DIAGNÓSTICOS/RESULTADOS E INTERVENCIONES DE ENFERMERÍA PARA PACIENTES GRAVES AFECTADOS POR COVID-19 Y POR SEPSIS

Ramalho Neto, José Melquiades; Viana, Renata Andréa Pietro Pereira; Franco, Andrezza Serpa; Prado, Patrícia Rezende do; Gonçalves, Fernanda Alves Ferreira; Nóbrega, Maria Miriam Lima da

José Melquiades Ramalho Neto

Universidade Federal da Paraíba, Hospital Universitário Lauro Wanderley. João Pessoa, Paraíba, Brasil.

https://orcid.org/0000-0002-4720-9085

Renata Andréa Pietro Pereira Viana

Hospital do Servidor Público Estadual de São Paulo. São Paulo, São Paulo, Brasil.

https://orcid.org/0000-0001-7539-3003

Andrezza Serpa Franco

Universidade do Estado do Rio de Janeiro, Departamento de Enfermagem Médico-Cirúrgica. Rio de Janeiro, Rio de Janeiro, Brasil.

https://orcid.org/0000-0001-5008-1345

Patrícia Rezende do Prado

Universidade Federal do Acre, Residência Multiprofissional Hospitalar em Terapia Intensiva. Rio Branco, Acre, Brasil.

https://orcid.org/0000-0002-3563-6602

Fernanda Alves Ferreira Gonçalves

Universidade Federal de Goiás, Hospital das Clínicas, UTI Pós-operatória. Goiânia, Goiás, Brasil.

Maria Miriam Lima da Nóbrega

Universidade Federal da Paraíba, Programa de Pós-Graduação em Enfermagem. João Pessoa, Paraíba, Brasil.

https://orcid.org/0000-0002-6431-0708

CORRESPONDING AUTHOR
José Melquiades Ramalho Neto melquiadesramalho@gmail.com

CONTRIBUTION OF AUTHORSHIP

Study desing: Ramalho Neto JM. Data collection: Ramalho Neto JM, Viana RAPP, Franco AS, Gonçalves FAF. Data analysis and interpretation: Ramalho Neto JM, Viana RAPP, Franco AS, Prado PR, Gonçalves FAF, Nóbrega MML. Discussion of the results: Ramalho Neto JM, Nóbrega MML. Writing and/or critical review of content: Ramalho Neto JM, Prado PR, Nóbrega MML. Review and final approval of the final version: Ramalho Neto JM, Viana RAPP, Franco AS, Prado PR, Gonçalves FAF, Nóbrega MML.

CONFLICT OF INTERESTS

There is no conflict of interest.

EDITORS

Associated Editors: Gisele Cristina Manfrini, Mara Ambrosina de Oliveira Vargas, Monica Motta Lino Editor-in-chief: Roberta Costa

