Monkeypox: Everything Nurse’s need to know when Caring for Monkeypox patients

Sep 18, 2022 | 2 comments

Monkeypox

A nurse’s guide to monkeypox

William Kelly, MSN, FNP-C

Author | Nurse Practitioner

Infectious Dz

Derm

Published: September 19, 2022

Unless you’ve buried your head under a rock, you probably have heard about the recent outbreak of Monkeypox.

Just like any infectious disease, nurses are on the front lines and we need to be educated about how to care for these patients, as well as how to minimize the risk of spread to our patients or families.

What is Monkeypox?

Monkeypox is a virus that is similar to smallpox because they are part of the same genus – the orthopoxvirus genus. It is a zoonotic disease, which means its natural hosts are animals – in this case primates and rodents. This virus causes a syndrome of fevers, body aches, malaise, and a pustular rash that is similar to smallpox, although less deadly and less contagious.

This is not a new virus, and normally tends to occur primarily in the tropical forests of West and central Africa. However, this does occasionally cause small outbreaks outside of these areas.

In 2003 there was a brief outbreak in the US, which included only 71 confirmed cases. Out of these, there was no spread to any healthcare staff or other patients within the hospital, and no associated deaths.

Since May 2022, there is another outbreak in the US that is current and continues to spread, this time much more prevalent with over 21,000 cases confirmed in Septemeber, and over 50,000 cases globally.

Check out CDC for updated statistics.

Transmission of Monkeypox

There are multiple ways in which viruses can be transmitted to other people.

Monkeypox has a few different routes of transmission, some more common than others. These routes of transmission include:

Skin-to-skin contact

Skin-to-skin contact with an infected lesion is the most common route of transmission for monkeypox. This. ismost contagious when the lesions are present on the skin. This is why it is commonly transmitted via sex, even though it is not a sexually transmitted infection.

Is Monkeypox an STI?

Despite what you may have heard on some news outlets, monkeypox is NOT a sexually transmitted infection and you cannot only get it through gay sex.

Most cases that are occurring are currently within the gay community of men who are having sex with men. This is sometimes how viruses work – they will spread in a certain community, and then make their way to other communities.

Respiratory Droplets

As with many viruses such as COVID, respiratory droplets can transmit infection. So if you cough sneeze or even speak, this can sometimes infect others depending on how close you are to them. Prolonged face-to-face contact may be required for this to occur with monkeypox.

Fomites

Fomite transmission is when the virus lives on a surface and another person picks up that object or touches that surface and then infects themselves. This can commonly be bed linens, clothing, or surfaces. This is different for every virus, and monkeypox has been known to be able to live on surfaces for up to 15 days!

Not Contagious Anymore?

A person is considered infectious from the onset of clinical symptoms until all lesions have scabbed over and re-epithelization has occurred.

What to do if Exposed?

The CDC recommends that if a patient is exposed to monkeypox in the community, they should:

Monitor for symptoms for up to 21 days
If any symptoms develop, should isolate for at least 5 days to watch for the development of a rash
If the rash develops, isolate until evaluated by a healthcare professional (likely isolate until lesions resolve)

How dangerous is Monkeypox?

It’s difficult to predict how dangerous monkeypox is for those in the US, as most of our data comes from Africa. In Africa, they have less access to quality healthcare, and the predominant strain (called a “clade”) is more deadly there.

From the data regarding Monkeypox in Africa, up to 3-6% of cases die.

So far. in the US, there have been one confirmed death from Monkeypox in LA.

Remember that most of the current monkeypox infections are circulating among younger, generally healthy men.

We have not yet seen monkeypox in large amounts in older patients with significant comorbidities and immunocompromised patients, and they’re expected to have higher rates of complications and death.

Even if monkeypox does not cause death, it can last for weeks and lead to very painful and sometimes scarring lesions.

Prevention

Prevention is the most important aspect of infection control. If we can prevent spreading the virus, we can’t control the virus. This leads to better patient outcomes overall.

With monkeypox, there are ways to prevent the spread within and outside of the hospital. Monkeypox prevention includes:

Universal Precautions

Universal precaution should ALWAYS be used on all patients in every setting, and includes proper hand hygiene, and the use of clean gloves when dealing with or anticipating contact with a patient’s body fluids. This is one of the most important things we can do in healthcare to prevent the spread of infection.

Isolation Precautions

Patients who have suspected or confirmed monkeypox should be placed into isolation as per your facility protocol. As we discussed, monkeypox is spread primarily through physical contact as well as through respiratory droplets. This means that you should be using contact and droplet precautions, so typically that involves the use of a gown, gloves, N95 facemask, and protective eyewear.

N95 Mask

The CDC currently recommends N95 masks when entering a patient’s room with Monkeypox.

Vaccination

Smallpox, a similar but more contagious and deadly virus than monkeypox, was essentially eradicated in 1977 thanks to vaccinations. Because of this, routine vaccination was discontinued in 1980.

Because smallpox and monkeypox are so similars and comes from the same family of viruses, the smallpox vaccine is effective against monkeypox. However, it is in short supply and is being given to patients who meet high-risk criteria.

Currently, vaccination is recommended for patients who:

Have had close contact with Monkeypox for extended periods of time
A recent sex partner (the last 2 weeks) has been diagnosed with Monkeypox
A man or transgender/non-binary who has sex with men and in the last 2 weeks has:
- Had multiple sex partners or group sex
- Had sex at a commercial venue (bathhouse, sex club, etc)
- Had sex in an area where monkeypox transmission is occurring

Assessment

Symptoms

Prodromal Symptoms

Patience with monkeypox will often present with a Prodromal period of symptoms, followed by the characteristic rash. During the prodrome, these symptoms will usually last up to 5 days and include:

Fever

A temperature above 100.4 F

Headache

Patients often complain of a severe headache

Back & Body Aches

Myalgias and pain are common with monkeypox, as with many other viruses

Fatigue

Patients are often very fatigued and tired

Lymphadenopathy

Patients often have swollen lymph nodes, which can be localized toa specific area, or generalized throughout their body

The Monkeypox Rash

The characteristic rash of monkeypox will typically develop 1-4 days after the prodromal symptoms start.

The Rash

Monkeypox will cause a characteristic vesicular/pustular rash that progresses through different stages (See more on the stages below). These lesions are often in the same stage as each other, but not always.

Other history

Recent Travel

Recent travel to an area where Monkeypox is Endmic, such as western Africa or the Congo Basin

Recent Exposures

Any recent contact with someone who may have had monkeypox

Sexual History

Any recent sexual contact or history that would place them at risk of getting monkeypox?

Physical Assessment

The physical inspection will primarily involve inspecting the skin for the monkeypox lesions, noting their quality, amount, number, and locations.

Generalized: May be febrile, sweaty, pale
HEENT: May have enlarged and tender anterior cervical lymph nodes, throat may be erythematous
Cardio: May have tachycardia, especially if fever present
Respiratory: may have increased respiratory rate, sometimes could have cough
Skin: Monkeypox lesions as described in detail below
Extremities: Lymphadenopathy may be present in axillae or groin

Vitals:

Temp: Often have fever >100.4
BP: Often normal
HR: May have mild tachycardia d/t fever, dehydration, etc
RR: May by mildly tachypneic
SPO2%: Often normal

THE RASH

The characteristic monkeypox rash begins approximately 1-4 days after the start off the other symptoms, although some people get the rash first. This begins as a macule, then slowly develops into vesicles, pustules, and then scabs over.

The rash will typically last 2-3 weeks. Patients are considered infectious until the scabs fall off and a new layer of skin forms.

1. Enanthem Stage

In some cases, lesions will first form in the mouth and/or on the tongue.

2. Macular Stage

Macular lesions will first appear, which are basically just rounded red spots that are flat.

This stage lasts 1-2 days

3. Papular Stage

The macular lesions will then turn into papules, which are raised red bumps.

This stage also lasts 1-2 days

4. Vesicular Stage

The papular lesions will then turn into vesicles, which are raised bumps filled with clear fluid.

