Coronavirus Disease 2019 (COVID-19)

COVID-19 spreads person to person through respiratory droplets, and the people most at risk of dying are the elderly, the very young, and anyone with a chronic condition. On the floor your priorities are respiratory isolation, monitoring oxygenation, and protecting yourself and other patients. There is no specific antiviral and no vaccine yet, so care is supportive.

COVID-19 was first identified at a seafood and wild-animal market in Wuhan, China, and declared a pandemic by the WHO, with roughly 5,000,000 people affected in more than 200 countries.

What is Coronavirus 2019 (COVID-19)?

COVID-19 is caused by a new coronavirus strain, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It ranges from common-cold symptoms to severe disease such as pneumonia and death, especially in vulnerable groups.

• The CDC clinical criteria for a COVID-19 patient under investigation (PUI) were built on what is known about MERS-CoV and SARS-CoV and change as new information arrives.
• Early Wuhan patients had links to a large seafood and animal market, suggesting animal-to-person spread. A growing number had no such exposure, indicating person-to-person spread.

Pathophysiology

Coronaviruses are common in many animals, including bats, camels, cats, and cattle.

• COVID-19 is a betacoronavirus, like MERS and SARS, all originating in bats.
• US patient sequences resemble China's initial posting, suggesting a single recent emergence from an animal reservoir.
• With MERS and SARS, person-to-person spread is thought to occur mainly via respiratory droplets when an infected person sneezes, similar to influenza and other respiratory pathogens.
• Most coronaviruses infect animals, not people, but one or more could evolve and spread to humans, as has happened before.
• Many patients had direct or indirect contact with the Wuhan Huanan Seafood Wholesale Market, believed to be the original outbreak site, though transmission from fish to humans is unlikely; COVID-19 and fish coronaviruses such as Beluga Whale CoV/SW1 belong to different genera with different host ranges.
• Evidence increasingly supports human-to-human transmission: people who never visited Wuhan but had close contact with infected family members became infected.

Causes

Coronaviruses are named for the crown-like spikes on their surface.

• There are four main subgroupings: alpha, beta, gamma, and delta.
• Human coronaviruses were first identified in the mid-1960s.
• The seven coronaviruses that infect people are 229E (alpha), NL63 (alpha), OC43 (beta), and HKU1 (beta), plus MERS-CoV, SARS-CoV, and COVID-19.

Statistics and Incidences

An outbreak of pneumonia of unknown etiology in Wuhan City was first reported to the WHO on December 31, 2019.

• Chinese health authorities confirmed more than 40 infections with a novel coronavirus as the cause. Most patients had epidemiological links to a large seafood and animal market, which was closed on January 1, 2020.
• Globally, there were 5,030,914 confirmed cases and 326,182 deaths as of May 21, 2020.
• The United States had the highest case count in the world, more than 1.5 million cases, with New York City the most affected.
• Most countries declared nationwide lockdowns and restricted travel.
• Cases on the Diamond Princess cruise ship in Japanese territorial waters reached 712.

Clinical Manifestations

Reported illness ranges from mild to severe and fatal. Symptoms may appear in as few as 2 days or as long as 14 after exposure, based on the incubation period seen with MERS viruses.

Primary symptoms: fever, dry cough, shortness of breath.

Other symptoms may include sore throat, runny nose, diarrhea, fatigue, and difficulty breathing in severe cases.

Assessment and Diagnostic Findings

At this time, diagnostic testing for COVID-19 can be conducted only at the CDC.

• To improve detection, the CDC recommends collecting three specimen types: lower respiratory, upper respiratory, and serum.
• The CDC deployed multidisciplinary teams to Washington, Illinois, California, and Arizona to assist with clinical management, contact tracing, and communications.
• The CDC developed a real-time reverse transcription polymerase chain reaction (rRT-PCR) test that diagnoses COVID-19 in respiratory and serum samples. Testing currently takes place at the CDC, which will share tests with domestic and international partners.
• The CDC uploaded the entire genome from all five reported US cases to GenBank and is growing the virus in cell culture for further genetic characterization.

