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MINISTRY OF HEALTH
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SOCIALIST REPUBLIC
OF VIETNAM
Independence - Freedom - Happiness
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No. 1125/QD-BYT
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Hanoi, February 08,
2021
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DECISION
ON
GUIDELINES FOR CARE OF COVID-19 PATIENTS IN HEALTHCARE ESTABLISHMENTS
MINISTER OF HEALTH
Pursuant to the Government’s Decree No.
75/2017/ND-CP dated June 20, 2017 on functions, duties, powers and
organizational structure of the Ministry of Health; at the request of Medical
Services Administration, Ministry of Health,
HEREBY DECIDES:
Article 1. Promulgated
together with this Decision are the guidelines for the care of COVID-19
patients in healthcare establishments.
Article 2. This
Decision takes effect from the date on which it is signed.
Article 3. Head
of Office of the Ministry of Health; Chief Inspector of the Ministry of Health;
heads of departments of the Ministry of Health; Directors of Departments of
Health; directors of hospitals and institutes with hospital beds affiliated to
the Ministry of Health; heads of health units of other ministries and central
authorities; and heads of relevant units shall implement this Decision./.
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P.P. THE MINISTER
THE DEPUTY MINISTER
Deputy head of National Steering Committee for COVID-19 Prevention and
Control
Nguyen Truong Son
GUIDELINES
CARE OF COVID-19
PATIENTS AT HEALTHCARE ESTABLISHMENTS
(Enclosed with
Decision No. 1125/QD-BYT dated February 08, 2021 by Minister of Health)
OVERVIEW ON SARS-COV-2
I. Overview
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After the first case
was confirmed in China on 08/12/2019, as of 02/02/2021, more than 1 year into
the pandemic, the world records 102.626.724 cases and 2.216.279 deaths in more
than 200 countries and territories. In Vietnam, as of 02/02/2021, there are 1.
851 cases and 35 deaths.
COVID-19 has diverse
clinical manifestations, ranging from asymptomatic infection to severe illness
such as severe pneumonia, respiratory failure, septic shock, multiorgan
dysfunction and death, especially in the elderly and those with chronic
diseases or immunodeficiency.
As of now, there is
no medication for the disease. Vaccination against COVID-19 has recently
started in some countries, which is facing multiple issues, thus, proactive
precautions such as the use of face masks, use of personal protective equipment
(PPE) in appropriate situations; hand hygiene; surface hygiene; keeping safe
distance, avoiding gatherings, etc. are of most importance to COVID-19
prevention.
II. Diagnosis
1. Definition of
COVID-19 cases
1.1. Suspected cases:
A suspected case
involves:
A. A patient who has
fever and/or acute respiratory disease that cannot be attributed to other
causes.
B. A patient who has
any respiratory symptom AND has traveled to/through/from or stayed in a
COVID-19 infected epidemiological zone* in the 14 days prior to symptom onset OR
has had close contact (**) with a suspected or confirmed COVID-19 case in the
14 days prior to symptom onset.
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** Close
contact includes:
- Contact at
healthcare establishments, including direct care of a COVID-19 case; working
with a health care worker infected with COVID-19; visiting a COVID-19 case or
staying in the same room with a COVID-19 case.
- Direct contact
within less than or equal to 2 meters with a suspected or confirmed COVID-19
case during period of illness.
- Living in the same
house as a suspected or confirmed COVID-19 case during period of illness.
- Working with a
confirmed or suspected COVID-19 case in the same team or office during period
of illness.
- Being in a tourist
group, business team, group of friends, etc. with a confirmed or suspected
COVID-19 case during period of illness.
- Traveling in the
same vehicle (sitting on the same row or within two rows in front of or behind)
with a suspected or confirmed COVID-19 case during period of illness.
1.2. Confirmed cases
Confirmed cases are
suspected cases or any person testing positive for SARS-CoV-2 confirmed by
testing facilities permitted to perform such testing by the Ministry of Health.
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1. Clinical symptoms
- Incubation period:
from 2 to 14 days, from 5 to 7 days on average.
- Onset: common
symptoms include fever, dry cough, fatigue and muscle pain. Some may experience
throat pain, stuffy nose, runny nose, headache, productive cough, vomiting and
diarrhea.
- Development:
+ Most patients (more
than 80%) have only mild fever and fatigue without pneumonia and usually
recover after about 1 week. However, some cases do not develop any clinical
symptom.
+ About 14% of patients
develop serious complications such as pneumonia or severe pneumonia and require
hospitalization; about 5% of patients need to be admitted to intensive care
units for treatment of acute respiratory manifestations (rapid breathing,
dyspnea, cyanosis, etc.), acute respiratory distress syndrome (ARDS), septic
shock, organ dysfunction, including kidney injury and heart muscle injury,
leading to death.
+ It takes an average
of 7 to 8 days after symptom onset for serious complications to develop.
+ Death is more
common in the elderly and persons with immunodeficiency and chronic diseases.
- Recovery period:
from 7 to 10 days after the period of illness; if without ARDS, patients will
no longer have fever, clinical signs will gradually disappear and they will
make a recovery.
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- In pediatric
patients, most of them have milder clinical manifestations compared to adult
patients or no symptom. Common signs include fever and coughing or
manifestations of pneumonia. However, some pediatric patients suffer from
multiorgan inflammation, fever; hyperemic eye or erythema, or swelling of the
oral mucosa, hands, feet; circulatory failure; manifestations of heart
dysfunction and high cardiac enzymes level; digestive disorders; coagulation
disorders and high inflammatory marker levels.
2. Paraclinical tests
Non-specific blood
tests and biochemical tests:
- Leukocyte count is
normal or decreases; lymphocyte count usually decreases, especially in severe
cases.
- C-reactive protein
(CRP) level is normal or increases, procalcitonin (PCT) level is usually normal
or increases slightly. ALT, AST, CK, LDH may increase slightly in some cases.
- Severe cases may
develop organ dysfunction, coagulation disorders, D-dimer level increase,
electrolyte and acid-base imbalance.
3. Lung X-ray and CT
scan
- In the early phase
of the disease or if there is only upper respiratory tract infection,
radiographs look normal.
- When pneumonia
develops, there are usually signs of bilateral interstitial pneumonia or
diffuse ground-glass opacity in peripheral or lower areas of the lungs. The
injury can progress rapidly in ARDS. Signs of cavity formation, pneumothorax or
pleural effusions are rare.
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- SARS-CoV-2 may be
detected via Real time RT-PCR or next-generation sequencing.
IV. Clinical form
classification
Clinical forms of
COVID-19:
1. Asymptomatic form
2. Mild cases: acute upper
respiratory tract infection
- There are
non-specific clinical symptoms such as fever, dry cough, throat pain, stuffy
nose, fatigue, headache and muscle pain.
- There are no signs
of pneumonia or oxygen deprivation.
3. Moderate cases: pneumonia
- Adult and old
pediatric patients: pneumonia
(fever, cough, dyspnea,
rapid breathing) and no sign of severe pneumonia.
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- Interstitial pneumonia
or complications is/are detected via lung X-ray, ultrasound or CT scans.
4. Severe cases:
severe pneumonia
- Adult and older
pediatric patients: have fever or are suspected of respiratory infection,
accompanied by any of the following signs: respiratory rate of > 30
breaths/minute, severe dyspnea.
- Young pediatric
patients: have
cough or dyspnea and at least one of the following signs: cyanosis or SpO2
< 90%; severe respiratory failure (grunting noises when breathing,
retractions);
+ Or the child is
diagnosed with pneumonia and has any of the following severe signs: inability
to drink/nurse; altered level of consciousness (lethargic or comatose);
convulsions. Other pneumonia signs such as retractions or rapid breathing may
be present (with the abovementioned respiratory rate).
- Diagnosis is made
based on clinical signs; complications are detected via lung X-ray.
5. Critical cases
5.1. Acute
respiratory distress syndrome (ARDS)
- Onset: respiratory symptoms
appear or worsen within one week starting from onset of clinical symptoms.
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- Pneumochysis is
not caused by heart failure or fluid overload. Subjective assessment (heart
ultrasound) is needed to exclude pneumochysis caused by hydrostatic pressure if
there are no risk factors.
- Hypoxemia in
adult patients: classification is done based on PaO2/FiO2
(P/F) ratio and SpO2/FiO2 (S/F) ratio if PaO2
value is unavailable:
- Hypoxemia in
pediatric patients: classification is done based on IO or OSI value for
patients on invasive ventilation and PaO2/FiO2 or SpO2/FiO2 for patients on CPAP or non-invasive
ventilation.
5.2. Sepsis
- In adult patients: there are signs of
organ dysfunction:
+ Altered level of
consciousness: somnolence, stupor, coma
+ Dyspnea or rapid breathing, low
oxygen saturation level
+ Fast heart rate, weak
pulse, cold extremities, or low blood pressure, livedo reticularis
+ Low urine output or
no urine output
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- Pediatric patients:
when
sepsis is suspected or confirmed and at least 2 criteria for systemic
inflammatory response syndrome (SIRS) are met, one of which must be change to
body temperature or abnormal leukocyte count.
5.3. Septic shock
- In adult patients: prolonged low blood
pressure despite volume resuscitation, use vasoactive drugs to maintain mean
arterial pressure (MAP) at ≥65 mmHg and serum lactate levels at >2 mmol/L.
- In pediatric
patients: septic shock is confirmed upon the presence of:
+ Low blood pressure.
+ Or 2-3 of the
following signs: altered level of consciousness, fast or slow heart rate; or
warm vasodilation with bounding pulses; rapid breathing; mottled skin or
petechial or purpuric rash; increased lactate; oliguria; hyperthermia or
hypothermia.
5.4. Other
severe-critical complications: lung infarction, stroke, delirium. They require close
monitoring, diagnostic testing upon suspicion and suitable treatments.
V. Treatment and care
1. General treatment
rules
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+ Suspected cases
shall be examined, monitored and isolated in a separate area in healthcare
establishments, and have their samples collected properly for confirmatory
testing.
+ Confirmed cases
must be monitored and treated in complete isolation in designated
establishments.
+ Mild cases shall be
treated in isolation areas of normal departments.
+ Severe cases shall
be treated in isolated emergency rooms of departments or intensive care units.
+ Severe-critical
cases shall be treated in intensive care units.
- As there is no
known effective cure, treatment mostly involves supportive care and symptom
treatment.
- Treatments shall be
individualized for each case, especially for severe-critical cases.
- Severe conditions
and complications must be monitored, detected and handled promptly.
2. General
monitoring, care and treatment measures
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- Clean the nose and
throat, can keep the nose moisturized with saline, gargle with regular mouth
wash.
- Keep the body warm.
- Drink enough water,
ensure fluid and electrolyte balances.
- Be careful when
administering IV fluids to pneumonia patients who have no signs of shock.
- Ensure a balanced
diet, improve the body’s condition and administer vitamin supplements if
necessary. For severe-critical cases, follow nutrition recommendations of
Vietnam National Association of Emergency, Intensive Care Medicine and Clinical
Toxicology.
- Reduce high fever.
- Reduce cough using
common cough medications if necessary.
- Evaluate, treat and
give a prognosis of comorbid chronic conditions (if any).
- Give advice and
encouragement to patients.
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- Treating
establishments shall be equipped with minimum emergency aid equipment and tools
such as pulse oximeters, oxygen supply systems/tanks, oxygen-delivering
interfaces (nasal cannula, simple face mask, and mask with reservoir bag), bag
valve masks, and endotracheal intubation equipment for different age groups.
3. Treatment of
respiratory failure
3.1. Oxygen therapy
and monitoring
- Give supplemental
oxygen therapy immediately to patients with SARI and respiratory failure,
hypoxaemia or shock.
- Closely monitor
each patient's condition to detect worsening signs or poor response to oxygen
therapy for timely handling.
3.2. Treatment of
critical respiratory failure and ARDS
- When low flow oxygen
therapy is not effective against hypoxemia, SpO2 ≤ 92%, or/and there is labored
breathing, consider administration of high flow nasal oxygen, CPAP, or BiPAP.
- Do not put patients
with hemodynamic disorders, multiorgan dysfunction and altered level of consciousness
on non-invasive ventilators.
- Closely monitor
patients to detect poor response for timely handling. If non-invasive breathing
support is not effective against oxygen deprivation, administer endotracheal
intubation and invasive ventilation.
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- Implement breathing
support regimens for ARDS in adults and children.
- Strictly control
fluid balance, avoid fluid overload, especially when not performing volume
resuscitation.
- In case of severe
and prolonged oxygen deprivation not responding to common therapies, consider
indication and use of extracorporeal membrane oxygenation (ECMO) techniques on
each case where qualified to perform such techniques.
- As ECMO can only be
performed at some large healthcare establishments, upon consideration of ECMO
indication, the treating establishment should contact a qualified
establishment, transport the patient early and follow the patient transport
procedure from the Ministry of Health.
4. Treatment of
septic shock
Apply treatment
regimens for septic shock in adult and pediatric patients.
5. Supportive care
for organ dysfunction
Supportive care shall
be provided as appropriate to each patient’s condition.
- Supportive care for
kidney dysfunction:
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- Treatment of
coagulation disorders: transfuse fresh plasma, platelets and coagulation
factors if necessary.
