Care of the COVID-19 Patient

Objectives

Caring for patients within an acute care COVID unit requires a practitioner to expand on existing nursing knowledge. It is an expectation that each practitioner has a baseline in fundamentals of care including strong assessment skills, communication, documentation and provides person centered 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 an escalation in care and interventions 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 too, please refer to a text or reference material. After this section, the practitioner will gain further understanding of:

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

Pathophysiology

  • 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.
  • • Viruses constantly change through mutation and replication. Currently, several variants of the virus (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) are creating concern because they contain mutations in the spike-like S protein that the virus uses to bind to and infect cells (CDC, 2021). The variants bind differently to the spike protein with more virality and strength. There appears to be increased transmissibility, decreased effectiveness of monoclonal treatments and increased risk of death. (CDC, 2021)

Presentation (Signs and Symptoms)

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 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's 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

The Government of Canada (2021) website holds the most up-to-date information on how this virus is progressing. Please be sure to check it often. Between April 12, 2021, and April 19, 2021:

  • the number of hospital beds occupied by COVID-19 patients increased from 2,749 to 3,205 beds
  • the number of ICU beds occupied by COVID-19 patients increased from 1,028 to 1,215 beds
  • the number of COVID-19 patients who were mechanically ventilated increased from 599 to 747 (Government of Canada, 2021)

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, and
  • Chronic liver disease.

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

 

COVID-19 Severity in Adults

People that can manage illness at home Admitted patients
Arrow pointing right
Mild Illness Moderate Illness Severe Illness Critical Illness
  • No symptoms, or
  • Mild upper respiratory tract symptoms: cough, muscle ache, fatigue, fever, sore throat
  • Symptomatic: cough, shortness of breath, weakness, and/or fever
  • Physical assessment findings or diagnostic indicators of respiratory impairment

Symptomatic with:

  • RR ≥ 30
  • O2 sats < 92% at res
  • PaO2/FiO2 ratio ≤300

This patient has severe respiratory distress, failure, or meets the criteria for Acute Respiratory Distress Syndrome (ARDS):

  • PaO2/FiO2 ratio ≤200
  • Deterioration despite trials of humidified HFNC* or CPAP* or requires mechanical ventilation
  • May also have signs of deterioration including:
    • Hypotension or shock
    • Impairment of consciousness, or
    • Other organ failures

This person does NOT have shortness of breath and can currently manage their symptoms without being admitted to hospital.

How to care for a person with COVID-19 at home: Advice for caregivers

This patient is admitted to hospital. They would be considered stable, but they have respiratory symptoms. They may require oxygen up to 4L by nasal prongs to maintain oxygen saturations > 92% This patient is admitted to hospital. They have respiratory symptoms and require oxygen therapy – they may benefit from trials of humidified high flow nasal cannula (HFNC)* or Continuous Positive Airway Pressure (CPAP)* This patient, if goals of care support, requires intensive care treatment, including mechanical ventilation and other supports (e.g. vasopressors, continuous renal replacement therapy (CRRT) etc.)

COVID Acute Care Concepts

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 concept regarding COVID.

Infection Prevention and Control Guidance

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

More Resources

Respiratory Concepts

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.

Cardiac Concepts

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 bodies 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.

Diagnostics / Investigations

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)

Treatments

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

Ventilation and Oxygenation strategies such as:

Medications

  • In hospitalized COVID-19 patients requiring supplementary oxygen or mechanical ventilation, Dexamethasone (Decadron), a coricosteroid, 6mg once daily for up to 10 days was shown in the RECOVERY trial to reduce mortality; there was no benefit (and trend toward harm) in those who did not require oxygen (Recovery Collaborative Group, 2021).
  • The following medications are being investigated in pragmatic research studies locally (e.g., CO-VIC, CATCO-NOS, CATCO):
    • Tocilizumab (Actemra), an interleukin-6 receptor antagonist, may increase survival in hospitalized COVID-19 patients with hypoxia requiring supplemental oxygen and with evidence of systemic inflammation (e.g.: an elevated CRP). It is prescribed in addition to dexamethasone as a one-time 8 mg/kg IV dose to a maximum of 800 mg. Tocilizumab is not currently approved in Canada for the treatment of COVID-19 but is approved for other indications in Canada, such as rheumatoid arthritis.
    • Bamlanivimab, a neutralizing monoclonal antibody, may reduce hospitalizations in outpatients with mild to moderate COVID-19 when given early in the disease course as a single 700 mg IV dose. Bamlanivimab has been approved by Health Canada with conditions for patients ≥12 years with mild to moderate COVID-19 who are at high risk of progressing to severe illness and/or hospitalization.
    • Remdesivir (Veklury), an antiviral that inhibits RNA polymerase, may reduce time to COVID-19 recovery in hospitalized patients. It is administered as a 200 mg IV loading dose on day 1 followed by 100 mg IV daily for 4 to 9 days. Remdesivir is authorized by Health Canada with conditions for the treatment of COVID-19 in patients ≥12 years with severe COVID-19 requiring supplemental oxygen.
  • Oseltamivir (Tamiflu) may be considered if influenza A/B is suspected.
  • Acetaminophen (Tylenol) to reduce fever/treat pain.
  • Venothromboembolism (VTE) prophylaxis and Bowel Regimes.
  • Antibiotics do not have any activity against SARS-CoV-2 so do not have a role in COVID-19 pneumonia. Antibiotics may however be indicated if a secondary bacterial infection develops, which is more common in individuals requiring mechanical ventilation. If sepsis is identified in a patient with COVID-19, empiric antimicrobials are indicated along with appropriate investigations (e.g. blood cultures) and can be de-escalated based on culture results and clinical judgement.

Additional Resources

Multisystem Compromise

Despite early recognition and intervention, your patient with COVID 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:

Key Nursing Considerations

  • 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

Recovery

Recovery happens when the patient gets better. At the time of writing, 94% of Canadian cases were considered recovered, with a 0.25% overall Canadian mortality rate (Government of Canada, 2021a). Mean viral shedding occurs around 20 days (Wiersinga, Rhodes, Cheng, Peacock, & Prescott, 2020). Follow IPAC guidance for removal of precautions.


Long-term Effects

  • 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)


Consider watching this short video from the Mayo Clinic regarding long term effects:

 

Long-term Symptoms, Complications of COVID-19

Mayo Clinic, 2020.

 

Discharge Planning

Australian National COVID-19 Clinical Evidence Taskforce. (2021). Australasian guidelines for the clinical care of people with COVID-19: Definition of disease and severity for adults. https://app.magicapp.org/#/guideline/4880

Centers for Disease Control and Prevention. (2020). Late sequelae of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/late-sequelae.html

Government of Canada. (2021a). Coronavirus disease (COVID-19): Outbreak update. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection.html

Government of Canada. (2021b). Hospitalizations, intensive care unit (ICU), mechanical ventilation and deaths. Retrieved March 3, 2021 from https://health-infobase.canada.ca/covid-19/epidemiological-summary-covid-19-cases.html#a7

Government of Canada. (2021c). Infection prevention and control for COVID-19: Interim guidance for acute healthcare settings. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/infection-prevention-control-covid-19-second-interim-guidance.html

Government of Nova Scotia. (2021a). Coronavirus (COVID-19): Symptoms and testing. https://novascotia.ca/coronavirus/symptoms-and-testing/

Mayo Clinic. (2020). COVID-19 (coronavirus): Long-term effects. https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-long-term-effects/art-20490351

Recovery Collaborative Group. (2021). Dexamethasone in hospitalized patients with Covid-19. New England Journal of Medicine, 384(8), 639—704. https://doi.org/10.1056/NEJMoa2021436

Wiersinga, W.J., Rhodes, A., Cheng, A.C. Peacock, S.J., & Prescott, H.C. (2020). Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): A review. JAMA, 324(8), 782—793. https://doi.org/10.1001/jama.2020.12839