Medical Management

The best prevention is avoiding exposure.

• Hand hygiene. Wash hands often with soap and water for at least 20 seconds; if unavailable, use an alcohol-based hand sanitizer.
• Keep hands off the face. Avoid touching eyes, nose, and mouth with unwashed hands.
• Social distancing. Stay at least 3 feet (1 meter) from people who are sick, and stay home when sick.
• Cough and sneeze etiquette. Cover coughs and sneezes with a tissue, then discard it.
• Supportive care. Relieve symptoms. For severe cases, support vital organ function.

For Healthcare Workers

Healthcare workers are among the most exposed population. Protecting them is a priority, and occupational health services help keep workplaces safe and address health problems as they arise. The WHO sets out the rights and responsibilities of health workers, including criteria for occupational safety and health.

Employers and managers should take responsibility for preventive and protective measures; provide information, instruction, and training on occupational safety and health, including refresher infection prevention and control (IPC) training and correct use and disposal of personal protective equipment (PPE); supply adequate IPC and PPE (masks, gloves, goggles, gowns, hand sanitizer, soap and water, cleaning supplies) at no cost to staff; keep personnel current on COVID-19 and equip them to assess, triage, test, and treat; provide security measures as needed; maintain a blame-free reporting environment with followup and victim support; advise self-assessment, symptom reporting, and staying home when ill; maintain reasonable working hours with breaks; consult workers on occupational safety and notify the labor inspectorate of occupational diseases; not require return to work where serious danger to life or health continues; allow workers to remove themselves from imminently dangerous situations without undue consequences; honor compensation, rehabilitation, and curative services for workplace-acquired COVID-19 as an occupational disease; provide mental health and counseling resources; and enable cooperation between management and workers or their representatives.

Health workers should follow established occupational safety procedures and training; use protocols to assess, triage, and treat; treat patients with respect, compassion, and dignity; maintain confidentiality; follow public health reporting procedures for suspected and confirmed cases; reinforce accurate IPC and public health information; put on, use, take off, and dispose of PPE properly; self-monitor, self-isolate, and report illness to managers; flag undue stress or mental health challenges that need support; and report any situation they reasonably believe presents an imminent, serious danger to life or health.

Pharmacologic Management

There is no specific antiviral medication recommended for COVID-19 and no current vaccine to prevent it.

Nursing Management

Nursing Assessment

• Travel history. Obtain a detailed travel history for patients with fever and acute respiratory illness.
• Physical examination. Patients with fever, cough, and shortness of breath who recently traveled to Wuhan, China must be isolated immediately.

Nursing Diagnosis

• Infection related to exposure to COVID-19.
• Deficient knowledge related to unfamiliarity with disease transmission.
• Hyperthermia related to increased metabolic rate.
• Impaired breathing pattern related to shortness of breath.
• Anxiety related to unknown etiology.

Nursing Care Planning and Goals

• Prevent the spread of infection.
• Improve understanding of the disease and its management.
• Improve body temperature.
• Restore a normal breathing pattern.
• Reduce anxiety.

Nursing Interventions

• Monitor vital signs. Infection usually begins with a high temperature; track temperature and respiratory rate, since shortness of breath is common.
• Monitor O2 saturation. Respiratory compromise causes hypoxia.
• Maintain respiratory isolation. Keep tissues at the bedside, dispose of secretions properly, instruct the patient to cover the mouth when coughing or sneezing, use masks, have everyone entering the room wear masks, and place respiratory stickers on chart and linens.
• Enforce strict hand hygiene. Teach the patient and family to wash hands after coughing to reduce transmission.
• Manage hyperthermia. Treat elevated temperature to maintain normothermia and reduce metabolic needs.
• Educate the patient and family. Cover disease transmission, diagnostic testing, disease process, complications, and protection.

Evaluation

Goals are met when the patient prevents spread of infection, understands the disease and its management, improves body temperature, restores a normal breathing pattern, and has reduced anxiety.

Documentation Guidelines

• Individual findings, including factors affecting, interactions, nature of social exchanges, and specifics of individual behavior.
• Cultural and religious beliefs and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.