ASU Nursing Care of the ICU Patient
with COVID-19
Subject
Person
NCM 120 RLE
Shawnrick Lloyd Yacapin
RESUSCITATION OF THE PATIENT WITH CONFIRMED OR
SUSPECTED COVID-19 (AHA, 2020)
Reduce Exposure
Before entering the scene, all rescuers should don PPE
Only essential personnel should be in the room
Use mechanical CPR devices instead of manual CPR when available
Communicate the patient's COVID-19 status to providers before arriving to the scene or when
transferring the patient
Reduce Aerosolization Risk
Attach a HEPA filter to any manual or mechanical ventilation device
Pause chest compressions to intubate
Reduce risk of failed intubation attempts (eg. use video laryngoscopy, assign provider with
best chance of first-pass intubation)
Minimize disconnections from the closed circuit
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Use HEPA filter on supraglottic airway or BVM if unable to intubate
Consider Appropriateness of Starting and Considering Resuscitation
Address goals of care in anticipation of potential need for increased levels of care
Lay Rescuers
Perform at least hands only CPR in adults
Consider mouth to mouth ventilation in children
Use face cloth or mask of rescuer and victim
EMS
Family members not to ride with patient to hospital
Consider not transferring patient to hospital if ROSC is not achieved
In-Hospital Cardiac Arrest
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Address advanced care directives and goals of care with all confirmed or suspected COVID-19
patients and with any patients with significant change in clinical status
Closely monitor for signs of clinical deterioration
Patients at risk for cardiac arrest- move to negative pressure room if possible
Close patient's door
For intubated patients, consider leaving patient on mechanical ventilator with HEPA filter
Patients without an advanced airway: place supine for resuscitation
Patients with an advanced airway: consider performing CPR prone and placing defibrillator pads
in the anterior/posterior position
Contact infection control after resuscitation
APPROPRIATE DONNING AND DOFFING OF PPE
Review the CDC Guidelines: https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.htmlLinks to
an external site.
Donning PPE (CDC, 2020)
1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on
training).
2. Perform hand hygiene using hand sanitizer.
3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other
healthcare personnel.
4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a
respirator is not available). If the respirator has a nosepiece, it should be fitted to the
nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand.
Respirator/facemask should be extended under chin. Both your mouth and nose should be
protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between
patients.
Respirator: Respirator straps should be placed on crown of head (top strap) and base of
neck (bottom strap). Perform a user seal check each time you put on the respirator.
Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom
tie). If mask has loops, hook them appropriately around your ears.
5. Put on face shield or goggles. Face shields provide full face coverage. Goggles also provide
excellent protection for eyes, but fogging is common.
6. Perform hand hygiene before putting on gloves. Gloves should cover the cuff (wrist) of gown.
7. Healthcare personnel may now enter patient room.
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Doffing PPE (CDC, 2020)
1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves
can be removed using more than one technique (e.g., glove-in-glove or bird beak).
2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than
untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and
carefully pull gown down and away from the body. Rolling the gown down is an acceptable
approach. Dispose in trash receptacle.
3. Healthcare personnel may now exit patient room.
4. Perform hand hygiene.
5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap
and pulling upwards and away from head. Do not touch the front of face shield or goggles.
6. Remove and discard respirator (or face mask if used instead of respirator). Do not touch the
front of the respirator or facemask.
Respirator: Remove the bottom strap by touching only the strap and bring it carefully over
the head. Grasp the top strap and bring it carefully over the head, and then pull the
respirator away from the face without touching the front of the respirator.
Facemask: Carefully untie (or unhook from the ears) and pull away from face without
touching the front.
7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if
your workplace is practicing reuse.
Donning and Doffing Guidelines: Documents from the CDC
General PPE Considerations for COVID-19 per the CDC (2020)Download General PPE Considerations
for COVID-19 per the CDC (2020)
Donning and Doffing PPE per the CDC (2020)
BEST PRACTICS AND RECOMMENDATIONS FOR CARE OF THE
CRITICALLY ILL COVID-19 PATIENT
Here is a summary of best practices and recommendations based on strong evidence from Surviving
Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease
2019 (COVID-19) (Waleed et al., 2020)Links to an external site.
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Best Practices
1. Recommended use of a fitted respirator mask (N95, FPP2 or equivalent)
2. Aerosol-generating procedures should be conducted in a negative pressure room
3. For patients requiring endotracheal intubation, the most experienced healthcare professional
should intubate the patient to minimize number of attempts
4. For adults with COVID-19 receiving Non-Invasive Positive Pressure Ventilation (NIPPV) or High
Flow Nasal Canula (HFNC), recommend close monitoring for worsening of respiratory status and
early intubation in a controlled setting if worsening occurs.
Recommendations Based on Strong Evidence
1. Acute resuscitation of adults with COVID-19 and shock, recommend against use of hydroxyethyl
starches
2. Recommend against use of dopamine if norepinephrine is available
3. Recommend starting supplemental oxygen if SpO2 is <90%
4. Recommend that SpO2 be maintained no higher than 96% in adult patients with with COVID-19 and
acute hypoxemic respiratory failure on oxygen.
5. In mechanically ventilated patients
Recommend using low tidal volumes (4-8mL/kg) over high tidal volumes
Recommend against using staircase (incremental PEEP) recruitment maneuvers
If they have ARDS: recommend target plateau pressures (Pplat) of <30cmH20
If they have moderate to severe ARDS: suggest higher PEEP (>10cmH20) over lower PEEP
Clinical Tips for Care of the COVID-19 Patient (CDC, 2020)
Review the entire document here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-tips-forhealthcare-providers.htmlLinks to an external site.
Highlights/Key Points Relevant to Nursing Care (CDC, 2020):
1. Non-respiratory symptoms of COVID-19: Nausea, diarrhea, neurological symptoms (anosmia, loss
of sense of taste/smell, headache)
2. CDC recommends that CT scans not be used as first line for screening
3. Co-infection with other viruses and bacterial pneumonia have been reported
4. Patients may deteriorate rapidly one week after symptom onset
5. Median time to ARDS ranges from 8-12 days
6. Lymphopenia, neutrophilia, elevated serum alanine aminotransferase and aspartate
aminotransferase levels, elevated lactate dehydrogenase, high CRP, and high ferritin levels
may be associated with greater severity of illness
7. Patients may present in a prothrombotic state
8. Use of Remdesivir should be reserved for severe cases of COVID-19 (SpO2 <94% on RA,
supplemental oxygen, mechanical ventilation, or ECMO) and not currently recommended for use
in mild or moderate cases outside of a clinical trial.
The CDC is continually updating clinical guidelines. Click here to
review: https://covid19treatmentguidelines.nih.gov/whats-new/Links to an external site.
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What else should the ICU nurse consider when caring for a patient
with COVID-19?
Cluster care: objective is to coordinate required tasks to be completed simultaneously. This
allows for reduction in PPE usage and exposure time.
Plan ahead- anticipate needs
Limit number of staff entering the patient room to only essential personnel
Avoid unnecessary entries into the patient's room
Ensure that you have all necessary equipment and supplies prior to entry
Try to cluster tasks into one entry, for example:
Complete patient assessment
Administer scheduled medications
Change IV tubing if indicated
Collect lab specimens if indicated
Complete I's & O's
Verify VTBI on the IV pump for continuous infusions and plan accordingly
Free COVID-19 Related Courses Offered by the American Nurses
Association:
How to Survive the Pandemic with An Unbroken Spirit: Actions to Take Right Now to Stay Strong
and Focused
How to Respond to Ethical Challenges and Moral Distress during the COVID-19 Pandemic
Be Confident Protecting Yourself and Providing the Best Care to Your Patients during this
COVID-19 Pandemic: Focus on PPE
Click here to sign up: https://event.on24.com/eventRegistration/EventLobbyServlet?
target=reg20.jsp&referrer=https://wcc.on24.com/webcast/groupregistration/2363573&eventid=2363573&s
to an external site.
Caring for Covid-19 Patients: Disease Progression and Nursing Interventions You Need to Know
Click here to sign up: https://event.on24.com/eventRegistration/EventLobbyServlet?
target=reg20.jsp&referrer=&eventid=2455061&sessionid=1&key=0771B67174DBDF6DC87DB3BB8F4B4303&regTag
to an external site.
American Nurses Association COVID-19 Resource Page:
https://www.nursingworld.org/practice-policy/work-environment/health-safety/disasterpreparedness/coronavirus/Links to an external site.
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