6. Other treatment
measures
- Antibiotics
- Antiviral drugs
- Systemic
corticosteroids
- Hemofiltration
- Intravenous
immunoglobulin (IVIG)
- Interferons
- Pulmonary
rehabilitation
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7. Complication
prevention
For severe cases
receiving treatment in intensive care units, take preventive measures against
the following common complications:
- Ventilator-associated
pneumonia
- Venous thrombosis
prevention
- Central
line-associated bloodstream infection
- Pressure ulcers
- Stress-induced
stomach ulcers and gastrointestinal hemorrhage
- Intensive care unit
acquired muscle weakness
VI. Discharge
criteria
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- No fever for at
least 3 days.
- Improved clinical
symptoms, good general condition, stable vital signs, normal organ functions,
normal blood test results and better lung X-rays.
- 03 samples
(collected at least 1 day apart) testing negative for SARS-CoV-2 via realtime
RT-PCR.
2. Post-discharge
monitoring
The patient shall
self-quarantine under the supervision of grassroots health unit and local CDC
for 14 days and take temperature twice a day; if their temperature is higher
than 38oC in two consecutive checks or there is any other abnormal
sign, they must visit a healthcare establishment for examination immediately.
MANAGEMENT OF COVID-19 CASES
1.
Receipt and screening of COVID-19 cases
As SARS-CoV-2 is
highly contagious, screening, early detection and timely treatment are crucial.
Prompt quarantine and precautions against transmission must be applied to
suspected cases.
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- Healthcare
establishments shall formulate plans for prompt detection, classification,
screening and management of confirmed or suspected cases, including patients,
patients' families, visitors and healthcare workers, upon their arrival at
these establishments. After arriving at these establishments, persons with
respiratory tract infection symptoms (cough, fever, runny nose, throat pain,
chest tightness, dyspnea, body aches) and persons having epidemiological
factors (traveling from infected areas, having contact with confirmed or
at-risk cases, etc.) shall receive instructions and be screened and examined
separately. Healthcare establishments not receiving COVID-19 patients for
treatment shall establish referral procedures for suspected cases.
- Healthcare
establishments shall formulate plans for screening of inpatients, patients’
families, visitors and healthcare workers, especially for departments facing
high risk such as kidney dialysis, intensive care, infection, respiratory
medicine, oncology, etc.
- Take precautions
and control contamination seriously (standard precautions and
transmission-based precautions).
1.2. Classification
and receipt of visiting patients
1.2.1. For establishments
with 2 or more gates
Step 1. At establishment’s
entrance (initial screening)
- Dedicate only one
gate to receipt and service of persons having respiratory tract infection
symptoms. Place a sign reading “Gate for persons having cough, fever, runny
nose, throat pain, chest tightness, breathing difficulty and body aches and
contact with confirmed or suspected COVID-19 cases” at this gate. Place another
sign reading “Persons having cough, fever, runny nose, throat pain, chest
tightness, breathing difficulty and body aches please enter via gate ..."
at the other gates.
- At the dedicated
gate, place a sign with colored lighting (e.g., LED light signs, box signs with
lights inside or requiring lighting) for reading at night.
- Similar instruction
signs, information on hotlines, etc. shall be placed at noticeable locations
outside of the gates.
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- Place a health
declaration and registration table at a well-ventilated location next to the establishment’s
gate or in the lobby. Remind patients and their families to wear face masks and
provide face masks for those not having them. Equip health declaration and
registration tables with alcohol-based hand sanitizer.
Step 2. Route to
screening rooms
- Dedicate a route
from the gate to the screening room using red/ yellow ropes (may be
reflective). Place a sign instructing persons with symptoms to use only this
route.
- Assign at least 1
specialized patient transport vehicle (for long distance) to transport
confirmed or suspected COVID-19 cases. This vehicle shall be parked in a
separate area denoted by a sign, not be used to transport other patients and must
be disinfected after each use.
Note: the route shall not
go through other departments and rooms, avoid going down corridors. Place
screening rooms as near health
declaration and registration tables as possible.
Step 3. Screening
rooms
- Place screening
rooms at well-ventilated locations separate from other departments and rooms.
- Each screening room
shall have only one examination table. Do not examine two people in one
screening room at the same time.
- Examination tables
shall be fully supplied with COVID-19 prevention equipment. Each room shall
have only one examination table.
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After screening a
person, if it is confirmed that the person has no epidemiological factor
or clinical symptom related to COVID-19, direct the person to the normal
examination area. Vice versa, the normal examination area shall transfer all
persons with suspected factors (epidemiological factors and/or clinical
symptoms) to screening rooms.
Step 5. Transfer to
another establishment or isolation area for COVID-19 treatment
- After screening, if
a patient is suspected to have contracted SARS-CoV-2, the establishment shall
transport the patient to one of the two following locations:
a) Temporary
isolation room in the establishment: transport the patient to a temporary
isolation room if the establishment is not designated for COVID-19 treatment.
The establishment shall contact the preventive medicine center/ CDC and the
nearest hospital designated for COVID-19 treatment to transfer the patient there
and prevent infection during the transfer process.
- Establishments
shall not transfer patients by themselves. They must contact their supervisory
bodies and hospitals at higher level immediately for guidance.
b) Isolation areas
for COVID-19 treatment:
- Hospitals
designated for COVID-19 treatment shall prepare isolation areas to receive
patients. Isolation areas shall conform to guidelines of the Ministry of Health
and accommodated the following three groups of patients separately:
+ Suspected cases
+ Mild cases
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Collect samples (at establishments or
another location)
If collecting a
sample for SARS-CoV-2 testing is indicated, collect the sample in the isolation
area or temporary isolation room. Establishments may collect samples in respiratory
examination rooms depending on their actual capacity. Establishments shall
contact CDC/ preventive medicine unit for sample collection or collect samples
themselves if they are permitted to perform SARS-CoV-2 testing by the Ministry
of Health.
Picture
1: Diagram
of classification and screening for establishments with multiple gates
1.2.2. For
establishments with 2 or more gates
Adhere to the
guidelines for hospitals with 2 gates and the following points:
- Place instruction
signs from the gate to the registration and classification tables/ rooms.
- Registration and classification
tables/ rooms shall be placed next to the gate or in the yard or main lobby as
close to the gates as possible. Do not place registration and classification
tables/ rooms inside the main buildings or near departments or rooms to
minimize infection risk.
- Screening rooms
shall be placed next to registration and classification tables/ rooms (within
10m from the gate).
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Picture
2: Diagram
of classification and screening for establishments with one gate
- During an epidemic,
instructional signs shall be affixed at entrances and in examination rooms to
instruct patients with fever or cough and their families to visit the screening
area immediately, preventing them from visiting other areas.
- Instruct patients
and their families to wear face masks, avoid having contact with other people
and practice hand hygiene as well as respiratory hygiene properly.
- Any family member
accompanying a confirmed or suspected case shall be considered to have been
exposed to SARS-CoV-2 and must be monitored for the prescribed period to faciliate
early diagnosis of COVID-19.
- Persons in charge
of transporting confirmed or suspected cases must wear PPE and use specialized
vehicles. Contaminated items, transport vehicles, discarded items and waste
associated with these persons shall be collected and handled according to
regulations.
2.
Organization of COVID-19 treatment areas
- A treatment area
shall have the following rooms: examination room, laboratory, treatment
monitoring room and cardiopulmonary resuscitation room.
- The building layout
and operational process must meet standards for hospital isolation.
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- Entry to isolated
treatment areas must be controlled strictly.
3.
Patient arrangement
- Suspected and
confirmed cases must be placed in separate areas in a department and not stay
in the same room.
- Serious cases shall
be placed in special care rooms (negative pressure if possible) in isolation
areas or isolation rooms fully equipped with ventilators and blood filters.
- Mild cases shall be
placed in separate rooms. If this is not possible, they may stay in the same
room.
- Suspected cases
must be isolated in single-occupancy rooms or placed in the same room with
their beds at least 1-2 meters apart.
- All patient
activities must be limited to isolation areas.
4. Workforce
preparation
- Healthcare
establishments shall prepare resources and workforce plans for receipt and
treatment of COVID-19 cases during epidemics, minimize mortality and control
infection in healthcare establishments and communities.
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+ Group working from
home
+ Group working in
treating departments
+ Group working in
screening areas, anterooms and areas where COVID-19 cases are treated.
- Formulate detailed
plans for workforce mobilization according to epidemic situation and possible
quarantine scenarios, avoiding mobilizing large workforce at the start.
- All healthcare
workers must be ready to work in unfamiliar situations such as working with new
teams in new situations and being led by members of emergency and infection
teams.
- Set targets at the
beginning: minimize risks and complications for patients; minimize
cross-contamination to healthcare workers. Care may not be perfectly and
promptly provided due to lack of PPE and prolonged fatigue and stress in
healthcare workers.
- Each care group
shall work no more than 1 shift/ day in COVID-19 treatment areas.
- Before end of
shift, healthcare workers must change out of their PPE and perform necessary
personal hygiene to prevent infection from their work.
4.
Health monitoring for healthcare workers
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- Healthcare workers
need to have a nutritious diet to boost their immune systems.
- Monitor and record
the health condition of all frontline healthcare workers, including temperature
and respiratory symptoms. If a worker develops any symptom such as fever or
cough, they must be isolated immediately and tested for the virus.
- Nurses directly
taking care of confirmed cases require assistance and mental preparation to
work and care for an increasing number of patients as well as risk of
cross-contamination from patients.
- When frontline
healthcare workers have completed their duties in isolated treatment areas and
return to their normal life, they should be tested for SARS-CoV-2. If testing
negative, they need to undergo quarantine in a separate area according to
regulations before returning home.
5. Preparation of
medical equipment and materials and PPE
- Draw up lists of
names and quantities of medical devices (premium ventilators, invasive/
non-invasive ventilators, electric syringe pumps, infusion pumps, monitors,
lights for endotracheal intubation, etc.) and medical consumables (PPE,
alcohol-based hand sanitizer, etc.) to be equipped for screening rooms,
isolation rooms and intensive care units as appropriate to the size and scope
of service of each establishment for each COVID-19 epidemic stage.
- Decide PPE quota
for each at-risk area (low, moderate or high risk) according to guidelines of
the Ministry of Health.
- Determine levels of
PPE necessity as suitable. All healthcare workers, patients’ families, visitors
(if any) and persons having contact with confirmed or suspected COVID-19 cases
or samples thereof shall be provided with recommended PPE (see Table 1).
- Cooperate with
departments in stockpiling essential materials to ensure operations of
healthcare establishments and units in charge of procurement shall promptly
formulate plans to stockpile essential goods according to the epidemic’s
progress and commitment on delivery time of manufacturers.
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Table 1. Selection and use of
COVID-19 personal protective equipment by location, user and professional
operation at healthcare establishments
Location
User
Professional
operation
Level
of COVID-19 PPE
Screening room
Healthcare workers
Consultation with
and physical examination of patients with no respiratory symptoms
Level 3 or higher
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Consultation with
and physical examination of patients with respiratory symptoms
Level 4
Cleaning staff
After and during
consultations and physical examination of patients with respiratory symptoms
Level 3 or higher
Healthcare workers
Preliminary
screening with no direct contact
Level 2
Emergency
department receiving patients with undetermined COVID-19 transmission risks
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Procedures
potentially capable of generating aerosols or surgeries
Level 4
Healthcare workers
All activities
Level 3
Isolation areas
Healthcare workers
Direct patient care
without aerosol generation
Level 3 or higher
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Level 4
Cleaning staff
Entering patient
rooms
Level 3 or higher
Laboratories
testing samples of confirmed or suspected COVID-19 cases
Healthcare workers
All activities
Level 4
Transport of
COVID-19 cases
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All activities
Level 3 or higher
Other areas with
patient presence in isolation areas
All staff,
including healthcare workers
Any activity
without contact with patients
Level 3
Departments of
infection control
Handlers of waste
at healthcare establishments
Collection and
handling of waste at healthcare establishments
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Morgues
All staff,
including healthcare workers
All activities
Level 4
6. Formulation of
COVID-19-related regular procedures
Healthcare
establishments shall look for guidelines of the Ministry of Health or formulate
guidelines and procedures for healthcare workers to ensure safety in the care
of COVID-19 patients.
- Procedures for
patient receipt, classification and screening
- Guidelines and
procedures for putting on and removing PPE
- Collection of
COVID-19 samples, preservation, packing and transport of samples from confirmed
or suspected COVID-19 cases
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- Procedures for
handling of bodily fluids and blood of confirmed or suspected COVID-19 cases
- Procedures for
handling of COVID-19-related biomedical waste
- Procedures for
handling of exposure to SARS-CoV-2 for healthcare workers
- Procedures for
handling of remains of confirmed or suspected COVID-19 cases
- Procedures for
handling of medical equipment and textile products
7. Training
- Establish a
COVID-19 training committee, which shall take charge of compiling training
materials and providing training for the whole healthcare establishment.
- Standardize all
procedures (making video clips) to facilitate online training and E-learning.
