key: cord-0996887-b6f6hek8
authors: Wang, Hui; Zeng, Tieying; Wu, Xinjuan; Sun, Hong
title: Holistic care for patients with severe coronavirus disease 2019: An expert consensus()
date: 2020-04-04
journal: Int J Nurs Sci
DOI: 10.1016/j.ijnss.2020.03.010
sha: adb8dc5cdc9f7d9a9f1ad32501e08f0509e699cf
doc_id: 996887
cord_uid: b6f6hek8

OBJECTIVE: To standardize the holistic care for patients with severe coronavirus disease 2019 (COVID-19). METHODS: The consensus was preliminarily formed by combining relevant literature findings and frontline medical working experiences, and it was eventually confirmed by five rounds of online discussions and expert consultations. RESULTS: This consensus included nursing assessment, nursing priorities, nursing goals, and thirteen key points of nursing procedures such as nursing of oxygen therapy and respiratory nursing. CONCLUSION: This scientific and practical consensus guideline can provide clinical guidance on the holistic nursing care of patients with severe COVID-19.

Association to assist Wuhan.

The Consensus applies to patients whose clinical condition is classified as either severe or critical according to the Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia(Trial version 6) [5] . When providing care to these patients, nurses should strictly implement personal protection measures.

Level Ⅱ protection should be adopted when working in isolation wards, and Level Ⅲ protection measures should be adopted when performing procedures that may produce aerosols (e.g., sputum aspiration, tracheal intubation, noninvasive ventilation, tracheotomy, cardiopulmonary resuscitation, etc.).

The Consensus was established jointly by 22 nursing experts, one medical expert, and one hospital infection control expert from different departments of 20 hospitals across China.

A draft of the consensus was developed after analysis, summary, and consolidation of information from a comprehensive review, which included the diagnosis and treatment protocols, management consensus, and related literature of COVID-19, as well as effective nursing measures and experiences gained by the experts during frontline care of patients in severe and critical condition.

Several revisions were made throughout five rounds of online discussion and expert consultations; a final version of the Consensus was then developed and reviewed by the medical expert and hospital infection control expert.

(1) Vital signs: Assess the patient's body temperature; blood pressure; pulse; blood oxygen saturation; breathing rate, rhythm, and depth; etc. [6] .

(2) Symptoms and signs: Assess the patient's level of consciousness, muscle pain, fatigue, cough, sputum, chest tightness, shortness of breath, diarrhea, etc.

(3) Skin and mucosa: Assess the patient's skin color and elasticity, peripheral extremity circulation, presence of bleeding, etc.

(4) Nutritional status: Assess the patient's food intake, presence of dehydration, etc.

Assess the patient's emotional response to the disease, cognitive changes, and compliance with protective measures.

Assess whether environmental factors can aggravate cross-infection, including inadequate bed spacing and the negative pressure ward, suboptimal protective measures for high-risk surgeries, and inadequate personal protective measures for all medical and nursing staff.

(1) Impaired gas exchange -related to increased airway resistance and decreased lung compliance.

(2) Hyperthermia -related to viral lung infection.

(3) Activity intolerance -related to impaired lung function and imbalanced oxygen supply and consumption.

(4) Potential complications -deep vein thrombosis, hyperglycemia, acute respiratory distress syndrome, septic shock, metabolic acidosis, coagulopathy, multiple organs dysfunction syndrome, stress ulcers, etc. [7] .

(5) Anxiety/fear -related to isolation and concerns over the disease's prognosis.

(1) Ineffective airway clearance -related to excessive mucus and ineffective cough.

(2) Diarrhea -related to intestinal dysfunction due to COVID-19 infection.

(3) Impaired comfort -related to illness-related symptoms, such as chest tightness, gasping breaths and fatigue.

(4) Imbalanced nutrition: less than body requirements -related to fever, diarrhea, reduced intake, etc.

(5) Risk for impaired skin integrity -related to fever, humidity, poor peripheral circulation, and forced position. 

(1) Alleviating dyspnea and hypoxemia.

(2) Ensuring effective coughing, with breathing gradually becoming stable and lung sounds clear.

(3) Controlling body temperature effectively.

(4) Relieving diarrhea. (10) Improving patients' activity endurance. (11) Ensuring high compliance to isolation and effective self-protection among patients.

(1) Promptly evaluate whether patients' respiratory distress and/or hypoxemia are relieved and provide patients with individualized respiratory support per medical orders based on their condition and tolerance [8] .

