Care of the COVID-19 Patient

Caring for patients within an acute care COVID unit requires a practitioner to expand on existing nursing knowledge. It is expected that each practitioner has a baseline in fundamentals of care, including strong assessment skills, communication, documentation, and providing person-centred care. The focus of this module is on principles of infection control and prevention, pathophysiology and symptom presentation, rapid assessment skills, recognition of decompensating patient, and when escalation in care and intervention is required. It is an assumption that each practitioner has a good understanding of anatomy and physiology as this content will not be extensively reviewed here. If you need to, please refer to a text or reference material. After this section, the practitioner will have further understanding of:

1. Foundational knowledge related to care of the COVID patient.
2. Foundational nursing knowledge and skill of caring for COVID patient with respiratory compromise.
3. Foundational nursing knowledge and skill of caring for a COVID patient with cardiovascular compromise.
4. Foundational nursing knowledge and skill of caring for a COVID patient with multisystem compromise.

• COVID-19 disease is caused by SARS-CoV-2 virus infection.
• Pathophysiology is related to the viral infection and the host inflammatory response to the infection.
• Early infection targets nasal and bronchial epithelial cells and pneumocytes, as the spike on the virus binds to angiotensin-converting enzyme-2 (ACE2) receptors.
• Type 2 transmembrane serine protease (TMPRSS2) in host cells promotes viral uptake and entry.
• Host humoral and cell-mediated immune responses impair lymphopoesis and increase lymphocyte apoptosis.
• In later stages, the SARS-CoV-2 virus directly infects pulmonary capillary endothelial cells, which leads to endothelialitis (infiltrates and pulmonary edema).
• The host immune response may contribute to bradykinin lung angioedema and activation of the coagulation cascade (cytokine storm), which may lead to micro thrombi formation.
• Viral sepsis (organ dysfunction related to dysregulated host response) to infection may further contribute to multi-organ failure.

As genetic changes to the virus happen over time, the SARS-CoV-2 virus begins to form genetic lineages. Just as a family has a family tree, the SARS-CoV-2 virus can be similarly mapped out. Sometimes branches of that tree have different attributes that change how fast the virus spreads, or the severity of illness it causes, or the effectiveness of treatments against it. Scientists call the viruses with these changes "variants". They are still SARS-CoV-2, but may act differently.

Transmission may occur from individuals who do not have signs or symptoms of infection (pre-symptomatic or asymptomatic presentations) (Government of Canada, 2021c).

Symptoms of COVID-19 can vary from person to person. They may also vary in different age groups. The Government of Canada (2021) lists the following as current symptoms of COVID-19, including variant symptoms.

Some of the more commonly reported symptoms include:

• new or worsening cough
• shortness of breath or difficulty breathing
• temperature equal to or over 38°C
• feeling feverish
• chills
• fatigue or weakness
• muscle or body aches
• new loss of smell or taste
• headache
• gastrointestinal symptoms (abdominal pain, diarrhea, vomiting)
• feeling very unwell

Children tend to have abdominal symptoms and skin changes or rashes.

Symptoms may take up to 14 days to appear after exposure to COVID-19.

The virus can be spread to others from someone who is infected but not showing symptoms. This includes people who:

• haven't developed symptoms (pre-symptomatic)
• never develop symptoms (asymptomatic)

This kind of spread is known to happen among those who are in close contact or are in enclosed or crowded settings.

Symptoms vary, and may take up to 14 days after exposure to COVID-19 for symptoms to appear (Government of Nova Scotia, 2021).

Severity of Illness

Among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization, intensive care, or a ventilator to help them breathe, or they may even die. People of any age with certain underlying medical conditions are also at increased risk for severe illness from SARS-CoV-2 infection.

Complications

While COVID-19 is primarily a respiratory disease, it can also lead to cardiac, dermatologic, hematological, hepatic, neurological, and renal complications (National Institute for Health, 2021).

Common comorbidities found in patients with COVID-19 include:

• Hypertension
• Diabetes
• Cardiovascular disease
• Chronic kidney disease
• Malignancy
• Chronic liver disease

(Wiersinga, Rhodes, Cheng, Peacock, & Prescott, 2020)

Adapted from Australian Guidelines for the Clinical Care of People with COVID-19, by National COVID-19 Clinical Evidence Taskforce, 2022, version 57. https://app.magicapp.org/#/guideline/L4Q5An/section/EPJoYL

* Please refer to guiding documents on the COVID-19 Hub:

Patients who require admission to hospital will be cared for in either an acute care COVID unit or, if care requirements are significant, they may require admission to a critical care environment. This section covers principles of COVID, physical assessment, rapid respiratory and cardiac review.

Please review the following PowerPoint on COVID that outlines general concepts regarding COVID.