- Prioritize training
for the following 3 groups:
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+ Extended group
(nurses of clinical departments participating in treatment of mild to moderate
COVID-19 cases in case of overload in emergency departments and specialized
areas for COVID-19 cases), which shall receive training in basic skills and
knowledge and general rules in care of confirmed or suspected cases,
precautions (use of PPE, negative pressure rooms, etc.), and educating patients
and their families about health matters.
+ Peripheral group
(orderlies, security guards, cleaning staff and other persons), which shall
receive training in infection prevention, rules for approaching confirmed or
suspected cases and basic precautions.
- Drills: organize
drills to inspect, assess and take note of areas of improvement to amend and
complete COVID-19 prevention and control plans of healthcare establishments.
8. Inspection and
supervision
- Establish a team in
charge of inspecting compliance with administrative regulations on COVID-19
prevention and control in each healthcare establishment.
- The nursing
department shall cooperate with the department of infection control, general
planning department, head nurses of clinical departments and head technicians
of paraclinical departments in inspecting and supervising compliance with
regulations on COVID-19 prevention and control.
9. Provision of
comprehensive care to suspected or confirmed COVID-19 cases
- Monitor vital signs
of patients continuously, especially changes in consciousness, respiratory rate
and oxygen saturation. Observe symptoms such as cough, sputum, chest pain, dyspnea
and cyanosis. Monitor arterial blood gas analysis closely. Promptly recognize
any worsening condition to adjust oxygen supply or take other emergency measures.
- Pay attention to
ventilator associated lung injury (VALI) with higher positive end-expiratory
pressure (PEEP) and high pressure support. Closely monitor changes in airway
pressure, tidal volume and respiratory rate.
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+ Monitor gastroparesis.
Evaluate gastroparesis every 4 hours. Replace fluid removed if remaining
gastric volume is under 100 ml; otherwise, inform the in-charge doctor.
+ Prevent aspiration
during patient transport: before transporting the patient, stop feeding via
nasogastric tube, remove gastric residue and connect gastric tube to a negative
pressure bag. Throughout transport, elevate the patient’s head to 30 degrees.
+ Prevent aspiration
for HFNC: check humidity every 4 hours to prevent overly high or low humidity.
Promptly remove water in the cannula to prevent cough and aspiration induced by
condensation. Keep the nasal cannula higher than the machine and tube. Promptly
remove condensation in the system.
- Adopt strategies
for prevention of catheter-related sepsis and catheter-related urinary tract
infection.
- Prevent skin damage
due to pressure, including medical device-related pressure injuries,
incontinence-associated dermatitis and medical adhesive-related skin injuries.
- Identify patients
with high fall risk and take precautions.
- Assess all patients
with venous thromboembolism risk to identify those at high risk and take
precautions. Monitor coagulation, Ddimer level and clinical manifestations
related to VTE.
- Assist patients who
are weak, have breathing difficulty or have significant oxygenation index
fluctuation with eating and drinking. Increase monitoring of oxygenation index
of these patients during their meals. Give tube feeding for those who cannot
eat. In each shift, adjust feeding volume and speed according to patient’s
intake capacity.
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1.
Rules for infection prevention
- Apply standard
precautions: all healthcare workers working in isolation areas shall wear
sufficient PPE properly. This is the most important measure to protect
healthcare workers from the disease.
- Take precautions
against contact and droplet transmission in examination and care of confirmed
or suspected COVID-19 cases.
- Take precautions
against airborne transmission while performing aerosol generating procedures
upon confirmed or suspected COVID-19 cases.
- All patients and
healthcare workers in isolated treatment areas shall practice respiratory
hygiene.
- Properly control
ventilation and environmental hygiene in patient rooms, isolation areas, etc.
- Minimize moving
patients. Prioritize bedside techniques (X-ray, ultrasound, etc.); if the
patient must be moved, notify the destination and ask the patient to wear a
medical mask during the move; use separate and predetermined ways to minimize
exposure for healthcare workers and other patients.
- Do not let the
family of isolated patients take care of them, excluding newborns and young
children; families of suspected or confirmed cases must strictly adopt
preventive measures.
- Patient care
equipment shall be used once for each patient. If this requirement cannot be
ensured, sanitize, disinfect and sterilize the equipment before using it on
another patient.
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3.
Transmission-based precautions
3.1. Droplet precautions
Wear medical masks
and goggles or face shields when in close contact with confirmed cases.
3.2. Contact
precautions
- Wear clean gowns
and shoe covers when visiting a patient’s room and remove them before exiting
the anteroom. Do not let work clothing touch any environmental surface or other
objects.
- Wear clean gloves
while caring for patients, change gloves after coming into contact with feces,
medical fluids, bodily fluids of patients, etc.
- Clean hands
immediately using hand sanitizer.
3.3. Airborne
precautions
- Wear gowns and
respirator masks (e.g., N95).
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- Perform medical
procedures in a single-occupancy room with a tightly shut door and safe
ventilation. Negative pressure rooms are recommended.
- Ensure safe
ventilation: natural ventilation, mechanical ventilation or mixed-mode
ventilation may be used provided that the minimum ventilation rate is 12 ACH.
Locate the exhaust system in a manner that allows air to be discharged close to
the ground (10 - 15 cm above the ground) to empty areas and prevents contaminated
air from recirculating.
4.
Rules for respiratory hygiene
- Cover the mouth and
nose with tissue papers when coughing and sneezing, and immediately discard
used tissues in waste containers.
- If no tissue paper
is available, cough into the elbow, DO NOT cough into the hand.
- Wash hands
immediately after coming into contact with patients.
5.
Control of isolation area environment
- Control of patient
bed, floor, wall and corridor environments is an important precaution against
the spread of SARS-CoV-2 with the following key areas:
- Patient receipt
area, corridors and waiting rooms shall be well-ventilated and spacious.
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+ Negative pressure
rooms are the optimal option.
+ In case negative
pressure rooms are unavailable, employ mixed air or natural ventilation and
ensure that the minimum ventilation rate is 12 ACH.
+ Aerosol generating
procedures shall be performed in closed rooms with suitable ventilation (12
ACH).
- If there is no room
meeting the abovementioned standards:
+ Perform the procedure
in a room far away from other patients, which must be well-ventilated, located
downwind and equipped with dual airflow windows opening out into empty areas.
+ An exhaust system
may be used to discharge air to empty areas instead of corridors or adjacent
rooms.
+ Environmental
surfaces must be cleaned and disinfected with suitable and licensed
disinfectants.
- Equipment,
machinery, beds and cabinets shall be cleaned and disinfected at least twice a
day and when necessary (when they are used for another patient or the current
user is deceased, transferred or discharged) using suitable and licensed
disinfectants.
Table 2. Chlorine-based
disinfectants for COVID-19 prevention and control at healthcare establishments
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Activated
chlorine concentration
Remark
Surfaces of
ordinary areas (floors, walls, objects)
0,1%
Minimum
concentration of 0,1% for wiping or spraying (for hard to wipe surfaces)
Surfaces of
isolation areas
0,1%
Surfaces of
equipment in isolation rooms
0,1%
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Patient transport
vehicles
0,1%
Minimum
concentration of 0,1% for wiping or spraying (for hard to wipe surfaces)
Spills of blood or
other bodily fluids
0,5%
Excreta (urine,
feces, vomit, fluids from suctioning, etc.)
1,0%
Add disinfectant to
excreta in a ratio of 1 to 1 for at least 30 minutes
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0,5%
Refer to
manufacturer’s guidelines
Handling of remains
0,1%
Place the whole
body in the first specialized bag and spray disinfectant over the bag. After
moving out of the isolation room, place the first bag in another bag and
spray disinfectant over this bag.
Disinfect
equipment, surfaces of operating tables, operating rooms and equipment
involved in encoffinment and dissection of remains
Patient’s tableware
0,05%
Soaking
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0,01%-
0,05%
Depending on the
state of the bloodstain or bodily fluid stain and type of fabric
6.
Use of PPE
- Infection usually
occurs when PPE is taken off. Excluding goggles and face shields, which may be
placed in basins containing a disinfectant solution for reuse, all PPE items
must be discarded in specialized bags, transported by specialized vehicles and
handled according to procedures for infectious waste handling.
- Place sufficiently
large and understandable posters about PPE wearing and taking off at noticeable
locations.
- Wear and take off
PPE according to regulations at designated locations.
- PPE removal
procedure is a reversal of the PPE wearing procedure.
- Besides use of PPE,
surface and equipment disinfection, minimizing unnecessary contact with
patients and surfaces and proper waste management are crucial to minimizing
infection risk.
- Speak loudly,
clearly and slowly when wearing face masks and masks. After hearing an
instruction, repeat it to the speaker. Wear a name tag or affix a portrait onto
the outside of the PPE for identification.
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7.
Prevention of infection in patient care
7.1. For patients
receiving oxygen therapy
Ensure the “SAS”
rule:
- Safe: safe for
caregivers and patients.
- Accurate: avoid
unreliable, unfamiliar or repetitive techniques.
- Swift: not hasty or
late.
Healthcare workers
face higher risk of infection when they directly take care of patients
receiving oxygen therapy:
- Take safety
measures to minimize contact or droplet COVID-19 transmission. When using HFNC,
ensure that the nasal cannula is located correctly (completely placed inside
the nostrils and secured to the patient’s head using a rubber band to minimize
loss).
- Minimize infection
in performance of aerosol generating procedures on suspected or confirmed
COVID-19 cases. Aerosol generating procedures comprise airway suctioning,
bronchial endoscopy, endotracheal intubation, tracheostomy and cardiopulmonary
resuscitation, including non-invasive ventilation.
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- Healthcare workers
who perform these procedures must wear waterproof long-sleeve gowns,
non-sterile gloves (2 pairs), safety goggles (with temples), N95/FFP2 masks and
face shields.
- Use closed sputum
suctioning equipment.
- Avoid mask
ventilation unless necessary and use the low pressure/ low volume technique. It
is recommended to use the two-hand two-person V-E technique with the second
person squeezing the bag.
- Endotracheal
intubation of suspected or confirmed COVID-19 cases poses high risk to healthcare
workers regardless of the clinical severity of the disease. Therefore, it is
imperative to follow all necessary precautions; and practices recommended for
special care and anesthesia teams.
- Prioritize early
and planned endotracheal intubation instead of emergency endotracheal
intubation to minimize infection risk.
- If possible, avoid
bag-mask ventilation.
- Ensure the patient
reaches the necessary level of sedation (no stimulation).
- Only essential
healthcare workers may remain in the room.
- Ensure all
necessary equipment and drugs are available in the room. Do not use trolleys.
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- Prepare a plan to
move the patient from the isolation area to the operating room and vice versa.
Warn other people that the patient is suspected or confirmed to have contracted
COVID-19 (using signage, labels, designated colors, etc.).
- The patient shall
wear a medical mask and headwear, lie on a bed or stretcher or sit in a
wheelchair and not talk during the move.
- Healthcare workers
shall notify the operating room before the move to have it ready.
- Wear PPE and move
the patient to the operating using the predetermined route. Avoid using the
elevator.
- Promptly hand the
patient over, go through the surgical safety checklist and move the patient
directly into the operating room without staying in any other room.
- Do not take the
patient’s medical record into the operating room; all post-surgery medical
records shall be provided online, on temporary notes or via a board shown through
the operating room’s window, which shall be copied and added to the patient’s
medical record and signed by the responsible healthcare workers after the surgery
in the administrative area after they have removed their PPE.
- The operating room:
prioritize negative pressure operation rooms. If the operating room has
positive pressure, turn the positive pressure system off if possible. A note
informing about the COVID-19 patient must be posted on the operating room’s
door.
- Minimize number of
people present in the operating room. Only the anesthesiologist,
anesthesiologist’s assistant, surgeon, surgeon’s assistant, surgical tech and
communication staff member may stay in the operating room. Additional personnel
may join depending on the situation.
- Select the most
experienced doctors and personnel.
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- Do not replace any
member of the surgical team throughout the surgery unless compulsory.
- Collect waste
according to regulations.
- Carry out
sterilization and disinfection according to regulations.
- Immediately
sterilize the operating room and equipment used on the patient (endotracheal
intubation light, mandrine, masks, ventilators and ventilator tubes, monitors,
electric syringes, etc., replace PetCO2 monitor’s tubes and breathing filters).
- After the patient
leaves the operating room, leave the room empty until 99,9% of its air has been
replaced (e.g., an operating room with at least 15 ACH requires at least 28
minutes).
- After the surgery,
clean and disinfect frequently touched surfaces at the anesthesia machine and
anesthesia area using disinfectants. Consider using disposable covers (such as nylon
covers) to prevent contamination of equipment and environmental surfaces.
Refer to the
guidelines for prevention and control of SARS-CoV-2 infection at healthcare
establishments promulgated together with Decision No. 5188/QD-BYT dated 14/12/2020
by the Minister of Health.
CARE OF SUSPECTED, ASYMPTOMATIC, MILD AND
MODERATE COVID-19 CASES
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- Suspected cases
(may be regarded as an emergency condition) shall be examined, cared for
monitored and isolated in a separate area in healthcare establishments, and
have their samples collected properly for confirmatory testing.
- Mild cases (upper
respiratory tract infection, mild pneumonia) shall be treated and cared for in
isolation areas of normal departments.