(2) Patients receiving nasal catheter oxygen or nasal high-flow oxygen therapy can wear a surgical or face mask to reduce the spread of viral aerosols [9] . Oxygen supply cannot be interrupted arbitrarily during nasal high-flow oxygen therapy [10] . Employ lung protective approaches during invasive mechanical ventilation, and apply a small tidal volume (4-8 ml/kg of ideal weight) and low inspiratory pressure (plateau pressure < 30 cmH 2 O [1 cmH 2 O = 0.098 kPa]) during the procedure to reduce ventilator-induced lung injury [5] .

(3) During administration of oxygen therapy, closely monitor patients' consciousness, heart rate, breathing characteristics (rhythm, rate, frequency, depth, synchronization of spontaneous breathing and ventilator), improvement of cyanosis, and oxygen therapy complications. Carefully monitor blood oxygen saturation or arterial blood gas analysis results [11] and promptly adjust oxygen flow rate, oxygen supply mode, and ventilator parameters accordingly, as per medical orders.

(4) Ventilator and catheter care: (i) Passively humidify invasive ventilators using a heat-moistureexchanger (HME) with a bacterial filter to reduce condensation in the circuit [12] .(ii) Use of disposable ventilator circuits and exhalation valves is recommended, and installation of virus filters at both the inhalation and exhalation ends of the ventilator. Replace these filters only upon contamination or mechanical failure, as opposed to on a routine basis [12] . (iii) Do not disconnect the ventilator. If the ventilator must be disconnected, for reasons such as replacing the sealed sputumaspirating tube, it must first be set to standby mode. (iv) Use 75% alcohol to wipe and disinfect the surface of the ventilator on a daily basis. Treat disposable catheters as infectious medical waste, and send reusable catheters to the disinfection center for sterilization after immersion for 30 minutes in a disinfectant containing 1,000-2,000 mg/L of chlorine-containing disinfectant.

(5) Prone ventilation: Implementation of prone ventilation for more than 12 hours per day can be considered when PaO 2 /FiO 2 ratio is continuously lower than 150 mmHg (1 mmHg = 0.133 kPa) [8] . (i) Prior to implementing prone ventilation, oropharyngeal and endotracheal secretions should be removed first to ensure an unobstructed artificial airway. (ii) Jejunal tube feeding is recommended for patients undergoing prone ventilation. If gastric tube feeding is employed, aspirate the patient's stomach contents before prone ventilation. When the patient is in the prone position, perform feeding in small amounts. (iii) Regularly evaluate and change the patient's prone position from side to side to avoid applying continuous pressure to the same area. Decompression dressings can be applied to pressured areas and the patient's apophysis area to reduce potential stressful skin damage. 

(1) Cough and expectoration: Teach patients the correct methods of deep breathing and effective coughing based on their condition. In particular, a sealed plastic bag should be used when patients expectorate to prevent the sputum from spreading the virus.

(2) Atomization inhalation: Administration of drugs via atomization inhaler may produce aerosols and pollute indoor air. Therefore, atomization inhalation should be avoided. If unavoidable, a quantitative inhalation device combined with an aerochamber is preferred.

(3) Sputum removal: Use a closed endotracheal suctioning system to aspirate secretions in the airway, and perform the procedure only when necessary.

(1) Patients with fever should be provided with antipyretic treatment as per medical orders and nursing assessment findings.

(2) Following antipyretic treatment, closely monitor patients' body temperature, sweating, and electrolyte changes. Dry patients' sweat and change clothes and bed sheets upon heavy sweating. Use gentle actions when replacing clothes and bedding. Treat contaminated clothes and sheets as infectious fabrics and place them into orange waste bags [15] .

(3) Encourage patients who are capable of independent oral food intake to drink more water, and report to the doctor for timely fluid supplements if necessary.

(1) Central venous catheterization should be performed by two nurses, strictly implementing maximum aseptic barrier techniques and protective measures [16] .

(2) Prior to treatment, monitor patients' vital signs, biochemical indicators, and coagulation functions, and evaluate the patency of vascular access.

(3) Choose the most appropriate anticoagulation approach, treatment mode, and treatment dose as per medical advice.

(4) During treatment, closely monitor patients' vital signs, coagulation functions, electrolyte changes, treatment effects, and so on. Promptly identify and deal with treatment-related complications such as hypotension, electrolyte disturbance, and thrombocytopenia [17] .

(5) Treatment devices should be used exclusively for the same disease. After treatment, wipe and disinfect the instrument with a disinfectant containing 1,000-2,000 mg/L of chlorine, and discard waste liquid bags and filters in double-layer yellow medical waste bags.

