In the 2020 coronavirus pandemic, thousands
of people with no nursing experience are about to be faced with the problem of
nursing a Covid-19 patient at home.
These suggestions are offered in good faith
by a retired GP drawing on 29 years of practice in a Somerset village. It
applies to nursing an adult – children have different needs, and mercifully are
rarely affected by Covid-19.
These suggestions will be revised if
further information comes along. You are reading version 1.05
Is it Covid?
This coronavirus usually starts with a cough, fever
(temperature, feeling hot and cold) and tiredness. People may also feel a sore
throat, muscle aches, headaches and diarrhoea. They may remember being in
contact with someone who has had the virus in the last week or two.
Blocked and runny nose is rarely a feature of Covid19,
but interestingly, about 60% of patients lose their sense of smell at least for
a time. This may be an early feature of infection, so if someone has been in
contact with a case, it may be useful to keep testing the sense of smell, say
with cloves or perfume, and self-isolate if the sense is suddenly lost. In most cases the sense of smell recovers in 1-2 weeks.
What to expect
Every case is different, but on average, if the virus
gains a foothold, the person may be walking around for 5-7 days feeling fine
but spreading viruses every time they breathe or speak (this is why we should
all, well or unwell, be wearing masks, to reduce the range of this spread).
Once symptoms begin, fever, aches and coughing may
last for 7-10 days.
After 10 days, we can expect improvement and recovery.
If things go worse at any time, especially around day
10, you may need to call 111, your GP surgery, or 999.
Don’t Panic!
In four out of five cases Covid-19 is a mild flu-like
illness. Your calm, unhurried assurance will help the patient to stay in that
category.
Where to nurse the patient
If you are looking after a partner, it is best that
you sleep somewhere else, even if it is out in the corridor, to decrease the
viral load that you receive, and so that you can sleep better.
The nursing room should be clean and tidy, with the
minimum of clutter.
Make it look good, maybe with a favourite picture, maybe some flowers or house plants, changed frequently.
Make it look good, maybe with a favourite picture, maybe some flowers or house plants, changed frequently.
See if quiet favourite music or an audio book is
helpful when awake.
TV and radio news is probably not a good idea.
Open the windows. The virus can survive in indoor air for about 3 hours, so it will tend to concentrate in the nursing room.
Keep the door of the nursing room closed. Airborne
particles are diluted if the windows are open, but if they are constantly
moving into the rest of the house, it may not be good for everyone else.
Sunlight carries UV that has viricidal properties. If
the weather is warm and sunny, and it is possible to move the patient outside,
then do so. This was used successfully in the 1918 epidemic.
Judicious sunbathing (don’t get burned!) is good for
both of you. It gives you a boost of Vitamin D, which helps the immune system.
Make sure that neither of you falls asleep in the sun – you could end up
burned.
Protect yourself
It is not going to help if you get infected too.
People are spreading (“shedding”) viruses in their
breath for up to a week before symptoms appear, but for only 3-6 days after symptoms
appear. Therefore you need to be extra careful for these 6 days. Shedding
continues in faeces (poo) for up to two weeks after recovery, so you need to be
very careful to clean the toilet seat and handles.
The patient should have his/her own towel, flannel and
if possible, bathroom.
If the patient is your partner, and you have been
sleeping and living together in the days before onset of symptoms, you may be
infected already. It may be very mild (many people never get any symptoms), and
in any case it is as well to try to reduce your exposure to the virus for as
much as you reasonably can. A lower exposure could mean that any illness will
be less severe.
Follow these suggestions to minimise your risk of infection:
1.
When you enter the room, ask the patient to put on a mask to reduce the range of their exhalations. This is especially important if they have a cough. If they cannot tolerate a mask, ask them to turn away and cover their mouth if coughing.
Mask up yourself too. This will reduce the risk to you if a droplet from the patient would otherwise land on your mouth or nose. It also stops you from touching your mouth or nose with a contaminated hand. Here is a brilliant DIY cloth mask designed by a Taiwanese doctor that anyone can make. It is best not to buy masks as they are needed for front-line health workers.
3. Wear nitrile gloves.
4. Get some goggles to protect your face.
When you enter the room, ask the patient to put on a mask to reduce the range of their exhalations. This is especially important if they have a cough. If they cannot tolerate a mask, ask them to turn away and cover their mouth if coughing.
