covid-19 · 2020-04-01 · diet diet, regular npo tube feeding iv fluids use conservative iv fluid...

COVID-19

This document contains the following resources.

• COVID-19 Order Set• COVID-19 Care Plans

Disclaimer: The clinical information contained this document is intended as a supplement to, and not a substitute for, the knowledge, expertise, skill, and judgment of physicians, pharmacists, or other healthcare professionals in patient care. You and the other healthcare providers responsible for patient care will retain full responsibility for all decisions relating to patient care, and the content is not to be used as a substitute or replacement for diagnosis or treatment recommendations or other clinical decisions or judgment. Zynx Health makes not representations or warranties about the content or its fitness for any purpose. Please use this information at your own discretion. Copyright © 2020 Zynx Health Incorporated. All rights reserved.

Last update: 04.01.20.

Content

COVID-19

General

The Zynx Health COVID-19 order sets are intended to facilitate the development of institution-specific order setsfor the diagnosis and supportive management of patients with suspected or confirmed COVID-19 infection

Zynx Health COVID-19 Information Page

Admission criteria for patients with COVID-19 infection

Consider the use of the SOFA score to determine prognosis

Surviving Sepsis Campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019(COVID-19)

Vital signs

Pulse oximetry

Activity

Ambulate

Up ad lib

Bed rest

Up to chair

Nursing Orders

Observe guideline-recommended transmission-based precautions, including eye shield, gown, gloves, and mask

Provide mechanical VTE prophylaxis for patients who have contraindications to pharmacologic prophylaxis

Saline lock

Airborne precautions

Contact precautions

Droplet precautions

Oxygen administration

Intermittent pneumatic compression

Pregnancy test, urine, point-of-care measurement

Respiratory

For severe infection, once the patient is stable, the target SpO2 is 90% or greater in nonpregnant adults andSpO2 of 92% to 95% in pregnant patients

For high-risk aerosolization procedures, use isolation room

Oxygen via nasal cannula

Oxygen via simple face mask

Oxygen via nonrebreather face mask

Biphasic positive airway pressure (BIPAP)

Continuous positive airway pressure (CPAP)

Ventilator settings

Diet

Diet, regular

NPO

Tube feeding

IV Fluids

Use conservative IV fluid strategies when there is no evidence of shock

Dextrose 5% and 0.45% Sodium Chloride IV

Sodium Chloride 0.9%

Medications

Analgesics/Antipyretics

acetaminophen

COVID-19 Order Set

Avoid the routine use of NIV because of a high failure rate and possibility of environmental contamination

2019-novel coronavirus (2019-nCoV), point-of-care measurement

Content

650 milligram orally every 6 hours as needed for fever or pain

650 milligram orally once

650 milligram rectally every 6 hours as needed for fever or pain

Antibacterial Agents: Reminders

In patients with suspected COVID-19 infection, give empiric antimicrobial agents for other likely respiratorypathogens, based on clinical diagnosis

As appropriate, refer to these ZynxOrder order sets: Chronic Obstructive Pulmonary Disease, Influenza,Pneumonia - CAP, Pneumonia - Nosocomial, Sepsis

For patients with sepsis, give antimicrobials within 1 hour of initial patient assessment

Stress Ulcer Prophylaxis Agents: Reminders

Provide stress ulcer prophylaxis in patients with risk factors for GI bleeding (ie, mechanical ventilation for 48hours or longer, coagulopathy, renal replacement therapy, liver disease, multiple comorbidities, and higherorgan failure score)

Stress Ulcer Prophylaxis Agents: Histamine-2 Receptor Antagonists

famotidine

20 milligram intravenously every 12 hours

20 milligram orally or by feeding tube every 12 hours

raNITIdine

50 milligram intravenously every 8 hours

150 milligram orally or by feeding tube every 12 hours

Stress Ulcer Prophylaxis Agents: Proton Pump Inhibitors

omeprazole

40 milligram by nasogastric tube once a day

omeprazole-sodium bicarbonate 40 mg-1,680 mg oral packet

1 packet orally once initial dose

1 packet orally once 8 hours after initial dose; intermediate dose

1 packet orally once a day maintenance dose

VTE Prophylaxis

Provide pharmacologic VTE prophylaxis for patients with COVID-19 infection who do not havecontraindications; otherwise use mechanical prophylaxis

dalteparin

5,000 unit subcutaneously once a day

enoxaparin

40 milligram subcutaneously once a day

heparin

5,000 unit subcutaneously every 12 hours

Reminders

Do not give corticosteroids to treat COVID-19 infection in the absence of other indications

