What is COVID-19?

In the recent past, a single stranded RNA enveloped Coronavirus evolved in 2019 causing a contagious disease in humans. It was identified in Wuhan state of China in December 2019 and soon spread out throughout the world leading to a pandemic. It was named Coronavirus 2019 (COVID-19) which primarily targets the respiratory system caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2).

What are the symptoms of COVID-19?

The common symptoms of COVID-19 are fever, cough, headache, fatigue, breathing difficulties, and loss of smell and taste. Whereas, at least one-third of the infected people do not develop noticeable symptoms but out of the people who are considered and classified as infected patients, 81% develop mild to moderate symptoms (up to mild pneumonia), 14% develop severe symptoms (dyspnea, hypoxia, or more than 50% lung involvement on imaging) and 5% suffers critically (respiratory failure, shock or multi-organ dysfunction). The incubation period of the virus is 3-12 days. Usually, one may develop the symptoms one to fourteen days after being exposed to the virus. Older people are vulnerable to infections of the disease. However, it is also observed that the 2nd strain of COVID-19 has largely affected the young adults too.

How does COVID-19 transmit?

COVID-19 transmits from person to person through breathing air containing droplets and small airborne particles contaminated by the virus. The risk of getting infected by the virus rises when people are in close proximity, even it may spread over long distances, particularly indoors. It can also transmit when contact with virus-laden fomites is followed by contact with mucous membranes (e.g. eye, nose, mouth) from face touching. Infected people are contagious for up to 20 days and may spread the virus even being asymptomatic themselves. 

Methods of Diagnosis?

The standard method for diagnosis of the disease is by detection of the Virus’ Nucleic Acid by Real-time Reverse Transcription Polymerase Chain Reaction (RT-PCR) or Transcription Mediated Amplification (TMA), or Reverse Transcription Loop-mediated Isothermal Amplification (RT-LAMP) from a nasopharyngeal swab. In India, RT-PCR is the primary diagnostic method for the detection of the disease.

Precautions in sample collection

Precautionary measures should be strictly followed in the collection of samples from suspected or identified COVID-19 patients. Nasopharyngeal swab and other COVID specimen collected for the purpose of assessment should be double bagged individually with only one specimen per double bag. The Lab Order Requisition (LOR) slips must be adhered to the outside of the double bag and not put inside the bag.      

Nursing Assessment

It is the most essential phase of Nursing Care in managing COVID-19 patients. The individual should be carefully assessed evaluating all the vital signs including Oxygen Saturation level at the time of admission, particularly those with fever, acute respiratory illness, and other symptoms of infection. A thorough and proper physical examination should be conducted and documented listing the following symptoms of COVID-19.

• Fever
• Chills
• Cough
• Dyspnea
• Headache
• Fatigue
• Myalgia
• Sore throat
• New loss of smell (anosmia) or taste (ageusia)
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

Every infected patient may develop few or all the above symptoms. Some patients may also be asymptomatic. A nursing diagnosis may also be conducted to evaluate the patient’s experiences and responses to COVID-19 infections. It will also help to evaluate the patient’s condition and level of knowledge regarding the transmission of COVID-19.

Nursing Care

Self-Protection: The foremost role of a nurse while managing COVID-19 patients is self-protection. The nurse should be wearing appropriate Personal Protective Equipment (PPE) before coming in close proximity to the COVID-19 patients. PPE includes protection of the mouth and nose with a N95 respirator covered by a surgical mask, a full body gown, gloves, eye protective goggles, face shield, shoe cover, and head cover. Wearing the PPE kit should be preceded by hand-washing. Proper donning (putting on) and doffing (putting off) procedures should be followed while using PPE kits. This may help the nurse to avoid accidental contamination as health workers are at high risk and maximum exposure

Patient Care: The vital signs including O2 saturation of COVID-19 patients should be frequently monitored and recorded. As COVID-19 is a respiratory disease, O2 saturation monitoring plays an important part in restoring normal respiratory patterns besides body temperature monitoring as fever and dyspnea are common symptoms of COVID-19. A pulse-oximeter is utilized to measure the O2 saturation level which should be 95% or higher normally. Severe patients may display extremely reduced O2 level which may warrant in providing supplementary Oxygen. In such cases, the nurse should provide propped up position. Proning or prone position can also be practiced depending on the stability of the patient.

The patient may be put under isolation to prevent transmission of COVID-19 to the family members. This may develop anxiety, therefore relaxation therapy should be administered which includes repo establishment, ventilation of emotions, encouragement, deep breathing exercises, providing calm environment, etc. The family members may also be encouraged to interact virtually with the patient through video calling. 