BHN for Oxygenation
Nursing diagnoses/outcomes
Lactate clearance, effective	Airway cleaning, impaired
Lactate clearance, impaired	Risk of bronchoaspiration
Acid-base imbalance (specify)	Cough
Ventilatory weaning, impaired	Gas exchange, impaired
Dyspnea (specify grade)	Spontaneous ventilation, impaired
Acid-base balance, effective	Mechanical ventilation (specify ventilatory mode)
Hyperlactatemia
Nursing interventions*
- Open airways using the 2Vs-2Es technique with a bag-valve-mask-reservoir device, coupled to an HEPA (High Efficiency Particulate Air) filter or to an HMEF (Heat and Moisture Exchange Filter) for an exceptional need for manual ventilation.1212. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19. Anaesthesia. [Internet] 2020 [cited 2020 Apr 14]. Available from: http://dx.doi.org/10.1111/anae.15054 http://dx.doi.org/10.1111/anae.15054... ^-1313. Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, et al. Interim Guidance for Basic and Advanced Life Support in adults, children, and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and get with the Guidelines® - Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: supporting organizations: American Association of Critical Care Nurses and National EMS Physicians. Circulation. [Internet] 2020 [cited 2020 Apr 19]. Available from: https://doi.org/10.1161/circulationaha.120.047463 https://doi.org/10.1161/circulationaha.1... - Adhere to the use of N95, PFF2 or equivalent masks; beanie; goggles and/or face shield; procedure gloves and waterproof apron for aerosol-generating procedures.1414. Ferioli M, Cisternino C, Leo V, Pisani L, Palange P, Nava S. Protecting healthcare workers from SARS-CoV-2 infection: practical indications. Eur Respir Rev. [Internet] 2020 [cited 2020 May 4];29(155):200068. Available from: https://doi.org/10.1183/16000617.0068-2020 https://doi.org/10.1183/16000617.0068-20... - Aspirate airway secretions with a closed suction system, when strictly necessary. - Watch for signs of immediate need for tracheal intubation: SpO₂ <93% with low-flow oxygen and/or respiratory rate >28 rpm or CO₂ retention (PaCO₂ >50 mmHg and/or pH <7.25). - Auscultate lung sounds and assess chest radiography. - Assist in the rapid sequence procedure of tracheal intubation and confirm position of the tracheal tube by continuous waveform capnography, when available.1212. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19. Anaesthesia. [Internet] 2020 [cited 2020 Apr 14]. Available from: http://dx.doi.org/10.1111/anae.15054 http://dx.doi.org/10.1111/anae.15054... - Assess skin color, temperature, and moisture. - Evaluate airway permeability and cough reflex. - Evaluate the characteristics of the respiratory secretions and record them in the medical record. - Evaluate ventilation mode and document parameters set on the mechanical ventilator in the medical record, in addition to variables such as driving pressure and plateau pressure. - Assess serial level and arterial lactate clearance, when initial lactate (2 mmol/L. - Assess response to the spontaneous breathing test (SBT). - Assess whether the patient's breaths are synchronous with the mechanical ventilator. - Calibrate the continuous oximetry of central or mixed venous oxygen saturation every 24 hours, when available. - Clamp the tracheal tube with forceps (e.g., Reynald forceps) and pause ventilation with a mechanical ventilator in standby mode for maneuvering and disconnecting the airways.1212. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19. Anaesthesia. [Internet] 2020 [cited 2020 Apr 14]. Available from: http://dx.doi.org/10.1111/anae.15054 http://dx.doi.org/10.1111/anae.15054... ^,1515. Wang H, Zeng T, Wu X, Sun H. Holistic care for patients with severe coronavirus disease 2019: an expert consensus. Int J Nurs Sci. [Internet] 2020 [cited 2020 Apr 22];7(2):128134. Available from: https://doi.org/10.1016/j.ijnss.2020.03.010 https://doi.org/10.1016/j.ijnss.2020.03.... - Collect nasopharyngeal swab, sputum or endotracheal aspirate for laboratory exam. - Collect arterial and/or central venous blood for blood gas analysis. - Raise the head of the bed by 30-45(. - Stimulate early mobilization in bed.1515. Wang H, Zeng T, Wu X, Sun H. Holistic care for patients with severe coronavirus disease 2019: an expert consensus. Int J Nurs Sci. [Internet] 2020 [cited 2020 Apr 22];7(2):128134. Available from: https://doi.org/10.1016/j.ijnss.2020.03.010 https://doi.org/10.1016/j.ijnss.2020.03.... - Avoid the administration of medications through nebulizations where there is no room with negative pressure. - Provide supplemental oxygen through a nasal cannula (up to 5 L/min) or non-rebreathing face mask with reservoir (up to 10 L/min) for a target SpO₂ (93%.16 16. Associação de Medicina Intensiva Brasileira. Recomendações da Associação de Medicina Intensiva Brasileira para a abordagem do COVID-19 em medicina intensiva [Internet]. 2020 Apr. São Paulo, SP(BR): AMIB; 2020 [cited 2020 Apr 22]. Available from: https://www.amib.org.br/fileadmin/user_upload/amib/2020/abril/13/Recomendaco__es_AMIB-atual.-16.04.pdf https://www.amib.org.br/fileadmin/user_u... ^-1717. World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance [Internet]. 2020 March. Geneva (CH): WHO; 2020 [cited 2020 Apr 22]. Available from: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected https://www.who.int/publications-detail/... - Establish standard precautions for droplets, contact and/or aerosols, as well as install1818. Akhtar MR, Ricketts W, Fotheringham T. Use of an antiviral filter attached to a pleural drain bottle to prevent aerosol contamination with SARS-CoV-2. Clin Med. 2 [Internet] 2020 [cited 2020 June 20];20(4):e60-1. Available from: https://doi.org/10.7861/clinmed.2020-0246 https://doi.org/10.7861/clinmed.2020-024... an HEPA or HMEF filter in the vent port (breather) of chest drain bottles under water seal. - Inflate the cuff with air to a pressure 25-30 cmH₂O.1515. Wang H, Zeng T, Wu X, Sun H. Holistic care for patients with severe coronavirus disease 2019: an expert consensus. Int J Nurs Sci. [Internet] 2020 [cited 2020 Apr 22];7(2):128134. Available from: https://doi.org/10.1016/j.ijnss.2020.03.010 https://doi.org/10.1016/j.ijnss.2020.03.... - Investigate mottle/livedo reticularis on the skin and stage using the mottling score tool. - Measure the patient's height to calculate the predicted tidal volume ((6 mL/kg).1919. Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, et al. Intubation and ventilation amid the COVID-19 outbreak: Wuhan’s experience. Anesthesiology. [Internet] 2020 [cited 2020 Apr 30];132:1317-32. Available from: https://doi.org/10.1097/ALN.0000000000003296 https://doi.org/10.1097/ALN.000000000000... - Monitor the peripheral oxygen saturation by pulse oximetry and communicate when SpO₂ <93%. - Monitor central or mixed venous oxygen saturation. - Monitor CO₂ levels at the end of expiration (EtCO₂) by capnography. - Position the enteral tube at post-pyloric level and check abdominal radiography. - Prevent accidental extubation during decubitus changes, bed bath, change of artificial airway fixation, transport or mobilization for exams/procedures. - Foresee and anticipate ventilatory weaning. - Promote oral hygiene with an aqueous solution of 0.12% or 0.2% chlorhexidine digluconate every 12 hours, with previous application of 0.5% to 1% hydrogen peroxide or 0.2% povidone in the oral structures through embryo with gauze or mouthwash.2020. Ministério da Saúde (BR). Agência Nacional de Vigilância Sanitária. Nota Técnica GVIMS/GGTES/ANVISA nº 04/2020, de 31 de março de 2020. Orientações para serviços de saúde: medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de infecção pelo novo coronavírus (SARS-CoV-2). Brasília, DF(BR): ANVISA; 2020 [cited 2020 Apr 22]. Available from: http://portal.anvisa.gov.br/documents/33852/271858/Nota+Técnica+n+04-2020+GVIMS-GGTES-ANVISA/ab598660-3de4-4f14-8e6f-b9341c196b28 http://portal.anvisa.gov.br/documents/33... - Provide adequate sedation, analgesia and/or neuromuscular block in invasive ventilatory support. - Perform patient pronation using the envelope maneuver and the three turning moments, with the participation of at least a physician, nurse, physiotherapist, and nursing technicians.2121. Oliveira VM, Piekala DM, Deponti GN, Batista DCR, Minossi SD, Chisté M, et al. Safe prone checklist: construction and implementation of a tool for performing the prone maneuver. Rev Bras Ter Intensiva. [Internet] 2017 [cited 2020 Mar 01];29(2):131-41. Available from: https://doi.org/10.5935/0103-507X.20170023 https://doi.org/10.5935/0103-507X.201700... - Perform safe prone checklist by a bedside professional who is not involved in the maneuver.2121. Oliveira VM, Piekala DM, Deponti GN, Batista DCR, Minossi SD, Chisté M, et al. Safe prone checklist: construction and implementation of a tool for performing the prone maneuver. Rev Bras Ter Intensiva. [Internet] 2017 [cited 2020 Mar 01];29(2):131-41. Available from: https://doi.org/10.5935/0103-507X.20170023 https://doi.org/10.5935/0103-507X.201700... - Perform scheduled extubation in agreement with the team and put a surgical mask on the patient.2222. D’Silva DF, McCulloch TJ, Lim JS, Smith SS, Carayannis D. Extubation of patients with COVID-19. Br J Anaesth. [Internet] 2020 [cited 2020 Apr 29];125(1):e192-5. Available from: https://doi.org/10.1016/j.bja.2020.03.016 https://doi.org/10.1016/j.bja.2020.03.01... - Change mechanical fan circuits for visible dirt, damage or ventilation (30 days. - Change the mechanical fan filter every 7 days for possible dirt, condensation or damage. - Verify cuff pressure 4 times a day and before oral hygiene.