Do not use inhaled bronchodilators in patients with COVID-19 who do not have comorbid asthma or COPD

Laboratory

Blood Studies

Consider a D-dimer test to determine prognosis

Complete blood cell count with automated white blood cell differential

Basic metabolic panel

Comprehensive metabolic panel

Blood gas, arterial

Blood gas, venous

Lactate, serum

D-dimer

Use a neuraminidase inhibitor for treatment of influenza if local circulation or for risk due to travel orexposure to animal influenza virus

Content

Microbiology

COVID-19 testing criteria

For patients with suspected COVID-19 infection, consider testing for other causes of respiratory illness (eg,influenza)

COVID-19 specimen collection recommendations

Do not induce sputum for 2019-nCoV testing

2019-novel coronavirus (2019-nCoV) by real-time RT-PCR

Culture, blood

Culture, sputum

Gram stain, sputum

Influenza virus A and B by nucleic acid amplification, rapid

Influenza virus A and B by real-time PCR

Methicillin-resistant Staphylococcus aureus, real-time PCR

Respiratory syncytial virus (RSV) antigen rapid test, point-of-care measurement

Respiratory viral panel by PCR

Urine Studies

Human chorionic gonadotropin (HCG), urine qualitative

Radiology

Radiograph, chest, 1 view

Radiograph, chest, 2 views

Diagnostic Tests

12-lead ECG

Consults

Consult to hospitalist

Consult to intensivist

Consult to infectious diseases

Consult to pulmonology

Sources1. British Medical Journal: Covid-19: ibuprofen should not be used for managing symptoms, saydoctors and scientists: https://www.bmj.com/content/368/bmj.m10862. Centers for Disease Control and Prevention: Information for Healthcare Professionals:www.cdc.gov/coronavirus/2019-nCoV/hcp3. Centers for Disease Control and Prevention: Coronavirus Disease 2019 (COVID-19): www.cdc.gov/coronavirus/2019-ncov4. World Health Organization: Coronavirus Disease (COVID-19) Technical Guidance: www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance5. Infectious Diseases Society of America: COVID-19: What You Need to Know: www.idsociety.org/public-health/Novel-Coronavirus

Content

COVID-19

Anxiety/Stress

Goals

Absence of physiologic stress signs

Alleviation of anxiety

Interventions

Assessments

Anxiety characteristics assessment – patient/caregiver

Physiologic stress signs assessment

Communication and Care Coordination

Communication, social services

Communication, spiritual care services

Education

Education, positive coping methods

Education, relaxation techniques

Breathing exercises

Mind-body interventions (eg, guided imagery, meditation, music therapy)

Pleasant activities

Positive visualization

Progressive muscle relaxation exercise

Treatments and Procedures

Coping support – patient/caregiver

Nonpharmacologic anxiety-relief provision

Communication about progress and status

Environmental regulation

Family presence

Massage

Music

Relaxation techniques

Spiritual support

Therapeutic touch

Use of calm voice

Cardiac Function - Impaired

Goals

Blood pressure within specified parameters

Cardiac rhythm stable

Circulatory function within specified parameters

Interventions

Assessments

Cardiac monitoring

Education

Education, cardiac disease symptoms

Education, peripheral edema management

Elevate legs

Light massage

Move legs frequently

COVID-19 - Starter Plan of Care (based on Admission to ICU)