This stage also lasts 1-2 days

5. Pustular Stage

The vesicular lesions will then turn into pustules, which are raised bumps that are filled with pus (suppurative fluid).

Initially, these are deep-seated, meaning firm and hard. Eventually, they develop an umbilication in the center.

This stage lasts 5-7 days

6. Scab Stage

Finally the pustules crust over and become scabs. These fall off after about 1 week.

This stage lasts 7-14 days

Nursing interventions

There are some nursing inventions that you can do right off the bat with these patients he suspected to have a monkeypox:

Isolate

Patients with suspected monkeypox or even chickenpox should be placed in contact and droplet precautions. The difference with chickenpox is that that tends to be airborne, whereas monkeypox is not, so a negative air pressure room is not required, although may be prudent just in case of chickenpox or other airborne viruses.

Follow proper isolation precautions to minimize the acquisition and spread of the virus. Always refer to your facility’s protocols.

Place the IV

Place at least one IV, preferably 20 gauge or larger, in order to infuse normal saline once it’s ordered. These patients are usually tachycardic and have fevers, and fluids will help rehydrate them, improve their vitals, and help them feel better overall.

Prime your Fluids

Prime at least 1 L of NSS spiked and ready to infuse. Verify a verbal or electronic order being administering (as always 😉).

Bedside Monitor

If these patients are significantly ill and tachycardic, it would be a good idea to hook them up to a cardiac monitor. While doing so, a full set of vitals should be taken if not done already in triage.

Administer Meds

Ask for and verify any medication that the patient may need, including antipyretics like Tylenol, an analgesic like morphine or Toradol, and/or an antiemetic like Zofran.

Diagnosis of Monkeypox

Diagnosis of monkeypox is largely clinical – so based on their history and the rash. However, it is recommended to confirm this in a lab due to the current outbreak.

There are a few ways monkeypox can be confirmed in the lab:

PCR Swab

A swab of the lesions can be obtained and sent to the lab, they should be obtained with a dry synthetic swab. For more information on how to collect the swab – see here.

2 swabs should be obtained from at least 2 different lesions. Vigorously swabbing back and forth is fine, and you do not need to “unroof” the lesions.

Antibody Testing

Some facilities can check for IgG and IgM antibodies to monkeypox. IgM is typically detected 5 days after onset of rash, and IgG is detected 8 days after onset of the rash.

Electron microscopy

Monkeypox can be identified under a microscope as well, where the pathologist visualizes brick-shaped poxvirus virions (indistinguishable from smallpox).

Other Lab abnormalities

There are other lab abnormalities that can present in patients with monkeypox, although these are NOT specific to monkeypox. these include:

Leukocytosis (increased WBC)
Transaminitis (Elevated liver enzymes)
Thrombocytopenia (Low platelets)
Hypoalbuminemia (low albumin levels)

Prognosis & Treatment

With the current US outbreak, patients who get Monkeypox generally have a good recovery, and most can fully recover at home without hospitalization. So far only one death has been specifically attributed to monkeypox in the US during this current outbreak.

However, patients can present with more severe symptoms and complications, which can lead to worse outcomes and even death. These patients are kept in the hospital and given more extensive treatment.

For most people who get Monkeypox, treatment is going to be symptomatic, just like with most viruses. Symptomatic or supportive care includes:

Supportive Care

Antipyretics

Antipyretics like Tylenol or Ibuprofen can be used to control fever and symptoms of pain.

Fluids

Encouraging oral hydration is important with any virus, and will help the body recover quicker, and prevent complications such as acute kidney injury. If the patient is admitted, these fluids can be given IV as well.

Rest

Resting while the body recovers from infection is important for any virus, and will help the body heal as quickly as it can.

Antivirals

TPOXX

TPOXX is the abbreviation for Tecovirimat – an antiviral used for severe monkeypox infections. This is reserved for patients who are admitted to the hospital and have severe disease. Although we don’t have much data in humans, this antiviral has been shown to decrease mortality rates in animals with monkeypox when started early in the course of the illness.

Rx: 600mg IV or PO Q12h x 14 days (depending on weight).
Side Effects: include headaches, nausea, and abdominal pain.

Tecovirimat

Antiviral

Mechanism of Action

Potently inhibits the orthopoxvirus protein required for the formation of virus particles

DOSING

600mg IV/PO Q12H x 14days (for 40-120kg)

SIDE EFFECTS

Headache, Nausea, abdominal pain

Cidofovir/brincidofovir

Cidofovir has been shown to be effective in killing monkeypox in animal studies. Brincidofovir is a prodrug of cidofovir and was also approved for the treatment of monkeypox, however, did show some elevated liver enzymes in animal studies.

Complications & Monitoring

As discussed, most patients recover well at home, but there are certain complications and monitoring that you should watch for.

Patients at increased risk of developing more severe complications include:

Immunocompromised: People with HIV/AIDS, leukemia, chronic steroid use or other immunosuppressants
Age < 8
Pregnant or breastfeeding women
People with active skin diseases like severe eczema, impetigo, burns, etc

Secondary bacterial infections can occur with viral infections, and this is no different than with monkeypox. Bacteria like to strike while the immune system is busy fighting the virus. This can lead to infections like pneumonia or sepsis.

Common secondary infections include:

sepsis

Bacterial infections in any location can cause sepsis. This often happens from UTIs, lung infections, or skin infections.

Bronchopneumonia

Pneumonia should be suspected with productive cough, shortness of breath, adventitious breath sounds, and respiratory distress. This is evaluated with a CXR.

Encephalitis

Encephalitis can occur with various infections and cause confusion, migraines, seizures, and overall altered mental status. This may be diagnosed by brain imaging (CT or MRI), EEG, and a lumbar puncture.

And hopefully that gave you a pretty good understanding of Monkeypox and how to care for your patients who may have it!

Also check out:

REFERENCES

Uptodate Articles:

Epidemiology, clinical manifestations, and diagnosis of monkeypox

Treatment and prevention of monkeypox

Other Reference Apps / Databases:

CDC (Clinical Guidance on Monkeypox)

FP Notebook (Monkeypox)

I&D: How to perform an Incision & Drainage

Sep 7, 2021 | 0 comments

I&D: How to perform an Incision & Drainage

William J. Kelly, MSN, FNP-C

Author | Nurse Practitioner

An I&D or Incision and Drainage is a procedure that is done to treat infections that have turned into abscesses.

Knowing how to perform an I&D is important for a nurse practitioner in most settings, but especially in the ER or Urgent Care.

Learn how to do an I&D (Incision and drainage) including step-by-step instructions how to drain an abscess, antibiotic selection, whether or not to pack the abscess, and discharge instructions

What is an I&D?

An I&D or Incision and Drainage is performed when there is an accumulation of fluid within the body that needs to be drained.

This is usually from a skin abscess.

An I&D is performed in urgent cares, emergency departments, or in outpatient clinics like general surgery.

Patients with an abscess will usually complain of pain, welling, and redness of the affected area.

Abscesses can occur anywhere on the body, but commonly occur:

In the axillae (armpits)
On the upper legs and buttock
Pilonidal region (above the buttcrack)
On fingertips next to nail (termed paronychia)

While anyone can get an abscess, these are more common in those with poor hygiene, as well as those who are immunocompromised.

Diabetics and patients who are obese are also at risk for abscess formation.

When To Do an I&D?

An I&D is performed to drain purulent fluid (pus) from the body.

These collections of pus are termed “abscesses”, and draining them is the best way to treat the infection, as well as preventing the abscess from getting bigger and causing a more serious infection.

If there is no fluctuance palpated (fluid felt underneath the skin), then a trial of PO antibiotics can likely be used without having to do an I&D.

Most cases of obvious abscesses will benefit from an I&D.

There are certain abscesses that require the expertise of a surgeon to drain. These include:

Perirectal or perianal abscesses
Anterior and lateral neck abscesses
Hand abscesses (except paronychia)
Abscesses adjacent to vital nerves or blood vessels
Abscesses in the center of the face
Breast abscesses near the areola and nipple

It is also best for abscesses >5cm to be drained and managed by a surgeon.