BHN for Vascular Regulation
Nursing diagnoses/outcomes
Arrhythmia (specify)	Tissue hypoperfusion
Septic shock	Peripheral tissue perfusion, impaired
Cardiac output, impaired	Tissue perfusion, ineffective
Cardiac function, impaired	Arterial pressure, altered
Hyperglicemia	Risk of bleeding
Hypoglycemia	Risk of deep venous thrombosis
Nursing interventions*
- Monitor the occurrence of cardiac arrhythmias and hemodynamic instability. - Monitor blood pressure, heart rate, pulse rate, frequency and depth of the breaths, body temperature with programming of adequate parameterization of alarms. - Monitor and evaluate hemodynamic response by means of dynamic variables (variation in pulse pressure, variation in systolic volume, change in systolic volume with passive elevation of the legs). - Monitor the CO₂ venoarterial gradient ((PCO₂), when necessary. - Monitor the QT interval in series electrocardiograms, when the patient is using hydroxychloroquine2323. Sanders JM, Monogue ML, Jodlowski TZ, Cutrell J. Pharmacologic treatments for coronavirus disease 2019 (COVID-19): a review. JAMA. [Internet] 2020 [cited 2020 Apr 29];323(18):1824-36. Available from: https://doi.org/10.1001/jama.2020.6019 https://doi.org/10.1001/jama.2020.6019... or prokinetic agents. - Monitor capillary filling time. - Monitor signs of tolerance to enteral nutrition in a patient with unstable hemodynamics using noradrenaline (<0.5 (g/kg/min). - Monitor signs and symptoms of pulmonary congestion, systemic congestion or low cardiac output. - Monitor signs and symptoms of hyperglycemia (polyuria, polydipsia, polyphagia, weakness, ketone breath, Kussmaul's breath) or hypoglycemia (irritability, sweating, confusion, tremors, dizziness). - Level a three-way stopcock connected to the invasive pressure transducer with the patient's phlebostatic axis. - Observe pulse amplitude, peripheral perfusion, temperature and aspect of the limb with an intra-arterial catheter. - Observe the presence of bruises, petechiae, hematomas or signs of bleeding. - Obtain data on the initial and current ejection fraction in two-dimensional echocardiogram tests, when available. - Perform a standard 12-lead electrocardiogram (ECG). - Perform cardiopulmonary resuscitation maneuvers immediately in a patient in the prone position with an advanced airway, with hand positioning on the T7-T10 thoracic vertebrae, in the interscapular region.1313. Edelson DP, Sasson C, Chan PS, Atkins DL, Aziz K, Becker LB, et al. Interim Guidance for Basic and Advanced Life Support in adults, children, and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and get with the Guidelines® - Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: supporting organizations: American Association of Critical Care Nurses and National EMS Physicians. Circulation. [Internet] 2020 [cited 2020 Apr 19]. Available from: https://doi.org/10.1161/circulationaha.120.047463 https://doi.org/10.1161/circulationaha.1... ^,2424. Guimarães HP, Timerman S, Rodrigues RR, Corrêa TD, Schubert DUC, Freitas AP, et al. Position statement: cardiopulmonary resuscitation of patients with confirmed or suspected COVID-19 - 2020. Arq Bras Cardiol. [Internet] 2020 [cited 2020 June 19];114(6):1078-87. Available from: https://doi.org/10.36660/abc.20200548 https://doi.org/10.36660/abc.20200548... - Perform Allen's test before cannulation of the radial artery or collection by puncture of arterial blood. - Perform capillary blood glucose test according to the institutional protocol and rotate puncture of the phalanges of the limbs. - Perform “zeroing” of the invasive pressure system every 2 hours, or when necessary, with a subsequent square wave test (flush test). - Change all the components of the invasive pressure system every 96 hours.