Content

Protect skin from injury

Education, prescribed activity level


Energy conservation management

Assist with position changes and transfers

Encourage activity to tolerance level

Group activities to allow rest

Increase activities slowly

Plan activities during peak energy level

Provide comfortable environment


Keep lighting level as per individual

Maintain consistent per-individual room temperature

Minimize environmental noise

Leg elevation

Pain management

Fluid and Electrolyte Imbalance

Goals

Absence of imbalanced fluid volume signs and symptoms

Electrolytes within specified parameters

Interventions

Assessments

Blood pressure monitoring

Body weight monitoring

Electrolyte imbalance signs and symptoms assessment

Arrhythmia

Breathing, shallow

Lethargy

Level of consciousness, altered

Renal function, impaired

Seizure

Tachycardia

Gastrointestinal symptom assessment

Education

Education, antiemetic therapy

Education, diarrhea self-management – dietary

Consume foods rich in potassium

Electrolyte supplementation (eg, oral rehydration solution, sports drinks)

Limit caffeine consumption

Limit consumption of milk and dairy products

Low-fat diet


Acute kidney injury prevention

Avoid nephrotoxic drug combinations

Avoid nephrotoxic drugs

Ensure adequate hydration

Content

Hemodynamic optimization

Use caution with contrast media

Implement conservative IV fluid strategies in patients with acute respiratory infection when there is noevidence of shock

Nutrition Deficit

Goals

Adequate nutritional intake

Interventions

Assessments

Indirect calorimetry

Nutritional intake assessment


Communication, dietitian

Education

Education, nutritional support


Nutrition provision

Give early enteral nutrition (within 24 to 48 hours of admission) for critically ill

Respiratory Function - Impaired

Goals

Adequate oxygenation

Absence of aspiration

Clear lung sounds

Reduced dyspnea

Interventions

Assessments

Respiratory distress signs and symptoms assessment

COVID-19 testing criteria: signs and symptoms compatible with COVID-19 (fever, cough, difficultybreathing)


Communication, respiratory therapy

Communication, speech therapy

Education

Education, aspiration prevention

Clear oral cavity between bites

Consume food consistency, texture, and type as prescribed and in small portion sizes

Drink thickened fluids

Elevate head of bed

Ingest oral intake while supervised

Maintain NPO status until medically cleared

Maintain side-lying position

Maintain upright position during feeding, for oral consumption, and 45 minutes after oral intake

Education, dyspnea management

Cool face with fan

Durable medical equipment to limit exertion (eg, walker, bedside commode)

In seated position, bend forward slightly at waist while supporting upper body by leaning forearms ona table or the thighs

2019-novel coronavirus (2019-nCoV), point-of-care measurement

Content

In standing position, lean forward and prop on a counter, etc.

Optimal breathing technique (eg, deep breathing, diaphragmatic breathing, pursed-lip breathing)

Progressive muscle relaxation

Education, energy conservation

Allow for rest periods

Avoid overhead activities

Avoid straining

Pace activities

Perform activities while sitting

Place items within reach

Schedule activities for periods with greater energy

Use assistive devices

Education, inhaler device technique

Education, secretion clearance techniques

Active cycle of breathing

Autogenic drainage

Directed cough

Forced expiratory technique

Consider airway clearance therapy only in patients with symptomatic retention of secretions, guidedby consideration of patient tolerance, preference, and effectiveness of the therapy


Hydration management

Inhaled medication management

Give inhaled medications by metered dose inhaler rather than nebulization

Use appropriate PPE if giving nebulized medications because of the risk for dispersion of aerosolizedvirus


Give supplemental oxygen immediately to patients with respiratory distress, hypoxemia, or shock

Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 93% or higher duringresuscitation; or use face mask with reservoir bag (at 10 to 15 L/min) if patient is in critical condition;once patient is stable, the target is greater than 90% SpO2 in nonpregnant adults and 92% to 95% inpregnant patients

For children, oxygen therapy during resuscitation should be targeted at SpO2 94% or higher;otherwise, the target SpO2 is 90% or higher; use of nasal prongs or nasal cannula is better toleratedin young children

Use high-flow nasal cannula (over NIPPV) for acute hypoxemic respiratory failure despite conventionaloxygen therapy; monitor closely for worsened respiratory status

