Sunday, March 29, 2020

NURSING A COVID-19 PATIENT AT HOME

Florence Nightingale




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 1.06

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.
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 you get 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.

2.     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. It should be removed and washed after each nursing episode.
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.

Pajamas would be good. Again, you will need a few sets to allow for washing.


Onesies may be useful.

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 to this post, 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, then rinsing thoroughly. Remember to wear protective gloves if you are getting things our of a bleach solution.



Managing Waste

Anything that may be contaminated with virus must be dealt with carefully. Tissues from coughing etc should go into a swing bin (remember to disinfect the lid of the 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 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 now 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. However, if desperate, you may wish to try it.



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. [In preparation].

There is an enormously helpful research project called the Covid Symptom Tracker that you can join on this link: https://covid.joinzoe.com/. You send in a daily report of how you are feeling. It will help to track spread of the disease.


A chart 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 above 20 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 (words not making sense) may occur, especially 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.]

Appendix B
List of things to have in readiness for nursing:

Gloves
Masks
Protective wear
Disinfectant
Bin Liners
Tissues
Waste bin
Dedicated crockery and cutlery

Appendix C
A Grab Bag is a small pre-packed case of things that your patient will need in hospital. Think Toothbrush, razor, charging plug and cable etc.

Appendix D

Medical history for admission to hospital. This will help the admitting doctor, who may be very busy indeed.

Write or print:
Full name of patient
Date of birth
Address
NHS number if known
Important medical history events:
Operations – with dates
Significant illnesses – with dates
Current medications  - names, how often they are taken

Name and contact details of next of kin


Disclaimer
Always 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 these 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.
 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

3 comments:

Anonymous said...

Thank you so much for this

Christine Prior said...

Thank you so much from the bottom of my heart for sensible, practical and helpful advice for everyone at home who is nursing a family member and has no idea what to do for the best. Stay Safe

DocRichard said...

Here is A breathing exercise from a nurse and doc at Queen's Hospital which is worth learning. Importantly, it includes lying prone, face down, to help prevent pneumonia https://twitter.com/jk_rowling/status/1247121896082157568?s=21