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
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.
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
Treatments and Procedures
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
Environmental regulation
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
Treatments and Procedures
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 and Care Coordination
Communication, dietitian
Education
Education, nutritional support
Treatments and Procedures
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 and Care Coordination
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
Treatments and Procedures
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
Oxygen administration
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
Treatments and Procedures
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
Treatments and Procedures
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 and Care Coordination
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
Treatments and Procedures
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
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.
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 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
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
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
Treatments and Procedures
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
Renal function, impaired
Sequential Organ Failure Assessment (SOFA) score, high
Infection surveillance
Sequential Organ Failure Assessment (SOFA) score
Communication and Care Coordination
Communication, infection control
Education
Education, antibiotic therapy
Education, handwashing
Education, infection control
Content
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
Treatments and Procedures
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 and Care Coordination
Communication, dietitian
Education
Education, nutritional support
Treatments and Procedures
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 and Care Coordination
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
Treatments and Procedures
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
Oxygen administration
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
Communication and Care Coordination
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
Cover mouth and nose when coughing or sneezing
Dispose of contaminated items properly
Maintain isolation at home if discharged before transmission-based precautions are discontinued
Perform proper hand hygiene
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
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.
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