Caution when using high-flow nasal oxygen because of the risk for dispersion of aerosolized virus inthe healthcare environment with poorly fitting masks

Supplemental humidification

Noninvasive ventilation initiation

Consider NIPPV for acute hypoxemic respiratory failure if high-flow nasal cannula is not available andwithout urgent indication for endotracheal intubation; monitor closely for worsened respiratory failure

Caution when using noninvasive ventilation because of the risk for dispersion of aerosolized virus inthe healthcare environment with poorly fitting masks

If BiPAP is used, a viral filter should be placed in-line with the exhalation tubing to reduceenvironmental contamination

Invasive ventilation initiation

Consideration for early invasive ventilation; oral intubation is preferable to nasal intubation inadolescents and adults

Content

During endotracheal intubation, video-guided laryngoscopy is preferred over direct laryngoscopy

Lung-protective ventilation strategies

Periodic prone positioning during mechanical ventilation

Oral hygiene care

Swallowing precautions

Sepsis, Risk of

Goals

Absence of sepsis (no further increase in temperature, absence of chills and diaphoresis, pulse andrespiratory rate within normal range, WBC and differential counts returning to normal, negative blood cultureresults)

Knowledge of infection prevention and control procedures

Interventions

Assessments

Blood glucose monitoring

Sequential Organ Failure Assessment (SOFA) score

Education

Education, antibiotic therapy

Education, advanced care planning

Education, prognosis

Education, handwashing

Education, infection control

Avoid touching bodily fluids

Cover mouth and nose when coughing or sneezing

Dispose of contaminated items properly

Follow infection control measures as directed

Follow isolation precautions as prescribed

Perform proper hand hygiene

Education, infection control – visitor

Limit visitation; use alternative mechanisms for patient and visitor interactions (eg, video-callapplications on cell phones or tablets)

Restrict routine visitation; all visitors need to be screened for fever and upper respiratory infectionsymptoms; do not enter the facility when ill

Restrict routine visitation for pediatric patients, limit to one parent who will stay with patient in PPEuntil testing negative, no other visitors

Visitation must be for a short amount of time, as appropriate, and based on urgent health, legal, orother issues that cannot wait until later

Perform frequent hand hygiene and follow respiratory hygiene and cough etiquette precautions whilein the facility, especially common areas

While visiting, limit surfaces touched and use PPE while in the patient’s room; only visit the patientroom; do not go to other locations in the facility; don’t present during aerosol-generating proceduresor other specimen collection procedures

Education, transmission-based precautions


Cooling-device application

Glucose management

Nonpharmacologic shivering management

Increase room temperature

Warm extremities with clothing

Warming blanket

Content

Transmission-based precautions

Perform hand hygiene before and after all patient contact, contact with potentially infectious material,and before putting on and after removing PPE, including gloves

Perform hand hygiene by using alcohol-based hand rub with 60% to 95% alcohol or washing handswith soap and water for at least 20 seconds; if hands are visibly soiled, use soap and water beforereturning to alcohol-based hand rub

Put on a respirator or facemask before entry into the patient room or care area; use N95 or higher-level respirators when performing or presenting for an aerosol-generating procedure

Put on eye protection upon entry to the patient room or care area; remove eye protection beforeleaving the patient room or care area

Put on clean, nonsterile gloves upon entry into the patient room or care area; change gloves if torn orheavily contaminated; remove and discard gloves when leaving the patient room or care area, andimmediately perform hand hygiene

Put on a clean isolation gown upon entry into the patient room or area; change the gown if soiled;remove and discard the gown in a dedicated container for waste or linen before leaving the patientroom or care area

Consider an observer for proper donning and doffing of PPE to minimize risk of self-contamination

Environmental decontamination

Once the patient has been discharged or transferred, refrain from entering the vacated room untilsufficient time has elapsed for enough air changes to remove potentially infectious particles

Routine cleaning and disinfection procedures are appropriate, including those patient-care areas inwhich aerosol-generating procedures are performed

Septic Shock, Risk of

Goals

Absence of septic shock signs and symptoms

Hemodynamically stable

Lactate, serum, within specified parameters

Interventions

Assessments

Fluid responsiveness assessment

Capillary refill

Skin temperature

Hemodynamic monitoring

Mean arterial pressure monitoring

Target MAP of 60 to 65 mm Hg by titrating vasoactive agents (eg, norepinephrine as the first line,vasopressin as second line if needed, DOBUTamine for cardiac dysfunction and persistenthypoperfusion despite fluid resuscitation and norepinephrine)

Serum lactate monitoring

For patients with sepsis, obtain blood lactate levels in first 3 hours; if initially elevated, remeasurewithin 6 hours

Education

Education, care goals

Address care goals within 72 hours of ICU admission


Cooling-device application

Infection control

Body position maintenance – shock

Elevate lower extremities 20 to 30 degrees

Maintain flat lying position

Maintain head in neutral position or turn to one side

Content

Fluid resuscitation

Avoid the routine use of albumin for initial resuscitation

Avoid using hydroxyethyl starches, gelatins, and dextrans

Use buffered/balanced crystalloids over unbalanced crystalloids

Use conservative over liberal fluid strategy

Use crystalloids over colloids

Extracorporeal membrane oxygenation management

Use venovenous ECMO for refractory hypoxemia despite optimizing ventilation, rescue therapies, andproning

Ensure optimal cannula positioning

Titrate blood flows and sweep gas flows to achieve oxygen and carbon dioxide targets

Do not change ventilator settings until adequate ECMO flows and gas exchange established

Monitor blood gases

Monitor aPTT or activated clotting time

Monitor for complications including abdominal compartment syndrome, acute kidney injury, bleeding,distal limb ischemia, hemolysis, infection, pulmonary edema, thrombosis

Regularly examine the circuit for air bubbles and clot formation

Venovenous ECMO weaning trial: For borderline patients, clamping cannulas for several hours beforeremoval; frequently or continuously flush cannulas with heparinized saline to prevent thrombosis

Venovenous ECMO weaning: Gradually turn down ECMO flow and FiO2 then turn off if tolerated

Cannula removal (venous site): Manual compression for at least 20 minutes following removal

Ventilator-Associated Event, Risk of

Goals

Absence of ventilator-associated events

Absence of secondary infection signs and symptoms

Interventions

Assessments

Mechanical ventilation weaning readiness assessment

Cough, effective

Gag reflex, present

Hemodynamically stable

Inspiratory effort initiation

Metabolic function, stable

Oxygenation, stable

pH, stable

Respiratory failure cause reversal

Sedation, interruption

Assess extubation readiness daily

Neuromuscular blockade monitoring

Train-of-four result

Avoid using peripheral nerve stimulation with train-of-four alone to monitor the depth ofneuromuscular blockade

Tracheal tube cuff pressure monitoring

Ventilator-associated event surveillance


Communication, physical therapy

Education

Education, mechanical ventilation weaning

Content

Education, venous thromboembolism prevention

Perform ankle and foot exercises

Use ankle pumps or intermittent pneumatic compression as prescribed


Acute respiratory distress syndrome management

Implement mechanical ventilation using lower tidal volumes (4 to 8 mL/kg predicted body weight)and lower inspiratory pressures (plateau pressure less than 30 cm H2O)

Use higher PEEP (instead of lower PEEP) for moderate or severe ARDS; monitor for barotrauma ifPEEP greater than 10 cm H2O

Avoid disconnecting the patient from the ventilator; use in-line catheters for airway suctioning andclamp endotracheal tube when disconnection is required (eg, transfer to a transport ventilator)

Periodic prone positioning during mechanical ventilation; 12 to 16 hours per day for moderate-to-severe ARDS

Use a conservative fluid management strategy if no tissue hypoperfusion

When needed, use intermittent boluses of neuromuscular blocking agents (over continuous infusion)to facilitate protective lung ventilation in moderate-to-severe ARDS; continuous infusion can be usedfor up to 48 hours for persistent ventilator dyssynchrony, persistently high plateau pressure, or proneventilation

Use recruitment maneuvers for hypoxemia despite optimizing ventilation; avoid the use of staircase(incremental PEEP) recruitment maneuvers

Artificial airway discontinuation

Avoid repeat endotracheal intubation

Clear secretions from above endotracheal tube cuff before cuff deflation or tube movement

Remove endotracheal tube as soon as clinical indications are resolved

Use spontaneous breathing trials and a weaning protocol for weaning

Artificial airway suction

Use a closed suctioning system; periodically drain and discard condensate in tubing

Early ambulation promotion

Eye care

Provide scheduled eye care (eg, lubricating drops or gel and eyelid closure) if receiving continuousinfusions of neuromuscular-blocking agents

Head of bed elevation

Elevate head of bed 30 degrees or more

Intermittent pneumatic compression initiation

Oral hygiene care

Apply mouth moisturizer to oral mucosa and lips every 2 to 4 hours

Brush teeth, gums, and tongue with soft toothbrush at least twice daily

Use chlorhexidine mouthwash twice daily

Oropharyngeal suction

Remove oral secretion prior to position change

Remove oral secretions prior to deflating endotracheal tube cuff

Position change

Change position every 2 hours

Sedation level management

Minimize continuous or intermittent sedation and target specific titration endpoints

Interrupt sedation daily

Choosing Wisely: Do not deeply sedate mechanically ventilated patients without a specific indicationand without daily attempts to lighten sedation

Stress ulcer prevention

Content

Tracheal tube cuff management

Maintain tracheal tube cuff pressure at greater than 20 cm water

Perform suctioning above cuff prior to deflating cuff


Sources

1. British Medical Journal: Covid-19: ibuprofen should not be used for managing symptoms, say doctorsand scientists: https://www.bmj.com/content/368/bmj.m10862. Centers for Disease Control and Prevention: Information for Healthcare Professionals: www.cdc.gov/coronavirus/2019-nCoV/hcp3. Centers for Disease Control and Prevention: Coronavirus Disease 2019 (COVID-19): www.cdc.gov/coronavirus/2019-ncov4. World Health Organization: Coronavirus Disease (COVID-19) Technical Guidance: www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance5. Infectious Diseases Society of America: COVID-19: What You Need to Know: www.idsociety.org/public-health/Novel-Coronavirus

Content

COVID-19

Anxiety/Stress

Goals

Absence of physiologic stress signs

Alleviation of anxiety

Interventions

Assessments

Anxiety characteristics assessment – patient/caregiver

Physiologic stress signs assessment


Communication, social services

Communication, spiritual care services

Education

Education, positive coping methods

Education, relaxation techniques

Breathing exercises

Mind-body interventions (eg, guided imagery, meditation, music therapy)

Pleasant activities

Positive visualization

Progressive muscle relaxation exercise


Coping support – patient/caregiver

Nonpharmacologic anxiety-relief provision

Communication about progress and status


Family presence

Massage

Music

Relaxation techniques

Spiritual support

Therapeutic touch

Use of calm voice

Fluid and Electrolyte Imbalance

Goals

Absence of imbalanced fluid volume signs and symptoms

Electrolytes within specified parameters

Interventions

Assessments

Blood pressure monitoring

Body weight monitoring

Electrolyte imbalance signs and symptoms assessment

Arrhythmia

Breathing, shallow

Lethargy

Level of consciousness, altered


COVID-19 - Starter Plan of Care (based on Admission to Med/Surg)

Content

Seizure

Tachycardia

Gastrointestinal symptom assessment

Education

Education, antiemetic therapy

Education, diarrhea self-management – dietary

Consume foods rich in potassium

Electrolyte supplementation (eg, oral rehydration solution, sports drinks)

Limit caffeine consumption

Limit consumption of milk and dairy products

Low-fat diet


Acute kidney injury prevention

Avoid nephrotoxic drug combinations

Avoid nephrotoxic drugs

Ensure adequate hydration

Hemodynamic optimization

Use caution with contrast media

Implement conservative IV fluid strategies in patients with acute respiratory infection when there is noevidence of shock

Infection

Goals

Absence of infection signs and symptoms

Absence of secondary infection signs and symptoms

Knowledge of infection prevention and control procedures

Interventions

Assessments

Adverse event risk assessment

Age, advanced

Cancer

Cardiopulmonary disease

D-dimer, high

Diabetes mellitus

Immunocompromise

Liver disease

Long-term care resident

Pregnancy


Sequential Organ Failure Assessment (SOFA) score, high

Infection surveillance

Sequential Organ Failure Assessment (SOFA) score


Communication, infection control

Education

Education, antibiotic therapy

Education, handwashing

Education, infection control

Content

Avoid touching bodily fluids



Follow infection control measures as directed

Follow isolation precautions as prescribed


Education, infection control – visitor

Limit visitation; use alternative mechanisms for patient and visitor interactions (eg, video-callapplications on cell phones or tablets)

Restrict routine visitation; all visitors need to be screened for fever and upper respiratory infectionsymptoms; do not enter the facility when ill

Restrict routine visitation for pediatric patients, limit to one parent who will stay with patient in PPEuntil testing negative, no other visitors

Visitation must be for a short amount of time, as appropriate, and based on urgent health, legal, orother issues that cannot wait until later

Perform frequent hand hygiene and follow respiratory hygiene and cough etiquette precautions whilein the facility, especially common areas

While visiting, limit surfaces touched and use PPE while in the patient’s room; only visit the patientroom; do not go to other locations in the facility; don’t present during aerosol-generating proceduresor other specimen collection procedures

Education, transmission-based precautions


Environmental decontamination

Once the patient has been discharged or transferred, refrain from entering the vacated room untilsufficient time has elapsed for enough air changes to remove potentially infectious particles

Routine cleaning and disinfection procedures are appropriate, including those patient-care areas inwhich aerosol-generating procedures are performed

Infection control

Single room (with door closed and a dedicated bathroom) is preferred for known or suspected COVID-19; if not feasible, cohort suspected and confirmed separately; maintain 2-meter distance betweenpatients

Minimize room transfers

Airborne Infection Isolation Rooms (AIIRs) reserved for patients undergoing aerosol-generatingprocedures

Limit transport and movement of the patient outside of the room to medically essential purposes; useportable radiograph equipment when needed

During transport, patients should wear a facemask to contain secretions or use tissues to cover theirmouth and nose

Standard precautions

Transmission-based precautions

Perform hand hygiene before and after all patient contact, contact with potentially infectious material,and before putting on and after removing PPE, including gloves

Perform hand hygiene by using alcohol-based hand rub with 60% to 95% alcohol or washing handswith soap and water for at least 20 seconds; if hands are visibly soiled, use soap and water beforereturning to alcohol-based hand rub

Put on a respirator or facemask before entry into the patient room or care area; use N95 or higher-level respirators when performing or presenting for an aerosol-generating procedure

Put on eye protection upon entry to the patient room or care area; remove eye protection beforeleaving the patient room or care area

Put on clean, nonsterile gloves upon entry into the patient room or care area; change gloves if torn orheavily contaminated; remove and discard gloves when leaving the patient room or care area, andimmediately perform hand hygiene

Content

Put on a clean isolation gown upon entry into the patient room or area; change the gown if soiled;remove and discard the gown in a dedicated container for waste or linen before leaving the patientroom or care area

Consider an observer for proper donning and doffing of PPE to minimize risk of self-contamination

Nutrition Deficit

Goals

Adequate nutritional intake

Interventions

Assessments

Indirect calorimetry

Nutritional intake assessment


Communication, dietitian

Education

Education, nutritional support


Nutrition provision

Respiratory Function - Impaired

Goals

Adequate oxygenation

Clear lung sounds

Reduced dyspnea

Interventions

Assessments

Respiratory distress signs and symptoms assessment

COVID-19 testing criteria: signs and symptoms compatible with COVID-19 (fever, cough, difficultybreathing)


Communication, respiratory therapy

Education

Education, dyspnea management

Cool face with fan

Durable medical equipment to limit exertion (eg, walker, bedside commode)

In seated position, bend forward slightly at waist while supporting upper body by leaning forearms ona table or the thighs

In standing position, lean forward and prop on a counter, etc.

Optimal breathing technique (eg, deep breathing, diaphragmatic breathing, pursed-lip breathing)

Progressive muscle relaxation

Education, energy conservation

Allow for rest periods

Avoid overhead activities

Avoid straining

Pace activities

Perform activities while sitting

Place items within reach

Schedule activities for periods with greater energy

Use assistive devices

Education, inhaler device technique

2019-novel coronavirus (2019-nCov), point-of-care measurement

Content

Education, secretion clearance techniques

Active cycle of breathing

Autogenic drainage

Directed cough

Forced expiratory technique

Consider airway clearance therapy only in patients with symptomatic retention of secretions, guidedby consideration of patient tolerance, preference, and effectiveness of the therapy


Hydration management

Inhaled medication management

Give inhaled medications by metered dose inhaler rather than nebulization

Use appropriate PPE if giving nebulized medications because of the risk for dispersion of aerosolizedvirus


Give supplemental oxygen immediately to patients with respiratory distress, hypoxemia, or shock

Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 93% or higher duringresuscitation; or use face mask with reservoir bag (at 10 to 15 L/min) if patient is in critical condition;once patient is stable, the target is greater than 90% SpO2 in nonpregnant adults and 92% to 95% inpregnant patients

For children, oxygen therapy during resuscitation should be targeted at SpO2 94% or higher;otherwise, the target SpO2 is 90% or higher; use of nasal prongs or nasal cannula is better toleratedin young children

Use high-flow nasal cannula (over NIPPV) for acute hypoxemic respiratory failure despite conventionaloxygen therapy; monitor closely for worsened respiratory status

Caution when using high-flow nasal oxygen because of the risk for dispersion of aerosolized virus inthe healthcare environment with poorly fitting masks

Supplemental humidification

Noninvasive ventilation initiation

Consider NIPPV for acute hypoxemic respiratory failure if high-flow nasal cannula is not available andwithout urgent indication for endotracheal intubation; monitor closely for worsened respiratory failure

Caution when using noninvasive ventilation because of the risk for dispersion of aerosolized virus inthe healthcare environment with poorly fitting masks

If BiPAP is used, a viral filter should be placed in-line with the exhalation tubing to reduceenvironmental contamination

Oral hygiene care

Transition Readiness

Goals

Able to safely transition to next level of care

Knowledge of care transition plan

Participation in care planning

Interventions

Assessments

Discharge-to-home readiness assessment

Able to home isolate

Acute illness, resolved

Chronic medical condition, stable

Home environment, suitable

Secondary transmission risk, household members, low

Healthcare knowledge assessment


Content

Hospital discharge coordination

Community liaison nurse

Community resources

Follow-up appointment

Follow-up test

Education

Education, fever management

For fever, take acetaminophen

Education, infection prevention



Maintain isolation at home if discharged before transmission-based precautions are discontinued


Remain current with vaccinations

Ingest food with key nutrients (including vitamins C, D, E; selenium; zinc)

Manage chronic conditions

Manage stress

Education, postdischarge follow-up

Education, prescribed medication

Education, when to call provider

Confusion

Cough up thick, dark, or blood-stained sputum

Discharge medication, interaction

Discharge medication, side effect

Painful breathing

Persistent fevers

Shortness of breath

Weakness

Weight loss

Worsening respiratory symptoms


Sources1. British Medical Journal: Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists: https://www.bmj.com/content/368/bmj.m10862. Centers for Disease Control and Prevention: Information for Healthcare Professionals: www.cdc.gov/coronavirus/2019-nCoV/hcp3. Centers for Disease Control and Prevention: Coronavirus Disease 2019 (COVID-19): www.cdc.gov/coronavirus/2019-ncov4. World Health Organization: Coronavirus Disease (COVID-19) Technical Guidance: www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance5. Infectious Diseases Society of America: COVID-19: What You Need to Know: www.idsociety.org/public-health/Novel-Coronavirus

covid-19 · 2020-04-01 · diet diet, regular npo tube feeding iv fluids use conservative iv fluid...

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