I&D and ANTBIOTICS

While antibiotics can help for skin infections like cellulitis, they often won’t be able to fully treat an infection if an abscess is there.

This is why an I&D is necessary.

Young, healthy patients who are not immunocompromised do not need antibiotics if an I&D is performed on a small abscess < 2cm.

Most others will require systemic antibiotics including:

Deep abscesses like in the abdomen
Multiple abscesses
Significant surrounding cellulitis
>2cm in size

However, these antibiotics likely won’t work without also performing an I&D!

Which Antibiotics?

Like skin infections, most abscesses are caused by staphylococcus aureus and other gram-positive bacteria.

However, MRSA is very common, especially with abscess formation. This means that standard antibiotics for cellulitis like Keflex may not work.

Antibiotic selection should cover MRSA

MRSA-covering PO agents include:

Bactrim 1-2 tabs BID x 10 days
Doxycycline 100mg BID x 10 days
Minocycline 100mg BID x 10 days
Clindamycin 300mg q6-8h x 10 days
Linezolid 600mg BID x 10 days (expensive)

Perirectal abscesses that are drained will need additional coverage for gram-negative bacilli and anaerobes, so options include:

Add Augmentin to the MRSA-covering agents above
Add Levaquin AND Flagyl to the MRSA-covering agents above
Add Cipro to Clindamycin

Severe infections and abscesses that require inpatient admission would be started on IV Vancomycin +/- Cipro/Flagyl or Zosyn.

Aerobic and anaerobic cultures should be obtained and sent to the lab to guide antibiotic use.

Patients at risk of bacterial endocarditis should be started on antibiotic prophylaxis. These should be given 1 hour prior to the I&D.

Bacterial Endocarditis Prophylaxis

Antibiotic prophylaxis is given to certain people at risk for developing bacterial endocarditis. These oral antibiotics should be given 1 hour prior to the I&D.

Antibiotic prophylaxis should be given for patients with:

Prosthetic heart valves
Rheumatic heart disease
Unrepaired congenital heart disease
H/o infective endocarditis
Central lines

Antibiotic prophylaxis for bacterial endocarditis include:

Bactrim
Doxycycline and amoxicillin
Minocycline and amoxicillin
Clindamycin

HOW TO PERFORM AN I&D

1. Collect your Equipment

An I&D is an invasive procedure and will require some equipment.

An I&D is also considered a clean procedure, so you do not need sterile gloves or a sterile field, although some do still utilize sterile technique.

Your facilities may have kits put together which contain much of what you need for the I&D.

I&D Equipment

I&D Kit	PPE
Scalpel (#11) Betadine or CHG 4×4 Gauze Curved hemostats Scissors	Clean or Sterile Gloves Gown Face shield (trust me)
ANESTHETIC	IRRIGATION
1-2% Lidocaine 3-5 cc syringe Blunt needle 25-30g needle	1-2% Lidocaine 3-5 cc syringe Blunt needle 25-30g needle
PACKING & DRESSING	Culture Swabs
Iodoform or plain gauze packing tape ABD pad and gauze Tape	Aerobic swab Anaerobic swab

3. Anesthetize

Before you make the incision, you should anesthetize the area you are going to cut.

Abscesses are already irritated and will be very painful.

Unfortunately, lidocaine doesn’t work as well as usual because abscesses are an acidic environment.

Draw up your 1-2% lidocaine into your 3cc syringe with a blunt needle.

Switch out to the smaller gauge needle (25-30g) and prime the lidocaine. You are now ready to infiltrate.

You have a few options when it comes to HOW you are going to anesthetize the area.

Linear Block

For smaller abscesses <5cm, locally infiltrate the lidocaine in a line where the incision will be, across the entire length of the abscess. This will be painful for the patient.

Incisions should be made along the lines of the body that have decreased tension to reduce scarring.

Local infiltration involves sticking the needle just underneath the epidermis, and injecting a small amount of lidocaine while you gently pull the needle back out.

You are infiltrating the subcutaneous tissue, but not deep enough to actually inject into the abscess itself.

This is done multiple times until the projected line where you will cut is fully infiltrated.

After 3-5 minutes, you can begin the incision.

Field Block

For larger abscesses >5cm, the linear approach above should be used, IN ADDITION to a ring or field block.

A field block is achieved by injecting a ring of subcutaneous 1% lidocaine around the abscess, approximately 1cm peripheral to the erythematous border.

Remember the max dose of lidocaine is 4.5mg/kg
(max 300mg)

This means for lidocaine 1% (10mg/mL) the max dose would be 30mL in most adults over 65kg – you hopefully should not be using anywhere near this amount.

Lidocaine should start working in 45-90 seconds, but you should give it 3-7 minutes to fully kick with an abscess.

Tips to Decrease pain with lidocaine

Buffer the lidocaine with 9:1 ratio (lidocaine to 8.4% bicarb)
Use a smaller needle
Inject slowly
Use room temperature lidocaine
Stimulate adjacent skin
Ring block/field block technique as above

4. Make the Incision

Once you have given enough time for the lidocaine to work (3-5 minutes), make a linear incision with the scalpel.

This needs to be deep enough to penetrate the abscess wall, but not too deep to cause injury.

It helps if you have 4×4 gauze in the other hand, as purulent fluid will usually immediately start gushing out.

Cut the entire length of the abscess, as not making a wide enough incision is one of the main causes of a recurrent abscess.

5. Obtain Cultures

Young healthy patients with small abscesses <2cm who won’t get antibiotics don’t need cultures obtained.

Patients started on antibiotics should have cultures obtained if:

Significant cellulitis
Systemic symptoms like fevers
History of recurrent abscesses
Failure of initial antibiotics
Very young or old
Immunocompromised

Make sure to obtain swabs for both aerobic and anaerobic gram stain and culture.

6. Loculations & Irrigation

Abscesses have a tendency to become loculated. This means there can be individual pockets of pus within the abscess itself.

To “break these up”, insert a hemostat into the incision and open it up in all directions in order to break up any possible loculations. This is often painful.

Draw up sterile saline with the 20-60cc syringe, attach the splash guard or IV catheter, and irrigate the incision to effectively clean out the abscess.

This is best practice although not always performed, especially for smaller abscesses.

7. Pack wound (optional)

I&D incisions are almost never closed with sutures but are left open to heal by “secondary intention”, meaning naturally.

Sometimes packing should be used.

Packing is when you insert special gauze into the wound that promotes drainage.

Packing is generally recommended for:

Abscesses >5cm
Pilonidal abscesses
Immunocompromised / diabetics

If you decide to pack the wound, do not over-pack the wound too tightly. This increased pressure can cause tissue damage.

Gently insert the iodoform ribbon into the wound with a blunt object such as a cutip swab. This does not have to “stuff” the wound. Leave a 1cm tail outside of the wound.

Cover the packing with an absorbable dressing.

Patients with packing will need to return for a wound check-in 2 days. If there is still significant drainage, more packing can be placed.

Discharge Instructions

Before discharge, make sure their tetanus is uptodate.

I&D without packing should soak in warm soapy water 2-3 times per day, and f/u in 7-10 days or sooner if systemic signs of infection present.

I&D with packing should return in 24-48 hours. Once packing is removed and the drainage stops, warm soapy soaks can be started.

You may also like:

REFERENCES

Approach to management of drainable abscess or skin infection with purulent drainage in adults. (2021). UpToDate. Retrieved September 7, 2021, from https://www.uptodate.com/contents/image?imageKey=ID%2F114919&topicKey=ID%2F110530
Graphic 114919 Version 10.0

Buttaravoli, P. M., & Leffler, S. M. (2012). Cutaneous Abscess or Pustule. In Minor emergencies (3rd ed., pp. 655-659). Saunders.