(1) Prior to transfusion of convalescent plasma, ensure that patients sign an informed consent form and administer anti-allergic drugs as per medical orders.

(2) Strictly follow aseptic operation procedures and blood transfusion technical specifications. (4) After treatment is completed, discard blood bags in double-layer yellow medical waste bags instead of recycling them. Keep careful records to ensure that donor and recipient information is traceable [17] .

(5) Closely monitor patients' condition after treatment to evaluate the effectiveness of the intervention.

Venous-venous extracorporeal membrane oxygenation is the preferred method of respiratory support for patients with severe COVID-19 [8] .

(1) Place the catheter carefully to avoid pulling, shifting, bending, leaking, or dropping. Check catheter connections regularly to ensure tightness.

(2) Closely observe patients' consciousness, pupils, breathing, blood pressure, body temperature, blood oxygen saturation, central venous pressure, mean arterial pressure, and other vital signs, and monitor arterial blood gas analysis results, coagulation functions, and so on [18] . 

(1) Administer drugs according to medical orders, and strictly follow the check system.

(2) Pharmacy Intravenous Admixture Services (PIVAS) is recommended to ensure accurate dosage and reduce unnecessary exposure.

(3) Pay attention to drug contraindications. Do not use antiviral drugs such as lopinavir and ritonavir in combination with drugs such as alfuzosin [8] . When traditional Chinese medicine injection is used in conjunction, flush the catheter with normal saline. Separate administration of intestinal microecological regulators by 2 hours from administration of antibiotics.

(4) Closely monitor adverse drug reactions. When administering antiviral and antibacterial drugs, regularly monitor patients' gastrointestinal responses and liver and kidney functions. When administering glucocorticoids, provide calcium and vitamin D supplements and regularly monitor patients' blood calcium concentration [20] . 

(1) Assess necessity of catheter retention on a daily basis.

(2) Ensure that all catheters are unobstructed, tightly connected, and fixed firmly to avoid shifting and dropping.

(3) Closely monitor the color, property, and quantity of the drainage fluid. 

(1) Closely monitor changes in patients' vital signs and consciousness, especially breathing frequency, rhythm, pattern, and depth.

(2) Observe the therapeutic effect of oxygen therapy and dynamically adjust the mode and oxygen flow rate based on patients' degree of dyspnea, blood oxygen saturation, and blood gas analysis results.

(3) Perform hemodynamic monitoring to detect arrhythmia and heart failure [5] .

(4) Observe associated symptoms such as general muscle pain, fatigue, cough, and chest tightness.

(5) Record patients' intake and output amounts within 24 hours to maintain water, electrolyte, and acidbase balances.

(6) Strengthen monitoring of infection indicators and collect blood, sputum, urine, stool, and other specimens promptly and correctly.

(7) Strengthen monitoring and nursing care of basic diseases, such as hypertension, diabetes, coronary heart disease, and so on. (8) Seek to prevent and promptly identify complications. In particular, be vigilant of disease exacerbation when patients develop symptoms such as persistent high fever, respiratory failure, shock, or multiple organs failure [22] .

(1) Ensure patients' oxygen supply is not interrupted when eating or drinking.

(2) Patients should have small frequent meals, with a diet predominantly composed of egg, beancurd, dairy products, fruit juice, vegetable juice, rice noodles, and so on.

(3) If nutritional demands are not met, oral or enteral nutrition can be administered.

(1) Enteral nutrition can be prescribed if patients are normally unable to eat or cannot orally intake at least 60% of their energy consumption for 3-5 consecutive days.

(2) Monitor nutrition indicators, including albumin, transferrin, and preprotein counts. Record the type, concentration, and quantity of enteral nutrition supplement [24] .

(3) During enteral nutrition infusion, elevate the head of bed at an angle ≥ 30° to prevent accidental aspiration.

(4) Observe development of gastrointestinal symptoms such as diarrhea, nausea, or vomiting.

(5) A permissive low-calorie program that can satisfy 60%-80% of nutritional intake is recommended during the early stage. Once the disease is alleviated, energy and nutrients can be gradually increased to the full amount.

(1) Parenteral nutrition is required for patients with severe gastrointestinal dysfunction.

(2) Closely monitor any development of metabolic disorders and complications.

Single rooms are recommended. However, if single rooms are not available, bed spacing should be at least 1 m. A negative pressure ward is recommended, allowing at least 12 air exchange cycle per hour. For nonnegative pressure wards, air flow rate must remain at least 160 L/s during natural air ventilation [25] .