BHN for Neurological Regulation
Nursing diagnoses/outcomes
Aphasia, expressive	Disorientation
Agitation (specify RASS score)	Stupor
Cognition, impaired	Risk of delirium
Coma	Sedation (specify RASS score)
Delirium	Sleepiness
Nursing interventions*
- Administer prescribed analgesic medication and evaluate response with the Numeric Pain Scale from 0 to 10, the Behavior Pain Scale (BPS) or the Critical Care Pain Observation Tool (CPOT). - Apply CAM-ICU every 12 hours or during changes in the Richmond Agitation-Sedation Score (RASS). - Assess cognitive function by applying the Mini Mental State Examination (MMSE). - Assess the need to apply chemical or mechanical containment in the bed. - Assess the patient's skin daily.1515. Wang H, Zeng T, Wu X, Sun H. Holistic care for patients with severe coronavirus disease 2019: an expert consensus. Int J Nurs Sci. [Internet] 2020 [cited 2020 Apr 22];7(2):128134. Available from: https://doi.org/10.1016/j.ijnss.2020.03.010 https://doi.org/10.1016/j.ijnss.2020.03.... - Evaluate and calculate the Braden or Evaruci scale score.2525. Souza MFC, Zanei SSV, Whitaker IY. Risk of pressure injury in the ICU: transcultural adaptation and reliability of EVARUCI. Acta Paul Enferm. [Internet] 2018 [cited 2020 June 20];31(2):201-8. Available from: https://doi.org/10.1590/1982-0194201800029 https://doi.org/10.1590/1982-01942018000... ^-2626. Zapata-Rodríguez MM, Murillo-Panameño CL, Millán-Estupiñan JC. Validez de las escalas de Braden y EVARUCI en pacientes hospitalizados en una unidad de cuidados intensivos. Rev Med Risaralda. [Internet] 2019 [cited 2020 June 20];25(2):138-48. Available from: http://www.scielo.org.co/pdf/rmri/v25n2/0122-0667-rmri-25-02-138.pdf http://www.scielo.org.co/pdf/rmri/v25n2/... - Assess the level of awareness using the Glasgow scale. - Assess the risk of falls and keep the bed protection rails elevated. - Assess pupil size, symmetry, and light accommodation. - Place a pneumatic mattress on the patient's bed, when available. - Determine the RASS score each shift. - Determine a target RASS score for the patient during the multi-professional rounds. - Implement eye care to prevent dry eye and corneal injury.2727. Freitas LS, Ferreira MA, Almeida Filho AJ, Santos CCG, Silva LB. Corneal injuires in intensive care patients: contributions to the systematization of nursing care and patient safety. Texto Contexto Enfer. [Internet] 2018 [cited 2020 May 4];27(4):e4960017. Available from: https://doi.org/10.1590/0104-07072018004960017 https://doi.org/10.1590/0104-07072018004... - Daily inform the patients about time (day, month, year, hour) and space (where they are). - Investigate the presence of precipitating factors of delirium. - Investigate hearing acuity and ability to communicate by means of gestures, head movements, writing support or drawings. - Investigate criteria for palliation together with the multi-professional team. - Limit noise in the ICU environment. - Monitor acute change in the patient's mental status in relation to baseline. - Monitor the sedation level using the RASS score. - Allow the patients to use their glasses or hearing aids, when possible. - Promote daily interruption of the sedation of eligible patients in the multi-professional rounds. - Promote the patient's sleep-wake cycle. - Provide emotional support. - Provide family approach with virtual visits by means of a tablet or robot, when available. - Make changes in body positioning when possible. - Use short, clear, and direct phrases in communication. - Use a communication tool (e.g.: ISBAR) in the moments of handover and multi-professional rounds.

