquid medium at the bottom of the tube.
    Rationale: Mixing the swab tip with the culture medium helps ensure live bacteria for testing.
  23. Place the top securely on the culture tube.
  24. In the presence of the patient, label the specimen per the organization’s practice.10
  25. Prepare the specimen for transport. Place the labeled specimen in a biohazard bag.
  26. Transport the specimen to the laboratory immediately per the organization’s practice, or if the test is an RIDT, place the swab in the designated holder, instill the appropriate liquid to activate the medium, and wait for the test result per the manufacturer’s instructions for use.
  27. Implement symptom treatment for influenza (e.g., relief of fever, pain, and nasal congestion), as needed, per the practitioner's order. If the patient’s symptoms are critical, arrange for transfer to an acute care facility.
  28. Evaluate the patient’s response to the procedure.
  29. Assess, treat, and reassess pain.
  30. Discard supplies, remove personal protective equipment (PPE), and perform hand hygiene.
  31. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient tolerates testing with no adverse reactions.
  • A good specimen is obtained for testing.

UNEXPECTED OUTCOMES

  • Patient has an episode of epistaxis caused by the culture swab.
  • A sufficient sample is not obtained due to the patient’s inability to cooperate with nasal swab.

DOCUMENTATION

  • Patient’s response to procedure
  • Unexpected outcomes and related interventions
  • Patient education
  • Test results
  • Evaluation findings and laboratory results communicated to the clinical team leader per the organization’s practice

PEDIATRIC CONSIDERATIONS

  • Young children should be allowed to demonstrate the technique for collecting a nasal swab with a family member, as appropriate for developmental level and skill. Incorporating a play activity should be considered for further understanding.

REFERENCES

  1. Burke, A. and others. (2014). Clinical implications of dual-positive rapid influenza diagnostic tests during influenza season: Co-colonization, coinfection, or false positive test? American Journal of Infection Control, 42(10), 1139-1140. doi:10.1016/j.ajic.2014.06.016
  2. Centers for Disease Control and Prevention (CDC). Influenza specimen collection. (n.d.). Retrieved December 11, 2019, from https://www.cdc.gov/flu/pdf/professionals/flu-specimen-collection-poster.pdf
  3. Centers for Disease Control and Prevention (CDC). Influenza (flu): Who needs a flu vaccine and when. (2018). Retrieved December 11, 2019, from https://www.cdc.gov/flu/prevent/vaccinations.htm
  4. Centers for Disease Control and Prevention (CDC). Influenza (flu): The flu season. (2018). Retrieved December 11, 2019, from https://www.cdc.gov/flu/about/season/flu-season.htm
  5. Centers for Disease Control and Prevention (CDC). Influenza (flu): Frequently asked questions about estimated flu burden. (2018). Retrieved December 11, 2019, from https://www.cdc.gov/flu/about/burden/faq.htm
  6. Centers for Disease Control and Prevention (CDC). Influenza (flu): Table 2: Rapid influenza diagnostic tests (RIDTs). (2018). Retrieved December 11, 2019, from https://www.cdc.gov/flu/professionals/diagnosis/table-ridt.html
  7. Centers for Disease Control and Prevention (CDC). (2017). Unexplained respiratory disease outbreaks (URDO): Specimen collection and handling. Retrieved December 11, 2019, from https://www.cdc.gov/urdo/specimen.html (Level VII)
  8. Clinical Overview. (2019). Influenza. Retrieved December 11, 2019, from https://www.clinicalkey.com
  9. Clinical Update. (2019). When your patient has the flu: Providing safe care for patients with influenza. Retrieved December 11, 2019, from https://www.clinicalkey.com
  10. Joint Commission, The. (2019). National patient safety goals: Ambulatory health care accreditation program. Retrieved December 11, 2019, from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_AHC_Jan2019.pdf (Level VII)
  11. Martin, C. (2017). Chapter 231: Influenza. In T.M. Buttaro and others (Eds.), Primary care: A collaborative practice (5th ed., pp. 1241-1243). St. Louis: Elsevier.
  12. Sokolovs, D., Tan, K.W. (2017). Ear, nose and throat emergencies. Anaesthesia and Intensive Care Medicine, 18(4), 190-194. doi:10.1016/j.mpaic.2017.01.004

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports