This document discusses the nursing management of critically ill patients with COVID-19. It begins with definitions of critical illness and critical care nursing. It describes the transmission and clinical features of COVID-19. It then discusses the indications for intensive care unit (ICU) admission, principles of ICU management, and the nursing processes involved in caring for critically ill COVID-19 patients. These include admission assessment, monitoring, respiratory support, and implementing infection control measures while providing comfort and communication. Modifications for COVID-19 patients include use of personal protective equipment and private rooms due to the risk of virus transmission.

1. CARE OF CRITICALLY ILL
PATIENTS WITH COVID-19
PRESENTED BY:
CHINGAKHAM BABITA DEVI
FACULTY COLLEGE OF
NURSING
UPUMS, SAIFAI, ETAWAH

2. CONTENTS
1. INTRODUCTION
2. DEFINITION
3. TRANSMISSION
4. CLINICAL FEATURES
5. WHAT ARE THE CONDITIONS CONSIDERED AS CRITICAL?
6. INDICATION FOR ICU ADMISSION
7. CLASSIFICATION OF CRITICAL CARE PATIENTS
8. GUIDING PRINCIPLES
9. ICU MANAGEMENT
10. PROCESS OF NURSING MANAGEMENT
 Admission & Orientation of the patient to ICU
 Quick check assessment in CCU/ICU
 Physical assessment in CCU/ICU
 Assessment of the patients & planning for patient care in CCU/ICU
11. NURSING MANAGEMENT OF CRITICALLY ILL PATIENT
12. CARING FOR CRITICALLY ILL PATIENTS WITH COVID-19
13. USUAL CRITICAL CARE
14. MODIFICATIONS TO USUAL CRITICAL CARE
15. BIBLIOGRAPHY

3. • There are 7 different strains of Corona Virus.
• (229E alpha, NL 63–Alpha, OC43 – beta, HKU1- beta, MERS-
cov-beta, SARS-Cov-beta & SARS-Cov-2- novel.)
• SARS-Cov-2 previously referred as 2019-ncov
• It is a SS RNA Virus, with size 120 nm.
• In Feb 2020 WHO designated the disease as covid-19 (Corona
Virus Disease 2019).
INTRODUCTION

4. • Initial reports suggest that COVID-19 is associated with severe
disease that requires intensive care in approximately 5% of
proven infections.
• critical care will be an integral component of the global
response to this emerging infection.
• The rapid increase in the number of cases of COVID-19 in
Wuhan, China, in late 2019 highlighted that how quickly health
systems can be challenged to provide adequate care.
CONTD…

5. NURSING
CRITICAL
CARE
UNITS
CRITICAL
CARE
NURSING
CRITICALLY
ILL
PATIENTS

6. DEFINITION
CRITICALLY ILL PATIENTS: Critically ill patients are
those who are at risk for actual (or) potential life
threatening health problems.
CRITICAL CARE NURSING: It is the field of nursing with
a focus on the utmost care of the critically ill (or) unstable
patients.
CRITICAL CARE UNITS: CCUs or Intensive care units
(ICUs) are designed to meet the special needs of acutely
and critically ill patients.

7. Virginia Henderson, 1968
SO WHAT IS IT TO BE A
NURSE?

8. Covid -19 is Transmitted -
• Mainly by droplet – cough, sneeze or talk.
• Droplet direct contact with mucus membrane
• Droplets don’t travel more than 6 feet.
• Virus persist for longer time in faces and urine.
TRANSMISSION

9. • Incubation period : 2-14 days, most cases within 5 days.
• Spectrum of illness: Most – self limiting
• Mild Illness : 80 – 82 %
• Severe Illness: 14 – 15 %
• (Dyspnea – RR > 30/ min, Hypoxemia – SpO2 < 93% PaO2 / FiO2
<300, >50% lung involvement on imaging within 24-48 hours )
• Critical disease : 4-5% (respiratory failure, Septic shock, MODS)
• Overall case fatality: 2.3 - 5%.
CLINICAL FEATURES

10. WHAT ARE THE CONDITIONS
CONSIDERED AS CRITICAL?
1. Any person with life Threatening condition
2. Patients with :
 Acute respiratory failure
 Acute myocardial infarction
 Cardiac tamponate
 Severe shock

11.  Heart block
 Acute renal failure
 Poly trauma
 Multiple Organ failure and
 Organ Dysfunction
 Severe burns
CONTD…

12. INDICATION FOR ICU
ADMISSION
In covid -19 cases criteria for admission to ICU includes
either one major criteria or three or more minor criteria.
MINOR CRITERIA
 Respiratory rate > 30 breaths per minutes.
 Confusion/disorientation
 Leukopenia (WBC count, 4000 cells/ml) Thrombocytopenia
(platelet count, 100,000/ml)
 Uraemia (blood urea nitrogen level >20mg/dl)