In clinical practice, nurses follow infection prevention and control (IPAC) guidance:

• Perform a Point of Care Risk Assessment (PCRA).
• Wear appropriate personal protective equipment (PPE) when caring for patients with confirmed COVID-19, or those patients under investigation for COVID-19 (Nova Scotia Health, 2020c, 2020d).
• Ensure universal pandemic precautions have been implemented in health care facilities in areas with increased viral activity (Nova Scotia Health, 2020e).
• Be aware of any Aerosol Generating Medical Procedures that your patient may have and choose the correct PPE.
• Review the COVID-19 PPE Recommendations at a Glance

More Resources

The respiratory system is the primary body system responsible for ventilation and oxygenation of the body. Ventilation, the process of inhaling oxygen and exhaling carbon dioxide in the lungs requires a patent airway (Giddens, 2017). Oxygenation refers to the amount of oxygen in the body, both in the blood and tissues. Oxygen is continuously needed by our bodies to give us energy and to maintain cellular metabolism. The respiratory system brings oxygen into the body via the lungs. Oxygen diffuses into the bloodstream from the alveoli then travels to the tissues. Cells utilize oxygen and produce carbon dioxide, which the body must eliminate quickly and effectively before a toxic, acidic environment is created. Any disruption in this system can impair the effectiveness of tissue oxygenation, and can be stressful and possibly life-threatening. Feeling short of breath can cause anxiety and fear in clients, as breathing is so fundamental to the basics of life. Maintaining respiratory health optimizes both ventilation and oxygenation.

Practitioners need to have strong assessment skills and understanding of respiratory and cardiac systems. Please review the following:

Review the following videos:

Oxygen transport or delivery involves the movement of gases from the pulmonary capillaries to the tissues. Oxygen content and cardiac output are the two main factors affecting the transport of gases.

The cardiac system is the primary body system responsible for the pumping of blood required for perfusion of body tissues. Perfusion is the flow of blood through arteries and capillaries to deliver essential cellular oxygen and nutrients (Giddens, 2017). Please review the following on cardiac assessment:

View the following video to see how the heart pumps:

Oxygen is carried by the blood in two ways. A small amount (3%) is dissolved in plasma and clinically this portion is measured as PaO₂. The largest portion of oxygen (97%) combines with hemoglobin. Together this is known as the oxygen carrying capacity of the blood. The body's arterial oxygen content (CaO₂) is affected by the hemoglobin level, oxygen saturations (SaO₂) and PaO₂ levels in the blood. A decrease in any one of these factors will result in a decrease in oxygen content.

The following are examples that can lead to decrease in the body's oxygen content:

1. Hypoxemia
2. Decreased hemoglobin:
   • Anemia
   • Hemorrhage
   • Renal failure (decreased production)
3. Abnormal hemoglobin:
   • Sickle cell anemia
4. Non-functioning hemoglobin:
   • Carbon monoxide poisoning

The relationship between ventilation and perfusion is important for nurses to understand, assess and manage in their patients. Ventilation is the movement of gases through the alveoli and perfusion is blood flow to the alveolar capillaries.

Reverse transcription polymerase chain reaction (PCR) based RNA detection from respiratory samples (i.e. nasopharyngeal swab) of SARS-CoV-2 is the standard for diagnosis of COVID-19. Sensitivity varies with timing of testing relative to exposure.

It should be noted that the presence of antibodies does not confer immunity.

A variety of other diagnostic tests may be considered based on patient clinical presentation. Common abnormalities among patients with COVID-19 include:

• Lymphopenia
• Elevated inflammatory markers (ESR, CRP, ferritin, TNF-a, IL-1, IL-6)
• Abnormal coagulation parameters (prolonged PT, thrombocytopenia and elevated D-dimer, low fibrinogen)
• Chest X-ray: bilateral lower lobe infiltrates
• CT scan: ground glass opacities

(Wiersinga, Rhodes, Cheng, Peacock, & Prescott, 2020)

There is currently no curative treatment for COVID-19. Treatments are supportive in nature.

Ventilation and Oxygenation strategies such as:

• Early awake proning
• Oxygen therapy
• CPAP trial
• Humidified high flow nasal cannula trial (HFNC)
• Intubation and mechanical ventilation

Order Sets

Additional Resources

Medication Summaries

IV Monographs

Additional Resources

Despite early recognition and intervention, your patient with COVID-19 may continue to rapidly decompensate. It is recommended to use an early warning acuity tool within your organization, like Modified Early Warning (MEWS). Be familiar with the clinical pathways found on the HUB as to how you escalate care within your site. Be sure to use an SBAR format to inform colleagues and physicians of the change in condition and remember, early recognition and escalation of care is essential.

Review the following on shock, sepsis and code blue:

• Follow IPAC guidance
• Consider goals of care / frailty scores
• Know your patient's code status and follow Code Blue guiding principles
• Monitor your patient with COVID-19 as acute deterioration is common
• Monitor and take care of yourself and support your colleagues

Recovering from COVID-19 is different for everyone. It does not matter how old you are or how healthy you were before COVID-19. Some people feel better in a few weeks. For others, it may take months. Research is still being done and there is a lot that we still do not know.

Post COVID

• There is emerging evidence that some patients who have recovered from COVID-19 still have long-term effects from the disease.
• This group of patients who continue to experience symptoms are called ‘long haulers’ or those with ‘late sequelae of COVID-19’
• Common symptoms include: fatigue, dyspnea, cough, myalgia, headache, fever and palpitations; other reported symptoms include: cognitive impairment & depression
• Research is ongoing to study the long term effects of COVID-19 in patients

(Mayo Clinic, 2020; Centers for Disease Control and Prevention, 2020)

Is your patient experiencing ongoing symptoms? Do they live in Nova Scotia and are a resident over the age of 16? If they have answered ‘YES’ to these questions, encourage them to complete the Post COVID Symptom Survey. This information will be used to determine the appropriate level of support they need from Nova Scotia Health’s Post COVID Navigation services