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Chapter 24 Coordinating Care for Patients With Infectious Respiratory Disorders
Many COVID-19 patients have a complete recovery within several weeks. Others, including those who had mild symptoms, will experience continued or recurring symp- toms lasting for months. These chronic and ongoing issues have been termed “post-COVID syndrome” and “long COVID.” Common reported problematic and sometimes debilitating symptoms have been extreme fatigue, altered concentration, insomnia, recurrent fevers, shortness of breath, and chronic cough. Nursing Management Assessment and Analysis Patients with COVID-19 can vary greatly in presentation. Some patients see a healthcare provider due to concern for exposure; other patients are brought in by emergency med- ical personnel after losing consciousness in the field due to hypoxemia and or hypercarbia. In general, a patient who develops serious infection will develop dyspnea in approx- imately 5 days after onset of symptoms, and that dyspnea may get worse until it peaks at about 10 days after onset of symptoms. This is when many patients require intubation and ventilator support. Nursing Diagnoses/Problem List l Ineffective breathing pattern related to dyspnea l Ineffective airway clearance related to increased production of mucus l Impaired gas exchange: secretion accumulation within alveoli and atelectasis l Altered thermoregulation related to inflammatory process l Altered activity tolerance related to hypoxia l Anxiety related to isolation, knowledge deficit, and powerlessness Nursing Interventions ■ Assessments l Vital signs Tachypnea: first compensatory mechanism in response to decreased oxygen delivery. Tachycardia: second compensatory response to a continued impairment in oxygen delivery. Decreased oxygen saturation: decreased gas exchange at the alveolar level results in hypoxia. Increasing oxygen delivery requirements to maintain saturation goal is a COVID-19 danger sign and indicates need for advanced airway place- ment and mechanical ventilation. l Neurological function Restlessness, agitation, and anxiety result from decreased per- fusion. Lethargy signals carbon dioxide retention. l Breath sounds Wheezing from inflammation and bronchospasm, rhon- chi and rales from accumulation of alveolar exudates, and diminished breath sounds from development of atelectasis, effusion, or pneumothorax. l Peripheral pulses, skin temperature and color Hypercoagulable state can cause loss of peripheral pulses, increased edema, and cyanosis.
l Laboratory testing • COVID RT-PCR test
A positive test indicates COVID-19 infection. A negative test requires further evaluation of patients’ presentation, history, and clinical trajectory. • Blood, sputum, and urine cultures To evaluate for presence of concurrent bacterial infection. • Arterial/venous blood gases Acute respiratory infections will cause an initial respira- tory alkalosis and progress to respiratory acidosis. ■ Actions l Initiate airborne, contact, and droplet isolation (see Table 24.4). Include clear visible signage outside of patient’s room indi- cating “Airborne/Droplet/Contact Isolation” and necessary donning/doffing procedures before entering patient room. l Oxygen administration Administer lowest oxygen percentage to maintain goal satu- ration between 92% and 96%. l Administration of antivirals Antivirals are indicated in treatment. Monitor for adverse and infusion-related effects. l Pulmonary hygiene Mask wearing when staff or visitors are in patient’s room and if travel outside negative pressure room is required. Cover mouth and nose when sneezing. Proper disposal of infected tissues and respiratory equipment. l Patient positioning Semi- to high Fowler’s to optimize lung expansion and relieve dyspnea. Prone positioning (if tolerated) can improve oxygenation by recruitment of alveoli in dependent portions of the lungs. l Closely monitor intake and output. Strict monitoring of intake and output avoids volume overload/deficit that can increase oxygen demands and result in end-organ dysfunction. Fever, tachypnea, and tachycardia contribute to excess fluid losses and can lead to dehydration resulting in decreased cardiac output, hypotension, and lowered end organ perfusion. A minimum target for urinary output is 0.5 mL/kg/hr. l Ensure adequate nutritional support. Delivery of adequate caloric needs is necessary to facilitate healing and maintain energy levels needed for rehabilitation. l Clustering patient care activities Conserve patient energy and moderate metabolic demands. ■ Teaching l Quarantine guidelines Due to spread of COVID-19, it is important that the patient and family understand and adhere to the specific restrictions related to this disease process. l Infection control measures Washing hands, wearing mask in public, self-isolation at home when infected, early testing for any respiratory symptoms.
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