Downey, K. A., & Becker, T. (2021). Techniques for skin abscess drainage. In T. W. Post (Ed.), UpToDate. https://www.uptodate.com/contents/techniques-for-skin-abscess-drainage

Sexton, D. J., & Chu, V. H. (2021). Antimicrobial prophylaxis for the prevention of bacterial endocarditis. In T. W. Post (Ed.), UpToDate. https://www.uptodate.com/contents/antimicrobial-prophylaxis-for-the-prevention-of-bacterial-endocarditis

What is an I&D
I&D Indications / Contraindications
Role of Antibiotics
- MRSA-Covering Abx
- Bacterial Endocarditis PPx
I&D Equipment
Consent
Anesthetics (lidocaine)
- Linear Block
- Field Block
The Incision
Cultures
Loculation & Irrigation
Wound Packing
Discharge Instructions

21+ mRNA Vaccine Questions Answered for Nurses

Jan 27, 2021 | 2 comments

21+ mRNA Vaccine Questions Answered for Nurses

Last updated: January 27, 2021

The new mRNA vaccines for COVID are being distributed, and as a nurse, it is important to know these vaccines, how they work, and their safety data!

Our patients respect our medical opinion, and we need to give accurate information so they can make an informed decision.

This article mainly focuses on the mRNA vaccines (Pfizer and Moderna), as they are currently the vaccines being distributed as they have obtained FDA emergency use authorization.

With these vaccines being so new – it leaves many wondering, “is it’s safe?”

I’m going to go over what the data tells us and hopefully give you enough insight into making an informed decision, and help your patients do the same!

Quick Note: I want to preface this article by first stating that I am a nurse practitioner and I see many COVID patients on the frontlines in the ED. I am not, however, an epidemiologist or scientist who works directly with COVID in a lab, so I am simply basing my own opinions on what the data says, as well as my understanding of the virus by seeing it firsthand.

1. How do mRNA Vaccines Work?

Vaccines generally work by introducing a dead or weakened virus, or part of a virus into your bloodstream via an Intramuscular or subcutaneous injection.

This creates an immune response that helps your body be able to attack the real virus whenever it comes into contact with it in the future. Typical vaccines include those with:

A live but weakened or “attenuated” virus, which leads to a better immune response, but can actually cause the disease in very few people – mainly those who are immunocompromised.
A dead or “inactivated” virus, in which the virus has been inactivated and is unable to replicate and cause disease. This doesn’t create as good of an immune response so it may need multiple doses or boosters. An example of this is the flu shot or hepatitis A.
Those that contain a piece of the virus, like part of its specific protein. This also cannot replicate or cause disease. Examples include hep B, meningitis, and HPV.
There’s also some vaccines that contain a toxoid that the virus creates, such as tetanus or diphtheria, like the Tdap vaccine.

The mRNA Vaccines (Pfizer and Moderna) actually do not inject the virus or any of it’s parts into you.

Instead, it contains mRNA which codes for the COVID spike protein – a protein specifically found on the COVID virus.

RNA is a single-stranded molecule that normally takes information from your DNA in the nucleus of the cell, and brings it to the ribosome of the cell to create proteins which basically keep the cell running and functioning appropriately.

So what scientists at Pfizer and Moderna have done is isolated the genome sequence of the mRNA which codes for the spike protein in the coronavirus, as this protein is not naturally found within your body. So what does the body do with this mRNA?

The mRNA is absorbed into your cells and carried to your ribosome where it is used as instructions to create the spike protein of COVID.

This protein cannot lead to disease, but it should lead to an immune response. Your body sees this foreign entity and creates antibodies to kill it and any future proteins it detects.

If the actual COVID virus now enters your body, your body should be able to detect it, and your immune system will target the cell and destroy it before it has a chance to replicate enough to cause disease and hopefully prevent you from spreading it.

2. Are mRNA Vaccines Safe?

This isn’t an easy question since it is so new, but so far it seems to be very safe and effective.

While mRNA vaccines have not actually been used in the US, researchers have been studying them for decades and have tested them on humans before for viruses like rabies, flu, CMV, and Zika.

In order to test the safety and efficacy of these new vaccines, clinical trials were conducted.

Pfizer and Moderna injected this vaccine into willing people and followed them for any adverse side effects, as well as those who ended up getting symptomatic COVID or severe disease.

Over 30,000 people were enrolled in the Moderna trial and over 40,000 people in the Pfizer trial.

Those who got the Pfizer vaccine get 2 injections, 21 days apart. Those who got the Moderna vaccine get 2 injections, 28 days apart.

Pfizer was tested on people 16 years and older, and Moderna was tested on adults 18 years and older.

Long story short – what they found was that most symptomatic covid cases were occurring in the placebo groups, which means those who did not receive the vaccine. Severe cases of COVID almost exclusively occurred in the placebo group!

The Pfizer vaccine boasts 95% efficacy beginning 1 week after the second dose, and Moderna boasts 94.1% efficacy 2 weeks after the second dose.

Both mRNA vaccines essentially use the same mRNA, basically the same ingredients, and both had very similar findings in their trials. This in and of itself is reassuring and offers an element of reproducibility.

The data from these trials are overall VERY reassuring. You can read more about the Pfizer or Moderna trials to get more information!

3. What Side Effects Can be Expected?

Common side effects include local injection site pain, headache, and fatigue. These vaccines should not cause COVID symptoms such as cough or SOB. It is impossible for these vaccines to cause actual COVID disease.

These vague side effects are common and expected when getting a vaccination, and are often an indication of the body’s immune response. They are short-lived and not severe.

Symptoms after the first injection tend to be less severe, and symptoms after the second injection were more significant – although both were very short lived (1-2 days).

Anecdotal Note: I have received both injections from the Moderna Vaccine. After the first shot, I had arm soreness which was worse than a typical vaccine, but resolved over 1-2 days. The day after my second injection, I had body aches and fatigue which resolved by the next day.
These symptoms seem common based on my colleagues experiences as well. Those who had symptomatic COVID anecdotally reported worsened symptoms after the first dose, although still short-lived.

Are all side effects mild and short-lived? We’ll dive more into that in future questions!

4. Can the mRNA Vaccines cause Anaphylaxis?

Just like any medication or vaccine, allergic reactions can occur.

Anaphylactic reactions have occurred after COVID vaccine administration, although not common, and seem to mainly occur in those with a history of severe allergies.

Overall it seems to be very rare – 11 people per million. Regardless, we know how to treat anaphylaxis and allergic reactions very well – Benadryl, Solumedrol, and Pepcid!

The CDC recommends those without a history of anaphylaxis to wait 15 minutes after their injection for monitoring, and those with a history of anaphylaxis to wait 30 minutes – just to be on the safe side.

5. Can the mRNA Vaccines cause Facial Paralysis?

Bell’s palsy is unilateral facial paralysis that can occur, which is usually temporary.

In the COVID vaccine trials, there were 7 reported cases of Bell’s palsy, in the over 70,000 participants in Pfizer/Moderna’s clinical trials.

While there were slightly more cases in the vaccine groups than the placebo groups, this rate is consistent with bell’s palsy rates in the general public, so likely not statistically significant.

However, some viruses and vaccines have been associated with bell’s palsy in the past, although rare.

Even if there is a small rare chance of the COVID vaccine causing Bell’s Palsy – it is usually temporary and treatable, and the benefits outweigh the risks.

6. Can the mRNA Vaccines cause COVID?

No – it is physiologically impossible for it to cause COVID disease.

Vaccines that contain live “weakened” viruses do have the capacity to cause disease in those who are immunocompromised – an example being the MMR vaccine.

However, those with only pieces of the virus or mRNA that code for pieces of the virus cannot cause COVID. So mRNA Vaccines cannot cause COVID illness.

7. Will these Vaccines cause False Positive Results on Testing?

No, the vaccine should not alter PCR or antigen testing. Test swabs collect viral particles and test for their genetic code. These swabs are collected from areas where you are expressing the virus, like the nasopharynx.

While the mRNA causes your cells to produce the COVID spike protein, they are not expressed or spread outside of your body.

The PCR and antigen tests check for active infection and do not check for antibodies. The vaccine should not alter these test results.

8. Do the Vaccines Change your DNA?

No. Only specific viruses can alter your DNA. These viruses are called retroviruses and require a specific protein called reverse transcriptase.

The mRNA in the COVID vaccines do not alter your DNA in any way.

9. Do the Vaccines Contain a Microchip?

No – this is nonsense and I’m not really sure what else to say about it.

10. Do the mRNA Vaccines cause Infertility Issues?

There is no convincing evidence to suggest that the mRNA vaccines cause infertility.

This idea was picked up and used by anti-vax propaganda. This myth started when a German Epidemiologist and a former Pfizer employee asked the FDA to not grant authorization to use the vaccine.

They said that the COVID vaccine’s mRNA is similar to the syncytin-1 protein which is used in mammals to help create placenta during pregnancy.

While the proteins do share a minimal amount of similar code, the scientist and medical community at large reject the notion that it could cause infertility.

While it is still so new – it cannot be said with certainty because we don’t have the data. However, 23 women did conceive during these trials, and they are still being followed.

11. Can Pregnant Patients Get an mRNA Vaccine?

This is a decision that should be discussed with the patient’s OBGYN, and they can come to a decision together.

The clinical trials did not study vaccination in pregnant mothers, so we don’t have specific data regarding pregnant individuals. There were some animal studies that looked promising.

The American College of Obstetricians and Gynecologists (ACOG) recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet the criteria for vaccination based on priority groups.

This means it is likely a good idea for pregnant mothers who are at an increased risk of getting COVID to get the mRNA vaccine.

What we do know is that pregnant mothers are at increased risk from side effects and complications if they get COVID.

They are more likely to be hospitalized, placed in the ICU, ventilated, and die than if they weren’t pregnant.

12. Can Breastfeeding Mothers get the Vaccine?

Again – this decision should be made with the patient’s OBGYN and Pediatrician.

There is just not enough data studying this to make a sweeping recommendation.

It is unlikely that the vaccines would be unsafe for the baby, and there is a possibility of passing on some passive immunity obtained from the vaccine to a breastfeeding infant.

13. Can those with Autoimmune Diseases get the Vaccine?

While there doesn’t appear to be any specific contraindications, this is something that should be discussed with the patient’s physician / Rheumatologist.

The risks of getting symptomatic COVID may be worse than the risks of getting the COVID vaccine.

14. Should Patients who had Symptomatic COVID get the Vaccine?

The idea is that if you had symptomatic COVID – you should have natural antibodies already for the virus – so why get the vaccine?

This is a decision you have to decide on with your Provider. It likely won’t hurt and could help, so the CDC is in favor or those who had COVID to also get vaccinated.

While it may be recommended to wait 90 days after symptomatic covid for the infection, this is not a rule and there is no specific timeline established.

This is more to allow those who have not built any immunity to receive the vaccine first.

You should get the vaccine after you recover from symptomatic COVID and when you feel it is appropriate.

15. What if you or your Patient doesn’t get the Vaccine?

As of today COVID has killed over 400,000 people in the US and 2.15 million people worldwide. This number is rising very quickly.

Even if COVID doesn’t kill you or your patients, it can cause many long-lasting side effects.

During an active COVID infection, it can cause multifocal pneumonia and respiratory failure leading to hospitalization, ventilation, and possibly death.

Severe COVID can also cause blood clots leading to pulmonary embolisms and embolic strokes.

It can cause inflammation of your brain and heart as well, leading to irreversible damage in some cases.

There have been observational studies done which show that up to one-third of patients who had symptomatic COVID had persistent symptoms after resolution of the virus. These include:

Fatigue
Dyspnea (Shortness of breath)
Chest Pain
Cough
Anosmia (loss of smell)
Ageusia (loss of taste)
More (joint pains, headaches, myalgias, etc)

There may still be other long-term side effects that we still don’t know about.

So what’s riskier? Getting a vaccine that seems to be very safe and doesn’t seem to have any serious long-lasting side effects, or take your chances with getting COVID?

I can’t make that decision for you or your patients.

But if you do decide to get the vaccine, what can you expect?

16. If you get the Vaccine, What can you Expect?

You can expect to get 2 injections, 21 days apart with Pfizer or 28 days apart with Moderna.

The full efficacy seems to be established about 1-2 weeks after the second injection, depending on the vaccine (1 week after Pfizer, 2 weeks after Moderna).

These were the timelines studied in the clinical trials.

17. Can I Stop Wearing Masks and Social Distancing once I’m Vaccinated?

Well – no, not immediately.

Remember that even a 94-95% efficacy still leaves that 5-6% of people who will still get symptomatic COVID.

These people will likely be contagious, and they still could get severe COVID and have to be hospitalized or worse.

Secondly, both Pfizer and Moderna require 2 shots before full efficacy is expected. The body takes time to build up an antibody response. It can take 1-2 weeks after the second dose for full efficacy.

Additionally, it has not been proven by evidence that these vaccines prevent you from spreading COVID. The trials only prove that they are 94-95% effective at reducing symptomatic COVID.

That’s right. Even if you don’t get symptomatic COVID – you could possibly spread it.

18. Could you get the COVID vaccine and be an Asymptomatic Spreader?

Theoretically, it is unlikely that you will be spreading the virus after vaccination.

Hopefully, your body has created an immune response and antibodies which will attack COVID before it can replicate and cause disease or be contagious.

HOWEVER – we don’t have the data to back this up, and there another important consideration – Mucosal Immunity.

We don’t know how well the antibodies penetrate the nasal mucosa. There is a possibility that the virus can still replicate in the mucosa of your nasopharynx.

While it may not cause symptomatic disease since you should have circulating antibodies – you might still spread it to others when coughing, sneezing, or even breathing.

This is something that we should have more data on soon.

This is why it is imperative to continue to wash our hands, wear our masks, and practice social distancing.

19. When will Herd Immunity be Established?

It is going to take some time for the majority of the US to become vaccinated.

This means we need about 70%+ of the population to be vaccinated or infected before some type of herd immunity can be expected and established.

Herd immunity occurs at different percentages of vaccinated/infected individuals based on each specific virus.

This number is unknown for COVID, but experts say at least 70% need to be vaccinated and/or infected for some type of herd immunity to protect us.

It is unlikely that mask mandates and social distancing will become a “thing of the past” until we get to this point.

20. Will the mRNA Vaccines Cover the New Strains?

Unfortunately, there are multiple mutated strains or variants popping up in the UK, Africa, and other places.

These strains are spreading fast as they are more contagious (30-70% more transmissible).

However, these don’t necessarily seem to be more deadly. However, with surges in COVID cases and hospitalizations, increased deaths could occur due to the burden put on the healthcare system.

As far as we know, these vaccines should be effective against these mutated variants.

However, preliminary data does suggest that the vaccines may not work as well against the South African variant! Just in case, Moderna has already begun production on a “booster shot” which would specifically target these variants.

21. How Long will Immunity Last from these mRNA Vaccines?

As mentioned above – complete immunity is not guaranteed.

However, if antibodies are created, it is unknown how long they will last.

What we do know is that immunity wanes over time. Those who get symptomatic illness tend to build a better immune response than those who get vaccinations.

Many patients who had symptomatic COVID in early 2020 still have antibodies – this is good news!

We don’t know how long immunity will last, and we don’t know how much further mutations will alter the effectiveness of the immunity.

22. Are there other Vaccines Available?

Pfizer and Moderna are mRNA vaccines which have already obtained emergency use authorization (EUA) from the FDA.

There are two other vaccines that may obtain approval as well. These are not mRNA vaccines. They include:

Johnson & Johnson, which uses adenovirus to carry genetic material for COVID
AstraZeneca, which uses a chimpanzee adenovirus to do this

These do not appear to be as effective as the mRNA vaccines, but may still prove helpful, and we must continue to follow the data.

Production and distribution of the mRNA vaccines will prove tough, and additional effective vaccines will be helpful!

So Should you or your Patient get the Vaccine?

That’s for you to decide, based on the data and taking into account what your physician or healthcare provider recommends.

Additionally, it is for your patients to decide based on informed consent.

It is not your job to judge them or tell them what to do. All you can do is offer evidence-based recommendations and up to date information, and allow them to make that decision for themselves.

You can also lead by example and get the vaccine for yourself, trusting the science and once again being that hero that we were once called in the beginning of this pandemic.

I think frontline workers and those with a high risk should seriously consider getting vaccinated.

As far as everyone else – that’ a decision you (or they) have to make, but the data looks promising and this could be our chance at returning to a state of semi-normalcy.

Note: If you want more information – you should follow Dr. Kat the Epidemiologist on TikTok! She creates great content backed in science on all things COVID and mRNA Vaccines!

I got my vaccine! Did you? Why or why not? Let us know in the comments below!

You might like: “These 8 COVID nursing tips could save your life”

References:

Pfizer / Moderna Studies:

Moderna Announces Primary Efficacy Analysis in Phase 3 COVE Study for Its COVID-19 Vaccine Candidate and Filing Today with U.S. FDA for Emergency Use Authorization

PFIZER AND BIONTECH CONCLUDE PHASE 3 STUDY OF COVID-19 VACCINE CANDIDATE, MEETING ALL PRIMARY EFFICACY ENDPOINTS

Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine (Pfizer)

Safety and Immunogenicity of SARS-CoV-2 mRNA-1273 Vaccine in Older Adults (Moderna)

Vaccine Info:

Coronavirus disease 2019 (COVID-19): Vaccines to prevent SARS-CoV-2 infection (UTD)

Facts about COVID-19 Vaccines (CDC)

Understanding mRNA COVID-19 Vaccines (CDC)

Vaccine Types

Anaphylaxis:

Allergic Reactions Including Anaphylaxis After Receipt of the First Dose of Pfizer-BioNTech COVID-19 Vaccine

Interim Considerations: Preparing for the Potential Management of Anaphylaxis After COVID-19 Vaccination

Bell’s Palsy:

FDA: Track Vaccine Recipients for Facial Paralysis

Pregnancy & Breastfeeding:

COVID-19 Vaccines and Pregnancy: Conversation Guide for Clinicians (ACOG)

Vaccination Considerations for People who are Pregnant or Breastfeeding (CDC)

Why COVID Vaccines are Falsely Linked to Infertility

Persistent COVID:

Coronavirus disease 2019 (COVID-19): Evaluation and management of adults following acute viral illness (UTD)

COVID Cheat Sheet

Everything you need to know about treating COVID pneumonia in the ER and Inpatient setting!

COVID cheat sheet promotional image

These 8 COVID Nursing Tips could save your life

Dec 14, 2020 | 3 comments

These 8 COVID Nursing Tips could save your life

This post may contain affiliate links, which means I get a commission if you decide to purchase through my links, at no cost to you. Please read affiliate disclosure for more information

Whether we want to admit it or not, the COVID19 pandemic is not ending anytime soon. Even with the vaccines coming soon, there is still be months of hard work ahead of us. Using these COVID nursing tips might be able to help!

As nurses, COVID can be exhausting and even somewhat demoralizing. I have felt plenty of burn-out since this all began, and nurses across the nation can relate.

In this article, I will list some COVID nursing tips for ER and inpatient nurses – to help you get through your shift safely!

1. Minimize Contact

This is easier said than done – but minimize your contact with patients who have symptoms consistent with COVID. If you need a refresher, common symptoms of COVID include:

Fevers
Cough
SOB
Body aches and Headache
Nausea and Vomiting
Loss of taste/smell

As an NP, this is actually fairly doable. I can conduct my history at 3-6 feet away, and perform a very limited physical assessment, often without even touching the patient. Sounds terrible, but the safety of healthcare workers is essential.

Bedside nurses are much more hands-on. What I’m going to say might be controversial, but you do not need to listen to every patient with lung sounds. We are going to get a chest X-ray anyway. Minimize contact, minimize exposure, and minimize your risk as best possible.

Patients with COVID often have normal or somewhat diminished lung sounds. Knowing this does not change management. When I do listen to lung sounds, they are patients with asthma, COPD, or CHF, because I’m specifically looking for wheezes or rales.

Make sure you get everything you need before garbing up and entering the room. Bring with your IV equipment and blood tubes, vital sign hookups if not already in the room, any medications already ordered, a COVID nasopharyngeal swab, etc.

If the patient may be discharged and an ambulatory pulse ox might be ordered – might as well get them up and walk them around the room while recording their SPO2. This is using your nursing judgment to anticipate orders. Let’s face it – not all Providers are great about putting in every order at the same time (guilty!).

2. Reduce, Reuse, Recycle (Your N95)

Don’t take your N95 for granted, because they’re running out! At least, that was the worry when this pandemic started and is definitely a possibility if infections and hospitalizations continue as they have been in the US.

However, we can’t afford to be wasteful. Before COVID, we would use an N95 like a surgical mask – apply it when taking airborne precautions, and removing it upon leaving the room. This life of luxury is no more.

Many hospitals have decontamination protocols for N95s – where they decontaminate them in some capacity. However, not every hospital will do this. If needed, there are multiple ways that you can decontaminate your N95 yourself using the following COVID nursing tips.

Bake It

No, really – throw that N95 in the oven! Baking with dry heat at 75° C (167° F) for 30 minutes effectively kills Sars-COV-2. Researchers at Stanford found that this can be done for 20 cycles without significantly reducing the filtration efficiency. Other studies indicated that only 2 cycles proved safe.

Hang the N95 from the oven rack with a wooden paperclip, or place an oven-safe fabric on a metal sheet. Do not place the N95 directly on the metal as this can overheat the mask.

Rotation Schedule

COVID has been found to survive on hard surfaces for 48 hours, plastic for 72 hours, and cardboard for 24 hours. While scientists aren’t 100% sure on the specifics of covid spread via surfaces, they do know that COVID doesn’t spread much through touch.

An alternative method to decontaminating your N95 is to leave it in a safe, warm, dry area and allow it to “air-dry” for 3-4 days. Placing it in a paper bag may be useful for this. This will kill the coronavirus without degrading the filter.

If you have three or four N95s, you can start a rotation cycle and effectively never run out of N95s.

Please note this does not appear to be a well-studied decontamination procedure and is solely based on theory.

Other methods

There are other methods to decontaminate your N95, including moist heat, UV radiation exposure, boiling, and even steaming. These all kill COVID but degrade the N95 at varying rates, and are likely more difficult to perform while at home.

If the idea of having to decontaminate and then reuse your N95 does not fit your desires – you can always skip this COVID nursing tip and buy a reusable N95 Device.

3. Buy a Reusable N95 device

They do make reusable N95 devices which are somewhat affordable and probably worth it.

Using a reusable N95 is more comfortable, less of a hassle, and can leave you feeling more protected.

Envo Mask is all the rage in my ER, and for good reason. This reusable N95 is comfortable and won’t fog your goggles. There are replaceable filters that you use, making this usable forever (but hopefully COVID won’t last forever too).

You can also buy a respirator, which can be cheaper depending on which one you get. If you do, you need to make sure you buy the appropriate filter though, as many of these respirators were intended to be used for occupational exposure. The 2091 filter is recommended by the CDC.

Please be aware it can be somewhat difficult to speak to people with a respirator on, as they can have a hard time hearing. This can be especially difficult over the phone.

4. Protego Skin!

We’ve all seen those horrid photos of nurses who worked 12+ hours in an n95 mask, with deep facial markings to prove it. Many of us have experienced this firsthand.

You shouldn’t only worry about your patient’s skin breakdown. Wearing an N95 for 12 hours straight can cause your own skin-breakdown, and it can be very irritating, painful, and eventually lead to open wounds. There are a few different COVID nursing tips regarding your skin protection that can help!

Take Breaks

To minimize skin breakdown, frequent removal of the N95 is recommended. However, with the COVID pandemic among us – that is not always feasible.

If able to safely remove your N95, the recommendation is to take a 15-minute break every 2 hours. For the vast majority of us, this just won’t work.

Skin Protectant

Probably one of the safest options, you can apply a liquid skin protectant onto your skin. Once applied and allowed to dry, this creates a protective barrier that minimizes moisture and friction.

Any skin protectant should work, and skin repair creams with dimethicone can also be effective. Apply it over the areas where the N95 will cause the most skin breakdown (nasal bridge, cheeks, behind ears). Avoid getting the product in your eyes or mouth.

Good skin protectants to use:

Make sure to always allow the product to fully dry before applying your N95.

Protective Dressing

If skin protectant doesn’t do the trick – you can try a protective dressing.

The issue with protective dressings is they can alter the fit of the N95. Unfortunately, that could mean catching COVID. This is why skin protectant is a safer option. Still – if your skin really needs it – you can likely put a protective dressing in a safe manner.

Cut a thin dressing into small pieces, and apply a thin layer to the nasal bridge, the cheekbones, and behind the ears.

You should use a foam dressing that has a non-permeable outer layer, so any hydrocolloid dressing should work well. A good example is the Duoderm Hydrocolloid Dressing.

You should attempt to confirm the N95 fit by blowing out and seeing if there are any leaks. Definitive fit testing can also be done and is more accurate, although may not be feasible on the unit.

5. Surgical Mask Woes

Even with using our N95s, we are still recommended to be using a surgical mask on top of that. This prevents soiling of the N95 mask and adds that extra layer of protection for splashes.

Unfortunately, surgical masks wrap around your ears and they can lead to skin breakdown of your ears and just hurt.

There are scrub caps and headbands with buttons sowed on which you can loop the surgical mask onto, which takes the pressure off of your ears entirely.

They also make plastic devices that connect both sides and loop around the back of your neck. You can even MacGyver your own version with some rubber hands and/or paper clips.

6. Bad Breath

No – wearing a mask won’t give you hypercarbia… But it can give you hyper-halitosis. If you have bad breath – you’ll definitely notice it now. Sure, bad breath won’t kill you, but it’s just not fun to be breathing in for 12 hours.

Working 12-hour shifts without time for water breaks will cause dry mouth and will increase the odor of your breath as well!

One easy fix is to buy some gum. This leaves your breath smelling minty and fresh. If you’re someone who needs more help for your halitosis, you can try special toothpaste or special mouthwash.

Make sure you are able to stay hydrated. Drink plenty of water before your shift (not that you’ll have much time to pee). Try to take a few breaks throughout the shift just to drink some water and stay hydrated.

7. Wrap it Before you Tap It

No – I’m not talking sex-ed. I’m talking about your smartphone!

Let’s be real, we all bring our phones to work. No, we probably don’t have time to scroll Instagram (follow me!), but we occasionally check the time and maybe our messages.

I personally use multiple apps on my phone throughout my shift to help with antibiotic selection or to reference something related to patient care.

The problem is, we don’t want to contaminate our phones with COVID or who knows what else.

One simple COVID nursing tip is to bring a Ziplock baggie to work that your phone easily fits in. Ziplock it shut. Your touch screen actually works through the ziplock bag!

You could also just leave your phone at home – but if that doesn’t give you anxiety thinking about it, then something is wrong with you.

If you risk it and just use your phone while at risk, you should know how to decontaminate your phone. Pro Tip: Don’t put your phone in the oven like the N95!

8. Decontamination Station

After a long shift working with COVID patients ALL day (or night), there is nothing you probably want more than to get home and crawl in bed. But you are also aware of all the NASTINESS on your body, scrubs, and everything else you’ve touched.

You need to have a procedure for how you clean yourself and your items. The last thing you want to do is infect members of your household!

Leave anything items you can at work, like your stethoscope, scissors, pens, penlights, etc. If you have a locker – use that!

Make sure you carry hand sanitizer in your car. Use it immediately once you get in before touching the steering wheel. Do not touch your face now that you are maskless.

Once you get home, find a way to strip quickly without touching anybody or anything. I put anything in my pockets (like my phone) on the island counter. I put my clothes directly in the washing machine. Take an immediate shower with hot water and plenty of soap.

After this, I personally go through and wipe down everything I touched including the doorknob, the bathroom door, etc with a disinfectant. I then wipe down all the items I had placed on the island counter. You can use clorox wipes, lysol wipes, but I personally use Original Pine-sol which kills COVID within 10 minutes (THAT’S the power of Pine-sol baby).

Other related content:

COVID Nursing Tip: Always Follow Hospital Policy

As always you should ALWAYS be following hospital policy and procedures whenever implementing any of these COVID nursing tips. This is an unconventional time, so there may not be much oversight regarding infection control practices, but make sure anything you do is safe for you and your patients.

Comment down below your COVID Nursing tips!

References:

COVID risk and statistics

Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

Sustainability of Coronavirus on Different Surfaces

Covid Skin Breakdown:

NPIAP position statement on preventing injury with N95 mask

OSHA: COVID-19

COVID Decontamination:

Assessment of N95 respirator decontamination and re-use for SARS-CoV-2

Reuse of N95 Masks

Respirator:

CDC: Certified Equipment List

COVID Cheat Sheet

Everything you need to know about treating COVID pneumonia in the ER and Inpatient setting!

COVID cheat sheet promotional image

Six Steps for Sepsis Management

Nov 26, 2018

Six Steps for Sepsis Management

Sepsis is not a specific disease but rather a clinical syndromewhich represents the body’s response to severe bacterial infection. Sepsis is very common. In fact, within the hospital, you will take care of patients with sepsis in any department. Sepsis is a very serious condition with a poor prognosis. As the medical team suspecting and treating sepsis – there are important management steps that need to be taken in order to maximize patient outcomes and save lives!

Early sepsis– while not clearly defined – is the presence of infection and bacteremia – which can and likely will progress to sepsis without intervention. Sepsis used to be identified using SIRS criteria– Systemic Inflammatory Response syndrome. This syndrome is defined as the presence of at least 2 of the following 4 clinical indicators: Fever >38C or <36C, HR >90bpm, RR > 22/min or PaCO2 <32 mmHg, or WBC >12,000/mm3, <4,000/mm3, OR 10% BANDS. Once SIRS is identified with suspected source of infection – sepsis diagnosis was met. However, the definition of sepsis has changed with 2016. Sepsis is now is defined as life-threatening organ dysfunction in response to infection. Organ dysfunction, usually from hypoperfusion, can be evidenced by hypotension, altered mental status, tachypnea, or increased sofa score by 2 points (see below). Septic shockis defined as those patients who have received fluid resuscitation and still have a MAP <65 mmHg and a lactic >2.0 mmol/L. These patients require vasopressors and should be monitored in the ICU.

Sepsis can be very serious and even fatal. Because of this – it is important to kn ow the steps to take in sepsis management. Performing these correct steps can literally mean the difference between life and death.

1. Recognition and Early Intervention

The most important aspect of sepsis management is recognizing it’s presence and acting quickly. Common symptoms of sepsis include fever, chills, sweats, and confusion. Common signs include altered mental status, elevated temperature, tachypnea, tachycardia, and hypotension.

Initial management should include investigating the extensiveness of their infection, and applying initial measures to help them. After vital signs are taken an IV should be established and lab work drawn. If the patient’s blood pressure is low – consider starting 2 large-bore IVs. Be sure to draw at least 1 set of blood cultures per IV site (up to 2) as this will need ordered in all sepsis patients. Make sure the blood cultures get drawn before antibiotics are started.

Diagnostics should investigate the source of the infection – sometimes it is not obvious. If unsure – it is a good idea to obtain a urinalysis with culture to r/o UTI and a Chest x-ray to r/o pneumonia should be ordered. A wound culture, sputum culture, or abdominal imaging may be ordered if clinically indicated. Blood work will usually include blood cultures x 2, CBC with differential, CMP, and a lactic acid level. Sometimes in severe cases, an ABG can be ordered to evaluate acid-base status.

Lactic acid levels are very important in sepsis. Lactate is released from cells when they are forced to utilize glycolysis instead of the Kreb’s cycle (throwback to Cell Biology!). This means that there is decreased tissue perfusion due to decreased volume, increased oxygen demand, and decreased oxygen delivery. Lactic levels correlate with severity of sepsis.

Apply oxygen at 2 L/min unless contraindicated – titrate if SPO2 <92%. During sepsis, oxygen demand increases and delivery diminishes. Supplemental oxygen will help put less stress on the body and may help diminish lactic acidosis.

The qSOFA (Quick Sequential Organ Failure Assessment) score is now starting to be used as a clinical tool for sepsis. This is usually used within the hospital to stratify the mortality of patients with sepsis (see infographic for more details).

2. Fluid Resuscitation!

Fluid resuscitation during sepsis is the staple of sepsis management. Evidence shows early fluid intervention decreases mortality. There is such a massive need for fluid because during sepsis there is poor tissue perfusion and often hypovolemia. To correct this – large amounts of fluids are needed.

Typically, 0.9% normal saline is used 9 times out of 10. The recommended standard volume is a 30 ml/kg bolus. So if a patient was 70 Kg, they would receive 2100 ml total. This should be given as quickly as possible – as tolerated. This amount is typically given to anybody recognized as possibly having sepsis, but is especially indicated in those with sever sepsis, fast heart rate, or low blood pressure. Traditionally even larger amounts of fluids were given (5-6 Liters), but several randomized control trials showed no difference in mortality compared with the now-recommended 2-3 Liters.

Exceptions to receiving this bolus includes those with active pulmonary edema. Those with a history of Heart Failure, end-stage renal disease, or severe liver disease should still receive fluids. However – it is recommended to give fluids in 500mL bolus increments and to reassess lung sounds and breathing status after each bolus. If pulmonary edema ensues – the bolus should be stopped and the patient may need diuretics.

3. Timely Antibiotic Administration

Another very important aspect of sepsis management is early antibiotics. The term empiric simply means antibiotics based on the best “clinical guess”.

The choice of empiric antibiotics will be selected based off of the patient’s signs or symptoms and where the likely source – since certain organisms are more likely from one source as opposed to another. This means the antibiotic regimen should be geared towards covering all likely gram-positive and gram-negative organisms. For sepsis – usually a broad spectrum antibiotic like Zosyn or a Carbapenem is combined with another antibiotic of a different lass – such as Vancomycin. Vanco is often added when the patient has risk factors for MRSA.

Correct regimen of antibiotics are important – however timely administration of those antibiotics are just as important. Antibiotics should be initiated within the first hour after suspecting sepsis – especially during severe sepsis or septic shock. This is because several observational studies have shown poorer outcomes with delayed antibiotic initiation. Once again, try to be sure you obtain both sets of blood cultures before you start the antibiotics!

As nurses, it is often up to you to choose which antibiotic to start first as both are often ordered concurrently. If you have both Zosyn and Vancomycin ordered – start with the broad-spectrum antibiotic first. But what exactly is broad-spectrum? This means heavy-hitter antibiotics that cover most pathogens – both gram positive and negative. Contrary to popular belief – vancomycin is NOT broad-spectrum. In fact, it has a very narrow spectrum specific for gram positive organisms such as Staph or Strep. Most cases of sepsis are from gram negative sources. This means starting the Zosyn first should be your priority. Additionally – Zosyn runs much quicker as a loading dose (4.5 grams over 30 minutes) – whereas vancomycin usually runs over 1.5 hours.

4. Hemodynamic Management

Sometimes when sepsis becomes severe – distributive shock can occur. This is termed septic shock. When this occurs – hemodynamic compromise is present. If blood pressure remains low, the patient’s tissue perfusion continues to suffer and steps need to be taken to improve outcomes.

The patient may require more fluid if they are still hypovolemic after the initial bolus and can tolerate more fluids. However, the mainstay of treatment of septic shock is intravenous Vasopressors. For the most part – Norepinephrine (Levophed) is the go-to pressor for sepsis. However, other choices can be chosen based on clinician discretion (i.e. If very tachycardic consider Vasopressin which has no beta stimulation). Sometimes, multiple vasopressors may need to run concurrently to manage septic shock.

When a patient is in septic shock with hemodynamic compromise – they should have a central venous catheter inserted and/or an arterial line. Vasopressors can be started in a peripheral line, but a central line should be ordered as vasopressors can be caustic and damaging to the peripheral vasculature. Additionally, these catheters can monitor CVP and continuous blood pressures. If a patient is in cardiogenic shock and has inadequate cardiac output – cardiac inotropes can be added such as dobutamine or epinephrine.

Sometimes during severe septic shock, IV glucocorticoids may or may not help. Usually this is ordered if fluid resuscitation and vasopressors have failed.

5. Monitoring

Monitoring is the essential last step to sepsis management. Patient’s with sepsis can respond well to the regimen – or they can decompensate unexpectedly. Sepsis has a high mortality and the patient’s should be monitored very closely.

If the patient has any hemodynamic compromise and are on pressors – they should be monitored in the ICU for a few days until they become stable. Patient’s with mild to moderate sepsis should be closely monitored on a med-surg or telemetry floor. Continuous cardiac monitoring is essential during sepsis. The increased tissue demand for oxygen places the heart at a greater risk for having cardiac events secondary to the sepsis. It is not uncommon for someone with sepsis and cardiac comorbidities to have secondary myocardial ischemia and/or infarctions.

Blood pressure should be monitored closely – especially initially. Normotensive blood pressure should be maintained (SBP >100). However – maybe even more importantly the MAP (mean arterial pressure) should be monitored closely. The goal of MAP should be >65mmHg – this ensures adequate tissue perfusion (i.e. brain). Heart rate is also an important metric to monitor. Tachycardia is usually present – often in the 120s-130s during fever and sepsis – sometimes higher. While giving fluids – heart rate should improve. This can be somewhat helpful in monitoring the response of fluid therapy. Fever should be monitored as well – as sometimes it can become very high and increases insensible water losses and further propitiates hypovolemia. Remember a rectal temperature is preferred in those with suspected sepsis – especially the elderly. Urine output is also often monitored during severe sepsis – as secondary hypoperfusion of the kidneys can cause acute kidney injury and decreased urine output.

Nursing assessments should include skin color and perfusion, mucous membranes (i.e. dry vs moist), mental status, and heart/lung sounds. Nurses should be vigilant in recognizing flash pulmonary edema or cariogenic shock which may develop after rapid administration of fluids with underlying comorbidities (i.e heart failure, ESRD, etc).

If the initial lactic acid level is elevated > 2 mmol/L, then a repeat level should be drawn in 4 – 6 hours. The lactic acid level should respond quickly to changes in tissue perfusion. CBC should be trended each day to monitor for resolution of the leukocytosis, bandemia, and/or thrombocytopenia. Electrolytes and kidney/liver function should also be monitored closely dpeneding on which abnormalities are present.

6. Patient Disposition and Follow-Up

Last but certainly not least – the patient needs to be sent to the correct unit, needs the correct consults, and needs adequate follow-up. Almost all patients admitted to the hospital with sepsis will warrant an Infectious Disease consultation. Additionally, if they have any pre-existing comorbidities these consults should be made as well (i.e. cardiology for heart failure, nephrology for kidney disease).

Patients should have frequent nursing assessments and daily physician assessments, with close follow-up of labs. Blood cultures can start showing growth at about 24 hours. The pathologist will gram-stain the growth and give a report of “gram positive cocci” a similar description. This tells the clinician if they are on the right track and can guess at the offending organism. At about 48 hours, most clinically significant bacteria will be identified and a sensitivity is done to detect the bacteria’s sensitivity vs resistance to various antibiotics. Urine, wound, and sputum cultures have similar timelines. Antibiotics may be changed depending on the results. Remember, Infectious Disease should likely be involved in this decision.

And those are the six steps to sepsis management. Knowing the general steps to sepsis can help you as the nurse provide high quality care to your septic patients and help improve outcomes. As always, it is a collaborative team effort in offering you patients the best possible care.

Do you have any other sepsis tips? leave them in the comments below!

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