BHN for Hydration	BHN for Elimination
Nursing diagnoses/outcomes
Electrolyte imbalance	Constipation
Liquid imbalance	Diarrhea
Dehydration (specify grade)	Urinary elimination, increased
Edema (specify location and grade)	Urinary elimination, reduced
Hypervolemia	Renal function, impaired
Hypovolemia	Urination, impaired
Fluid intake, impaired	Nausea
Process risk of the regulatory system, impaired (specify)	Vomits
Nursing interventions*
- Monitor fluid loss due to bleeding, vomits, diarrhea, sweating and/or sialorrhea. - Monitor for the presence of dyspnea, fatigue or dizziness. - Monitor the intestinal eliminations for stool frequency, volume, consistency, color and odor. - Monitor the drainage rate of the gastric tube, intestinal fistula, episodes of vomits and/or diarrhea, recording volume and characteristics in the medical record. - Monitor the behavior of the professionals who provide patient care with hand hygiene. - Monitor fluid balance and the serum electrolyte levels.1515. Wang H, Zeng T, Wu X, Sun H. Holistic care for patients with severe coronavirus disease 2019: an expert consensus. Int J Nurs Sci. [Internet] 2020 [cited 2020 Apr 22];7(2):128134. Available from: https://doi.org/10.1016/j.ijnss.2020.03.010 https://doi.org/10.1016/j.ijnss.2020.03.... - Monitor for signs of dehydration. - Monitor for signs of paralytic ileus (absent hydro-air sounds, nausea, vomits, abdominal distension). - Observe the type of diet offered. - Guide bed rest. - Position the patient's head laterally during an episode of vomits. - Promote an adequate supply of liquids. - Provide parrot bottle or trimmer. - Bathe in bed with warm water or at room temperature. - Perform relief or delay bladder catheterization as needed. - Perform bladder ultrasound and assess residual urinary volume, when available.