Fever or hyperthermia is the most common symptom of the disease, therefore managing fever should be crucially considered. In case of increasing fever, the following may be done :

• - Adjust the room temperature,
• - Remove extra clothing or coverings,
• - Apply cold compress (soaked clot or ice packs to the forehead),
• - Increase or start Intra-venous (IV) fluids as prescribed, 
• - Antipyretic medications may also be administered as prescribed,
• 
  
• The metabolic demands for oxygen during a fever rises leading to respiratory problems, requires reading oxygen therapy constantly. 

Strict hand hygiene should be enforced to reduce as well as prevent transmission of COVID-19. Along with the patients whoever visits the room is also required to wash their hands.

The patient and their family should be well-informed about the transmission of COVID-19, probabilities of infections, diagnosis tests, possible complications, benefits of proper hand hygiene and breathing exercises and ways to protect themselves from the disease. They should be continuously advised to put on their masks.

Patients with chronic illness: While managing COVID-19 patients who have a history of other chronic illness such as diabetes, hypertension, etc. the need for proper nutrition plan arises. They are at a higher risk of getting infected with COVID-19 and have high probability to suffer from severe symptoms. Beside following the basic Covid nursing monitoring norms, these patients also require monitoring of blood sugar level, blood pressure, etc. They should be provided with a balanced diet according to their individual nutritional requirements. If such patient is put under home isolation, then the nurse should educate and counsel the patient regarding diet, exercise and rescue therapy in the event of escalating oxygen needs.

Managing Critical Patients: Patients suffering from severe symptoms in COVID-19 requires special care. The O2 saturation of such patients should be constantly monitored and apt positioning of the patient should be ensured to meet the rising demands of oxygen and provide for supplementary oxygen support as required. Prone positioning should be practiced immediately unless there is any medical contraindication such as spinal instability, facial or pelvic fractures, open chest or unstable chest wall, inability to independently change position, recent nausea or vomiting, advanced pregnancy, etc. Changing of positions is also required to prevent the patient from bedsore and Catheter Care to prevent from infections of the urinary tract. A chart should be maintained strictly monitoring the patient’s intake and output. 

Evaluation

One of the prime role of a nurse is to evaluate and document their course of intervention and the patient’s response which includes external factors affecting the patient’s illness, interactions, nature of social exchanges and specific patient behaviours. The nurse should closely examine the cultural and religious beliefs expressed by the patient, expectations of the patient, responses to care plan and teaching plan, responses to nursing intervention and education, progress towards desired clinical outcome and patient’s expectation fulfillment, communication with family and caregiver of the patient, connecting the family with the patient virtually by video call or by audio call, etc. A holistic approach can help in expediting the healing process with positive response of the patient to medications. 

Review of Literature (ROL)

Sarath Rathnayake, Damayanthi Dasanayake, Sujeewa Dilhani Maithreepala, Ramya Ekanayake & Pradeepa Lakmali Basnayake (2019) conducted a qualitative study on Nurses’ perspectives of taking care of patients with Coronavirus disease 2019: A phenomenological study. This study strives to explore the experiences and challenges of nurses who worked with hospitalised patients with COVID-19 in Sri Lanka. In this qualitative study, a purposive sample of 14 nurses participated in in-depth telephone interviews. Data were analysed using Colaizzi’s phenomenological method. This phenomenological study provides an insight into the experiences of a sample of nurses who took care of patients with COVID-19 in Sri Lanka. Although COVID-19 is a frightening disease with many negative impacts on nurses and their families, with their commitment and professional obligation, taking care of patients with COVID-19 is a new experience that leads to personal satisfaction among nurses. Physical and psychological distress among nurses is a common phenomenon due to worries related to witnessing the suffering of patients, guilty feelings related to limitations of care, work-related factors, discomfort associated with wearing PPE, negative impact to family and stigma and discrimination. Addressing psychological distress among nurses is a priority need. Hospital administrators and nurse managers have a significant role in making a comfortable work environment for nurses, including creating timely policies, providing adequate resources, training opportunities, comfortable shift methods, welfare, appreciation methods and incentives for nurses. Main support networks include the support received from management, peers, co-workers, family, friends, and neighbors. Strengthening these support mechanisms is essential. Previous education and training, as well as proper guidelines, are necessary to provide adequate care for patients with COVID-19. The main learning needs of nurses include donning and doffing of PPE, breaking bad news and performing nursing procedures. Expanding learning opportunities and revision of basic curricula have emerged. Moreover, modern technology, particularly robotic interventions and modern ICT can be integrated into patient care and nurses’ education. To face future challenges, the establishment of new care models, training programs, nursing specialties and favorable policies related to COVID-19 care is crucial in the Sri Lankan context.

REFERENCE

Rathnayake S, Dasanayake D, Maithreepala SD, Ekanayake R, Basnayake PL (2021) Nurses’ perspectives of taking care of patients with Coronavirus disease 2019: A phenomenological study. PLoS ONE 16(9): e0257064. https://doi.org/10.1371/journal.pone.0257064