13. CONTD…
 Multi-lobar infiltrates.
 Hypotension requiring fluid resuscitation.
 Hypothermia 36.8 degree Celsius
 PaO2 < 50 mm hg on room air / SpO2 < 90% on
supplemental oxygen of 6 liter per min.
MAJOR CRITERIA
 Need for mechanical ventilation
 Need for vasopressors

14. CLASSIFICATION OF CRITICAL
CARE PATIENTS
 Level O : Normal acute ward care.
 Level 1: acute ward care, with additional advice and
support from critical care team.
 Level 2 : More observation or intervention, single failing
organ or post operative care
 Level 3: Advanced respiratory support alone, or basic
respiratory support and multi-organ failure.

15. GUIDING PRINCIPLES
1. Delivery of optimal and appropriate care
2. Relief of distress
3. Compassion and support
4. Dignity
5. Information
6. Care and support of relatives and caregivers

16. ICU MANAGEMENT
1. Initial Resuscitation (sepsis or septic shock)
2. Vasoactive medications ( nor epinephrine, vasopressin
or epinephrine, dopamine)
3. Blood products ( RBC transfusion when Hb decreases
i.e, < 7.0 g/dl )
4. Mechanical ventilation (if respiratory condition is
worsening)
5. Glucose control (target <180mg/dl and fasting
<110mg/dl)
6. Nutrition (early initiation of enteral feeding )

17. PROCESS OF NURSING
MANAGEMENT

18. ADMISSION & ORIENTATION
OF THE PATIENT TO ICU
CCU or ICU Orientation to patient & family members.

19. ADMISSION QUICK CHECK
ASSESSMENT IN CCU/ICU
General appearance : (consciousness) .
Airway: Patency Position of artificial airway (if present)
Breathing: Quantity and quality of respirations (rate,
depth, pattern, symmetry, effort, use of accessory
muscles) Breath sounds Presence of spontaneous
breathing.

20. CONTD…
Circulation and Cerebral Perfusion: ECG (rate, rhythm,
and presence of ectopy) Blood pressure Peripheral
pulses and capillary refill skin, color, temperature,
moisture. Presence of bleeding Level of consciousness,
responsiveness.

21. CONTD…
Past Medical History
Medical conditions, surgical procedures
Psychiatric/emotional problems
Hospitalizations
Medications (prescription, over-the-counter,
illicit drugs) and time of last medication dose
Allergies
Review of body systems

22. PHYSICALASSESSMENT IN
CCU/ICU
Nervous system
Cardiovascular system
Respiratory system
Renal system
Gastrointestinal system
Endocrine
Hematologic
Immune systems
Integumentary system

23. ASSESSMENT OF THE
PATIENTS & PLANNING FOR
PATIENT CARE
KNOW : medical history, social history, medical
interventions
SEE : airway patency, pallor, sweating, mental state,
posture, facial expression, general condition
FIND : respiratory care, adequacy of oxygenation,
pulse, blood pressure, urine output, conscious level,
monitor for changes in any of the above .
( Norman & Cook, 2000)

24. EXAMINATION SEQUENCE
 A, B, C, D, E MODELS APPROACH
 Airway: patent
Breathing: respiratory rate
Circulation: pallor, hemorrhage
Disability: altered conscious level
Environment and Exposure: unseen hemorrhage,
wound leakage.
(Smith, 2000)

25. NURSING MANAGEMENT OF
CRITICALLY ILL PATIENT
Continuous monitoring
Respiratory care
Cardio vascular care
Gastrointestinal
Nutritional care
Neuromuscular
Comfort and reassurance

26. CONTD…
Communication with the patient
Infection control, skin care ,general hygiene and
mouth care
Fluid, electrolyte and glucose balance
Bowel and Bladder care
Dressing and wound care
Communication with patient and relatives

27. CONTINUOUS MONITORING

28. RESPIRATORY CARE
Improving Oxygenation
Appropriate use of medication
Monitoring of treatment efficacy
Positioning (Fowlers position)
Suctioning if necessary
Tracheostomy care.
Recognition of early warning signs of
an exacerbation with rapid access to appropriate
services(Ventilator, Crash trolley, Emergency drugs,etc.)