(1) Patients who can do self-care for themselves should be encouraged to perform oral care themselves.

(2) Patients who cannot care for themselves should be assisted by nurses to perform oral care 2 or 3 times per day.

(3) Be vigilant of potential splash of secretions when performing oral care for patients. Nurses should wear Level Ⅲ personal protection equipment if necessary.

(1) Closely monitor facial skin for any pressure injury during oxygen therapy.

(2) Observe patients' overall skin condition and instruct them to either change position regularly or use protective products to prevent skin damage.

(1) Prevent constipation. During and after defecation, carefully increase patients' oxygen concentration to prevent hypoxia.

(2) Prevent diarrhea. If patients develop diarrhea, administer drugs as per medical orders and be vigilant to prevent incontinence dermatitis.

(3) Bedpans should be used exclusively for each patient. After use, immerse the bedpan in a disinfectant solution containing 5,000 mg/L of effective chlorine and subsequently clean it for future use.

(4) If the medical institution is equipped with a sewage treatment system, excreta can be discharged directly into the sewage tank. If not, excreta must be disinfected in accordance with the Regulation of Disinfection Technique in Healthcare Settings [26] .

(1) Introduce patients to the ward environment and isolation regulations upon admission.

(2) Regularly assess patients' psychological condition and consult with the psychiatry department if necessary.

(3) During bedside operations, provide patients with appropriate emotional support through gestures such as eye contact, touch, nods, handshakes, and thumbs-up gestures, thereby helping them to build confidence in their ability to overcome the disease [27] .

(4) Help to communicate information to external relatives, provide patients with continuous information support, and encourage them to actively collaborate in their treatment.

(1) Principle: Collaborate with the clinical medical team to assess the feasibility of commencing respiratory rehabilitation program for patients. Respiratory rehabilitation activities should not reduce the patient's blood oxygen saturation and blood pressure [28] .

(2) Instructional format: Videos, brochures, etc.

(3) Rehabilitation contents: Routine changes in body posturing (e.g., semi-recumbent position, lateral position, prone position, etc.) to reduce the work of breathing muscles and save energy; respiratory control techniques (e.g., abdominal breathing and pursed-lip breathing) to expand the lower chest and relieve breathing difficulties; effective sputum excretion techniques (e.g., postural drainage and effective coughing) to promote sputum excretion and maintain an unobstructed airway.

(1) To ensure adequate sleep, instruct patients to rest in bed. Those with sleep disorders should be managed by drugs as per medical orders.

(2) Patients who can get out of the bed should follow the "Three Steps to Get Up" guideline (lie in the bed for 30 seconds before getting up, drop both legs for 30 seconds before standing up, and stand for 30 seconds before walking). Instruct patients to perform activities such as sitting, standing, and stepping along the bedside once they are out of bed [29] .

(3) Prevent patients from falling out of bed. Instruct patients to perform muscle training such as clenching their fists, raising their arms, ankle pumping, heel slipping, lifting their legs, and contracting quadriceps and gluteal muscles, according to their tolerance levels. Compression stockings can be utilized to prevent the formation of deep vein thrombosis in lower limbs.

(4) Avoid excessive activities to reduce patients' blood oxygen saturation and blood pressure.

(1) Instruct patients to perform respiratory rehabilitation activities according to their rehabilitation program.

(2) Ensure timely transmission of patients' medical information and instruct them to go to the designated place for centralized isolation of 14 days [30] .

(3) Inform patients of follow-up instructions for weeks 2 and 4 and carefully perform follow-up and review.

(4) Instruct patients to work and rest regularly and ensure they maintain adequate sleep, a balanced diet, and a calm emotional state.

(5) Instruct patients to be vigilant of hand hygiene, maintain distance from family members, wear a mask, have separate meals, and avoid sharing personal items such as tableware and washing materials during home isolation [31] .

Expert Consensus Panel on Holistic Care of COVID-19 Patients in Severe and Critical Condition

Xin Fu

Guimei Li (the People's No. 3 Hospital of Anyang

Peking Union Medical College Hospital, the Chinese Academy of Medical Sciences), Hong Sun (Peking Union Medical College Hospital, the Chinese Academy of Medical Sciences), Xinjuan Wu (Peking Union Medical College Hospital, the Chinese Academy of Medical Sciences

Yinghui Zhang (the Second Hospital of Shanxi Medical University), Jianping Zhao (Tongji Hospital Affiliated with Tongji Medical College of

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The authors would like to acknowledge the dedication of the nurses in fighting against COVID-2019.