Mask up yourself too. This will reduce the risk to you if a droplet from the patient would otherwise land on your mouth or nose. It also stops you from touching your mouth or nose with a contaminated hand. Here is a brilliant DIY cloth mask designed by a Taiwanese doctor that anyone can make. It is best not to buy masks as they are needed for front-line health workers.
3. Wear nitrile gloves.
4. Get some goggles to protect your face.
5. Wear
defensive clothes. As you will probably not be able to
access PPE (Personal Protective Equipment), think out what you can manage.
An apron will offer some protection.
An apron will offer some protection.
A dedicated dressing gown of smooth
fabric (not furry, because virus can hide in the fur) is worth considering. It
should ideally be washed after each time you go into the room. You will need a
few to allow washing to take place.
Pyjamas would be good. Again, you will need a few sets.
If you are useful with a sewing machine, you might be able to make yourself a nifty special gown, and even a hood with a clear panel to see out of. We hope to add patterns for these gowns in time.
Pyjamas would be good. Again, you will need a few sets.
If you are useful with a sewing machine, you might be able to make yourself a nifty special gown, and even a hood with a clear panel to see out of. We hope to add patterns for these gowns in time.
Clothing
should ideally be washed after each nursing episode. If this is not possible,
try to shower after going into the nursing room, and have one set of clean
clothes, also one set to nurse in. When removing contaminated clothes, put them
away from general washing. Ideally put them straight in the washing machine, or
consider filling the bath with a bleach solution (1 of bleach to 5 of water).
Dip the clothes in the bleach, then lift them out, and hang them to drip dry
over the bath before rinsing thoroughly.
Waste must be dealt with carefully. Tissues from coughing etc should go into a swing bin, and disposed of once or twice a day into their own waste bag. When full, the bag should be tied off, then put into another bin bag, and should wait outside for two days before it is put out for collection.
Do not forget to wash your hands and forearms very thoroughly in soap and water while singing Happy Birthday to Me twice over, after each nursing episode.
Keep
the bed clean and tidy
Make sure that there are no crumbs in the bed.
Make
sure the sheet is changed regularly, because it will get wet with sweat.
The
turned-down sheet in front of the patient will be covered with viruses from
coughing and breathing, which will get on to the patient’s hands and add to the
viral load that the patient is dealing with. It may be helpful to pass a hot
iron over this area when possible, as heat destroys the virus. Be careful not
to burn the patient.
Food
and drink
Drink
– 6 to 8 glasses in 24 hours -is vital in fever, because a significant amount
of fluid is lost in sweat. Make sure that a fresh glass is by the bed at all
times. Fizzy Vitamin C tablets are ideal, as this vitamin helps the immune
system. Trials are under way in China giving the equivalent of 10 big fizzy tablets
of Vitamin C daily intravenously for patients with coronavirus.
If
the patient is only passing small amounts of dark urine, s/he must drink more
fluids.
If
urine flow stops despite plenty of drinks, the patient may have to go to hospital.
Food
is not so important. The patient may not want food, and there is certainly no
need to press them to eat. Small amounts of favourite soups may be acceptable.
Chicken soup (for non-veggie/vegans) has a great reputation.
The patients should have their own crockery and cutlery, kept separate from the rest of the family..
Dealing
with faeces.
If
the patient can make it to the toilet (that’s bathroom if you are reading this
in the US) without getting exhausted, fine. But you need to wipe the seat,
bowl, handle and any switches that the patient may have touched.
If there is diarrhoea, or if the patient is very weak, you may need a wheel-chair to get to the toilet, or a commode by the bed. Contact the Community Nursing Services via your local General Practice for a commode.
If there is diarrhoea, or if the patient is very weak, you may need a wheel-chair to get to the toilet, or a commode by the bed. Contact the Community Nursing Services via your local General Practice for a commode.
If possible, the patient should have their own bathroom and toilet.
Managing
Fever
Fever
is a natural reaction to infection, and modern medicine is moving away from
trying to bring fever down. We think that “the higher the temperature, the
shorter the illness”.
However,
fever can be distressing, especially if accompanied by headaches or muscle
aches, and in this case it is sensible to offer PARACETAMOL (called ACETAMINOPHEN
in the USA).
There
are theoretical reasons not to use IBUPROFEN in Covid, as it may increase the
ACE-2 enzyme that the virus uses as an entry portal, and also IBUPROFEN should
not be given on an empty stomach.
Observations
In
medicine, the course of the disease is very important. The illness is either
getting better, getting worse or staying the same. Observations are not
absolutely necessary, but they may be helpful to see what is going on, and they
help to give a sense of control. A chart will give you a sense of whether
things are getting better or worse.