29. CARDIO VASCULAR CARE
Continuous Cardiac Monitoring (dysrhythmia)
Appropriate use of medication
Monitoring of treatment efficacy
Recognition of early warning signs of an exacerbation
with rapid access to appropriate services (Defibrillator ,
ECG, Emergency drugs)
Positioning

30. GASTRO-INTESTINAL/
NUTRITIONAL CARE
The supine position predisposes to gastro- esophageal
reflux and aspiration pneumonia, Patients with
30 degree head up prevents this.
 Early enteral feeding reduces infection, stress
ulceration and GI bleeding.
Immobility is associated with gastric stasis and
constipation, So, provide gastric stimulants and
laxatives.

31. NEUROMUSCULAR CARE
Immobility, prolonged neuromuscular blockage and
sedation promotes atrophy, joint contractures and foot
drops may occur.
 Physiotherapy and splints may be required.

32. COMFORT AND REASSURANCE
Anxiety, discomfort and pain must be recognized and
relieved with reassurance, physical measures,
analgesics and sedatives.
In particular, endotracheal or nasogastric tubes, bladder
or bowel distension, inflamed.
Line sites ,painful joints and urinary catheters often
causes discomfort, and are often overlooked.

33. INFECTION CONTROL
Hand washing.
Disposable aprons are recommended, sterile technique
(e.g. Donning) is essential for all invasive
procedures(e.g. line insertion).
Isolation for transmissible infections
Thorough cleaning of bed spaces (e.g. routinely and
after patient discharge)

34. SKIN CARE, GENERAL
HYGIENE AND MOUTH CARE
Cutaneous pressure sores are due to local pressure
(e.g. bony prominences).
Provide sponge bath, mouth care and
general hygiene to the patient.
Turn patient every 2 hourly and protect susceptible
areas. Special beds relieves pressure and assist turning.
Provide back care.

35. FLUID ELECTROLYTES AND
GLUCOSE BALANCE
Regularly assess fluid and electrolytes balance by
maintaining I/O chart hourly.
Insulin resistance and hyperglycemia are common but
maintaining normo-glycemia improves outcomes

36. BLADDER CARE , DRESSING
AND WOUND CARE
Urinary catheters causes painful urethral ulcers and
must be stabilized by providing urinary catheter care.
Early removal reduces urinary
tract infections.
Replace wound dressings as
necessary.
Change arterial and central
venous catheter dressings every 48 - 72 hours.

37. COMMUNICATION WITH
RELATIVES
 Family members receive information from many care
givers with different perspectives and knowledge.
 Critical care teams must aim to be consistent in their
assessments and honest about uncertainties.
 All conversation should be documented.

38. CARING FOR CRITICALLY ILL
PATIENTS WITH COVID-19
It is based on the usual management of viral pneumonia
with respiratory failure with additional precautions to
reduce risk of transmission.

39. USUAL CRITICAL CARE
 Many patients with severe COVID-19 develop acute respiratory
distress syndrome (ARDS). Evidence-based guidelines for ARDS in
the context of COVID-19 include treatments such as
Conservative intravenous fluid strategies
 Empirical early antibiotics for possible bacterial pneumonia
Consideration for early invasive ventilation
Lung-protective ventilation strategies
Periodic prone positioning during mechanical ventilation
Consideration of extracorporeal membrane oxygenation

40. MODIFICATIONS TO USUAL
CRITICAL CARE
Admission of patients with suspected disease to private
rooms when possible.
Use of medical face masks(N 95 and PPE) for symptomatic
patients during assessment and transfer.
Maintain distancing of at least 2 m between
patients.

41. CONTD…
Caution when using high-flow nasal oxygen or non-invasive
ventilation due to risk of dispersion of aerosolized virus in the
health care environment with poorly fitting masks
Clinicians involved with aerosol-generating procedures should
use additional airborne precautions including N95 respirators
and eye protection.

42. BIBLIOGRAPHY
 Covid-19 guidelines WHO. Also available at: https://www.who.int/news-
room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-
implications-for-ipc-precaution-recommendations
 Ms. Mononita Bhattacharjee Msn. Care for Critically Ill Patients . Slide Share.net.
Also available at: https://www.slideshare.net/MononitaBhattacharje/nursing-
management-of-critically-ill-patient
 Dr. Krishna Dhakal. Assessment of critically ill patient. Slide share.net. Also
available at: https://www.slideshare.net/krishnadhakal5/assessment-of-critically-
ill-patients-130876392
 Srinivas Murthy, MD, CM, MH Sc; Charles D. Gomersall, MBBS; Robert A. Fowler,
MD, CM, MSc. Care for Critically Ill Patients With COVID-19. 2020 American
Medical Association. JAMA Insights Clinical Review& Education. April 21, 2020,
Volume 323;15; pp: 1499-1500. Also available at: https://jamanetwork.com/ on
05/09/2020.
 Covid -19 guidelines- position statement ISCCM.