- As there is no
known effective cure, treatment mostly involves supportive care and symptom
treatment.
- Treatments and care
measures shall be individualized for each case.
- Severe conditions
and complications must be monitored, detected and handled promptly.
2.
Care
2.1. Assessment
- Physical condition,
mental condition, skin, mucous membranes.
- Temperature, heart
rate, blood pressure.
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+ Respiratory rate,
respiratory pattern, dyspnea level.
+ Oxygen saturation
level (SpO2).
+ Symptoms: stuffy
nose, cough, sputum, throat pain, chest pain and tightness.
- Other symptoms:
digestion, urology, headache, muscle pain, etc.
2.2. Nursing
interventions
2.2.1. Respiratory
assurance
- Have the patient
lie down with their head elevated; sitting and walking will help the patient's
diaphragm function better and prevent sputum accumulation.
- Administer oxygen
therapy (if necessary) according to indications.
- Administer clapping
and vibration, instruct the patient on how to breathe slowly and deeply to
prevent sputum accumulation.
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- Clean the nose and
throat, can keep the nose moisturized with saline drops, gargle.
2.2.2. Physician
order execution
- Carry out physician
orders for infusion, injection and drug administration properly and promptly.
- Assist doctors with
procedures where indicated.
- Conduct tests
promptly and adequately according to indications.
- Execute other
physician orders.
2.2.3. Nutrition
assurance
- Evaluate the
patient’s nutritional status on a daily basis.
- Provide meals and
water at the patient’s bed throughout the isolation period.
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2.2.4. Health advice
and education
- Immediately after
the patient is admitted, inform the patient of the department’s rules and
provide them with information sheets.
- Give encouragement and
instructions about the disease to reassure the patient.
- Instruct the
patient on diet, physical exercise, breathing exercise and therapeutic
exercise.
- Instruct the
patient on use of face masks, respiratory hygiene when coughing, hand hygiene
and personal hygiene.
- Advise the patient
on how to follow COVID-19 prevention guidelines at home after they complete
their quarantine. The patient needs to check their temperature twice a day. If
their temperature is higher than 38 degrees Celsius in two consecutive checks
or there is any other abnormal sign, they must visit a healthcare establishment
for examination immediately.
2.2.5. Complication
monitoring and prevention
- Monitor respiratory
rate, SpO2, heart rate,
temperature and blood pressure at least twice a day and when necessary;
promptly detect abnormal signs such as worsening dyspnea and respiratory
failure to make suitable interventions.
- For patients with
worsening pneumonia, notify the doctor and prepare equipment for endotracheal
intubation/ tracheotomy and mechanical ventilation.
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2.3. Assessment
Good progress:
- The patient no
longer has fever, has stable heart rate and blood pressure, does not develop
respiratory failure, complications or nursing care accidents such as pneumonia,
pressure ulcers, etc.
- The patient and
their family understand about COVID-19, care methods and how to prevent
COVID-19.
- Healthcare workers
and the patient’s family are not infected with the disease.
No progress or
worsening:
The patient’s general
condition worsens. The patient develops severe respiratory failure, functional
disorders, complications such as pressure ulcers, pneumonia, etc. or suffers
from multiple sequelae or spreads COVID-19 to healthcare workers and their
family.
CARE OF SEVERE AND CRITICAL COVID-19 CASES
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I.
COVID-19 cases with acute respiratory distress syndrome
1.
Rules for care:
COVID-19 patients
with acute respiratory distress syndrome (ARDS) shall be monitored and promptly
handled to prevent fatality according to the “SAS” rule: Safe: safe for
caregivers and patients; Accurate: avoid unreliable, unfamiliar or repetitive
techniques; and Swift: not hasty or late.
Prevent transmission
to healthcare workers during administration of oxygen therapy, high flow nasal
cannula (HFNC), continuous positive airway pressure (CPAP), noninvasive
ventilation (NIV), inspiratory positive airway pressure (IPAP) and expiratory
positive airway pressure (EPAP).
2.
Care
2.1. Assessment
- General condition:
consciousness (wakefulness, contact, Glasgow coma scale), skin, mucous
membranes, body temperature.
- Respiratory
condition:
+ Respiratory rate,
respiratory pattern, level of dyspnea, cyanosis, respiratory muscle
contraction.
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+ Symptoms: cough,
sputum, throat pain, chest pain and tightness, etc.
- Other symptoms:
digestion, urology, neurology (headache), muscle, bones, joints (muscle and
joint pain, etc.).
2.2. Nursing
interventions
2.2.1. Respiratory
assurance:
- Take safety
measures to minimize contact or droplet transmission. Place a medical mask on
top of the nasal cannula when administering HFNC.
- Continuously
monitor oxygen saturation before and during oxygen therapy administration. Some
patients may develop rapid oxygen desaturation over time.
- The patient must
wear a medical mask when they use the nasal cannula.
a. HFNC/ NIV:
- Monitor general condition:
consciousness, skin, mucous membranes, face, vital signs, respiratory pattern,
SpO2.
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- Ensure airway is
clear: instruct the patient on how to cough and spit out sputum or suction
sputum for the patient (if necessary).
- May stop the
therapy when the patient spits out sputum or eat and drink with their mouth.
b. Prone ventilation
- Closely monitor the
patient’s respiratory state and consciousness. Prevent the tube from moving
when the patient has endotracheal intubation.
- Keep the airway
clear; prevent the oxygen tube or endotracheal tube from folding when the
patient is in prone position and turned to another position.
- Properly handle the
patient’s bodily fluids (saliva, nasal discharge, sputum, etc.) using a
disinfectant containing chlorine (2500 mg/L).
2.2.2. Physician
order execution
- Carry out physician
orders for infusion, injection and drug administration properly, promptly and
accurately.
- Perform
paraclinical tests and functional tests according to doctor’s indications.
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- Move the patient
for X-ray, CT scanning, ultrasound, etc. in compliance with patient
classification rules.
2.2.3. Complication
monitoring and prevention
- Detect signs of
respiratory failure and circulatory failure such as weak rapid pulse, hard to
measure blood pressure, rapid breathing, retractions, blue lips, peripheral
cyanosis, etc. early on.
- Detect aspiration
in HFNC/ NIV and prone ventilation early on.
- Monitor and prevent
pressure ulcers and venous thrombosis.
- Pay more attention
to elderly patients and patients with existing chronic diseases such as
cardiovascular diseases, chronic pulmonary diseases, diabetes mellitus, cancer,
etc.
2.2.4. Nutrition
Ensure nutrition and
improve the body’s condition. For severe - critical cases, follow nutrition
recommendations of Vietnam National Association of Emergency, Intensive Care
Medicine and Clinical Toxicology and indications of nutrition doctors.
2.2.5. Other
monitoring and care
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- Monitor urine
output once every 3 hours; monitor daily fluid balance to ensure fluid and
electrolyte balance.
- Reduce fever by
cold compression. Administer antipyretics if when indicated.
- Clean and disinfect
tools (stethoscopes, thermometers) before using them on a patient.
- Closely monitor
short-term (<2 hours) NIV; if the patient has acute left ventricular
failure, chronic obstructive pulmonary disease or immunodeficiency, administer
endotracheal intubation as soon as possible if respiratory failure symptoms do
not improve. Add a virus filter between the mask and valve for single-tube NIV.
It is recommended to choose a suitable mask to reduce risk of transmission via
air leakage.
- Monitor aspiration
risk.
2.2.6. Pulmonary
rehabilitation
- Instruct the
patient on deep-slow breathing and chest-opening combined with shoulder-opening
breathing techniques.
- Administer clapping
and vibration as soon as possible.
- Provide physical
rehabilitation early to help the lungs expand fully and prevent sputum
accumulation.
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2.3. Assessment
Good progress:
If the patient feels
comfortable and breathes steadily without fatigue, and SpO2 is stable ≥ 95%, may reduce
oxygen flow (with doctor’s indication).
No progress or
worsening:
If the patient has
worsening dyspnea, respiratory muscle contraction, blue lips, peripheral
cyanosis and SpO2
≤
92%, notify the doctor immediately and prepare endotracheal intubation
equipment as the patient may require ventilation.
II.
Care of mechanically ventilated COVID-19 cases
1.
Modes of mechanical ventilation in respiratory support
Mechanical
ventilation is a process where medical gas and oxygen are mixed together in a
predetermined ratio and pushed into the airway to reach the alveoli. When the
lungs expand, pressure inside the alveoli also increases. When the signal for
termination (usually for pressure or air flow) is emitted, the machine stops
pushing air into the airway, which reduces airway pressure, followed by passive
expiration with the air flow travels from the alveoli (high pressure) to the
airway (lower pressure). Invasive ventilation is the most common mode of
mechanical ventilation and is used to carry out a part or the whole natural
respiration process by taking over respiration and gas exchange in patients
with respiratory failure. Invasive ventilation provides positive pressure ventilation
for the lungs via an endotracheal tube or tracheostomy tube while non-invasive
ventilation provides ventilatory support via other tools, usually masks.
Modes of mechanical
ventilation:
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- Assisted
ventilation, including synchronized intermittent mandatory ventilation (SIMV)
and SIMV + PS (support for spontaneous breathing).
- Spontaneous
ventilation, including PS and CPAP (no support for spontaneous breathing).
2.
Rules for care of COVID-19 cases requiring invasive ventilation
- Use PPE according
to regulations while giving care.
- Ensure that the
whole ventilator circuit, especially joints on the tubes, has no leak. Act in a
careful manner and avoid unnecessary disconnection when the endotracheal tube
is inserted into a patient to prevent the virus from escaping outside (e.g.,
closed sputum suctioning equipment needs to be integrated with the circuit, if
possible).
Clip the endotracheal
tube when the circuit needs to be disconnected (such as for squeezing the ambu
bag, switching to a mobile ventilator) and release it after the set is
connected again. This is regarded as an aerosol generating procedure and should
be performed in an isolated room if possible.
- Other precautions
include use of circuits consisting of separate inspiratory and expiratory tubes
with virus filters as well as heat and moisture exchangers (HME). Filters with
HME should be placed between the expiratory portal and the endotracheal tube.
- It is of utmost
importance to comply with standards for maintenance of endotracheal tube cuff
pressure at 25 - 30 cm H2O to maintain a seal within the airway.
- All ventilators
should have suitable filters, which shall be changed according to schedule.
After each change, the ventilators shall be wiped clean.
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- Mechanically
ventilated COVID-19 cases should stay in negative pressure rooms.
- In case negative
pressure rooms are unavailable, employ mixed air or natural ventilation and
ensure that the minimum ventilation rate is 12 ACH.
- Locate entrance and
exit as appropriate.
- Ensure that the
rooms’ doors are always closed and have a warning sign with red background and
yellow writing that reads “KHU VỰC CÁCH LY Y TẾ - KHÔNG NHIỆM VỤ MIỄN VÀO”
(“MEDICAL ISOLATION AREA - UNAUTHORIZED ACCESS NOT ALLOWED”).
- Arrange for a hand
washing area with water and soap or a hand sanitizer with at least 60% alcohol.
- Provide yellow
containers with lids and foot pedals, lined with yellow bags used for
infectious waste, and affixed with a “CHẤT THẢI CÓ NGUY CƠ CHỨA SARS- CoV-2”
(“SARS-CoV-2 DANGERS”) label. All wastes from isolation areas shall be
considered as infectious waste.
- Have plans to clean
and disinfect surfaces at least twice a day and when necessary.
4.
Care
4.1. For mechanically
ventilated patients
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a. Patient’s general condition
- Vital signs:
consciousness, heart rate, blood pressure, respiratory rate, temperature, SpO2.
- Skin and mucous
membrane: pink or bluish.
- Breathing and chest
movement.
- The patient’s
cooperation with the ventilator, no ventilator resistance, sedation level.
- The patient’s
response to the ventilator: lying still, pink skin and mucous membranes, no
ventilator resistance, stable vital signs, satisfactory SPO2, normal blood
gas.
- Sputum: quantity,
color, properties.
- Stomach secretions:
quantity, color, properties.
- Endotracheal tube:
size, length, fixed location; cuff pressure.
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- Assessment of skin
areas at risk of pressure ulcers: stomach catheter location, endotracheal tube
location, heels, tailbone, pinna, elbows, etc.
b. Ventilators:
- Ventilator supply
sources: power, oxygen, compressed air, etc.
- Ventilator
settings: breathing mode, pressure, VTE, breathing rate, PIP, FiO2, etc.
- Warning levels.
- Humidity of circuit
and filters.
c. Assessment of
infection risk posed by mechanically ventilated patients:
- Risk of aerosol and
droplet generation of patients.
- Necessary
procedures.
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- Compliance with infection
prevention practices of healthcare workers.
4.1.2. Interventions:
Note: comply with
regulations on use of PPE and cross-contamination control in care of COVID-19
cases.
a. Management of
patients responding to tranquilizer and analgesics:
- Monitor vital signs
and SpO2.
- Monitor levels of
consciousness, sedation and pain; assess cooperation between the patient and
the ventilator.
- Monitor and ensure
dosage of tranquilizers in use.
- Monitor and detect
complications such as prolonged coma, apnea, slow heart rate and hypotension
early on.
b. Airway management:
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+ VTE: exhaled tidal
volume, especially for volume controlled ventilation, to detect air leak from
the endotracheal tube and insufficient air input into the lungs.
+ VTE decrease:
* For volume
controlled ventilation: VTE decrease means large air leak from the endotracheal
tube, requiring a larger tube or a tube with a cuff.
* For pressure
controlled ventilation: VTE decrease means the ventilator is unable to cover
the amount of air leaking from the endotracheal tube or elasticity decreases
and airway obstruction increases.
+ VTE increase:
usually occurs when the patient’s condition improves; ventilator weaning or
spontaneous breathing should be considered.
+ Peak inspiratory
pressure (PIP):
* For volume
controlled ventilation: PIP changes depending on lung elasticity and airway
obstruction.
* PIP increase:
occurs when lung elasticity decreases due to lung collapse, pneumothorax or
pneumochysis or obstruction increases due to bronchospasm or obstructed
endotracheal tube.
- Ventilator
respiratory rate:
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+ Ventilator resistance:
consider administration of respiratory inhibitors and tranquilizers.
+ Improvement of
clinical condition and SpO2: start ventilator weaning.
- Ventilator
warnings:
+ Air delivery system
must be clean, closed and always placed lower than the endotracheal/
tracheostomy tube.
+ Prioritize locating
HME filters at the inspiratory limb and before the expiratory limb of the
ventilator. If humidification and heating systems are used, keep the water at
permitted level, maintain the temperature at 30-350 degrees Celsius and
check the presence of condensation. Place bacteria filters at the expiratory
limb. The presence of
condensation means excessive humidity, requiring lower temperature.
+ Sputum suctioning:
use closed suctioning system, select a suctioning catheter of suitable size (catheter
size = (inner diameter of endotracheal tube - 1) x 2), suctioning time ≤15
seconds.
Table
4. Suctioning
pressure by age
Age
Suctioning pressure
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50-80mmHg
Children
80-100mmHg
Adults
100-120mmHg
c. Prevention of ventilator-associated
pneumonia:
- Choose a suitable
endotracheal tube. It is recommended to use a subglottic secretion drainage
endotracheal tube and suction secretions every 2 hours.
- Use disposable
circuits.
- Place HME filters
at the inspiratory limb and before the expiratory limb of the ventilator.
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- Monitor
endotracheal tube cuff pressure every 4 hours and maintain it at 25 - 30 cmH2O.
- Take measures
against hospital-acquired infection.
- Use sterile sputum
suctioning technique and closed sputum suctioning system.
- Monitor the
patient’s temperature and detect infection signs from sputum color, quantity
and properties as well as complete blood count early on.
- Use new circuit for
each patient; change the circuit only if it becomes soiled or damaged when the
patient is put on the ventilator.
- Change heat and
moisture exchangers when they are soiled or damaged or every 5-7 days.
- Regularly change
the patient’s position.
- Clean the patient’s
nose and mouth using chlorhexidine 0.2%; keep these areas clean and prevent
secretion accumulation.
d. Monitoring and
early detection of ventilator complications:
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Complication
type
Sign
Cause
Handling
1.
Ventilator
resistance
Irritation,
cyanosis, sweating, respiratory muscle contraction, rapid pulse, high blood
pressure, low SpO2, etc.
- Unsuitable
breathing mode or settings
- Spontaneous
breathing due to insufficient tranquilizer - muscle relaxant
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- Pneumothorax
- Inform doctor
- Check circuit and
ventilator
- Squeeze ambu bag
with Fi02 at 100%
- Suction sputum
from endotracheal tube, nose and mouth
2.
Endotracheal tube
slipping out
- Cyanosis, no
breathing sound from ventilator
- Low exhaled
volume warning from ventilator
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- Patient thrashing
- Do bag mask
ventilation with filter between mask and bag
- Insert new
endotracheal tube
3.
Obstructed
endotracheal tube
- Irritation,
sweating, low SpO2
- High airway
pressure warning from ventilator
- Sputum or
inserted too deeply
- Suction sputum
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- Insert new tube
4.
Pneumothorax
Sudden cyanosis,
irritation, unequal chest expansion, decreased or no breath sounds on one
side, possible subcutaneous emphysema
- Too high pressure
or tidal volume setting
- Improper
respiratory inhibition
- Ventilator
resistance
- Chest X-ray,
emergency chest drain
- Adjust settings
as suitable
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Lung collapse
Decreased or no
breath sounds on one side
Endotracheal tube
is inserted too deeply into one lung side
Sputum
- Not changing
patient's position regularly
- Clapping and
vibration
- Suction sputum
-Postural drainage
- Change patient’s
position every 2-3 hours
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e. Prevention of
reflux and aspiration:
- Elevate the
patient’s head to 30 - 45 degrees (if not contraindicated).
- Check and evaluate residue
stomach secretions every 4 - 6 hours, stomach, feces and gastrointestinal
hemorrhage.
Use feeding tubes
made from soft materials (silicon; polyurethane) for prolonged period of time.
- Monitor digestion
in the intestines.
g. Management of
urinary tract and other types of drainage:
Monitor and prevent
urinary and reproductive tract infections and correctly measure daily urine
output depending on whether the patient uses diapers, incontinence pads or a
urinary catheter.
For other cannulae:
monitor quantity, colors, etc. of secretions.
h. Management of
fluid input - output:
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i. Prevention of
pressure ulcers:
- Add padding under
skin areas placed under pressure; administer Sanyrene to reddened skin areas.
- Use a
pressure-relief mattress with a thickness of at least 20 cm or air mattress.
- Change the
patient’s position every 3 hours (supine, right lateral, left lateral) if not
contraindicated.
- Evaluate the
patient’s skin condition regularly, manage secretions to ensure that the skin
is always dry and clean.
k. Prevention of deep
vein thrombosis:
- Change the
patient’s position and do passive exercise to prevent circulatory stagnation as
soon as possible.
- Check the vascular
system to detect thrombosis, arterial thrombosis or venous thrombosis, and
inform the doctor for timely handling.
l. Nutrition for
mechanically ventilated patients:
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- Combine enteral and
parenteral nutrition.
4.2. Care of patients
weaning from ventilators
4.2.1. Ventilator
weaning conditions:
Ventilator
setting
Patient’s
condition
- Gradually reduce
the following ventilator settings in order of priority before weaning:
- Gradually reduce
PIP to < 35cm H2O.
- Gradually reduce
FiO2 to < 60%.
- Gradually reduce
I-time to < 50%.
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- Gradually reduce
FiO2 to < 40%.
- Gradually reduce
PEEP, PIP, I-time and respiratory rate.
- Consider
switching to breathing support if currently on control ventilation to start
weaning from ventilator
- Cause(s) of
respiratory failure has/ have been treated.
- Improved
consciousness or no more convulsions.
- Stable
spontaneous breathing, sufficiently strong coughing reflex.
- Good blood oxygen
level: SpO2 ≥ 95% with FiO2 ≤ 40%.
- PEEP ≤ 5 cm H2O,
Pi ≤ 18 cmH2O.
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PaO2/FiO2≥ 300
- Stable
hemodynamics; no or low-dose administration of vasoactive drugs.
- Normal pulse and
blood pressure.
- No fever or mild
fever (temperature < 38oC).
- Chest X-ray shows
improvement with little or no infection.
- Good nutritional
status, no anemia (Hct ≥ 30%), good response to enteral tube feeding.
4.2.2. Monitoring
during ventilator weaning:
When the patient is
weaning from the ventilator, nurses must stay with them to monitor and
encourage them. If the patient shows sign of weaning failure, put the patient
back on the ventilator immediately.
Signs of failure with
spontaneous breathing:
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- Increased
respiratory rate (≥ 20% of normal rate for age).
- Increased heart
rate.
- Increased or
decreased blood pressure.
- Retractions.
- SpO2 < 92%.
- Worsening blood
gas.
4.2.3. Notes for
ventilator weaning:
- Stop administering
all muscle relaxants and tranquilizers for at least 2 hours.
- Stop enteral tube
feeding for at least 2 hours.
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ĐT: (028) 3930 3279 DĐ: 0906 22 99 66
- If the patient
shows signs of weaning failure, put them back on the ventilator.
4.3. Assessment
Good progress:
- The patient feels
comfortable and can breathe naturally without fatigue and with the endotracheal
tube removed; SpO2 ≥ 95%.
No progress or
worsening:
- Increased dyspnea,
respiratory muscle contraction, continuous ventilator resistance, increase of
tranquilizer and vasoactive drug dosages.
- No improvement in oxidative
stress.
- No improvement in
blood oxygen when put on ventilator; nurse shall prepare ECMO equipment.
III.
COVID-19 cases requiring emergency hemofiltration
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Emergency
hemofiltration, also known as renal replacement therapy, is a treatment that
aims to remove wastes and soluble substances using semi-permeable membranes,
which is similar to the filtration process in the kidneys.
Hemofiltration in
COVID-19 patients aims to remove toxins and perform liver and kidney functions.
Extracorporeal
hemofiltration techniques include intermittent hemofiltration, continuous
hemofiltration, plasma replacement, hemoperfusion, etc.
Purposes of emergency
hemofiltration:
- Replace kidney
functions.
- Ensure water,
electrolyte and acid - base balances.
- Reduce toxic
substances such as urea, creatinine, etc. in blood.
Rules for safety in
care: take standard precautions in combination with precautions against contact
and droplet transmission in patient care.
2.
Complications
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Immediate
complications: inserting the needle into an artery, blown veins, hematoma,
retroperitoneal bleeding, hemothorax, pneumothorax and gas embolism.
Late complications:
thrombus, infections, arteriovenous fistula.
* Treatment-related internal
complications:
- Hemodynamics:
hypotension, arrhythmia.
- Bleeding.
- Electrolyte or acid
- base disorder.
- Dialysis
disequilibrium syndrome.
* Technical
complications:
- Gas embolism:
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- Hypothermia.
- Coagulation in
filter membranes and tubes.
- Tube and catheter
slipping or twisting.
- Allergy to filter
membranes.
3.
Care
3.1. Assessment
- Evaluate
consciousness level, physical condition and mental condition of the patient.
- Vital signs,
respiratory condition.
- Vessels used for
filtration.
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- Skin and mucous
membrane conditions, signs of anemia, hemorrhage, etc.
- Diet, intravenous
fluids and drugs administered daily.
- Risk of infection
via direct contact with the patient, environmental surfaces, filtration
equipment, wastes, including post-filtration waste fluids, and droplets from
close contact (< 2 meters).
3.2. Nursing
interventions
3.2.1. Before
hemofiltration:
- Inform and give explanation
to the patient.
- Evaluate
consciousness level, heart rate, blood pressure, respiratory rate, temperature,
SpO2 of the patient.
- Perform biochemical
tests, coagulation factor tests and other tests according to physician orders.
- Clean the catheter
insertion site.
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- Replace filtration
fluids using the correct technique.
- Administer
medications as per physician orders, check Heparin dosage.
- Check catheter
location (obstructed or slipping), filter membranes and air traps (coagulation
in filter membranes and air chamber, membrane breaking).
- Perform personal
hygiene for the patient and execute other physician orders for care.
3.2.3. After
hemofiltration:
- Check heart rate,
temperature respiratory rate, blood pressure, consciousness level and urine
after hemofiltration is completed.
- Record the
patient’s developments during the hemofiltration process.
- Take care of the
filtration catheter: prevent clotting using Heparin and change bandages. If
there are signs of infection (red swelling, pus), notify the doctor, remove the
catheter, and obtain blood culture from catheter tip.
- Clean and disinfect
bed surface and equipment using disinfectants.
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- Waste fluids from
filtration shall be processed in the common medical wastewater treatment system
of the healthcare establishment. If this system does not meet environmental
standards, waste fluids must be disinfected using a chemical solution containing
1,0% activated chlorine before they may be discharged outside. Filtration fluid
containers shall be handled immediately after each filtration and must not be
shared between patients.
3.2.4. Nutrition
assurance:
- Evaluate the
patient’s nutritional status.
- Provide nutrition
according to physician orders.
- Encourage the
patient to finish their indicated meals.
- Monitor intake,
water input - output and weight.
3.2.5. Health advice
and education:
- Give encouragement
and explanation for the patient to understand the necessity of hemofiltration
and have trust in their treatment.
- Give instructions
on drug use, diet and water intake required for the patient's condition.
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3.2.6. Complication
monitoring and prevention:
- Monitor results of
biochemical tests and coagulation factor tests before and after hemofiltration.
- Monitor
consciousness level, heart rate, blood pressure, respiratory rate, temperature,
SpO2, and water input -
output of the patient every 2 hours during and after hemofiltration until
the patient's condition stabilizes.
- Monitor to detect
allergic signs such as rashes, dyspnea and anaphylactic shock early on.
- Monitor settings
and warnings of the hemofiltration machine, filter system and air trap.
- Monitor signs of
hemorrhage such as skin and mucous membrane conditions and bleeding at catheter
insertion site.
- Monitor signs of
blood infection and infection at catheter insertion site.
3.3. Assessment
Good progress:
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- Healthcare workers,
other patients and the patient’s family are not infected with the disease.
No progress or
worsening:
- Respiratory
failure, hemodynamic disorders, electrolyte disorders and/or renal dysfunction
do/does not improve or worsen/s; edema remains unchanged or increases; there
are decreased or no urine output and complications or accidents related to
hemofiltration.
- Healthcare workers,
other patients and the patient’s family are not infected with the disease.
IV.
COVID-19 patients having sepsis and septic shock
1.
Overview
Approximately 5% of
COVID-19 patients require intensive care with acute respiratory manifestations
(rapid breathing, dyspnea, cyanosis, etc.), ARDS, septic shock and organ
dysfunction, including kidney injury and heart muscle injury, leading to death.
These cases need to be monitored and handled promptly.
There is risk of
infection via:
- Droplets
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- The air
Rules for safety in
care: take standard precautions in combination with precautions against
contact, droplet and airborne transmission in patient care.
2.
Care
2.1. Assessment
2.1.1. Questioning: promptly evaluate the
patient: consciousness level, vital signs. Find severe signs of shock, preliminary
shock orientations and cause.
Quickly discuss with
the doctor to grasp the patient’s current condition and development trend
thereof.
Give an explanation
on the situation to the patient if they are conscious or to the patient’s
family if the patient is in coma.
2.1.2. Physical
examination: determine
sepsis level and clinical manifestations
Sepsis: somnolence, stupor,
coma, dyspnea? or rapid breathing, low oxygen saturation level; fast pulse,
weak pulse, cold limbs, or low blood pressure, livedo reticularis; decreased or
no urine output; test results indicating coagulation disorders,
thrombocytopenia, acidosis, increased lactate level, increased bilirubin level,
etc.
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2.1.3. Infection
risk:
There is risk of
infection from direct contact with the patient, environmental surfaces, medical
and care equipment (ventilators, monitors, pulse oximeters, etc.), wastes;
droplets from close contact (< 2 meters); and the air when performing
aerosol generating procedures on the patient (open sputum suctioning, NIV,
etc.).
2.2. Nursing
interventions
2.2.1. Airway control
and maintenance to ensure ventilation:
- Lower the patient’s
head if they have low blood pressure and turn the face to one side to prevent
reflux. Give the patient oxygen at a flow rate of 4-6 liters/minute, or oxygen
mask according to indications.
- Use a Mayo tube to
prevent tongue retraction; suction sputum and saliva in the mouth and throat.
- Squeeze Ambu bag if
the patient stops breathing or breathes weakly.
- Prepare equipment
and additional ventilators to assist the doctor with intubation and ventilation
where indicated.
- Closely monitor
respiratory rate, respiratory pattern and SpO2 every 15-30 minutes
when the patient has respiratory
failure.
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- Use closed sputum
suctioning system if the patient is mechanically ventilated (to prevent
airborne transmission) and observe sputum quantity, color and properties.
2.2.2. Blood loss
replacement:
- Immediately insert
a peripheral venous catheter; promptly administer fluids, blood or vasoactive
drugs according to indications.
- Prepare equipment
and assist the doctor with inserting a central venous catheter.
- Prepare transfusion
equipment, electric syringe pumps, intravenous fluids and vasoactive drugs
according to physician orders.
- Set up monitors;
keep the patient warm in case they have hypothermia.
- Monitor the
patient’s hemodynamics such as pulse, blood pressure and temperature every 15 -
30 minutes; monitor capillary refill time.
- Monitor urine
output every hour. Measure central venous pressure.
- Immediately notify the
doctor of abnormal parameters to adjust vasoactive drugs, transfusion rate,
etc.
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- Evaluate
overhydration signs such as chemosis, anasarca, acute pneumochysis and central
venous pressure >15 cm H2O.
- Or dehydration
signs such as dry and wrinkled skin, dry lips and mouth, dry tongue and
CVP<2 cm H2O.
- Collect blood
samples for electrolyte panel; perform an arterial blood gas test.
- Handle acid - base
imbalance according to indications.
- Monitor the
patient’s weight, fluid input (fluid transfusions, blood transfusions, water,
food) - output (urine, vomit, etc.) balance, central venous pressure and
electrolyte panel levels.
2.2.4. Adequate and
timely execution of medication and testing orders:
- Prevent shock:
transfuse approximately 500 ml fluids or colloids within the first 30 minutes -
1 hour to replace blood loss according to indications. Make a clinical
assessment and adjustment. Administer vasoactive drugs as indicated; use
electric syringe pumps and transfusion machines to ensure transfusion rate of
dopamine, noradrenaline, etc. Transfuse blood and blood preparations in
compliance with regulations on blood transfusion safety.
- Administer
antibiotics: collect samples to identify the bacterium/a causing superinfection
before administering antibiotics as indicated.
- Collect samples for
basic tests, blood glucose control, chest X-ray, abdominal ultrasound and heart
ultrasound.
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2.2.5. Assurance of
patient’s nutrition and personal hygiene:
- Nutrition: provide the patient
with a protein-rich fluid-based diet with sufficient calories; use enteral tube
feeding or parenteral feeding for patients in coma or unable to eat.
- Personal hygiene: assist the patient
with dental hygiene 2-3 times/day or after a meal.
Wash the patient’s
eyes and give them eye drops on a daily basis. For comatose patients, cover
their eyes with sterile gauze pads to prevent dry eyes.
Clean the patient’s
body, genitalia and anus using warm water on a daily basis, ensure that the
patient is always cleaned and keep the patient warm in cold season (using
heaters instead of air-conditioners). Change the sheets and the patient’s
clothing on a daily basis (turn the patient left and right gently, do not raise
their head, etc.). Lay the patient on a waterbed or pressure-relief mattress to
prevent pressure ulcers, and change the patient's position every 2 - 3 hours. Take
measures to control bowel and/or urinary incontinence.
- Clap and vibrate
the patient’s chest (after shock stage); exercise the patient’s limbs gently.
2.2.6. Health advice
and education for patients:
If the patient is not
comatose, regularly give them encouragement. Always be ready to carry out the
patient’s requests to help them feel rest assured and cooperate in the
treatment process.
Explain the patient’s
condition, development trend thereof and possible unfavorable scenarios to the
patient's family.
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2.2.7. Complication
monitoring and prevention:
- Respiration: monitor respiratory
condition (SpO2, blood gas, etc.),
ventilator response, etc.
- Renal failure: monitor urine output
every hour, urea, creatinine,
electrolyte panel, etc. Prepare equipment for continuous renal replacement
therapy and assist the doctor with hemofiltration.
- Cardiovascular
complications: set
up monitors for heart rate, blood pressure and response to vasoactive drugs.
Monitor arterial blood pressure continuously. Monitor endocarditis,
pericarditis and arrhythmia.
- Hemorrhage and
coagulation disorders:
+ Hemorrhage: cyanosis,
necrosis.
+ Gastrointestinal
hemorrhage (haematemesis, bloody stool).
+ Monitor results of
coagulation factor tests: prothrombin, D- dimer, Hb, erythrocytes, platelets,
etc.; monitor capillary refill time if it is longer than 2 seconds.
2.2.8. Assessment:
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- The patient is
conscious and comfortable with temperature remaining stable at 36,5 - 37
degrees.
- Normal blood
pressure, capillary refill time is less than 2 seconds.
- Urine output is
more than 100ml/hour.
- Respiration: the
patient breathes easily, SpO2 > 94%.
V.
COVID-19 cases requiring ECMO
1.
Overview
Extracorporeal
membrane oxygenation (ECMO) is a resuscitation technique of providing
respiratory and/or cardiac support to persons sustaining severe lung injuries
and/or reversible heart injuries or persons not responding to common treatments.
ECMO works by using an external pump (extracorporeal centrifugal pump or roller
pump) to deliver the patient’s venous blood (not oxygenated) pass an artificial
oxygenator, allowing oxygenation of the blood and removal of carbon dioxide,
and then return the oxygenated blood to the patient’s circulatory system.
There are 2 main
types of ECMO:
- VA - ECMO, which
supports hemodynamics maintenance and gas exchange.
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Purposes of ECMO:
- Provide sufficient
oxygen for the patient.
- While ECMO does not
treat the patient’s heart or lungs, it helps the patient overcome the critical
stage and supports their treatment.
- Reduce heart
medications.
- Reduce ventilator
use to decrease risk of ventilator-related lung injury.
ECMO complications:
- Bleeding due to
continuous use of anticoagulants and thrombocytopenia.
- Pulmonary vascular
obstructive disease caused by a blood clot formed in the ECMO machine.
- Coagulation
disorders resulting in blood clotting.
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- Infections.
- Stroke.
- ECMO technical
issues.
There is risk of
infection via:
- Droplets
- Contact
Rules for safety in
care: take
standard precautions in combination with precautions against contact and
droplet transmission in patient care.
2.
Care of COVID-19 cases requiring ECMO
2.1. Assessment
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- Respiratory
condition:
+ Respiratory rate
and pattern.
+ Oxygen saturation
level (SpO2).
+ Cough, sputum.
- Circulatory
condition: heart rate, blood pressure, temperature, inotropic drugs, peripheral
perfusion (foot dorsum, extremities).
- Other symptoms such
as urology (urine output and color), digestion (stomach condition, feces,
stomach fluids) and skin (areas affected by pressure ulcers).
- Catheter/cannula
tip, ECMO machine.
- Risk of infection
via direct contact with the patient, environmental surfaces, ECMO machine,
ventilators, wastes, and droplets from close contact (< 2 meters).
2.2. Nursing
interventions
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- Observe and
evaluation the catheter’s fixed location (whether it has slipped in or out),
inflammation (reddened, swollen, etc.).
- Prepare emergency
equipment (tube clamps, crank handles, oxygen supply).
- Prevent cannula
slipping.
- Change the bandages
around the cannula carefully in a sterile manner, control and observe the
cannula's tip (may be bleeding).
- Change bandages and
place paddings to prevent pressure ulcers induced by medical devices.
- Monitor limb
temperature, color and movements.
- Monitor heart rate.
- Monitor tubing and
oxygenators.
2.2.2. Respiratory
assurance:
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- Monitor respiratory
muscles and nose movements; check airway obstruction every 1-2 hours.
- Check skin color
(this symptom might not be reliable in patients with hypothermia).
- Check arterial
blood gas level values every two hours (blood gas before and after the
oxygenator, patient’s blood gas).
- Monitor response to
tranquilizers and anesthetics administered to the respiratory system.
- Monitor disorders
such as anxiety, aggression and insomnia.
- Monitor the
patient’s response to mechanical ventilation.
- Use closed sputum
suctioning system if the patient is mechanically ventilated (to prevent
airborne transmission) and observe sputum quantity, color and properties.
- Monitor arterial
and peripheral oxygen saturation (SpO2).
- Check tube cuff
pressure.
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2.2.3. Monitoring and
prevention of complications and infection risks:
- Monitor ECMO
operation (check presence of air, blood clots, etc.), including perfusion
support, control of hemodynamic values and other important values, monitor
respiratory readings and record into the monitoring sheet.
- Hemorrhage:
+ Check bandages
(cannula tip) and blood buildup around the cannula.
+ Monitor and notify
coagulation test results promptly.
+ Monitor bleeding
via urine, feces, vomit, nosebleeds, epilepsy, diarrhea or pathological
bruising on the skin.
+ Monitor brain
hemorrhage (consciousness level, vital signs, pupils, muscle weakness or
paralysis, etc.).
- Infections.
+ Monitor signs such
as reddened or hot skin and elevated temperature.
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+ Evaluate quantity,
color and properties of respiratory tract secretions.
+ Comply with sterile
procedure/ surgery requirements.
- Pressure ulcers:
+ Assess risk of
pressure ulcers and take preventive measures (use waterbeds or air mattresses).
+ Change the
patient’s position every 2 hours, pay attention to ECMO tubing.
+ Take care of the
patient’s skin properly, regularly moisturize the skin, and keep the skin clean
after urination or defecation.
- Minimize infection
risk:
+ Clean and disinfect
bed surface and equipment using disinfectants authorized by the Ministry of
Health.
+ Solid waste shall
be handled as highly infectious waste and put in a yellow nylon bag labelled
“chất thải có nguy cơ chứa -SARS-CoV-2” (“COVID-19 dangers") in the
isolation room, which shall be put inside another bag outside of the isolation
room, before it may be moved to the waste storage facility of the healthcare
establishment.
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- Administer an
enteral feeding tube, always check the tube’s location, record feeding volume
and leftover (if any).
- Provide parenteral
nutrition with suitable quantity and components to ensure sufficient daily
dietary intake.
2.2.5. Mental care,
personal hygiene and health education:
- Give explanation
and encouragement to the patient. Provide comprehensive care, including
personal hygiene, dental care, prevention of hospital-acquired pneumonia, skin
moisturization, daily bed linen change and prevention of pressure ulcers using
suitable mattresses.
- Notify and explain
to the patient before providing care services.
- Communicate
non-verbally to explain to the patient why they could not talk, use papers,
pens, etc. to explain care procedures.
2.3. Assessment:
Good progress:
- Stable vital
functions.
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- The patient has
improved heart functions, is weaned from VA ECMO and has the ECMO cannula
removed.
No progress or
worsening:
The patient’s general
condition worsens, severe respiratory failure occurs, heart and lung functions
do not improve, ECMO is ineffective.
CARE AND MANAGEMENT OF PREGNANT WOMEN
SUSPECTED OR CONFIRMED TO HAVE COVID-19
1.
Overview
During pregnancy,
women experience physiological changes in their immune, respiratory and
circulatory systems, thus, they have higher chance of severe illness and
mortality in respiratory tract infection. SARS-CoV and MERS-CoV can cause
serious pregnancy complications such as respiratory failure requiring
endotracheal intubation or intensive care and renal failure. COVID-19 mortality
rate among pregnant women are 25%. However, there is no study indicating that pregnant
women face the risk of more severe COVID-19 infection or pneumonia.
Viral pneumonia
increases the risk of premature birth, fetal growth retardation (FGR), low-weight
birth, APGAR score at 5 minutes being under 7 and neonatal death compared to the
non-pneumonia group (n = 7310).
Fever is a common
COVID-19 symptom. A study of 80.321 pregnant women showed that the rate of
fever in early pregnancy was 10% and the rate of fetal malformations was 3,7%
while 8.321 cases were reported having fever above 38 degrees Celsius for 1 - 3
days in early pregnancy with no change in fetal malformation rate (odd ratio
[OR] = 0,99) (KTC 95%, 0,88 - 1,12).
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ĐT: (028) 3930 3279 DĐ: 0906 22 99 66
2.
Care of pregnant women suspected or confirmed to have COVID-19
2.1. Outpatient care
Obstetric facilities
should employ telemedicine as much as practicable to provide prenatal care
(consultancy) in compliance with recommended social distancing measures.
Recommended prenatal
care schedule for low-risk pregnancy (to reduce exposure and workload in case
of workforce shortage)
No.
Gestational
age
Physical
examination
Ultrasound
Task
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# 12 weeks
In person
Nuchal translucency
Obtain past medical
history
First-trimester
screening tests
Provide health
education: nutrition, precautions against droplet and contact transmission,
and COVID-19 symptoms
Provide antenatal
care schedule
2
# 16 weeks
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3
# 20 weeks
In person
Morphology
Tripple test,
amniocentesis (if applicable)
Provide
instructions on blood pressure monitoring at home
4
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Online examination
Monitor blood
pressure at home
5
# 28 weeks
In person
Regular checkup
Oral glucose
challenge test
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Provide
instructions on fetal movement monitoring
6
30 weeks
Online examination
Monitor blood pressure
at home
7
32 weeks
In person
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Regular checkup
8
34 weeks
Online examination
Monitor blood
pressure at home
Monitor fetal
movements
9
36 weeks
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Regular checkup
GBS screening
10
37-40 weeks
In person
Regular checkup
Formulate delivery
plan
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2.2.1
Hospitalization: undergo screening at the gate of the healthcare establishment
Flowchart of
intrapartum and postpartum maternal management
2.2.2 Monitoring of
vaginal labor and delivery: in specialized negative pressure room
In case of
miscarriage, the placenta/ fetus shall be handled as infectious tissues and may
be tested for SARS-CoV-2 via qRT-PCR if necessary. Adhere to the national
guidelines for reproductive healthcare services promulgated together with
Decision No. 4128/QD-BYT dated 29/7/2016 by the Minister of Health.
No.
Monitored
item
Early
labor
Active
labor
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Evaluation
1
Vital signs: heart
rate, blood pressure, temperature, respiratory rate, oxygen saturation
Respiratory
infection symptoms
Cough, fever,
diarrhea, dyspnea
Regular: every 4
hours
Progressing
illness: every hour
Administer drugs in
compliance with treatment requirements
Progressive
illness: monitor using monitoring equipment
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Lower body
temperature by wiping
Record water input
- output. Give instructions on mask use and hand hygiene
Oxygen saturation
level ranges between 92 - 95%. There is no fever and no dehydration signs.
2
Fetal heart rate
Every hour
Monitor fetal heart
rate and contractions continuously
Give instructions
on positions and breathing techniques for each labor phase
Monitor using
monitoring equipment
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Check fetal heart
rate before and after ROM/ amniotomy.
3
Contractions
Every hour
Monitor fetal heart
rate and contractions continuously
Labor progresses as
appropriate to each labor phase
Early labor lasts
for 8 hours. Active labor lasts for a maximum of 7 hours.
4
Amniotic sac
condition
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Every 2 hours
Perform physical
examination at the appropriate time
Inform labor
situation to the mother
5
Lightening degree
Every hour
Every 30 minutes
6
Cervical dilation
rate
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Every 2 hours
7
Epidural analgesia:
pain, leg movements
Dressing over
epidural insertion site
Catheters and
electric syringe pumps
Maintain dosage in
compliance with treatment requirements
Check dressing
Evaluate level of
loss of pain sensation and leg movements
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The mother’s pain
is reduced; epidural analgesia system is not obstructed.
Joinings are
protected by gauze pads.
2.2.3 Cesarean
delivery:
It is recommended to
perform Cesarean sections in negative pressure operating rooms to protect
healthcare workers and use appropriate PPE when performing aerosol generating
procedures such as endotracheal intubation.
2.2.4 Postpartum
care:
If both mother and
baby are healthy, place the baby in the same room with the mother in a bassinet
that is 2 meters away from the mother or has a physical divider such as a
curtain. No viral ADN has been found in breast milk so far. Healthcare workers
shall provide the mother with assistance and instructions for hand hygiene, use
of 3-layer face masks upon close contact and breastfeeding.
The mother may
experience anxiety and depression. Healthcare workers need to pay attention to
her mental health and promptly assess her sleep pattern as well as causes of
anxiety or depression or even suicide.
3.
Care of babies born to mothers suspected or confirmed to have COVID-19
Immediately after
birth, healthcare workers wearing suitable PPE shall promptly evaluate whether
the baby requires resuscitation to move the baby away from other workers and
place it in an incubator for breathing support. Babies born to mothers
confirmed to have COVID-19 are not required to be admitted to the pediatric
department. Such admittance shall be considered based on other criteria.
Regularly monitor and assess the baby for infection signs.
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4.
Nutrition care
No food can prevent
or cure COVID-19 during pregnancy. Some food that is rich in antioxidants
(vitamins C, E and A), protein, iron, zinc, selenium, omega 3 and omega 6 may
strengthen the immune system. Healthcare workers shall give advice according to
the national guidelines on nutrition for pregnant women and breastfeeding
mothers (Decision No. 776/QD-BYT dated 08/3/2017 by the Minister of Health).
Ensure food safety during purchase; store and process food at recommended
temperatures.
- Provide at least
three main meals as well as one nutritious snack for the first trimester and
two nutritious snacks for the second and third trimesters.
- Each meal must
include food that provides energy and builds the body and healthy food.
- Continue to
supplement micronutrients (iron, folic acid and calcium) daily.
- Consult the
nutrition and obstetric departments if the mother gains too much or too little
weight during pregnancy or has anemia.
- Drink enough water
(8-10 glasses of drinking water).
- Pregnant women
should rest for 2 hours during the day and sleep for 8 hours at night.
- Do light exercise
for at least 20-25 minutes every day.
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5.
Health advice and education
There is no evidence
that a baby may be infected with SARS-CoV-2 from its mother or during
childbirth if its mother has COVID-19.
Pregnant women who
have COVID-19 are not required to have a C-section unless otherwise indicated.
Unless the mother
requires intensive care, it is recommended to let the baby have skin-to-skin
contact and breast milk early in compliance with requirements for hand hygiene,
surface hygiene, use of face masks upon any contact with the baby and placing
the baby 2 meters away from the mother. It is not necessary to wear a face
shield for the baby as it increases the risk of suffocation and the screen is
not secured.
Provide instructions
on postpartum care of the mother (including care during 6 weeks after birth,
breastfeeding and contraception) and baby (including health, nutrition and
jaundice monitoring and vaccination) according to the national guidelines for
reproductive healthcare services promulgated together with Decision No.
4128/QD-BYT dated 29/7/2016 by the Minister of Health.
6.
Progress and complication monitoring
All pregnant women
should be monitored for development of symptoms and signs of COVID-19 (which
are similar to those in nonpregnant individuals), particularly if they have had
close contact with a confirmed or suspected case. Common symptoms include
fever, cough, dyspnea, loss of taste, muscle pain, diarrhea and throat pain.
However, in a systematic review involving 77 studies of 11.432 pregnant women,
7% tested positive for COVID-19 and 3/4 of them are asymptomatic
CARE OF CHILDREN SUSPECTED OR CONFIRMED TO
HAVE COVID-19
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Children make up 1%
of total global COVID-19 cases. Clinical symptoms from incubation to recovery in
children are similar to those found in adults. However, children have mostly
milder clinical manifestations or no symptoms. Common signs in children include
fever, cough or pneumonia manifestations. Children are less likely to have
severe and critical cases than adults.
There is risk of
infection via:
- Droplets
- Contact
- The air
Rules for safety in
care: take
standard precautions in combination with precautions against contact, droplet
and airborne transmission in patient care.
2.
Care
2.1. Assessment
- General condition:
consciousness (AVPU scale), skin, mucous membranes, edema, hemorrhage, body
temperature, height and weight.
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- Circulation: pulse
frequency, pulse volume, pulse, heart anomalies, warm extremities, capillary
refill time, blood pressure, central venous or peripheral line, and drugs/
fluids in use.
- Digestion: vomit,
nausea, soft abdomen, abdominal distension, eating or enteral tube feeding,
daily meal quantity and intake, remaining stomach fluids, defecation.
- Urology: urine
color and output, urinary catheter?
- Neurology: muscle
contractions, pupils, fontanel.
- Signs: headache,
muscle and joint pain.
- There is risk of
infection from direct contact with the child, environmental surfaces, medical
and care equipment (ventilators, monitors, pulse oximeters, etc.), wastes;
droplets from close contact (< 2 meters); and the air when performing
aerosol generating procedures on the child (open sputum suctioning, NIV, etc.).
2.2. Care
2.2.1. Respiratory
assurance
* For those without
respiratory failure
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- Monitor their
general condition, vital signs, fever, cough and respiratory tract infection 2
- 4 times a day and where necessary. To minimize unnecessary contact,
healthcare workers may monitor the child via camera or communicate with the
child’s caregiver via the bedside speaker or phone.
- Nose and throat
hygiene:
+ For older children:
instruct them on how to clean the mouth and throat with NaCl 9‰ solution or
mouthwash.
+ For young children:
clean their nose and mouth using NaCl 9‰ solution.
* For those with
respiratory failure
For children
receiving oxygen support
- Elevate the child’s
head to 30 degrees, let the child lie in a comfortable position and suction
sputum where necessary.
- Provide oxygen with
suitable flow rate to reach SpO2 ≥ 94% via mask or nasal cannula. When the
child’s condition has stabilized, adjust rate to reach SpO2 ≥ 90%.
- Monitor general
condition, vital signs and SpO2 every 3 hours and where necessary depending on
the child’s condition. Inform the doctor of any anomaly.
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- Clean the nose and
mouth using NaCl 9‰ solution.
For mechanically
ventilated children
- Elevate the child’s
head to 30º- 45º, use closed sputum suctioning system.
- Evaluate the
following every 30 minutes - 1 hour depending on the child’s condition and
inform the doctor of any abnormally:
+ Vital signs, SpO2,
chest movements, skin color, mucous membranes and consciousness (AVPU scale).
+ Fluid input -
output balance
- Change the child’s
position every 4 - 6 hours, provide dental care daily.
- Take care of the
ventilator and heat and moisture exchanger, ensure that the system is closed
and prevent condensation in the circuit. Closely monitor the ventilator’s
values.
- Promptly detect and
handle ventilator-related accidents.
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- Use closed sputum
suctioning system (to prevent airborne transmission) and observe sputum
quantity, color and properties.
2.2.2. Body
temperature control
- Check the child’s
temperature on a daily basis and notify the doctor if there is any abnormally. If
the child has fever:
+ Loosen the child’s
clothes.
+ Place the child in
a well-ventilated cool room (air-conditioners are not recommended).
+ Place a warm
compress on the forehead, in the armpits and in the groin.
+ Have the child
drink a lot of water (ORS, fruit juice, etc.).
+ Administer
paracetamol with a dosage of 10 - 15 mg/ kg body weight every 4 - 6 hours when
the fever is ≥ 38º5.
2.2.3. Superinfection
prevention
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- Wash hands at the
five moments of hand washing when taking care of the child. Ensure all nursing
interventions are carried out in a sterile manner.
- Administer oral or
injectable antibiotics (if any) according to physician orders.
- Prevent
complications related to ventilation, central venous line, venous thrombosis,
ulcers, etc. (if any).
2.2.4. Nutrition
assurance
- Evaluate the
child’s nutritional status to provide a suitable diet.
- Provide the child with
liquid, digestible and vitamin-rich food. Food must be fully cooked and contain
all necessary nutrients.
- For breastfed
children, have the child breastfed both day and night. Provide the mother with
nutritional care and supplementary formula.
- If the child cannot
eat or has respiratory failure, provide enteral tube nutrition.
- Carry out
transfusions according to physician orders (if any).
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- The child’s
caregiver may monitor the child’s fever, dry cough, fatigue and muscle pain. If
the child develops any of these symptoms, transfer them to an adult healthcare
establishment for examination and treatment according to regulations.
- Evaluate
psychological development of the child and their caregiver during their stay in
the healthcare establishment and give them encouragement as suitable. Explain
about the disease and instruct them on how to learn more about the COVID-19
situation via mass media.
- Guidance on
infection prevention:
+ Instruct the child
on how to wear face masks and replace face masks daily or immediately when the
mask gets wet.
+ When the child
coughs or sneezes, cover their nose and mouth with a disposable tissue paper
and then discard it in the garbage bin according to regulations.
+ Practice hand hygiene
regularly using soap or hand sanitizer, avoid letting the child touch their own
eyes, nose and mouth.
+ The child’s
caregiver shall wear sufficient PPE, including a face mask, headwear,
protective clothing and safety goggles or face shield.
+ Avoid hugging or
holding the child where unnecessary.
+ Discard waste
properly.
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Good progress:
- Improved clinical
symptoms, stable vital signs, good general condition, normal blood test results
and better lung X-rays and at least 2 negative SARS-CoV-2 tests.
- The child and their
family understand about COVID-19, care methods and how to prevent the disease.
- Healthcare workers
and the child’s caregiver are not infected with the disease.
No progress or
worsening:
- The child’s general
condition makes no progress or worsens. The child develops respiratory failure
signs or worsened respiratory failure, functional disorders, complications such
as superinfection, pressure ulcers, etc. or spreads COVID-19 to healthcare
workers and their caregiver.
APPENDIX
OXYGEN
THERAPY PROCEDURES
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Step
Requirement
and purpose
A.
Nasal cannula/ Nasopharyngeal cannula oxygen
1
Nurse wears PPE.
N95 mask fits
properly to the face.
2
Prepare all
necessary equipment
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Evaluate the patient’s
condition, pay attention to the patient’s respiratory and circulatory
conditions.
Explain the
procedure’s purpose to the patient (if possible).
Place the patient
in a suitable position.
Loosen the
patient’s clothes and suction sputum (if necessary).
Identify the
correct patient.
4
Unlock, check
oxygen equipment, clock and humidifier.
5
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6
Adjust oxygen flow
rate as indicated. Check oxygen flow on dorsum of the hand or in a glass of
water.
Check if oxygen flow
rate is set as indicated by doctor.
7
Place nasal cannula
on the patient’s nasal bridge (cannula tab facing downwards). Insert a
nelaton catheter through the nose into the nasopharynx.
Perform the tasks
gently.
8
Secure lower part
of the cannula to the patient’s head or chin/ secure nelaton catheter to the
nostril or cheek.
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9
Check and adjust
oxygen flow rate as indicated by doctor.
Follow doctor’s
indication.
10
Monitor the
patient’s condition and oxygen system.
Prevent the cannula/
catheter from folding, being obstructed or dislocating.
11
Recollect
equipment:
Sort biomedical
wastes.
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Wastes and
equipment must be disinfected before being moved to storage.
12
Return other
equipment to its location (after disinfection)
Ensure they are
available for emergency use.
13
Remove PPE in the
anteroom and wash hands
Seriously take
measures to prevent transmission.
14
Update the care sheet
(if the patient’s medical record is available electronically, immediately update
the record in the patient’s room and print it outside of the room; otherwise,
communicate via handheld transceivers with workers outside of the patient’s
room to update the medical record).
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AEROSOL
DRUG DELIVERY PROCEDURE
No.
Step
Requirement
and purpose
1
Healthcare workers
wear PPE.
Wear N95 masks;
wear face shields.
2
Check operation of
aerosol generating equipment.
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Prepare and check
all equipment before entering the patient’s room.
3
Identify the
correct patient.
Evaluate
respiratory condition, vesicular breathing, lung rales.
Pulse, blood
pressure
Explain the
procedure to the patient.
Place the patient
in a suitable position.
Patient sits
comfortably/ patient’s head is elevated (600-900).
4
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Check “5 right’s”.
5
Use the syringe to
dispense the dose to a cup containing NaCl 0,9%.
According to
doctor’s indication.
6
Connect the aerosol
mask or jet nebulizer to the drug cup.
7
Place the mask onto
the patient’s face and adjust the strap to fit the mask to the nose and mouth
or place the jet nebulizer to the patient's mouth.
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8
Turn the aerosol
generating equipment on.
Instruct the
patient on how to perform the procedure properly.
Exhale with maximum
effort.
Inhale slowly and
deeply.
Exhale slowly.
Repeat until the
drug in the cup is finished.
9
Disconnect the
aerosol mask or jet nebulizer and the drug cup from the aerosol generating
equipment.
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Disinfect surfaces
of the aerosol generating equipment.
Disinfect before
moving the equipment from the patient's room to the disinfection area.
10
Evaluate the
patient’s condition after using aerosols.
11
Wastes
Disinfect and label
wastes as COVID-19 dangers before moving them to waste storage area.
12
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13
Update the care
sheet (if the patient’s medical record is available electronically,
immediately update the record in the patient’s room and print it outside of
the room; otherwise, communicate via handheld transceivers with workers
outside of the patient’s room to update the medical record).
Reduce transmission
to healthcare workers. Include initial data such as time, patient’s condition
and patient evaluation after aerosol use.
SPUTUM
SUCTIONING PROCEDURE
PROCEDURE:
No.
Step
Requirement
and purpose
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1
Wear PPE.
Cover the whole
body.
2
Prepare equipment
(On trolley or
shelf secured at bed head).
Ensure that all
equipment is available before performing the procedure/ entering the
patient’s room.
3
Explain the
procedure’s purpose to the patient.
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Place the patient’s
head on its side (if possible).
Identify the
correct patient.
Prevent choking as
it may stimulate vomiting.
4
Nurse wears clean
gloves.
5
Connect the suction
catheter with the suction machine. Turn the machine on and check suctioning
pressure.
Infants: from -60
to -80
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Adults: from -80 to
-120
(unit: mmHg)
6
Perform suctioning:
Oral suctioning:
insert the suction catheter 4-6 cm into the inside corner of the jaw and into
the Mayo tube.
Nasal suctioning:
insert the suction catheter into both nostrils and move it along the septum
and palate until it reaches the nasopharynx (approximately 7-8 cm).
Start suctioning by
pushing down on the valve. Suction intermittently and twist the catheter
while withdrawing it gently.
Insert gently; do
not suction.
When inserting the
catheter, do not move it up or down to avoid injuring the mucous membrane.
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7
Clean the catheter
and repeat suctioning until all sputum has been removed.
8
Turn the suction
machine off; remove the suction catheter and soak it in a bucket containing
disinfectant solution.
Prevent
hospital-acquired infection.
9
Place the patient
in a comfortable position.
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Replace the bottle
containing catheter cleaning solution.
11
Recollect
equipment:
Sort biomedical
wastes.
Move dirty
equipment to cleaning room and handle according to regulations.
Return other
equipment to its location. Clean and disinfect surfaces.
Disinfect, place in
tightly closed containers, label as COVID-19 dangers and move to disinfection
area.
12
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Reduce transmission
to healthcare workers.
B.
Lower respiratory tract sputum suctioning via endotracheal or tracheostomy tube
1
Wear PPE.
2
Prepare all
necessary equipment.
(On trolley or
shelf secured at bed head).
Check all equipment
before entering the patient’s room.
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ĐT: (028) 3930 3279 DĐ: 0906 22 99 66
Explain the
procedure’s purpose to the patient (if possible).
Clap and vibrate
from lower lobes in 3 positions (if possible).
Evaluate FiO2, SPO2,
PEEP (for mechanically ventilated patients); diagnose tetanus and increased intracranial
pressure.
Check cuff
pressure.
Increase FiO2 to
100% before, during and after 3 minutes of suctioning (for mechanically
ventilated patients).
Help loosen sputum
for effective suctioning.
Prevent endotracheal
or tracheostomy tube from slipping. Prevent oxygen loss during suctioning.
Ensure SpO2 >
90%.
3
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ĐT: (028) 3930 3279 DĐ: 0906 22 99 66
Clap and vibrate
from lower lobes in 3 positions (if possible) or in prone position (for
special cases).
Evaluate FiO2,
SPO2, PEEP (for mechanically ventilated patients); diagnose tetanus and
increased intracranial pressure.
Check cuff
pressure.
Increase FiO2 to
100% before, during and after 3 minutes of suctioning (for mechanically
ventilated patients).
Help loosen sputum
for effective suctioning.
Prevent
endotracheal or tracheostomy tube from slipping. Prevent oxygen loss during
suctioning.
Ensure SpO2 >
90%.
4
Open suction
catheter in advance (for open suction catheter).
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Connect the suction
catheter with the suction machine.
Turn the machine on
and check suctioning pressure.
Infants: from -60
to -80
Children: from 80 to
-100
Adults: from 80 to
-120
(unit: mmHg)
5
Perform suctioning:
Insert the suction
catheter gently until it touches the mucous membrane to stimulate coughing.
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Twist the catheter
while withdrawing it gently.
Suction in 3
positions (if possible).
Ensure
sterilization.
Comply with “clean
hand” rule: after wearing sterile gloves, the hand holding the suction
catheter shall only hold the catheter without touching anything else.
Do not suction
while inserting the catheter.
During suctioning,
do not move the catheter up or down to avoid injuring the mucous membrane.
Monitor the
patient’s facial expression, SpO2, pulse, etc..
Each suctioning
shall last for 10-15 seconds.
Do not suction
continuously. Reconnect the patient to the ventilator to achieve SpO2 > 90%.
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6
Repeat suctioning
until all sputum has been removed.
7
Turn the suction
machine off; remove the suction catheter and soak it in a bucket containing
disinfectant solution.
Prevent
hospital-acquired infection and cross-contamination.
8
Place the patient
in a comfortable position.
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Replace the bottle
containing catheter cleaning solution.
10
Recollect
equipment:
Sort biomedical
wastes.
Move dirty
equipment to cleaning room and handle according to regulations.
Return other
equipment to its location. Disinfect surfaces.
Disinfect, place in
tightly closed containers, label as COVID-19 dangers and move to disinfection
area.
11
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12
Update the care
sheet (if
the patient’s medical record is available electronically, immediately update
the record in the patient’s room and print it outside of the room; otherwise,
communicate via handheld transceivers with workers outside of the patient’s
room to update the medical record).
Reduce transmission
to healthcare workers.
DENTAL
CARE PROCEDURE
No.
Step
Requirement
and purpose
1
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Cover the whole
body; wear face shields.
2
Prepare all
necessary equipment.
Check all equipment
before entering the patient’s room.
3
Explain the
procedure’s purpose to the patient and their family (if possible).
Place the patient
on their side.
4
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Do not wet the
sheets or patient’s clothes.
5
Nurse disinfects
hands.
6
Open care kit.
Pour solutions into
stainless steel bowls: 01 bowl of saline, 01 bowl of mouthwash such as
chlorhexidine 0,12%, povidone, Listerine, Givalex, etc.
Put gauze sponges
in care kit.
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Nurse wears clean
gloves.
8
Remove dentures (if
any).
Perform physical
examination and evaluate patient's condition.
Evaluate
consciousness.
Check cuff
pressure.
Endotracheal or tracheostomy tube.
Examine patient’s
mouth according to BRUSHED.
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Start providing
dental care:
Use tweezers to dip
gauze sponges in NaCl 0,9% solution, use a pincer to wash the patient’s teeth
from the upper set, lower set, lingual side, incisal side, occlusal side,
tongue, palate, inside sides of the jaws to the gum.
Use a tongue
depressor to open the patient’s mouth for easy access.
Replace gauze
sponges and clean multiple times. Soak round sponges in chlohexidine 0,12%
solution and wipe the teeth, tongue and gum.
Ensure
sterilization in case of oral injury.
For comatose
patients, be careful when soaking gauze sponges to prevent choking.
Use a syringe to
clean the mouths of patients who cannot spit or gargle and suction the liquid
afterwards.
Do not wash the
mouth after using disinfectant.
9
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Clean both eyes
first.
10
Apply
Glycerine/Vaseline to patient’s lips to alleviate dryness.
After cleaning.
11
Place the patient
in a comfortable position.
12
Recollect equipment:
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Move dirty
equipment to cleaning room and handle according to regulations.
Return other
equipment to its location. Disinfect surfaces.
Disinfect, place in
tightly closed containers, label as COVID-19 dangers and move to disinfection
area.
Remove PPE in the
anteroom.
Update the care
sheet (if
the patient’s medical record is available electronically, immediately update
the record in the patient’s room and print it outside of the room; otherwise,
communicate via handheld transceivers with workers outside of the patient’s
room to update the medical record).
Reduce transmission
to healthcare workers.
...
...
...
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TABLE
OF CONTENTS
Overview on
SARS-CoV-2
Management of
COVID-19 cases
Prevention of
infection in care of COVID-19 cases
Care of suspected,
asymptomatic, mild and moderate COVID-19 cases
Care of severe and
critical COVID-19 cases
Care and management
of pregnant women suspected or confirmed to have COVID-19
Care of children
suspected or confirmed to have COVID-19
Appendix
...
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