BHN for Immune Regulation	BHN for Thermal Regulation
Nursing diagnoses/outcomes
Allergy	Fever
Organic dysfunction (specify)	Hyperthermia
Infection (specify focus)	Hypothermia
Sepsis
Nursing interventions*
- Administer prescribed antihistamine medication and assess clinical response. - Administer prescribed antipyretic medication and assess clinical response. - Apply physical means to control fever, when necessary. - Schedule and supervise the administration of broad-spectrum antimicrobials within the first hour of sepsis or septic shock recognition, after culture collection. - Heat the limbs with heating plates or orthopedic cotton. - Watch for signs of organic dysfunction: arterial hypotension; oliguria ((0.5 mL/kg/h) or creatinine elevation ((2 mg/dL); PaO₂/FiO₂ ratio (300 mmHg or low oxygen saturation by pulse oximetry; thrombocytopenia; hyperlactatemia; change in the level of consciousness; agitation; delirium, and/or significant increase in bilirubins. - Evaluate laboratory tests: complete blood count, creatinine, bilirubins, transaminases, RT-PCR, serological test, coagulogram, D-dimer, arterial blood gases, and/or central venous blood gases.88. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. [Internet] 2017 [cited 2020 Apr 12];43(3):304-77. Available from: https://doi.org/10.1007/s00134- 017-4683-6 https://doi.org/10.1007/s00134-... ^-99. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically ill Adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. [Internet] 2020 [cited 2020 Apr 5];46:854-87. Available from: https://doi.org/10.1007/s00134-020-06022-5 https://doi.org/10.1007/s00134-020-06022... - Evaluate the healing process and record the evolution of the wound in the medical record. - Calculate the Sequential Organ Failure Assessment (SOFA) score and evaluate its variation ((SOFA) every 24 hours. - Collect two samples of blood culture early and, when appropriate, from other relevant sites (urine, cerebrospinal fluid, wound, tracheal secretion or catheter tip). - Immediately report an adverse reaction episode to the intensive care physician. - Pre-screen for allergies or severe drug reactions. - Ensure safety in the medication chain: the right patient, the right medication, the right dose, the right time and interval between the doses, the right way, the right pharmaceutical form, the right record, and the correct orientation and evaluation of the response. - Implement preventive measures for bloodstream infection associated with a central venous catheter. - Implement preventive measures for pneumonia associated with mechanical ventilation. - Start a continuous intravenous insulin infusion protocol in the presence of two blood glucose levels (180 mg/dL and change solution every 12 hours. - Stop the drug infusion in the presence of adverse reactions, changing solutions and equipment in use. - Investigate infection focuses. - Keep warm using a blanket, thermal mattress or forced air devices (thermal blanket). - Monitor the permanence time of invasive devices. - Monitor clinical response to antimicrobials and assess resolution of infection. - Monitor for signs of bronchoaspiration. - Monitor signs and symptoms of infection. - Observe breathing for dyspnea, bronchospasm or stridor due to high obstruction. - Program adequate alarm parameterization. - Heal every 24 hours or whenever the dressing is dirty, loose and damp (blood, secretion, sweat). - Perform and (re)assess water balance periodically. - Remove the intravascular access considered as the source of the septic condition, after installing a new device. - Remove or change the site of the intra-arterial catheter in the face of signs of local infection, ischemia or necrosis. - Rescue results of cultures and assess sensitivity profile to antimicrobials. - Respect the objection of the Jehovah's Witness patients or their legal guardians regarding the refusal of blood transfusion therapy according to the principles of the religion they profess. - Supervise state of hyperglycemia and hypernatremia in a patient with unstable hemodynamics and using intravenous hydrocortisone. - Use a sepsis screening tool daily (e.g., SOFA score or own institutional screening system). - Check vital signs every 15 minutes until the first hour in the event of an adverse reaction.

[1] CORRESPONDING AUTHOR
José Melquiades Ramalho Neto melquiadesramalho@gmail.com

Brasil

Brasil

DIAGNÓSTICOS/RESULTADOS E INTERVENCIONES DE ENFERMERÍA PARA PACIENTES GRAVES AFECTADOS POR COVID-19 Y POR SEPSIS

RESUMEN

Objetivo:

Método:

Resultados:

Conclusión: