Department of Nursing

Apollo Hospitals Group

 Introduction
Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus.

Most people infected with the virus will experience mild to moderate respiratory illness and recover without
requiring special treatment. However, some will become seriously ill and require medical attention. Older people
and those with underlying medical conditions like cardiovascular disease, diabetes, chronic respiratory disease, or
cancer are more likely to develop serious illness. Anyone can get sick with COVID-19 and become seriously ill or die
at any age.

The best way to prevent and slow down transmission is to be well informed about the disease and how the virus
spreads. Protect yourself and others from infection by staying at least 1 metre apart from others, wearing a properly
fitted mask, and washing your hands or using an alcohol-based rub frequently. Get vaccinated when it’s your turn
and follow local guidance and hospital protocols.

The virus can spread from an infected person’s mouth or nose in small liquid particles when they cough, sneeze,
speak, sing or breathe. These particles range from larger respiratory droplets to smaller aerosols. It is important to
practice respiratory etiquette.

Nurses play an important role in caring for patients suffering from Covid-19
Modes of transmission of COVID-19 virus (based on current evidence):

 Primarily transmitted between people through respiratory droplets and contact routes
 Droplet transmission occurs when a person is in close contact with some one who has respiratory symptoms (e.g.
coughing/sneezing)
 Asymptomatic carrier – the disease may be transmitted from individuals who may carry the virus without
showing any symptoms
 Risk of having his/her mucosae (mouth or nose) or conjunctiva exposed to potentially infective respiratory
droplets
 Transmission may also occur through fomites in the immediate environment around the infected person that is
-Indirect contact with surfaces in the immediate environment or with objects used on the infected person
(e.g. stethoscope, thermometer)
 Airborne transmission may be possible in specific circumstances in which procedures or support treatments that
generate aerosols are performed e.g. endotracheal incubation, open suctioning, manual ventilation before
intubation, non-invasive positive pressure ventilation, tracheostomy, and cardiopulmonary resuscitation.
How to protect?
5 Moments for Hand Hygiene

The contaminated hands of a

nurse can be a source of
infection to the patient and to
themselves. It is very vital to
follow hand wash and hand
rub as per policy
 Steps of Hand Hygiene

It is important to carry a small bottle of hand sanitizer in your pocket

 Usage of mask
 Appropriate masks have to be worn in recommended areas (there are guidelines for the same in
the hospital)
 When masks are worn especially in patient care areas appropriate use and disposal is essential
to ensure they are effective and to avoid any increase in risk of transmission associated with the
incorrect use and disposal of masks
 Place mask carefully to cover mouth and nose and tie securely to minimize any gaps between
the face and the mask
 While in use, avoid touching the mask
 Remove the mask by using appropriate technique (i.e. do not touch the front but remove the
lace from behind)
 After removal or whenever you inadvertently touch a used mask, clean hands by using an
alcohol-based hand rub or soap and water if visibly soiled
 Replace masks with a new clean, dry mask as soon as they become wet/ damp/humid/ soiled
Masks should always be discarded in the appropriate bin based on hospital policy
 3 Ply Mask
• Fit flexible nose piece over nose
bridge
• Place over nose, mouth and chin
• Adjust to fit
• Secure by tying in the form of ‘figure
of eight’

Masks should never be pull down while caring for a patient. Walking around with a mask
handing on the neck is not permitted. This is a single use mask; DO NOT REUSE
 N-95 mask

1. Hold N95 in 2. Place over nose, 6. Perform a fit check

4. Pull the UPPER
cupped hand mouth and chin – Inhale : Mask should
ELASTIC over head
3. Fit flexible nose collapse
5. Adjust to fit
piece over nose – Exhale : Check for
bridge leakage around face
 Personal Protective Equipment

All team members MUST don appropriate PPE prior to

attending to a patient regardless of the urgency of the
situation.
Donning and Doffing of PPE
Personal Protective Equipment (PPE)
Donning & Doffing

• PPE COMBINATION may vary according to the type of the precautions

required
• PPE SEQUENCE may vary according to the type of PPE used
• Hand-hygiene is essentially to be performed prior to donning PPE
• Hand-hygiene is essentially to be performed in-between every doffing step and
Always at the end of PPE removal
Donning Sequence
(Don the PPE before entering the isolation area)
1. Hand-hygiene
1a. Shoe-covers
2. Hand-hygiene
2a. Gown
3. Hand Hygiene
3a. Cap / hood
4. Hand Hygiene
4a. Mask
5. Hand Hygiene
5a. Goggles or face shield
6. Hand Hygiene
6a.. Gloves
Shoe covers
After hand-hygiene, wear shoe-covers
• Sit down on a chair
• Wear shoe-covers one by one on each foot
• Ensure that the scrub is tucked inside the shoe cover

Perform Hand Hygiene

Gown

• Select appropriate type and size

• Wear such that the front is fully covered
• Opening of the gown should be at the back
• Secure with ties at neck and waist
Cap / Hood

• Wear Cap / Pull on Hood over the

hair so as to contain all the hair inside
from front and back
• If the hood has a tie, tuck the tie
inside the gown

Perform hand Hygiene

Surgical 3-ply Mask (If donning Surgical 3-ply Mask

• Fit flexible nose piece over nose bridge

• Place over nose, mouth and chin
• Secure by tying in the form of ‘figure of eight’
• Adjust to fit

Perform hand hygiene

If Donning N95 Mask/ Respirator
1. Hold N95 in cupped hand 2. Place over nose, mouth
and chin over nose bridge – Exhale : Check for
leakage around face
3. Fit flexible nose piece

4. Pull LOWER ELASTIC FIRST over head

5. Next, Pull the UPPER ELASTIC over head 7. Perform a fit check –
Inhale: mask should inhale:mask should collapse
6. Adjust to fit

Perform Hand hygiene

Goggles / Eye Protection / Face shield

• Pull the elastic of the goggles over the

back of the head

• Position goggles over eyes

• Adjust the goggles over the eyes and
forehead to fit comfortably
• Even if you are wearing prescription
glasses - goggles can be worn over it

Perform Hand Hygiene

Gloves

• Don gloves last

• Select correct type and size
• Insert hands into gloves
• Extend gloves over sleeve cuffs of gown

Perform hand hygiene

PPE- Dos and Don’ts

• Adjust the entire PPE in the PPE donning area

BEFORE contact with the patient
• Keep gloved hands away from face, goggles,
mask
• Remove gloves if they become torn
• Perform hand hygiene before donning new
gloves
• Limit touching surfaces and items
DOFFING

Removal of PPE (Doffing) : The following sequence to be followed

1.Gloves
1.b Hand-hygiene
2.Gown
2.b Hand-hygiene
3.Goggles or Face shield
3.b Hand-hygiene
4.Mask
4.b. Hand-hygiene
5.Cap / Hood
5.b.Hand-hygiene
6. Shoe-covers
6.b. Hand-hygiene- use alcohol-based hand-rub and Wash hands with
soap and water thoroughly
Removal of Gloves

Never touch outside of the gloves with your bare hands

Perform hand hygiene

Removal of gown

Peel gown away from Fold or roll into a bundle

neck and shoulder Discard appropriately
Unfasten tie
Removal of Goggles / Face shield

Perform Hand hygiene

•Lean Forwards
•Grasp elastic from back
•Lift away from face
•Discard appropriately
Removal of 3 ply Surgical Mask

Lean Forwards

Untie the bottom first, then untie the top strings HOLD THE MASK BY
STRINGS ONLY.

•NEVER TOUCH THE OUTSIDE OF THE MASK

Perform hand hygiene

 Removal of N95 Respiratory mask

•Discard designated bin

•Always handle N95 respirator by ELASTIC ONLY

•NEVER TOUCH THE OUTSIDE of the N95 respirator
 Nursing Care Goals
 To maintain effective oxygenation
 To assess vital signs
 To maintain fluid and electrolyte balance
 To ensure safe medication practices
 To ensure infection control measures
 To ensure appropriate patent positioning
 To ensure care of lines and drains
 To ensure adequate nutrition
 To ensure elimination needs are met
 To promote early ambulation
 To ensure care of personal hygiene
 To provide comfort/ emotional support
 To provide patient and family education

To ensure patient safety at all times

 Nursing Interventions
 Based on assessment data, nursing interventions for COVID-19 should focus on monitoring vital signs,
maintaining respiratory function, managing hyperthermia, and reducing transmission.
 Monitor vital signs – particularly temperature and respiratory rate, as fever and dyspnoea are common
symptoms of COVID-19.
 Temperature : Use single thermometer for individual patients .Disinfect the thermometer after checking the
temperature and perform hand hygiene.
 Blood Pressure : Blood pressure cuff should be disinfected with recommended solution after each use
 Saturation : Pulse oxymeter should be disinfected with recommended solution after each use
 Monitor Oxygen saturation – normal Oxygen saturation as measured with pulse oximeter should be 94 or
higher; patients with severe COVID-19 symptoms can develop hypoxia, with values dropping low enough to
warrant supplemental oxygen.
 Manage fever – use appropriate therapy for hyperthermia, including adjusting room temperature,
eliminating excess clothing and covers, using cooling mattresses, applying cold packs to major blood vessels,
starting or increasing intravenous (IV) fluids as prescribed, administering antipyretic medications as
prescribed, and ensuring preparations for oxygen therapy in the event of respiratory problems resulting from
the metabolic demands for oxygen during a fever.
 Follow doctor’s prescription for fluid and electrolytes and for medications and transfusions
(follow Rights of medication (Right patient, Right Medicine, Right dose, Right route, Right
time and Right patient education, and right documentation)
 Follow the prescription for dietary advice. Ensure that the dietitian is consulted and the patient
is provided with the prescribed meal and completes the meal .. The same should be
documented in the nurses’ notes
 Assess skin integrity and ensure appropriate position change to prevent pressure ulcers
 Provide adequate assistance for meeting personal hygiene / toilet needs / and other comforts
 Provide emotional support as the patient will be alone …. Connect to family members if
possible through videocalls and telephone calls
 Do not discuss the medical condition of the patient to any family member or to any unknown
person (request the doctor to communicate all clinical aspects)
Every patient will have a doctor’s prescription – please follow every advice on time – report any
untoward effects of treatment
 Patient Communication
 Be respectful, polite and empathetic
 Be aware that suspected and confirmed cases, and any visitors accompanying them,
may be stressed or afraid
 The most important thing you can do is to listen carefully to questions and concerns
 Use local language and speak slowly
 Gather accurate information from the patient: their name, date of birth, travel
history, list of symptoms…
 Answer any questions and provide correct information about COVID-19
 You may not have an answer for every question: a lot is still unknown about
COVID19 and it is okay to admit that
 Explain the healthcare facility’s procedure for COVID-19, such as isolation and
limited visitors, and the next steps
 Provide updates to visitors and family when possible
 Patient and Family Education (if you are posted in the OPD)
Ideally this will be done by the registration desk but if anyone is asking a nurse for an
appointment you may guide them as follows:
• Ask them to bring their own pen
• Preferred mode of payment is digital
• Be on time as the scheduled time
• Wear a mask always
• Patients should be instructed to come alone unless they need special assistance
• Attendant (if accompanies) should wear a mask
• For patients coming alone, advise patients to leave personal belongings in their vehicle or the waiting room.
• Preferably empty their bladder while coming to the hospital
• Maintain social distancing
• Carry a hand sanitizer/ use sanitizer at the hospital at the entrance
• Information on online reports if tests are done
• Avoid touching areas like stair handles, lift buttons, door knobs etc
• OP Pharmacy to follow the que management & token system to avoid the crowd. Ensure social distancing.
 Patient and Family Education - Inpatients

The patient and the family must be provided with necessary information and education to deal
with the challenging situation they are faced with

 Necessary infection control practices must be taught – hand hygiene / mask and disposal of
waste
 Families of infected patients must follow government guidelines while at home and outside
 Patients must be taught on medication and its effects
 Patients should be taught to report early warning signs of deterioration - example- breathing
difficulty, high fever, pain, discomfort etc.
 Patients should be taught on nutrition and any specific advice from the doctor
 Any other education relevant to the patient’s condition must be provided
 Wherever in doubt, consult the in charge nurse
 Biomedical waste Management
There are color coded bins based on Government recommendations – always dispose waste in the
appropriate bin. Example given below (but may change from state to state)

Yellow Human Anatomical Waste

bin

Red Infected Plastic Waste

bin

Blue All Infected glassware

bin

Black All general non – infected plastic paper,

bin disposable etc.
Separate containers for sharps is also available (blade, needle etc)
Details of Biomedical waste segregation
 Handling Biomedical equipments
Nurses will be handling a lot of biomedical equipments- equipment training will be provided while on
boarding.

The basic equipments used are as follows:-

 Bipap
 ABG
 Glucometer
 Infusion Pump / Syringe pump
 ECG Machine
 Ventillators
 Monitors
 Defibrillators
A simple operating guide is attached as an Annexure
All equipment should be in working condition and cleaned as per infection control protocols and any
repairs and maintenance should be routed through biomedical engineering department.
 Recognizing Early Warning signs- Pediatric

Criteria for announcing a code : (There is a dedicated telephone number and a public announcement system
– a special team will arrive to evaluate and manage the patient )

 Heart Rate more than 180 less than 80 (less than 5 yrs.)
 Heart Rate more than 160 less than 60 I minute more than 5 yrs.)
 Blood Pressure: 0-1 yrs.: less than 60 mm Hg (systolic)
 1-8 yrs. : less than 70 mm Hg (systolic) Above 8 yrs.: less than 90 mm Hg systolic
 Respiratory rate more than 60/minute and less than 20 /minute
 Increased work of breathing (retractions, nasal flaring, grunting)
 Reduction in urine output less than 1ml/kg/body weight over last 4 hours
 Cyanosis
 Fall in saturation less than 90%, in spite oxygen requirement more than 6 liter/per minute
 Cold extremities
 Convulsion
 Hypothermia less than or equal to 36-degree C

You can even call a code if you are worried about the patient
 Recognizing Early Warning signs - Adult

 Acute change in heart rate less than 60 or more than 130-beats /minute
 Acute change in systolic BP less than 90 mmHg
 Acute change in respiratory rate less than 10 or more than 28 per minute
 Acute change in saturation less than 90% despite supplemental oxygen
 Acute change in conscious/ mental state i.e. drowsy / irritable
 Acute change in urinary output to less than 5O ml in 4 hours
 Persistent chest pain not relieved by analgesics.

You can even call a code if you are worried about the patient
 Handling cardiac arrest
There is designated number to call a code blue (cardiac arrest) which will be activated
through a public announcement system and a special team will arrive

Initiate CPR (Cardio Pulmonary Resuscitation) – chest compression and respiration

 If the patient is unresponsive

 Absence of pulse
 Absence of respiration

Link for steps of BLS and ACLS

https://apollodelhi-
my.sharepoint.com/:p:/p/simmy_r/EQ3VVOUrDIhJvtp77Y0FiWUB-
_Gi444Ypbj0jA4xavLrww?e=WSM7Qo
Algorithm – BLS & ACLS
 Patient discharge
 The patient will be discharged on the doctor’s advice and a written order
 The patient and the family should be informed well in advance to prepare the patient’s
transfer and arrival at home
 All necessary billing entries should be done at the earliest (indents of medication and
consumables)
 Patient belongings must be handed over
 All necessary records and investigations reports should be handed over as per the hospital
policy ( digital / manual)
 Discharge summary should be explained to the patient
 Facilitate for billing
 Discharge the patient only on billing clearance
 All necessary stakeholders should be informed
 All necessary checkouts should be done on the computer

Please follow the discharge checklist

 Handling the Dead body

 Standard Precautions to be followed by all personnel handling the dead body by wearing all the personnel
protective equipment i.e. gloves, gown, N95 respirator, Cap/hood, face shield/goggles, long nitrile
gloves/double nitrile gloves, full length shoe covers/ boots.
 Dispose off intravenous catheters into the red garbage bag or as per BMW (Biomedical waste)
 Disinfect all wound drainage and needle puncture holes with 1% hypochlorite and dress with impermeable
material.
 Discard all sharp devices directly into a sharps container.
 Clear secretions in oral and nasal orifices by gentle suction, if needed.
 Plug the oral, nasal and rectal orifices of the dead body to prevent leakage of body fluids.
 Used equipment, if reusable, shall be sterilized or disinfected as per protocol.
 All disposable items and other waste shall be handled and disposed off in accordance with Bio-medical waste
management rules.
 All clothes used for known cases shall be disposed off in designated bins
 Wrap the body in the double body-bag. Body-bags shall be impermeable and opaque and be zipped up
exterior of the body bag should be decontaminated with 1% hypochlorite
 The body bag can be wrapped with a mortuary sheet or sheet provided by the family members.
 The dead body should not be removed/ Unzipping of the body bag is NOT allowed from the body bag.
All surfaces of the isolation area (floors, bed, railings, side tables, IV stand, etc.) should be wiped with 1%
Sodium Hypochlorite solution and allowed to remain in contact for at least 20 minutes. allow a contact
time of 30 minutes, and then allowed to air dry.
 The attendants shall be instructed to avoid any contact and any other rituals involving close contact with
the body.
 The personnel wearing PPE shall doff as per protocols and wash hands with soap and water
 Support the grieving family
 Seek help of the medical social worker wherever appropriate

Pay your last respect to the departed soul

Eating and drinking protocols at work
 Self protection and reporting

 At all times the infection control protocols must be practiced. The Dos and Don’t’s are
already highlighted in the document in the earlier part.
 Ensure you have taken your vaccination as per due date
 In case of any sickness, report to staff clinic.
 Follow the doctor’s prescription
 In case of being tested covid positive follow hospital protocol for quarantine / treatment
and return to work

Be Healthy Be Safe
Protect yourself and Protect those around you
Thank you