Never
wake the patient to take a reading.
Take regular temperature readings when you are in the room doing general nursing things.
If
the patient is getting periods of fever, it may be helpful to take more
frequent temperature readings on one of the fevers, to get a picture. The
temperature may be quite low at the beginning, if the patient feels cold and
shivery. The average temperature is 37 degrees C, but the normal temperature for
any person may vary from this.
Modern
thermometers are electronic. The old mercury thermometers are no longer used
because of the difficulty in using them and the dangers of mercury poisoning.
“Fever scan” strips applied to the forehead are convenient, but not very
accurate.
Most people can find a pulse, on the under side of the
wrist, thumb side. Count the pulse for 30 seconds, and multiply by two to get
the beats per minute.
Respiration (breathing) can be counted over a full
minute by watching chest movements while the patient is not talking.
Many households now have a blood pressure machine.
You can mark all your readings on the accompanying
chart. [to be made]
They will give you a sense of the rhythm of the
temperature, and of any trends in pulse and respiration. The normal respiratory
rate is between 12-20. It can vary greatly, but a respiratory rate between 20
and 30 suggests that pneumonia is coming on.
Pneumonia
The commonest danger of Coronavirus is that it will lead to pneumonia.
The symptoms of pneumonia are:
·
Increasing difficulty of breathing (this
may show in your observations as increasingly rapid breathing)
·
Rising temperature (your chart may show an
upward trend)
·
Pain in the chest on breathing in deeply
·
Bloody or rust coloured sputum coming up
off the chest
·
Vivid dreams
·
Confusion in the elderly
·
The lips may get a bluish tinge
A paper in the BMJ suggests that a patient with pneumonia
should go to hospital if
·
Temperature is greater than 38 degrees C
·
Respiratory rate is above 20 per minute
·
Pulse rate is above 100 beats per minute
·
Oxygen saturation in blood is less than
94% (you need an oximeter to do this, but they only cost about £12 on the web.
You may
find this on-line tool for assessing the severity of your patient’s pneumonia useful:
https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap
Pneumonia cannot be treated at home. If you think your
patient is getting pneumonia, now is the time to call your GP if you can to
discuss what to do, to call 111 or, if you cannot get through on these numbers,
even 999.
At any other time, if you feel in your stomach that
things are not going well, do call your GP or 111.
If you are sure your patient needs to go to hospital,
it may well be that you can get him there quicker than an ambulance, depending
on the distance to hospital, and the ability to get the patient into your car.
Do phone the hospital first to say you are coming. Do decontaminate the car
thoroughly after the journey.
Appendix A
[Download Temperature Pulse and Respiration Chart – in
preparation. Help would be appreciated from a person skilled in Excel]
Appendix B
[List of things to have in readiness]
Pleas
follow the official advice from the WHO and Public Health England; these pages
are in addition to, not instead of, official advice. I have written suggestions, in good faith, to
help people faced with an anxiety -provoking situation in a time of national crisis.
I offer these not as advices or instructions, and in the end you must form your
own judgment as to what to do.
These
suggestions are offered in good faith. This paper does not claim to be perfect,
and people reading these words do so at their own risk .
You
are welcome to give feedback and suggestions, and in fact if you can scan your
charts and send them to me, this would be hugely useful to better understand
the pattern of illness created by this new virus.
When
this pandemic is over, the world will have learned an enormous amount. Hopefully
it will transform politics and economics from the destructive competitiveness
to a kinder, more cooperative and more ecological system.
Dr Richard
Lawson MB BS, MRCPsych,
Churchill, Somerset, UK
rlawson@gn.apc.org
25/3/2020
8 comments:
Thank you for this information hope we don't need it though i will save it to read again if it is needed.
Thanks Liz.
Another DIY face mask here https://www.consumer.org.hk/ws_en/news/specials/2020/mask-diy-tips.html?fbclid=IwAR1_w5Ik08SG9RA2J7cu8sS4WmIx0zAvPQMzZHaMkz9FZLDiuOxzpg_I53s
brilliant
x
More on cleaning materials https://greenerblog.blogspot.com/2020/03/how-to-nurse-covid-patient-at-home.html
Well done, writing this Richard. Practical advice to help keep us safe.
Thanks Jim. If you are downloading, use the post above, as I have added some important updates
Hi Richard ,great advice.from you it’s worked in the past! Stay well Ant
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