Clinical nursing care of a nurse diagnosed with COVID?19 in Wuhan Union Hospital

BING-RuI WEI, DIAN FRANcIs SAVELLANO,CHANG-SHENG ZHANG, CuI-HuAN HU

1School of Nursing; 2Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

ABSTRACT

The coronavirus disease (COVID?19) has claimed thousands of lives.The patients have been quarantined and treated in special shelter hospitals,and mild illness accounts for the majority of the total number of patients.This article reports one case of the first batches of infected medical staff, who got infected with 2019 novel coronavirus and later discharged 2 weeks after receiving treatment and nursing care in Wuhan Union Hospital.Considering all aspects of the patient’s hospitalization, the patient was performed ward environment management, medical nursing,symptomatic treatment, nutrition management, vital signs monitoring, observation and nursing, psychological assessment and support, and infection protection and management.As the earliest successful case of cure, the patient’s manifestations are classical and common.Moreover,we hope to share it with colleagues to fight against COVID?19 for reference.The treatment and nursing guidelines can be applied to treat a large number of mild cases, thus improving the discharge rate of patients and reducing the pressure of epidemic situation.

Keywords: Clinical nursing care, coronavirus disease, environment management, symptomatic treatment

INTRODUCTION

Till April 30, 2020, the coronavirus disease (COVID?19)has caused 84,373 cases in China.[1]To date, our medical knowledge on how to deal with disease is still limited.[2]Treatment mainly focuses on the improvement of the immunity of an individual and the application of palliative treatment.Those who are infected receive appropriate care to relieve and treat the symptoms and are performed with optimized supportive care.From the beginning of January to the end of April 2020, 78,787 cases have been treated and cured in the shelter hospitals and the cure rate of COVID?19 in China reached more than 94%.[1]Early intervention for symptomatic treatment of patients with mild diseases is effective.The focus of treatment and nursing is to prevent the conversion of mild diseases to severe diseases and promote the rehabilitation of patients with mild diseases.[3]This article presents the detailed contents of clinical nursing intervention and treatment for the patient with mild COVID?19 and analyzes and discusses how to enhance the treatment efficiency.

CASE PRESENTATION

The patient is a 32?year?old male, married, working as a nurse in Wuhan Union Hospital.He had no preexisting medical conditions.On January 17, 2020, he complained of fatigue, body pain, and intermittent fever for 2 days.Whenever his temperature went up to around 38.5°C, he took antipyretic drugs.He sometimes successfully brought down the temperature to around 37°C.Worried about his medical condition, he submitted himself for a physical checkup and other assessments necessary to understand what his body was going through.Unfortunately, his chest X?ray and computed tomographic (CT) scan showed abnormal spots which suggested pneumonia.His respiratory specimen pathogen nucleic acid test showed positive for 2019 novel coronavirus (2019?nCoV).The patient was admitted on January 19, 2020.He was previously healthy and had no history of allergy.He had clear consciousness, no nasal congestion or runny nose but dry cough, inflammatory uvula, coarse breath sounds in lungs, no dry or moist rales, or chest tightness, and no nausea or vomiting upon admission.The heart and abdomen were unremarkable.

During the hospitalization, the lungs and the immune system were closely monitored.A summary of the chest CT scans and the blood examinations is shown in Figure 1 and Table 1.The patient was given phentermine tablets (8 mL, TID) for 3 days to relieve hyperthermia.The patient was given moxifloxacin hydrochloride tablets (0.4 g, QD)to manage bacterial infection until discharged.Since there are few known efficient medicines for the 2019?nCoV,oseltamivir phosphate tablets (75 mg BID) for 5 days and abidol tablets (0.2 g TID) as an antivirus drug were given until discharged.Oseltamivir phosphate and abidol were used to treat respiratory virus infection.Five million IU of interferon?α added to 2 mL normal saline was given twice a day through nebulization.Interferon?α is a potent drug that can combat viral infection.

Figure 1: Computed tomography scans of the chest of the patient.(a)On January 17, 2020, computed tomography showing the increase and thickening of lung markings in both lungs, high?density plaque shadow in the right middle lung, high?density nodular shadow in the right superior lung with calcified and clear border, 0.7 cm in diameter.(b) On January 22, 2020, computed tomography showing multiple patchy shadows in the middle lobe of the right lung and inferior lobes of the both lungs.(c) On January 26, 2020, computed tomography showing that the infectious lesions in both lungs were increased compared with before.(d) On January 31,2020, computed tomography showing that the infectious lesions in both lungs were similar compared with before with reduced density absorption

Table 1: Laboratory results of the patient during hospitalization

The patient was offered eucalyptus lemongrass enteric soft gel as an expectorant.On the 3rdday of hospitalization,alpha?interferon inhalation (2 mL bid) was given via nebulization.Alpha?interferon is a potent drug that can combat viral infection and can improve the immune system.

On February 6, 2020, the patient was discharged.The doctor prescribed oral bicyclic tablets (25 mg tablets, TID) as a supplement to protect liver function due to the amount of drugs taken during hospitalization.The patient was tested twice for 2019?nCoV and it all showed normal results, and symptoms improved significantly.

Nursing interventions

Ward environment management

Wards were divided into different areas depending upon the severity of the case.Patients with different levels of illness were managed separately.[4]To maintain fresh air in the ward,the windows were left open for at least 2 or 3 times a day for around 30 min each time.[3]The patient’s room was kept clean and tidy, the warmer was turned on for a while to keep the room warm, but the central air?conditioning system was not suggested, for this will only promote the transmission of the disease.With a temperature of 25°C and a humidity of 50%–60%, the patient felt comfortable.

A quite environment was kept to promote rest and recovery.[4]Sufficient sleep and rest promote faster recovery.Reduced activity can promote further healing of the damaged tissues.Appropriate exercise can promote blood circulation that can supply oxygen to affected areas, thus avoiding development of ulcer.The patient is ambulatory;henceforth, he can do some simple exercises to promote blood circulation.

Disinfection is strictly implemented.1000 mg/L chlorine?containing disinfectant or 75% alcohol is used to disinfect objects and the floor.[4]If no one was around,circulating air disinfection equipment was used for indoor air disinfection.The patient ate alone and was instructed to use disposable tableware.If the patient needed to use reusable wares, we advised that the utensils must be disinfected using boiling water for at least 15–30 min.

Proper hygiene is also promoted.The patient was advised to be hospitalized with bathroom privileges.Frequent hand washing is advised; in addition, hot foot baths are promoted to promote blood circulation.The patient was advised to keep a distance of at least 1 m and to wear a mask when talking.The mask and the distance are important since the virus can be airborne and can be transmitted through droplets.

Medical nursing

Administration of medicine in a timely fashion with proper dosage and observation of any adverse effects are all important.The positive and possible adverse effects of all the prescribed drugs were explained to the patient for further understanding.The patient was advised to report any discomfort.Due to the potency and the number of drugs taken by the patient, oral bicyclic tablets were prescribed to promote liver function.[5]Alpha?interferon inhalation was also prescribed.The patient was thought how to properly inhale the mist during the procedure for efficiency.Immediately after the treatment, the patient’s facial skin was cleaned to keep the integrity of the skin.[6]

臨床中的多層螺旋CT可以快速成像進行大范圍的掃描,在胸外科中具有重要的應用,但是臨床中使用CT檢查容易引起輻射,常規(guī)劑量CT掃描時90~180張胸部X線平片的劑量,CT的應用較廣泛,因此輻射量也會增加?，F(xiàn)在對于輻射的防護意識強,CT檢查的輻射危害也引起了大家的關(guān)注,因此為了提升圖像質(zhì)量,放射科應該要想辦法降低輻射劑量[6]。

Symptomatic treatment

In the event of hyperthermia, tepid sponge bath and cooling gel sheets were applied.If the temperature is high, the patient was given antipyretic drugs as per the doctor’s advice to manage fever.Hyperhidrosis, chills, and body temperature were closely monitored.[4]Dehydration due to fever is also watched out, which sometimes will lead to hypotension, so fluid intake is increased at the occurrence of fever.

The oxygen is administered as per the doctor’s order if the patient suffers from difficulty in breathing, low oxygen saturation, and any signs of respiratory distress and hypoxemia.[7,8]During oxygen administration, whether the patient’s pulse, blood pressure, mental state, and skin color have improved was observed, and the oxygen concentration was adjusted in time.For continuous nasal catheter oxygen administration, the nasal catheter was replaced more than 2 times a day, bilateral nostrils were intubated alternately,and nasal secretions were clear in time to prevent nasal catheter blockage.[3]

As per the doctor’s advice, montmorillonite powder was administered orally if the patient had diarrhea.It can not only relieve the diarrhea but also maintainin vivomicro?ecological balance.When the patient continuously experiences diarrhea, the nurse would closely observe the amount, color,quantity, and character of stool, timely take stool samples for detection, closely observe whether diarrhea has improved,and do a good job in distinguishing diarrhea caused by drugs.Because the patient has lost much body fluid, it is necessary to add oral rehydration salt to avoid dehydration.Semi?liquid food with low?residue, low?fat, easy?to?digest,and low?cellulose liquid food was given to the patient; raw and cold food was avoided to reduce intestinal peristalsis.The patient’s abdomen was kept warm by hot compress to relieve diarrhea accompanied by abdominal pain.Because of frequent defecation that can lead to impaired perianal skin, gentle wiping of the anus with soft tissue paper every time after defecation and cleaning the perianal area with warm water are suggested.Body pain is also a symptom of COVID?19, rest in frequently changed positions and warm baths were advised promote relaxation of the tensed muscles.[7]

Nutrition management

To prevent the disease from deteriorating, it is very important to maintain the patient’s strong immunity against the virus.Diet management enables patients to take in sufficient nutrition, restore the functions of various organs, and enable the immune system to generate sufficient antibodies to resist infection.[4]The nutrition department of the hospital has designed a nutrition package for patients with COVID?19.The patient was given a high?calorie, high?protein, high?vitamin diet.[4]When the patient has high fever and poor appetite,contact the dietary center in time to prepare liquid foods or fresh fruits such as vegetable soup, porridge, and milk for the patient, which can supplement water, vitamins,proteins, etc., to ensure the nutrition of the patient and promote the early recovery of the body.Food rich in Vitamin C, such as vegetables and fruits, especially tomatoes, apples,and oranges, were suggested to eat; Vitamin C tablets and zinc oral tablets are also suggested.High?fluid intake was advised to dilute sputum and to balance the lost fluid during episodes of hyperthermia.

Vital signs monitoring, observation, and nursing

Heart and kidney injuries are the most frequently attacked parts of 2019?nCoV, except lung, so protecting heart and kidney function is an effective means to prevent mild diseases from turning into severe diseases and is also the key to cure.Nurses would regularly detect and monitor patients’ mental state, cardiac function, and changes in salt and electrolyte and would be alert to changes in illness and take appropriate measures.[4]The vital signs of the patient were closely monitored: Body temperature, the depth and rhythm of breathing, and oxygen saturation were closely monitored.The medical team also paid attention to the patient’s consciousness, episodes of cough, and its discharges, if there are any chest tightness, dyspnea, and cyanosis.Blood routine examinations, urine examinations,C?reactive protein, biochemical index (liver enzyme,myocardial enzyme, renal function, etc.), coagulation function, arterial blood gas analysis, chest imaging, etc.,are monitored according to prognosis of the condition.The results of the patient’s blood examination showed that the number of white blood cells in the peripheral blood decreased and the number of lymphocytes decreased.This is because the immune cells in the body will respond to the virus infection and will be consumed in large quantities.[9]Bedsores are caused by long?term bed rest; ambulation was advised to prevent any instances of ulceration.Dyspnea and hypoxemia are the common causes of death related to 2019?nCoV.[8,10]Patients with immune compromised diseases, with chronic diseases, and with old age are more susceptible of contracting the disease.Mortality rate is high if the disease is not managed at the beginning.Preventing and detecting any complications at the onset of this virus, giving medical care at a timely manner, and implementing proper care will definitely increase the chances of survival.[4]

Since 2019?nCoV is a new strain of virus, there is no symptomatic treatment, and it has caused great panic among the masses.Isolation is also a factor that adds more problems on the mental state of the patient; it adds fear, loneliness,and sleeping disorders to name a few.[3]

It is vital to assess the patients’ psychological conditions.Proper interventions when the patient is feeling any psychological disorder can promote a positive attitude toward the current situation.Building confidence by providing information and news regarding the research and development of a cure, the patients’ prognosis, and by listening to his concerns can possibly eliminate or at least reduce anxiety and promote peace of mind.[8]

Infection protection and management

During hospitalization, the patient was required to wear a mask.Strict isolation was promoted and visitation was prohibited.All wastes were instructed to be disposed of properly.The patient’s respiratory tract secretions and blood samples that were collected are properly disposed of using a three?level protection technique.The respiratory secretions,excreta, and vomit of the patient were managed separately;these wastes are not exposed and transferred by special personnel.These wastes are treated as medical waste and handled strictly with double?layer packaging, and the outside of the packaging was clearly marked, sealed, and disposed of.Proper sterile techniques are strictly followed.[3]

CONCLUSION

In nursing practice, the case of the patient turned for the better, proving that the skills of nurses in how to nurse and manage, prevent, and treat mild patients with COVID?19 are becoming favorable for reducing the pressure of epidemic situation.Nurses have professional responsibilities to constantly think about nursing quality, which relate to the recovery of patients and prevention from getting worse.Moreover, contents in regard to analyze and discuss how to improve and enhance the nursing interventions efficiency need to be emphasized.While we still need to know more about the virus, people in the older age group, people with preexisting medical conditions such as diabetes and heart diseases, and immune compromised patients are also required more attention in clinical nursing.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent.In the form, the patient has given his consent for his images and other clinical information to be reported in the journal.The patient understands that his name and initial will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Acknowledgments

The authors would like to thank the patient for providing us with his signed written informed consent for publication of this case study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.